Real-time magnetic resonance (MR) guidance during brachytherapy (MRgBT) offers superior soft tissue definition and precise target identification during catheter implantation while minimizing treatment-related complications. This report reviewed the use of MRgBT in a series of complex clinical situations where brachytherapy would have been impossible without MR guidance, and alternate treatment modalities would have involved potentially significant morbidity to the patients. We highlighted the safety and efficacy of MRgBT in controlling targetable disease in a specific group of patients without precluding the ability to go for subsequent treatment options when indicated.

BACKGROUND:Advanced practice radiation therapist (APRT) roles have expanded internationally to address cancer workforce shortages and improve service delivery. A Canadian consensus process previously established 20 standardized APRT clinical activities across five themes. This study evaluated the international applicability of these activities through expert consensus to establish a global framework for APRT practice. METHODS AND MATERIALS:A systematic three-round international Delphi consensus study was conducted following established quality framework recommendations. Expert panel members were recruited from an international Community of Practice using objective selection criteria ensuring recognized APRT expertise and diverse geographical representation. Participant anonymity was maintained throughout all rounds. Controlled feedback provided quantitative results and anonymized qualitative comments between rounds. Consensus threshold was defined a priori at 80% agreement, and activities were evaluated for inclusion in international APRT scope of practice across five themes: patient interactions, multidisciplinary consultation, virtual consultation, resource optimization, and technical activities. RESULTS:Twenty-three international experts were invited to take part in the study with response rates of 81% (Round 1), 89% (Round 2), and 89% (Round 3). Twenty clinical activities were systematically evaluated. Five activities achieved immediate Round 1 consensus: Planning Consultation (83%), Multidisciplinary Pre-treatment Consultation (83%), Care Coordination (96%), Patient Navigation (87%), and Technical Consultation (87%). Following iterative three-round evaluation, 16 of 20 activities (80%) achieved final international consensus for APRT practice inclusion. Four activities failed to reach consensus: Patient Education/Informed Consent (75%), Follow-up Consultation (78%), Clinical Examination (78%), and MR Applicator Assessment (65%). The validated framework demonstrates substantial global alignment while identifying specific jurisdictional variations in advanced practice acceptance. CONCLUSIONS:This study establishes international consensus on core APRT clinical activities, providing evidence-based foundations for standardized global APRT role development and implementation. These findings support healthcare systems in addressing workforce challenges through validated advanced practice frameworks while maintaining quality cancer care delivery.

Purpose This series reviews real-time MRI-guided brachytherapy (MRgBT) in complex clinical scenarios where conventional brachytherapy was not feasible, and alternative treatments carried high morbidity. Materials & Methods Procedures were done in a MRgBT suite equipped with custom-integrated closed-bore MRI, C-arm, and a remote afterloader. Patients were under general anesthesia, positioned feet-first on a flat-topped MR couch, and immobilized with a custom leg strap. A transabdominal or endorectal coil with an HDR (High dose rate) template was used for guidance. MR scans were acquired to assess disease extent, and a 3.5-mm spaced grid template was fused with images. Proton density-weighted imaging verified catheter placement, followed by T2-weighted axial scans for planning. Target volumes were contoured in RayStation. Finalized contours were imported into the treatment planning system, inverse optimization was performed and treatment was delivered. Results Prostate 1. A 71-year-old man with prior pelvic External Beam Radiation (EBRT) and abdominoperineal resection for rectal cancer 26 years back developed intermediate-risk prostate cancer. Surgery was high-risk, so he received MRgBT boost with 14 catheters (15 Gy/1 Fr HDR, Transrectal Ultrasound was not feasible due to absent rectum) + EBRT to the prostate (46 Gy in 23 Fr), which was well tolerated. 2. A 68-year-old man with prior LDR (Low Dose Rate) brachytherapy developed a mesorectal recurrence after 6 years. MRgBT with 4 catheters (18 Gy and 15 Gy in 2 weekly Fr) initially controlled PSA levels, but the disease later progressed to bone metastases. Sarcoma 3. A 42-year-old man with pelvic myxoid liposarcoma had a para coccygeal recurrence 3 years post-surgery/RT (50Gy in 25 fractions). He declined salvage surgery, so MRgBT (12 Gy/1 Fr with 4 interstitial catheters) with + EBRT (30 Gy/15 Fr) was delivered. He has complete disease regression at 7 years, with minimal toxicity (Figure 1a,b and c). Bladder 4. A 69-year-old woman with muscle-invasive bladder cancer had a positive urethral margin post-cysto-hysterectomy. She received post op MRgBT (7 Gy* 3 fr with vaginal cylinder and 6 interstitial catheters) + adjuvant chemotherapy. She has been disease-free for 8 years with no toxicities. 5. A 77-year-old man with ypT2N0 bladder cancer had malignant cells in urine cytology one year after surgery but no imaging evidence of recurrence. Salvage MRgBT (15 Gy/1 fr) to the urethral stump delivered through a single catheter+ EBRT (37.5 Gy/15 fractions) was given. Persistent positive cytology after treatment was resolved with BCG therapy. Anal Cancer 6. A 68-year-old man treated with chemoradiation (57.6 Gy / 32 fr with concurrent chemo) for T2N0 anal cancer developed periaortic mets (managed with EBRT) and subsequent mesorectal recurrence. MRgBT (7 Gy x 3) controlled the mesorectal nodule initially, but it later progressed, leading to salvage APR. He now has an unresectable presacral lesion, with MRgBT or SBRT under consideration. Conclusion MRgBT enables precise, dose-escalated treatments where conventional brachytherapy and EBRT are limited due to technical challenges, prior RT, or large treatment volumes. Half of the treated cases recurred, emphasizing the need for careful patient selection. No patients experienced grade 3 or higher toxicities. Its safety, tolerability, and efficacy in controlling targeted disease can be used to maximum advantage with proper patient selection and realistic expectations of outcomes.1a. MRI with catheters in situ, 1b. EBRT dose distribution, 1c. Resolution of the mass (red arrow)

