Purpose/Aim Adaptive radiation therapy (ART) enables precise management of complex organ motion and tumour response, potentially improving patient outcomes. Online ART is resource-intensive and requires radiation therapists (RTs) to develop technical competencies across treatment planning, delivery, and in some workflows, target segmentation. This work outlines our experience implementing ART and developing RT skills for safe, efficient clinical application. Methods/Process Our institution implemented ART using a dedicated planning platform with a ring-based linear accelerator (Ethos, Varian Medical Systems). The system supports cone beam CT (CBCT)-guided online and offline ART with AI-assisted contouring and automated planning. Initial implementation and training were multidisciplinary, including 6 RTs. Daily online ART delivery followed a collaborative team model with RTs, a physicist, a radiation oncologist, and a dedicated radiation oncology fellow. The same RTs delivering ART also generated the initial reference plans. Training included system operation, anatomy and segmentation, reference planning, and online ART workflows. To support and evaluate training, we developed an ART-specific competency framework by adapting 27 competencies from the national RT entry-to-practice profile, which does not explicitly address ART. Competency validation was based on RT self-assessment after training and two months of clinical experience. RT training evaluation and skill development were conducted as an approved quality improvement initiative (QI #25-1064). Initial ART cases included genitourinary and sarcoma sites, with additional sites added as experience grew. Results or Benefits/Challenges Over 12 months, 13 RTs were trained in ART delivery and reference planning. To date, 126 patients have been planned and treated in the system: 41 sarcoma, 41 genitourinary, 16 upper gastrointestinal, 8 gynecologic, 7 head-and-neck, 5 other, and 8 palliative cases using a CTsim-free technique. Of these, 92 received daily online ART, while 20 underwent offline replanning, mostly using CBCT directly rather than a new CTsim. RTs reported increased competency across all domains after two months. Skills in reference planning increased to an intermediate level, requiring occasional support and skill development, especially among RTs without prior dosimetry experience. This did not significantly affect online ART delivery due to the team-based model. Challenges included the steep learning curve for complex cases, managing different techniques for multiple disease sites, adapting to a new planning system with distinct workflows, and initially low case volumes limiting hands-on experience. Conclusions/Impact CBCT-guided ART has been successfully implemented across multiple disease sites through an online, multidisciplinary model involving RTs, physicists, and oncologists. To support expansion to four ART-enabled linear accelerators in the coming year, increasing multidisciplinary experience and enhancing RT proficiency in reference planning are key priorities. Early success also demonstrates the feasibility of RT-led online ART to enable clinical expansion, with targeted skill development actively underway to support this approach for pelvic and head-and-neck treatments.

Purpose/Aim Interfraction bladder volume variation due to bladder filling poses challenges to the precision and efficiency of radiation therapy. Before the availability of a ConeBeamCT (CBCT) -guided adaptive radiation therapy (ART) platform, bladder patients at our institution were treated in two phases using CBCT for image guidance: Phase 1 used a 10mm planning target volume (PTV) margin for the first 7 fractions, and Phase 2 generated a patient-specific PTV (PS-PTV) using information from Day 1-4 CBCT. Despite this approach, some patients continued to have difficulty reproducing the bladder volume observed at simulation, resulting in longer appointment times and repeated CBCTs. Since implementing bladder treatments on the Ethos Adaptive platform in June 2025, our objective was to assess and compare treatment session durations between the IGRT and the ART workflow. Methods/Process Approval was obtained from the Quality Improvement Review Committee to retrieve data for comparison of radiation therapy workflows. All bladder patients were prescribed 55Gy in 20 fractions to the bladder, with or without pelvic lymph node (45Gy in 20 fractions). They were simulated and treated with a full bladder. For the IGRT workflow, a localization CBCT was acquired, and treatment was delivered using a 2-arc VMAT after correcting interfraction variation by couch shift based on image registration. If the anatomy is deemed unacceptable (e.g. bladder that was too small or extended outside of the PTV), patients were asked to wait for bladder filling or partially void, followed by acquisition of a repeat CBCT. Treatment proceeded once the anatomy met institutional imaging criteria. For the ART workflow, a localization CBCT was acquired and registered with the reference image. Autosegmentation of relevant volumes and target propagation were performed. The reference plan was re-computed to