PURPOSE:The goal of this study was to evaluate the image quality provided by a novel cone beam computed tomography (CBCT) platform (HyperSight, Varian Medical Systems), a platform with enhanced reconstruction algorithms as well as rapid acquisition times. Image quality was compared with both status quo CBCT for image guidance, and to fan beam CT (FBCT) acquired on a CT simulator (CTsim).METHODS AND MATERIALS:In a clinical study, 30 individuals were recruited for whom either deep inspiration (DIBH) or deep exhalation breath hold (DEBH) was used during imaging and radiation treatment of tumors involving liver, lung, breast, abdomen, chest wall, and pancreatic sites. All subjects were imaged during breath hold with CBCT on a standard image guidance platform (TrueBeam 2.7, Varian Medical Systems) and FBCT CT (CTsim, GE Optima). HyperSight imaging with both breath hold (HSBH) and free breathing (HSFB) was performed in a single session. The 4 image sets thus acquired were registered and compared using metrics quantifying artifact index, image nonuniformity, contrast, contrast-to-noise ratio, and difference of Hounsfield unit (HU) from CTsim.RESULTS:HSBH provided less severe artifacts compared with both HSFB and TrueBeam. The severity of artifacts in HSBH images was similar to that in CTsim images, with statistically similar artifact index values. CTsim provided the best image uniformity; however, HSBH provided improved uniformity compared with both HSFB and TrueBeam. CTsim demonstrated elevated contrast compared with HyperSight imaging, but both HSBH and HSFB imaging showed superior contrast-to-noise ratio characteristics compared with TrueBeam. The median HU difference of HSBH from CTsim was within 1 HU for muscle/fat tissue, 12 HU for bone, and 14 HU for lung.CONCLUSIONS:The HyperSight system provides 6-second CBCT acquisition with image artifacts that are significantly reduced compared with TrueBeam and comparable to those in CTsim FBCT imaging. HyperSight breath hold imaging was of higher quality compared with free breathing imaging on the same system. The median HU value in HyperSight breath hold imaging is within 15 HU of that in CTsim imaging for muscle, fat, bone, and lung tissue types, indicating the utility of image data for direct dose calculation in adaptive workflows.

Impact/Outcomes: By naming the discomfort that is typically experienced when placed in a team setting, power is returned to the individual and an opportunity is created for them to recognize when it is lacking.This awareness acts as a precursor to fostering psychological safety and allows for action to be taken. Development of an Online Adaptive radiation therapy framework on an Ethos treatment unitDave McAloney, Kenny Zhan, Natasha Macmaster Nova Scotia Health Aim: To develop an efficient adaptive therapy workflow at our local cancer center.Currently, there is no protocol for adaptive therapy at our center.Due to the complexity and multi-disciplinary approach to adaptive therapy, a specific model should be in place to guide practice.Adaptive therapy requires input from radiation therapists, dosimetrists, physicists, and radiation oncologists at the time of treatment delivery.Process: Due to the multidisciplinary nature of adaptive therapy, there will be overlapping scopes of practice during the treatment process.Our center is proposing that a radiation therapist with specialty training could critically review the automated segmentation and make changes, if required, to normal and target structures.Once the plan is developed by the Ethos treatment planning system (TPS), the therapist could be the one to review the adaptive plan and determine if it should be chosen over the scheduled treatment plan.Once the desired treatment plan is chosen, final treatment approval would be done by a medical physicist prior to treatment delivery.Benefits/Challenges: Adopting the proposed workflow as outlined above would reduce the workload required to deliver adaptive therapy.It would be difficult to facilitate physician availability during clinical hours for each treatment session.A specially trained therapist would work to develop the knowledge and clinical reasoning skills to become autonomous in making the proposed treatment decisions required to deliver adaptive therapy.Adaptive therapy is only feasible if the process becomes more efficient and streamlined.Reducing the number of staff required to deliver adaptive therapy and increasing their scope of practice is one feasible way to achieve this result.Impact/Outcomes: The goal at our cancer center would be to complete the adaptive planning process and treat within a 30-minute appointment.Ethos potentially allows this due to shorter image acquisition times, improved image quality and automated contouring and treatment planning processes.Adaptive therapy could now be clinically feasible due to decreased workload and staffing requirements.A radiation therapist with specialty training would be required to achieve these goals.