BACKGROUND:In November 2021, the highly transmissible Omicron BA.2 variant led to a surge in demand for COVID-19 testing within Ontario's cancer care system, overwhelming established testing clinics and delaying radiation therapy (RT) start dates. To address this, a small team of Radiation Therapists (RTTs) was trained to conduct nasopharyngeal swabs (NPS) on the same day as CT simulation for eligible patients. METHODS:This single-centre quality improvement project, approved by the institution, involved collecting data on patient demographics, RTT swab clinic throughput, and test outcomes via a retrospective chart review. An online questionnaire gathered insights from RTTs about their experiences, and training procedures were documented. RESULTS:An urgent medical delegation was obtained from the hospital's Office of Medical Directives, and eight RTTs were trained to perform NPS. Over 4.5 months, 402 new RT patients were swabbed. The positivity rate for asymptomatic patients was 2%. None of the patients with negative NPS results developed symptoms or tested positive during the Omicron incubation period. Initiation of the RTT swab clinic significantly reduced the decision-to-treat to treat time (p = 0.01). All involved RTTs felt the initiative enhanced patient and staff safety. CONCLUSIONS:RTTs successfully and safely performed NPS on the same day as CT simulation, helping identify asymptomatic COVID-19 patients before starting RT. This approach minimized exposures to asymptomatic cases, prevented treatment delays, and reduced the radiobiological risks associated with COVID-related RT interruptions.

PURPOSE:Magnetic resonance image-guided brachytherapy (MRgBT) is the gold-standard treatment for cervical cancer. This study examined workflow times in an integrated MRgBT suite and conventional operating room (OR), and factors contributing to intraoperative efficiency. METHODS AND MATERIALS:Consecutive patients with FIGO stage IB-IVA cervical cancer who underwent MRgBT procedures between 2019-2022 were retrospectively reviewed. Workflow times were collected: applicator insertion, MR-imaging, contouring, treatment planning, treatment execution and total procedure time. Procedure durations between applicators and over time were compared. RESULTS:The 161 patients included in this study underwent 267 procedures in the MRgBT suite, and 56 procedures in the OR using ovoid and tandem applicator (O&T, 46%), ring and tandem (R&T, 28%), or Syed-Neblett template (Template, 27%). The median duration (minutes) of each step was: general anesthesia induction (18), applicator insertion (31), MR-imaging (28), parallel contouring (48) and applicator/needle registration & treatment plan optimization (83), and treatment execution (19). Total procedure time was much longer in the OR (488 minutes) than MRgBT suite (205 minutes). Template cases were significantly longer in insertion, MR-imaging, contouring, planning and total procedure time (by 52 minutes) compared with those using the R&T/O&T applicators (p<0.001). Total procedure time for Template cases reduced by 10 minutes/year since 2019 (p<0.001). Regardless of applicator type, total procedure time for subsequent insertions was 21 minutes less than the first (p<0.001). CONCLUSIONS:MRgBT procedure time was longer for Syed-Neblett template cases, but shorter in subsequent insertions. The overall procedure time was much shorter in the integrated MRgBT suite than conventional OR.

