Introduction/Background . Despite growing interest in magnetic resonance imaging (MRI), integration in external beam radiotherapy (EBRT) treatment planning uptake varies globally. In order to understand the current international landscape of MRI in EBRT a survey has been performed in 11 countries. This work reports on differences and common themes identified. Methods . A multi-disciplinary Institute of Physics and Engineering in Medicine working party modified a survey previously used in the UK to understand current practice using MRI for EBRT treatment planning, investigate how MRI is currently used and managed as well as identify knowledge gaps. It was distributed electronically within 11 countries: Australia, Belgium, Denmark, Finland, France, Italy, the Netherlands, New Zealand, Sweden, the UK and the USA. Results . The survey response rate within the USA was <1% and hence these results omitted from the analysis. In the other 10 countries the survey had a median response rate of 77% per country. Direct MRI access, defined as either having a dedicated MRI scanner for radiotherapy (RT) or access to a radiology MRI scanner, varied between countries. France, Italy and the UK reported the lowest direct MRI access rates and all other countries reported direct access in ≥82% of centres. Whilst ≥83% of centres in Denmark and Sweden reported having dedicated MRI scanners for EBRT, all other countries reported ≤29%. Anatomical sites receiving MRI for EBRT varied between countries with brain, prostate, head and neck being most common. Commissioning and QA of image registration and MRI scanners varied greatly, as did MRI sequences performed, staffing models and training given to different staff groups. The lack of financial reimbursement for MR was a consistent barrier for MRI implementation for RT for all countries and MR access was a reported important barrier for all countries except Sweden and Denmark. Conclusion . No country has a comprehensive approach for MR in EBRT adoption and financial barriers are present worldwide. Variations between countries in practice, equipment, staffing models, training, QA and MRI sequences have been identified, and are likely to be due to differences in funding as well as a lack of consensus or guidelines in the literature. Access to dedicated MR for EBRT is limited in all but Sweden and Denmark, but in all countries there are financial challenges with ongoing per patient costs. Despite these challenges, significant interest exists in increasing MR guided EBRT planning over the next 5 years.

Background and purpose: Magnetic Resonance Imaging (MRI) is increasingly being used in radiotherapy (RT). However, geometric distortions are a known challenge of using MRI in RT. The aim of this study was to demonstrate feasibility of a national audit of MRI geometric distortions. This was achieved by assessing large field of view (FOV) MRI distortions on a number of scanners used clinically for RT. Materials and methods: MRI scans of a large FOV MRI geometric distortion phantom were acquired on 11 MRI scanners that are used clinically for RT in the UK. The mean and maximum distortions and variance between scanners were reported at different distances from the isocentre. Results: For a small FOV representing a brain (100–150 mm from isocentre) all distortions were < 2 mm except for the maximum distortion of one scanner. For a large FOV representing a head and neck/pelvis (200–250 mm from isocentre) mean distortions were < 2 mm except for one scanner, maximum distortions were > 10 mm in some cases. The variance between scanners was low and was found to increase with distance from isocentre. Conclusions: This study demonstrated feasibility of the technique to be repeated in a country wide geometric distortion audit of all MRI scanners used clinically for RT. Recommendations were made for performing such an audit and how to derive acceptable limits of distortion in such an audit.