Aim: To assess the implementation of an electronic patient reported outcomes (ePRO) application across a multi-center radiation oncology department. Process: Dalhousie University's Department of Radiation Oncology (DRO) is composed of four radiotherapy (RT) centres (Halifax, Sydney, Saint John, Charlottetown) across three provinces. The implementation of ePRO across our centres has been made possible by several key events: In 2009, a Canadian Partnership Against Cancer (CPAC) grant enabled 2 centres to begin paper-based distress screening using the Canadian Problem Checklist (CPC) and Edmonton Symptom Assessment System (ESASr). In 2015, a PRO retreat included representatives from all 4 centres to devise an action plan for ePRO implementation. In 2017, Accreditation Canada mandated routine evaluation of patient outcomes and in 2019, three DRO centres were awarded CPAC funding to launch ePROs. The fourth centre now hopes to use lessons learned in order to facilitate their ePRO implementation. Within the ePRO application (Noona) Canadian Partnership for Quality Radiotherapy (CPQR)-endorsed PRO tools are used to capture patient responses including CPC, ESASr, and the Brief Pain Inventory (BPI). Needs assessments were conducted in the areas of human resource (e.g. administrative support) as well as staff and patient education. Clinic workflows were revised to include an ePRO assessment at consultation, first and last RT review as well as follow-up in clinic or remotely. Official roll-out began in November 2021 with a phased approach across centres and tumors sites to allow for stakeholder and user feedback and to facilitate continued project planning. Benefits/Chellenges: Multi-centre and multi-disciplinary collaboration has been a major enabler of this project with significant potential to expand our Department's clinical and research programs. While the challenge of coordinating such a large-scale initiative was aggravated by constantly changing pandemic restrictions, project priority was escalated across the institutions with recognition of the electronic platform as a powerful tool to assess patient distress/symptoms remotely. While implementation of an ePRO program has been feasible, it has also been complex. Approvals from Privacy Impact Assessments to IT architectural reviews were required. An advisory board was formed to facilitate multi-stakeholder feedback including patient representatives, project managers, clinical clerks, nurses, radiation therapists, radiation oncologists, industry representatives, IT and legal. The project has been dependent on support from cancer program leadership to front line staff. Given that implementation of an ePRO application has introduced change in clinic workflow, change management strategies have been required to obtain buy-in for a system that aims to ultimately improve the quality and efficiency of patient care. Impact / Outcomes: PROs capture the patient perspective on physical, emotional and practical impacts of treatment, with the literature showing benefits to include improved patient-provider communication, patient quality of life and even survival. Future evaluation of the program will hopefully confirm that uptake and efficiency of PROs improves with use of the electronic versus paper system. More importantly, we await data collection and analysis to determine whether our multiple RT centres see improved patient outcomes through use of ePROs.

Evidence-based practice is an expectation in healthcare. However, practicing in this manner is not always achievable. This can lead to gaps between what is known to be best practice and what is actually done. Tobacco cessation in cancer care is a good example of this kind of gap. Tobacco use can render treatment less effective and can have a negative impact on outcomes. Despite this knowledge, many patients continue to use tobacco after their diagnosis and during treatment. Knowledge to Action (KTA) frameworks are beneficial in closing knowledge gaps by aiding in implementing and sustaining evidence-based practices and policies. It is the goal of this study to identify the barriers to tobacco cessation within the local context of this center and use this information in conjunction with a KTA framework to form a successful and sustainable tobacco cessation model. Radiation oncologists, radiation therapists, and radiation oncology nurses were invited to participate in uniprofessional focus groups and semi-structured interviews. Questions regarding barriers to providing cessation support were used to help guide the discussions. Audio recordings were taken of each group and interview and transcribed verbatim. These transcripts were analyzed by a coding process which was utilized to identify themes within the data. Information gathered from a local tobacco cessation working group and a review of tobacco cessation processes in neighbouring provinces was used to support the data from this study. Insufficient recourses and unclear roles and responsibilities were the main themes identified in the data by all three professional groups. Data from the provincial working group and neighbouring centers showed a large variation in tobacco cessation practices. The consequences of continued tobacco use during cancer treatment highlights the need for a tobacco cessation model within our department. Identifying the barriers to tobacco cessation within the context of this center and applying the information to a knowledge to action framework outlined a plan for the development of a tobacco cessation model. This framework also outlined methods to evaluate this model, monitor its use, and propose ways to ensure its sustainability. The goal of this process is to ensure that our patients are receiving care based on the best available evidence.