Purpose: Advanced practice (AP) in radiation therapy (RT) is being implemented around the globe. In an effort to advance the understanding of the similarities and differences in APRT roles in Ontario, Canada, a community of practice (CoP) sought ways to provide quantitative data on the nature of APRT clinical activities and the frequency with which these activities were being executed. Methods: In 2017, a consensus building project involving 20 APRTs and 14 radiation therapy (RT) department managers in Ontario was completed to establish a mechanism to quantify APRTs’ clinical impact. In Round 1 & 2, expert feedback was gathered to generate an Advanced Practice (AP) Activity List. In Round 3: 20 APRTs completed an online survey to assess the importance and applicability of each AP Activity to their role using Likert scale (0–5). A final AP Activity List & Definitions was generated. Results & discussion: Round 1: Forty-seven AP activities were identified. Round 2: 3/14 RT managers provided 145 feedback statements on Round 1 AP Activity List. The working group used RT managers’ feedback to clarify AP activities and definitions, specifically merging 33 unique AP activities to create 11 inclusive AP activities and eliminating 8 activities identified from Round 1. The most inclusive AP activity created was #1 New Patient Consultation, this AP Activity is merged from 7 unique AP activities. Incorporating RT managers’ feedback with the internal AP clinical workload lists from 2 Ontario cancer centres resulted in a revised AP Activity List with 20 AP inclusive activities. Round 3: 14/20 APRTs provided Likert scores on this revised list. The most applicable AP activities (mean score) were #16 Technical Consultation (4.0), #15 Contouring Target Volume (3.8) and #2 Planning Consultation (3.8); the least applicable was #18 MR Applicator Assessment (0.9). Conclusions: This is the first systematic attempt to build consensus on AP clinical activities. Non-clinical APRT activities related to research, education, innovation, and program development were not in the scope of this project. The Final AP Activity List & Definitions serves as a framework that allows standardized and continuous monitoring of AP clinical activities and impact.

PurposeClinical specialist radiation therapist (CSRT) is the title assigned to a radiation therapist practicing in an advanced capacity with advanced knowledge, skills and judgement and is used synonymously with Advanced Practice Radiation Therapist (APRT) in Ontario. CSRTs formed a Community of Practice (CoP) and a working group (WG) to develop a standardized Advanced Practice (AP) Activity List (APAL) to measure the clinical impact of CSRTs. The list was translated into 20 codes integrated into radiation therapy electronic medical record (RT-EMR) systems (2019). This report will share the WG learnings from the first 2 years of using APAL including AP activities as captured by codes to evaluate the CSRT AP clinical workload and any trends within and across CSRT roles.MethodologyAll CSRTs (n = 22) were invited to capture AP codes quarterly related to patient interactions throughout 2021 to 2022 via a secured online shared drive. Data analysis was completed by the CoP WG. In addition, in Q1 2023, the WG circulated an e-survey to all CSRTs to evaluate AP codes and descriptions and to identify any barriers to code capture.ResultsSeventeen CSRTs (9 palliative, 2 breast, 2 head & neck, 2 Stereotactic body radiotherapy (SBRT), 1 adaptive and 1 brachytherapy) from 8 of 11 cancer centres submitted AP codes at least once. Total number of AP codes submitted was 21600 (11167 in 2021, 10433 in 2022). The top 5 AP codes captured by CSRTs were Care Coordination (14%), Contouring Target Volumes (13%), Patient Navigation (11%), Patient Education (11%) and New Patient Consultation (10%). Palliative CSRTs submitted the majority of AP codes (89%). Care Coordination was the most captured AP code by palliative, breast and brachytherapy CSRTs. Critical Image Assessment & Approval was the most captured AP code captured by head & neck, SBRT and adaptive CSRTs. Eighteen of 25(72%) CSRTs completed the e-survey evaluation. CSRTs identified RT-EMR setup, ambiguity in AP code description, difficulty in distinguishing AP versus regular radiation therapy activities and lack of incentive as barriers to data collection. The biggest challenge is encouraging the uptake of the coding process. As AP code captures declined from 2021 to 2022, strategies to reinforce the value of data collection need to be implemented to ensure that code reporting increases going forward.ConclusionsThis is the first systematic attempt to quantify AP clinical activities performed by APRTs and there is much to be learned from the data collected. As this list only records patient-related AP activities, non-clinical AP workload codes for research, education and program evaluation/development must be developed and added to the APAL. In addition, efforts will be made to test the generalizability of the activity list beyond Ontario.