generate the Scheduled Plan, and an adapted plan was created by re-optimization based on the anatomy of the day. Both plans (9-field IMRT) were evaluated, and the clinically appropriate plan was selected. A physics quality check was performed, followed by a second CBCT to verify that the target was within the PTV before treatment delivery. For each fraction, timestamps for the initial CBCT and treatment beam delivery were collected. Treatment session duration was defined as the time interval between the first CBCT and the end of the beam delivery. Descriptive statistics were used to summarize the results. Results or Benefits/Challenges A total of 240 fractions from 12 IGRT patients and 195 fractions from 11 ART patients were analyzed. The average treatment session duration was 18 minutes (range: 5 – 186 minutes) for IGRT and 17 minutes (range: 11 – 29 minutes) for ART (p = 0.49). A total of 134 repeated CBCTs were acquired from 10 of the 12 IGRT patients. Overall, 88% of ART fractions were completed in less than 20 minutes compared to 75% for IGRT. Notably, 2% of IGRT fractions (10 fractions from 6 patients) exceeded 60 minutes, whereas no ART fractions required more than 60 minutes. Prolonged IGRT sessions were primarily associated with challenges in achieving the planned bladder volume. Conclusions/Impact The Ethos adaptive workflow demonstrated comparable average treatment session durations to the IGRT workflow while reducing variability and eliminating excessively prolonged sessions. ART offers greater workflow stability and efficiency in bladder radiation therapy. Future work will examine the dosimetric difference between the two workflows.

Purpose/Aim The development and implementation of techniques for online adaptive radiotherapy (ART) necessitates re-evaluating conventional duties and workflows within the multi-disciplinary team (MDT). The aim of this work is to demonstrate the critical input of Radiation Therapists (RTTs) when generating practical ART innovation, as detailed in the commissioning of a head and neck (H&N) ART clinical trial by a Clinical Specialist RTT (CSRT). Methods/Process Commissioning of a H&N ART clinical trial within the MDT began with conceptualization of various strategies for submandibular gland (SMG)-sparing on Ethos (Varian, Siemens). Planning templates were developed to standardize ART plan generation in Ethos, incorporating innovation of planning target volume (PTV) margins (non-isometric 1mm-3mm PTVs), optimisation structures, and standard of care dosimetric endpoints for evaluation of organs-at-risk (OARs) and PTVs. Five test cases were generated in Ethos and benchmarked against the clinically delivered image-guided radiotherapy (IGRT) plans (isometric 5mm PTVs). Clinical trial test cases were additionally evaluated in the Ethos emulator, a simulated ART workspace, to ensure inter-fractional consistency of daily ART plans throughout treatment. An ART delivery workflow was devised, including tasks of organ contour correction, PTV reproducibility through rigid propagation and manipulation, and ART plan evaluation. An RTT training framework was developed to ensure competency in H&N-specific ART processes, and comprehensive documentation was generated to support protocol reproducibility and adherence. Results or Benefits/Challenges Benchmarking results revealed consistent SMG-sparing while preserving PTV coverage per institutional standards. Across five test cases, the spared-SMG received a mean dose of 27.7Gy (SD 1.3Gy, range 26.2-28.9Gy), representing a mean reduction of 19.8Gy (SD 7.6Gy, range 8.3-26.6Gy) compared to IGRT plans. PTV reduction through ART demonstrated appreciable dose sparing to additional OARs including parotid glands and pharyngeal constrictors. Planning templates facilitated standardization for plan generation, yet in H&N ART, case-specific template modification was required based on individualized PTV volumes. Analysis within the Ethos emulator confirmed that customized planning templates remained effective for clinical use, even when inter-fractional changes in anatomy were observed. Training sessions and educational resources were provided to RTTs to upskill H&N-specific ART delivery, data collection to evidence competency remains ongoing. After institutional review of standardized documentation, the SMG-sparing ART clinical trial was successful implemented with one patient currently receiving treatment under the trial protocol. The increased resources required for daily ART compared to IGRT includes an additional 10-15 minutes per fraction and online MDT consultation for target placement and ART plan approval. Conclusions/Impact For emerging ART techniques, RTTs play a crucial role when transforming theoretical protocols into standardized practice. CSRT commissioning of a H&N ART clinical trial established a reproducible ART workflow that leverages SMG-sparing without compromising PTV coverage, with training and documentation to support protocol reproducibility and scalability. Continued advancement in RTT competency will reduce ART resources for online MDT consultation, with the goal to gradually progress to a completely RTT-led workflow.