participants completed a survey and results were analyzed using thematic analysis to develop the educational outreach intervention.The educational outreach intervention was completed from October 2018 to January 2019 with inter-professional palliative healthcare teams.All participants completed a survey and results were analyzed using descriptive statistics to evaluate the impact of the educational outreach intervention. Results:A total of 78 survey responses were analyzed for the needs assessment.Thematic analysis informed content of the educational outreach intervention and included: how to access rapid response PRT, common indications for PRT, case studies, and management of side effects after completion of radiotherapy.A total of 131 survey responses were analyzed following the educational outreach intervention.Although only 22.9% of participants had previously recommended or referred patients for PRT, 96.2% of participants agree or strongly agree that they are likely to recommend or refer patients for PRT in the future. Conclusions:The educational outreach intervention improved knowledge and the likelihood of interprofessional palliative healthcare teams accessing PRT for patients in the community.As a future direction, ongoing monitoring of radiotherapy referrals from the community could provide insight regarding the impact of the educational outreach intervention on local PRT utilization rates.

Radiation therapy is a field filled with rapidly advancing technology that allows us to treat patients more precisely and efficiently. While these changes are necessary and important, we need to remember that patients do not see all the behind the scenes advancements and technology. For them, it can be the smiling face that greets them in the waiting room, the warm blanket, the reassuring touch or words, and many other simple things that can make all the difference in their treatment experience. This may be especially true for those patients requiring an immobilization mask for treatment or for the pediatric population who may be too young to fully understand what treatment entails. The latter is what sparked the beginning of our mask decorating program. The concept of customizing and decorating masks is not new to the field by any means—for us, inspiration was taken from processes used in other clinics. It started small, a few details here and there, then the idea was brought forward to make a sample mask to show patients at the time of CT simulation. Then the requests started pouring in, and we have not looked back. What we have noted from the patient's reactions and comments is that customizing the mask gives them something to look forward to when they come for treatment. It takes their mind off of what they are going through, and gives them a small sense of control over their treatment process. For the therapists, it is very rewarding to see the reactions of patients when they see their masks for the first time and to see what a difference such a small gesture can make. The following story truly reflects the power of "the little things." A request was received to decorate a mask for a pediatric patient in the style of wrestler Rey Mysterio's mask. When the patient arrived for treatment, they were thrilled with how it turned out and the patient's family asked to take some photos of the patient in the mask. These photos were shared with family members, and one family member shared a photo on social media. This was then shared again and again, and the photo and story eventually reached the wrestler himself. Rey Mysterio then reached out and contacted the patient directly, a dream come true for the patient. Rey then proceeded to send gifts to the patient, one of which being an actual wrestling mask to match the one we made for treatment. He made regular phone calls to check up on the patient during treatment, and has since continued to stay in touch with the patient to follow his progress. For the patient and their family, this was beyond what they could have expected and they have expressed such gratitude and stated what a difference this made in the treatment experience. While the above experience is not the norm, the overall feedback has been that this small gesture has appeared to have helped in reducing anxiety and stress related to treatment for patients and, in some cases, their families as well. It is something we are extremely proud of and hope to continue and expand on in the future. Natasha McMaster MRT(T) is a Radiation Therapist at the Nova Scotia Cancer Centre, Halifax, Nova Scotia. Natasha graduated from the University of Toronto/The Michener Institute in 2007 with a BSc in Radiation Therapy. Since then, she has worked as a Radiation Therapist in Halifax and is currently undertaking her Masters in Radiation Therapy through the University of Toronto. Natasha's main interests lie in imaging, SBRT technique, and the pediatric patient population. Jennifer DeGiobbi MRT(T) is a Radiation Therapist at the Nova Scotia Cancer Centre in Halifax, Nova Scotia. Jennifer graduated from Cape Breton University with a BSc (concentration in Biology) in 2005 and completed her education at the University of Toronto with a BSc in Medical Radiation Sciences and The Michener Institute with a diploma in Radiation Therapy in 2010. She began her career at the Ottawa Hospital Cancer Centre where she worked for 2 years before moving back to her home province. Currently in Halifax, Jennifer is a team lead on a Linear Accelerator that specializes in Total Marrow Irradiation and has helped with its technique and policy development. Jennifer's creativity, along with her desire to bring a smile to patient's faces, was the driving force behind the collaborative effort in initiating the Pediatric Mask Design program at the Nova Scotia Cancer Centre.