INTRODUCTION:Advanced radiotherapy practice (APRT) has been growing in several jurisdictions around the world.Outputs and publications from the different countries demonstrate the positive impacts of these roles on the local delivery of radiotherapy care.Until recently, that work and growth was conducted within countries and often focused solely on individual roles.Much of the existing data examines local perspectives and may not be generalizable to other jurisdictions.The Advanced Practice Radiation Therapy International Community of Practice (APRT iCoP) was established in September 2021 to provide a platform for international collaborations, to overcome the silo-effect of previous work.METHODS: At the Leading the Way in Radiotherapy Advanced Practice (LTWRAP) 2018 conference, there was significant interest that led to an initial call for membership.Due to the timing of the Covid-19 pandemic, this initiative was delayed until August 2021, when another call for members took place via email.This was distributed to several local, provincial and international contacts.Through these various networks of advanced practitioners, the group is continuing to grow with new members.An online platform was built to communicate and disseminate information, and a social media account was created to connect the iCoP with the broader radiation therapy community.RESULTS: An inaugural virtual meeting was held on Sept 24, 2021.Presently, the APRT iCoP is comprised of 55 members from 15 different countries.Since that time, Terms of Reference have been written and approved.The APRT iCoP objectives have been defined as (i) Advocacy -to work with our external stakeholder to affirm and promote role identity to influence increasing utilization in the cancer care system, and (ii) Collaboration -providing an accessible mechanism for sharing knowledge, advancing roles, and providing mentorship.To date, four full group meetings have taken place, resulting in the formation of several smaller working groups.Current areas of activity include development of an international set of codes to capture APRTs' clinical workload, development of an international definition for Advanced Practice Radiation Therapists, mentorship for jurisdictions developing and implementing new APRT roles, as well as establishment of an APRT podcast series.A quarterly iCoP podcast series has also been initiated to showcase excellent and innovative APRT initiatives and activities.CONCLUSION: The APRT iCoP was formed in an effort to bring together the global community of advanced practitioners in radiation therapy and related experts to learn about and promote APRT through collaborative works.These international, multi-centre partnerships have the potential to accelerate the gathering of evidence about how APRT can improve the quality and safety of radiation therapy delivery and patient care, ensure a consistent and standard interpretation of what constitutes advanced radiation therapy practice, and enable us to improve global access to safe and high quality radiation therapy treatment more effectively and efficiently.