The benefits of integrating MRI into the radiotherapy pathway are well published, however there is little consensus in guidance on how to commission or implement its use. With a view to developing consensus guidelines for the use of MRI in external beam radiotherapy (EBRT) treatment planning in the UK, a survey was undertaken by an Institute of Physics and Engineering in Medicine (IPEM) working-party to assess the current landscape of MRI use in EBRT in the UK. A multi-disciplinary working-party developed a survey to understand current practice using MRI for EBRT treatment planning; investigate how MRI is currently used and managed; and identify knowledge gaps.The survey was distributed electronically to radiotherapy service managers and physics leads in 71 UK radiotherapy (RT) departments (all NHS and private groups). The survey response rate was 87% overall, with 89% of NHS and 75% of private centres responding. All responding centres include EBRT in some RT pathways: 94% using Picture Archiving and Communication System (PACS) images potentially acquired without any input from RT departments, and 69% had some form of MRI access for planning EBRT. Most centres reporting direct access use a radiology scanner within the same hospital in dedicated (26%) or non-dedicated (52%) RT scanning sessions. Only two centres reported having dedicated RT MRI scanners in the UK, lower than reported in other countries. Six percent of radiotherapy patients in England (data not publically available outside of England) have MRI as part of their treatment, which again is lower than reported elsewhere. Although a substantial number of centres acquire MRI scans for treatment planning purposes, most centres acquire less than five patient scans per month for each treatment site. Commissioning and quality assurance of both image registration and MRI scanners was found to be variable across the UK. In addition, staffing models and training given to different staff groups varied considerably across the UK, reflecting the current lack of national guidelines. The primary barriers reported to MRI implementation in EBRT planning included costs (e.g. lack of a national tariff for planning MRI), lack of MRI access and/or capacity within hospitals. Despite these challenges, significant interest remains in increasing MRI-assisted EBRT planning over the next five years.

To demonstrate how advancing the role of the Radiographer in vaginal vault HDR (high dose rate) brachytherapy can lead to a streamlined patient pathway and improved patient experience. In 2015, 48 patients were treated with vaginal vault brachytherapy treatment at St Thomas’ Hospital. This equated to 163 individual applicator insertions and treatments delivered over a course of either 2, 3 or 4 fractions. This was either as a primary treatment or boost following external beam radiotherapy. Historically the role of inserting vaginal applicators has been that of the Clinical Oncologist, the planning of the vault treatments carried out by Physicists and the treatment carried out by Radiographers. However in the UK it has been recognised that certain areas of practice can be led by a Radiographer with appropriate training, thus reducing the workload for the Clinical Oncologist and Physicist and subsequently expanding and developing the scope of practice for the Radiographer. Previous practice required the patient to attend a lengthy clinic appointment, consisting of an internal examination, insertion of applicator by the Clinical Oncologist followed by a CT scan. The applicator would be removed and the patient would wait while the plan was produced and checked by the Physicist using the TPS (treatment planning system). The plan would then be imported into the HDR afterloader. The applicator would be re-inserted and the treatment delivered. To streamline this pathway we have implemented a series of standard plans for a variety of common treatment lengths and vault applicator sizes available directly on the afterloader. This has removed the need for the applicator to be reinserted and removed the need for the Physicist to produce an individual treatment plan for each patient. A training package was created by the Radiographer with input from the Clinical Oncologist to ensure the Radiographer underwent appropriate training and met the competence requirements. This included observing and inserting vaginal applicators for subsequent fractions under the supervision of the Clinical Oncologist. A total of 15 reflective case studies were completed to support the underpinning knowledge gained by the Radiographer in the insertion of these applicators. Training was also undertaken by the Radiographer to use the TPS to produce a record of the standard plan on the patients CT images. This current new and improved single step process led by the Radiographer has reduced the need to rely on Oncologist and Physicist availability providing greater flexibility for the patient. Producing a more seamless patient pathway has put the patient at the forefront of the service. Analysing the time taken (see table) from acquiring the CT images to starting the patients treatment for a sample of 10 patients before and after the change in practice has resulted in a significant reduction in waiting time for the patient of nearly 2hrs. The advanced role of the Radiographer in the insertion and treatment of vaginal vault HDR brachytherapy patients has resulted in an improved patient experience, significantly reducing the overall time spent in the brachytherapy clinic. It has led to a more streamlined patient pathway and subsequently a more patient focused service. In addition the Radiographer has led training of other Radiographers to perform this role, providing comprehensive service availability. Further development of this advanced role could see the introduction of the Radiographer performing the initial sizing and examination, as well as consenting the patient for the treatment, within a defined competency framework.Tabled 1Pre Radiographer LedPost Radiographer LedMin Time91 mins8 minsMax Time175 mins23 minsAverage Time130 mins14 mins Open table in a new tab