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Scenario Planning
CLINICAL ONCOLOGY 17 Optimal Planning and Delivery of Radiotherapy for Oesophago-gastric Junction (OGJ) Cancers R. Sripadam*, A. Amery, T. Marchanty, J. Stratfordz, C. McCarthyz, C. Faivre-Finnx, C. Moorey, P. Price* *Academic Department of Radiation Oncology, Christie Hospital, Manchester, UK; yNorth Western Medical Physics, Christie Hospital, Manchester, UK; zWade Centre for Radiotherapy Research, Christie Hospital, Manchester, UK; xClinical Oncology Department, Christie Hospital, Manchester, UK Introduction: Radiotherapy to OGJ cancers is challenging due to the complex target shape, close relation to critical structures and movement with respiration. This study aimed to investigate the relative magnitude of intrafraction motion and interfraction bony setup errors and their implications for radiotherapy planning. Methods: 16 lower oesophageal and OGJ cancer patients in a prospective study treated with radical radiotherapy chemotherapy had serial orthogonal KV fluoroscopies and X-ray volumetric images (XVI) offline in the treatment position over 9 days using Elekta SynergyTM. 30e60 frames over 10 seconds (3e4 breathing cycles) were obtained. Barium was used to record the tumour position through each fluoroscopy frame in the x (lateral), y (antepost) and z (supeinf) axes. Translational and rotational displacements were noted by bony co-registration of the XVIs to the planning scan. Results: Data were generated from 260 fluoroscopies and 130 XVIs. The 95th percentile of intrafraction motion (range) in the x, y, z axes are 1 (0.4e1.2), 0.7 (0.2e0.8) and 1.9 (0.5e2.2) cm, respectively. Motion in the supeinf direction was largest. Marked inter- and intrapatient variability was noted. In contrast, the bony setup error was not as great d systematic errors in x, y, z were 0.34, 0.24 and 0.5 cm; random errors were 0.3, 0.14, 0.3 cm, respectively. Rotations were predominant in the AP axis. The recommended generic margins from the BIR working party formula are: lateral 1.2, AP 1.1, SI 2.9 cm, respectively. Daily online XVI imaging, however, will reduce them to 0.4, 0.7 and 1.6 cm, respectively. Using fluoroscopic intrafraction motion data during CT planning will help individualise margins and may result in further margin reductions. Conclusions: Respiratory intrafraction motion is an important source of error in OGJ radiotherapy. Tailoring margins based on individual intrafraction motion measurements, and daily online XVI imaging can result in more optimal planning and delivery of radiotherapy for OGJ cancers. Further reduction in margins may be made by coached or restricted respiration (to reduce daily variability), gating and 4D techniques to minimise intrafractional errors. T9 Pain Management M. Fallon Edinburgh Cancer Centre, Western General Infirmary, Edinburgh, UK Neuropathic pain, along with spontaneous and movement-related bone pain prevent significant clinical challenges. We know that in all these situations, unacceptable side-effects usually appear before adequate analgesia is achieved. There are identifiable reasons for the struggle with these pains which have been characterised in the laboratory. These can be broadly classified as: electro-physiological, neurochemical and anatomical. These changes are unique for neuropathic pain and for bone pain, however there is some overlap. There are various techniques for manipulation of opioid response. Such manipulation has various elements, however the glutamate system is a common target for both neuropathic and bone pain. Basic science, current and future clinical research and directions will be discussed. 18 A Randomised Controlled Trial of Elemental Diet During Pelvic Radiotherapy C. McGough*, C. Baldwiny, C. Hacketty, L. Wedlake*, A. Norman*, G. Frosty, P. Blake*, D. Tait*, V. Khoo*, K. Harrington*, H. J. N. Andreyev* *Royal Marsden NHS Foundation Hospital Trust, London, UK; yImperial College London, UK
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Background: Acute gastrointestinal symptoms occur in 80% of patients during pelvic radiotherapy. Changes in the gastrointestinal tract include denudation of the mucosal layer which renders the small intestine vulnerable to damage from proteolytic enzymes and bile acids. Elemental diet taken during radiotherapy has been shown to be highly protective in animal models perhaps because of reduction in the production of irritant secretions. Methods: This study aimed to assess the efficacy of elemental diet in reducing gastrointestinal toxicity during radiotherapy. Patients with pelvic malignancy undergoing radical or adjuvant pelvic radiotherapy were randomised to intervention with elemental diet (Elemental 028 Extra, SHS International) replacing 1 meal daily for the first three weeks of treatment only or to no intervention. Toxicity was assessed using the IBDQ, Vaizey Incontinence scale and RTOG questionnaires. Faecal calprotectin and CRP were measured as markers of intestinal mucosal inflammation. Statistical analyses were conducted on an intention to treat basis. Results: 50 patients (29 female; 21 male) with a median age of 61.5 years (29e82) were recruited to the study (13 endometrial, 11 prostate, 9 rectal, 7 cervical, 4 anal, 3 other, 2 bladder and 1 ovarian carcinoma). Median radiotherapy dose was O50 Gy. Gastrointestinal symptoms increased significantly in both groups, scores at week 3 and week 5 of treatment were significantly higher than at baseline (P ! 0.001). Patients taking elemental diet (median intake 500 ml per day) did not have fewer symptoms, lower RTOG toxicity rating or lower markers of inflammation (P O 0.2). Conclusions: No therapeutic benefit was found in terms of reduction of clinical gastrointestinal symptoms or markers of inflammatory change when patients replaced up to one third of their total calories using elemental diet. The scientific rationale for the use of elemental diet is compelling; however, future study should focus on 100% replacement of nutritional intake with elemental diet. 19 Scenario Planning S. Erridge Abstract not published