Purpose:The COVID pandemic has impacted radiotherapy (RT) workflow, including brachytherapy (BT).BT is an integral part of RT, many BT procedures require the support of general anesthesia and are considered aerosol generating medical procedures (AGMPs).During COVID pandemic, AGMPs required additional infection control precautions.This work summarized the impact of the COVID-19 pandemic on the BT program in two distinct cancer centres, located in Ontario, Canada.Methods: The study period was March 1 to July 31, 2020, the 'first wave' of pandemic.The two centres are 73 km apart and located in a city with population of 2.79 million (Centre 1) and 0.7 million (Centre 2) respectively.BT services offered by these centres were high-dose-rate (HDR) treatments to postoperative endometrial cancers (Centre 1&2), cervix cancer (Centre 1), prostate cancer (Centre 1), lung cancer (Centre 2), esophagus cancer (Centre 2) and low-dose-rate (LDR) treatments to prostate cancer (Centre 1) and ocular cancer (Centre 1).A retrospective program audit was conducted as part of a quality assurance project.Data sources were identified by the BT Clinical Specialist Radiation Therapist (CSRT) in each centre using the radiation therapy electronic medical records (RT-EMR) system, electronic medical records and departmental reports, policies and procedures.Results: COVID impact on BT services and workflow were recorded.BT SER-VICES: Both centres continued to treat non-AGMP for post-operative endometrial cancer patients.However, BT services for AGMP procedures were on hold: LDR and HDR prostate treatments (Centre 1), HDR lung and esophagus treatments (Centre 2).The lung and esophagus cancer patient group had the most impact as patient were offered non-BT treatments for symptoms relieve.WORKFLOW: both centres implemented virtual care strategies for review and follow up appointments where telephone consultation were used.Both centres had a 'no visitor' policy in their hospital.Both centres adopted a "size and treat" strategy for non-AGMP HDR treatment to the vaginal vault.The strategy was implemented to eliminate one hospital visit required by post-operative endometrial cancer patients.Both centres used appropriate personal protective equipment (PPE) to reduce occupational exposure to staff.For AGMP (Centre 1), there is a change in anesthesia workflow where only anesthesia staff remained in the BT procedure room with doors closed during intubation and extubation.At the end of the procedure, the doors were closed for 30 minutes to allow sufficient room air exchange.Centre 1 and 2 had differences in asymptomatic COVID screening & test requirement for AGMP and non-AMGP. Conclusion:The centres were marginally different in their approaches to adjusting their BT workflows in AGMP and non-AGMP procedures.BT treatments that are considered high-risk AGMP and low-risk cancer were on hold temporarily.Both BT program delivered treatment to most patients with minimal delays and cancellations.

In a universal health care system, SES (residential instability and material deprivation) were associated with the increased risk of ED within 90 days of RT. Proactive care and virtual monitoring during the 90-day period after RT in high-risk patients may reduce ED visits. ED visits beyond our tertiary institution are being gathered to address this study limitation.

Introduction: Most brachytherapy (BT) procedures require general anesthesia and are therefore considered aerosol generating medical pro-cedures (AGMPs). The COVID-19 pandemic impacted BT as services were prioritized by balancing the harm associated with COVID-19 in-fection versus the effect of delay of potentially curative treatment. This article summarizes the impact of the pandemic on BT programs in two cancer centers in a Canadian province.Methods: As part of a quality assurance project, a retrospective study was conducted for the first five months of the pandemic (March 1 to July 31, 2020). Chart review and COVID-19 related mitigation strategies were identified by BT Clinical Specialist Radiation Thera-pists (bCSRT) in each center using electronic medical records, depart-mental reports, policies and procedures.Results: Impact included start of virtual care (VC), shortened frac-tionation, suspension of services and workflow changes. Both centers implemented VC strategies to reduce clinic visits: "same-day size and treat" strategy for post-operative endometrial cancer patients and vir-tual patient education for all patients. BT services that were suspended were low-dose-rate and high-dose-rate (HDR) prostate treatments (Center 1), lung and esophagus HDR treatments (Center 2). Work-flow changes that affected staff and patients in both centers included COVID-19 screening and the use of personal protective equipment. The centers were marginally different in workflow adjustments for AGMP procedures. Those considered high-risk AGMP and low-risk cancer were suspended temporarily with alternate treatment strategies sought for some patients. Others had temporizing treatment such as androgen deprivation therapy to facilitate oncological safe deferral of procedures.Conclusion: Both BT programs delivered treatment to most patients with minimal delays and cancellations, where feasible. Some of the pandemic workflow changes continued to the current state of the pan-demic. Long-term follow-up is needed to assess the impact of COVID-19 and treatment interruptions on oncologic outcomes.

regional and national level and further understanding of funding and investment processes to support national education and training activities.A strong element of peer support based on inclusive and compassionate leadership traits was noted to be a strong motivating factor.The radiography clinical fellows reported mentorship from senior leaders was instrumental in increasing their confidence and self-efficacy of leadership.CONCLUSION: The radiography clinical fellows provided valuable subject matter expertise to support several national projects around the upskilling of radiographers.The secondment opportunity improved their confidence and knowledge around strategic leadership through both experiential learning and planned developmental activities.The