Aim: Head and neck (H&N) cancer patients do not receive treatment to their sexual organs, but these patients undergo a multimodality approach to treatment and its effects may still negatively affect their sexual health (SH). Radiation therapists (RTs) have a unique opportunity to develop a strong rapport with patients and to discuss sensitive issues related to relationship, body image and intimacy (RBI). This project aimed to address the SH needs of our H&N patients by providing RTs at our institution with the knowledge and skills to provide SH information to our patients. We also addressed increasing our accessibility to SH information by creating a specific SH document tailored to help our patients who are receiving H&N radiation treatment. Process: This Quality Innovation involved a multidisciplinary collaborative effort. We surveyed our staff to identify the perceived barriers in preventing RTs from having a SH conversation with their H&N patients. This needs assessment allowed us to identify how we can best help our staff. Working with our institution's patient education and patient partners groups, we created a patient education document on SH concerns for patients receiving H&N radiation treatment. We also created education sessions for our RTs to improve their knowledge about SH concerns. The workshops covered the impact of sexual dysfunction in oncology; clinical approaches to optimizing sexual healthcare in oncology; and provided future direction on how to access resources for our patients. Finally, we standardized the procedures and improved RT practical skills by creating documentation processes and conversational scripts for staff to help them initiate conversations about these sensitive topics. Benefits/Challenges: A challenge we experienced during our project included inconsistent staffing due to COVID19 interruptions. This project experienced a 7 month pause due to clinical demands at our institution. In addition, our team lost a team champion as they had left the institution. This challenge was rectified by recruiting extra team champions to help facilitate this project. The benefits of our quality initiative interventions included increasing our staff knowledge and comfort levels in having SH conversations with our H&N patients through educational staff workshops. For consistent staff delivery, we standardized the procedure and provided staff with conversational scripts so that staff could start a SH conversation with their patients. Impact/Outcomes: This quality initiative is midway through completion. Four team champions of this project were able to receive SH training in oncology, and other team members have various experience in sexual health care in oncology. So far, we have conducted one educational SH workshop for staff. Based on participant feedback, staff were motivated and eager to increase their knowledge and skill levels. Another education session will be organized for early 2022, focused on H&N sexual health. Prior to clinical implementation, the champions piloted the process with patients. From participant interviews, patients were very appreciative and accepting of SH information from RTs. This initiative will be fully implemented in late January.