20 Radiotherapy d a Workforce for Tomorrow J. Barrett Royal Berkshire Hospital, Reading, UK Radiotherapy is still a very important modality of treatment for patients with cancer; over 50% will receive it during their illness. It is important that services to deliver radiotherapy are up to date and capable of coping with the increased demands of the future. The National Radiotherapy Advisory Group (NRAG) has looked at radiotherapy provision in England both in relation to equipment and the problems of staffing in radiotherapy departments. The workforce subgroup of NRAG recognises that the main limiting factor for achieving increased service capacity is workforce. Currently approximately 3400 FTE staff are involved in delivering radiotherapy services including radiographers, medical physics staff, clinical oncologists, nurses and related support staff. A cohesive workforce strategy is needed to deliver the required numbers and skill mix of staff to support service improvements and increases to radiotherapy services. While real issues exist in each of the professions around shortages and recruitment difficulties, this is an opportunity to look at radical redesign of the workforce. Changes in training for the entire workforce need to be linked to changes in career structure for all groups of employees. Some of the issues identified have been the high attrition rates in training schemes which will need to be addressed by new ways of training staff both within and outside the clinical setting. Commissioners will need to recognise that fast track career progression will be required to develop the higher level skills that are essential to underpin non-medical advanced level practice to help optimise skill mix across the radiotherapy pathway. Deployment of staff must be a local issue and radiotherapy centres must be supported
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Background: Acute gastrointestinal symptoms occur in 80% of patients during pelvic radiotherapy. Changes in the gastrointestinal tract include denudation of the mucosal layer which renders the small intestine vulnerable to damage from proteolytic enzymes and bile acids. Elemental diet taken during radiotherapy has been shown to be highly protective in animal models perhaps because of reduction in the production of irritant secretions. Methods: This study aimed to assess the efficacy of elemental diet in reducing gastrointestinal toxicity during radiotherapy. Patients with pelvic malignancy undergoing radical or adjuvant pelvic radiotherapy were randomised to intervention with elemental diet (Elemental 028 Extra, SHS International) replacing 1 meal daily for the first three weeks of treatment only or to no intervention. Toxicity was assessed using the IBDQ, Vaizey Incontinence scale and RTOG questionnaires. Faecal calprotectin and CRP were measured as markers of intestinal mucosal inflammation. Statistical analyses were conducted on an intention to treat basis. Results: 50 patients (29 female; 21 male) with a median age of 61.5 years (29e82) were recruited to the study (13 endometrial, 11 prostate, 9 rectal, 7 cervical, 4 anal, 3 other, 2 bladder and 1 ovarian carcinoma). Median radiotherapy dose was O50 Gy. Gastrointestinal symptoms increased significantly in both groups, scores at week 3 and week 5 of treatment were significantly higher than at baseline (P ! 0.001). Patients taking elemental diet (median intake 500 ml per day) did not have fewer symptoms, lower RTOG toxicity rating or lower markers of inflammation (P O 0.2). Conclusions: No therapeutic benefit was found in terms of reduction of clinical gastrointestinal symptoms or markers of inflammatory change when patients replaced up to one third of their total calories using elemental diet. The scientific rationale for the use of elemental diet is compelling; however, future study should focus on 100% replacement of nutritional intake with elemental diet. 19 Scenario Planning S. Erridge Abstract not published
20 Radiotherapy d a Workforce for Tomorrow J. Barrett Royal Berkshire Hospital, Reading, UK Radiotherapy is still a very important modality of treatment for patients with cancer; over 50% will receive it during their illness. It is important that services to deliver radiotherapy are up to date and capable of coping with the increased demands of the future. The National Radiotherapy Advisory Group (NRAG) has looked at radiotherapy provision in England both in relation to equipment and the problems of staffing in radiotherapy departments. The workforce subgroup of NRAG recognises that the main limiting factor for achieving increased service capacity is workforce. Currently approximately 3400 FTE staff are involved in delivering radiotherapy services including radiographers, medical physics staff, clinical oncologists, nurses and related support staff. A cohesive workforce strategy is needed to deliver the required numbers and skill mix of staff to support service improvements and increases to radiotherapy services. While real issues exist in each of the professions around shortages and recruitment difficulties, this is an opportunity to look at radical redesign of the workforce. Changes in training for the entire workforce need to be linked to changes in career structure for all groups of employees. Some of the issues identified have been the high attrition rates in training schemes which will need to be addressed by new ways of training staff both within and outside the clinical setting. Commissioners will need to recognise that fast track career progression will be required to develop the higher level skills that are essential to underpin non-medical advanced level practice to help optimise skill mix across the radiotherapy pathway. Deployment of staff must be a local issue and radiotherapy centres must be supported