PURPOSE: To demonstrate the feasibility of treating cervical cancer patients with MRI-guided brachytherapy (MRgBT) using 24 Gy in 3 fractions (F) versus a standard, more resource-intensive regimen of 28 Gy in 4F, and its ability to meet EMBRACE II planning aims. METHODS AND MATERIALS: A retrospective review of 224 patients with FIGO Stage IB- IVA cervical cancer treated with 28 Gy/4F ( n = 91) and 24 Gy/3F ( n = 133) MRgBT between 2016-2021 was conducted. Multivariable linear regression models were fitted to compare dosi-metric parameters between the two groups, adjusting for CTVHR and T stage.RESULTS: Most patients had squamous cell carcinoma, T2b disease, and were treated with intracavitary applicator plus interstitial needles (96%). The 28 Gy/4F group had higher CTVo (median 28 vs. 26 cm3, p = 0.04), CTVIR D 98% (mean 65.5 vs. 64.5 Gy, p = 0.03), rectum D2cm3 (mean 61.7 vs. 59.2 Gy, p = 0.04) and bladder D2cm3 (81.3 vs. 77.9 Gy, p = 0.03). There were no significant differences in the proportion of patients meeting the EMBRACE II OAR dose constraints and planning aims, except fewer patients treated with 28 Gy/4F met rectum D2cm3 < 65 Gy (73 vs. 85%, p = 0.027) and ICRU rectovaginal point < 65 Gy (65 vs. 84%, p = 0.005).CONCLUSIONS: Cervical cancer patients treated with 24 Gy/3F MRgBT had comparable target doses and lower OAR doses compared to those treated with 28 Gy/4F. A less-resource intense fractionation schedule of 24 Gy/3F is an alternative to 28 Gy/4F in cervix MRgBT. (c) 2022 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

Purposes: Communities of Practice (CoP) group people of common concerns & problems to deepen their knowledge by interacting on an ongoing basis. In 2015 the clinical specialist radiation therapists (CSRTs) in Ontario formed a CoP with Ontario Health (formerly Cancer Care Ontario) to promote knowledge creation & exchange, ultimately to sustain these advanced practice (AP) positions. The CoP formed a working group (WG) to develop a standard AP code set aimed to measure AP clinical and technical work carried out by all CSRTs in their respective cancer centers. This AP code set is aligned with the National Hospital Productivity Improvement Program (NHPIP) code system, which is a listing of radiotherapy procedures & activities with their respective measures of output (workload). Lessons learned in the development, implementation & feasibility of using this AP code set will be presented. Methods: In 2016, the WG compiled a list of codes from all CSRTs that captured AP activities and aligned with NHPIP code system. The initial list (47 codes) was sent to radiation therapy department managers in Ontario for comment. The WG incorporated their feedback to finalize an AP code set (20 codes) in 5 CSRT core competency categories: patient interactions, multi-disciplinary consult, virtual consultation, resource optimization and technical activities. In 2018, the codes & descriptions were finalized by all CSRTs. In 2019, clinical application specialists (CAS) in each Ontario centre incorporated the AP code set to their radiation therapy electronic medical record (RT-EMR) system for implementation. In 2020, all CSRTs were asked to capture codes for each patient interaction in two data collection periods: January–March and April–June. Results: During AP code set development, the WG experienced the most difficulty in differentiating between AP versus standard radiation therapy or administrative activities. During data collection, CSRTs experienced inconsistencies in code interpretation between cancer centres, specifically related to prescriptions with multiple target volumes and virtual consultations. Some CSRTs also felt that the duration of each activity/code needs to be assigned. In this pilot, 15 of 22 (68%) CSRTs submitted data, including 8 palliative, 2 head & neck, 2 breast, and 1 of each brachytherapy, stereotactic radiotherapy and image-guided adaptive CSRTs from eight of ten centres in Ontario. All codes were used at least once. CSRTs that have a clinical component to their roles captured more codes in the patient interaction and technical categories. Barriers to data collection included a delay due to RT-EMR upgrade and CSRTs not having the capacity to capture AP codes. Conclusions: As the CSRT Project Series concluded and the CSRT positions continued, it is crucial to continuously monitor CSRT impacts. A standardized AP code set enables workload measurement and streamlining of CSRT roles in different cancer centres. More consistent data collection is needed in the future so that individual CSRTs can understand their roles over time. This also allows local and provincial leadership to assess impact and contribution to the health care system and to make informed decisions on future strategic plans.