Aim: It is estimated that approximately 25% of cancer patients are currently taking cannabis to alleviate symptoms of their disease and/or cope with the side effects of their treatment. Patients want to learn more about cannabis from their cancer healthcare team, but most Radiation Therapists (RTs) feel too uninformed to discuss this subject. The purpose of this abstract is to provide information about cannabis that is relevant and useful for RTs. Process: Cannabis is a broad term used to describe organic products derived from the Cannabis plant. The unique group of active chemical compounds found in cannabis are called cannabinoids. Among the more than 100 different types of cannabinoids, the most abundant and well-studied are delta9 tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is the primary intoxicating compound of cannabis, which is responsible the euphoric “high”. CBD is a non-intoxicating constituent of cannabis. Terpenes are the third most prevalent compound in cannabis, these give cannabis its distinctive fragrance. Plants are selectively bred to produce particular THC/CBD ratios, and there are more than 200 medical strains currently available from licensed producers in Canada. Cannabis comes in many forms, including dried flower, processed oil, pharmaceutical grade pills and topical patches. Cannabis can be ingested by inhalation, orally, sublingually and topically. Each of these methods has its own rate of onset and duration of effects, and differences in the bioavailability of cannabinoids. Cannabinoids are absorbed into the blood, then rapidly distributed into the brain and other high perfusion tissues. They are then metabolized by CYP liver enzymes and eventually eliminated via feces or urine. All forms of cannabinoids work on the endocannabinoid system within the human body, which consists of a series of neuromodulators and their associated receptors located throughout the brain, peripheral nervous system and immune system. Benefits/Challenges: Cancer patients most frequently take cannabis to improve nausea and appetite, pain, stress and sleep, with 51% - 83% self-reporting a major benefit. The Canadian Cannabis Act (2018) provides access to cannabis for those over 18yrs via medical cannabis programs, prescription pharmaceuticals, pharmacies, provincial websites and retail storefronts. Despite widespread availability, there are multiple precautions and contraindications when considering taking cannabis. These include patient risk factors (e.g. schizophrenia, cardio-metabolic disorders, respiratory conditions), drug-on-drug interactions (e.g. anti-coagulants, statins, SSRIs), lifestyle risk factors (e.g. driving, working, travelling) and the development of a use disorder. Short term harms associated with cannabis use include impaired cognitive and motor function, tachycardia, anxiety and paranoia. Long term harms include impaired learning and memory and development of chronic bronchitis. Evidence-based guidelines are now available to lower the risks associated with taking cannabis. Impact/Outcomes Most RTs have little knowledge about the therapeutic use of cannabis by cancer patients, and <15% of patients receive any information about cannabis from their healthcare team. This leaves our patients exposed to cannabis myths and misrepresentations found during internet searches. Educational opportunities are urgently needed to provide RTs with information about the science of cannabis so they can support and advise their patients.

INTRODUCTION:Using patient demographics to tailor cancer patient education processes results in improved patient outcomes. However, there is little information on how to successfully tailor radiation therapy (RT) educational content and delivery. The aim of this quality improvement project was to describe the information preferences of a diverse group of patients undergoing RT and determine if different RT education processes were associated with certain patient demographics.MATERIALS AND METHODS:An educational needs assessment questionnaire, based on a validated tool, was offered to all patients undergoing RT on a single day. Questionnaire sections included demographics and questions regarding the importance of topics related to RT treatments, desired mode of information delivery, quantity of information, desired timing of information, and satisfaction with information received. Patients were also asked to answer qualitative questions focused on what was working well and what could be improved. Participants' responses were cohorted based on demographic groupings (age, gender, education level) and were tested for statistically significant differences and associations.RESULTS:130 patients completed the questionnaire. Compared to those over 60 years, more participants who were 50 - 59 years old thought the topics were 'very important' (96% vs 77%, p<0.001) and wanted a higher quantity of information about the topics (80% vs 66%, p<0.001). More participants over 70 years old preferred pamphlets compared to those less than 70 years (48% vs 30%, p<0.047) while more participants under 50 years old preferred one-on-one sessions compared to those older than 50 years (40% vs 25%, p<0.038). Fewer participants <50 years wanted information at their first meeting with the Radiation Oncologist compared to those older than 50 years (57% vs 73%, p<0.001). Compared to the male cohort, more female participants felt the information topics were more important (83% vs 74%, p<0.0001) and had more unmet education needs (29% vs 17%, p<0.001). Compared to those with post-secondary education, more participants with primary or high school education desired a higher quantity of information (76% vs 65%, p<0.001), preferred to receive that information using pamphlets (43% vs 32%, p=0.006) and wanted all the information at the first opportunity (81% vs 67%, p<0.001).CONCLUSIONS:This quality improvement project found that age, gender and education level influenced patient preferences for information quantity, delivery mode and timing of RT education. These findings are promising and support further evaluations to determine a more precise definition of the personal factors that could help to individualize our approach to educating patients receiving RT.

PURPOSE:The spine is the most common site of bone metastasis from cancer and can be divided into 5 locational subsections, varying in mobility. The purpose of this research was to determine if the mobility of the metastases-bearing vertebral segment influenced pre-treatment pain intensity or health-related quality of life (HR-QoL) for patients about to receive palliative radiation therapy for painful spine metastasis. METHODS:This study was a retrospective chart review of patients referred to the Palliative Radiation Oncology Program, about to receive radiation therapy for vertebral metastasis between January 2014 and June 2016. The main variables included patient-reported Edmonton Symptom Assessment Score pain intensity, the EQ-5D score for HR-QoL and the location of the vertebral metastasis (categorized using the SINS mobility score (mobile, junctional, semi-rigid, or rigid)). Various patient, disease and treatment characteristics were also collected, and entered into a multivariate analysis. RESULTS:The eligible sample included 196 patients. Spinal metastases were distributed with approximately equal frequency (~27%) between the junctional, mobile and semi-rigid spine segments. Rigid spine was the least common site for spinal metastases (19%). Patients with metastatic disease in the mobile spine regions experienced greater pre-treatment pain compared to patients with disease in junctional subsections (Odds Ratio [OR] 1.37; p0.012). No relationship between HR-QOL and spinal mobility was found. Multivariate analysis also revealed that spinal metastases from a primary lung diagnosis reported worse pre-treatment pain compared to those from genitourinary cancers (OR 1.15; p0.05). Only age significantly influenced HR-QoL (75-95yrs vs. 35-55yrs; p0.041). CONCLUSIONS:Patients referred to an RT clinic for the treatment of painful spinal metastases have a different distribution of disease throughout the spine compared to those referred for surgery or SBRT. Those with metastases in mobile spine segments were more likely to experience severe pre-treatment pain than those with metastases in junctional segments. Although further corroboration is needed, our results suggest that the mobility of the metastasis-bearing spinal section could be added to the existing list of predictors that aid clinicians in identifying patients that will benefit from closer follow-up or early intervention.

INTRODUCTION:Workplace violence (WPV) is defined as any act in which a person is abused, threatened, intimidated, or assaulted during their employment. Despite an absence of published evidence, radiation therapists (RTs) are considered a "low-risk" profession for WPV. The aim of this research was to determine the incidence, severity, and impact of WPV on RTs perpetrated by patients and/or their caregivers.MATERIALS AND METHODS:A cross-sectional online questionnaire, based on established components of WPV, was distributed via e-mail to all RTs in a large, urban cancer clinic. The questionnaire was divided into the five categories of WPV and asked about the frequency, severity, perpetrator, location, and impact of WPV.RESULTS:Seventy-eight responses were received from a department of 165 RTs (47% response rate). Fifty-nine RTs reported experiencing at least one verbal abuse event during their career. Twenty-five reported experiencing a verbal threat at least once, 46 reported at least one occasion of harassing behaviour, and 18 experienced a threatening action at least once. Five RTs reported suffering from at least one physical assault. The majority of this WPV took place on the treatment unit, with the patient as the perpetrator, and was not reported by the RT. High numbers of RTs reported suffering from stress (35), frustration (34), and anxiety (29) as a consequence of WPV.CONCLUSIONS:The close, longitudinal relationship between RTs and cancer patients puts RTs at considerable risk of experiencing multiple WPV events during their career. WPV is infrequently reported by RTs, perhaps linked to the belief that excellent patient care requires you to accept and excuse poor behaviour by patients. Prevention programs and de-escalation training are needed for RTs, but short-term measures such as shift or unit changes may prevent multiple WPV exposures which are associated with an increased risk of emotional and psychological sequelae.

Radiation therapy students enter their clinical practicum with the expectation to hit the ground running. However, transitioning from the didactic student-focused education setting to the fast pace patient-centred clinical environment may prove to be a challenge. Providing opportunities for students to consolidate their knowledge and experience through interprofessional (IP) knowledge sharing may assist in reducing the theory practice gap and redirecting focus to the patient.