To analyse the patterns of care and clinical outcomes of patients diagnosed with cervical cancer International Federation of Gynecology and Obstetrics (FIGO) stage IVA treated at a tertiary care centre in South India.

The electronic medical records of 2,476 patients diagnosed with cervical cancer at a tertiary care institution between January 2005 and December 2018 were reviewed. Among them, 96 patients diagnosed with histologically proven carcinoma cervix stage IVA established by either cystoscopy or proctoscopy were included. Four patients who did not receive treatment at the study centre were excluded and 92 patients were available for final analysis.

The median follow-up period was 12 months (2–131 months). Of the 92 patients, 59 patients (64·13%) received radiation therapy (RT) alone, 22 patients (23·9%) received chemoradiation (CRT), three patients (3·26%) received neoadjuvant chemotherapy (NACT) followed by RT, one (1·08%) received NACT followed by CRT, four patients (4·35%) received chemotherapy alone, while three (3·26%) were offered best supportive care. The median progression-free survival (PFS) was 12 months (95% CI: 9·6–14·4 months) and median overall survival (OS) was 25 months (95% CI: 16·6–33·4 months). The 2-year and 3-year PFS was 30 and 20%, respectively, and the OS was 50 and 32%, respectively.

The management of stage IVA cervical cancer needs to be individualised to achieve a fine balance between local control, toxicity, and quality of life. RT is the mainstay of treatment with concurrent chemotherapy in carefully selected patients. Involvement of palliative care team early in the course of treatment adds a holistic approach to the continuum of oncological care.

Direct observation in the radiotherapy clinic remains the primary method for the assessment of procedural skills. But with increasing automation and reductions in clinical placement time during the recent pandemic, the role of summative, simulation-based assessment is being revisited. The aim of this article is to share early experiences of using Virtual Environment for Radiotherapy Training (VERT) in the assessment of a palliative, parallel pair, external beam treatment delivery technique in a new pre-registration undergraduate programme.

Eight first-year students completed a campus-based individual virtual assessment using virtual patient plans representing metastatic disease in the brain and pelvis and late-stage primary lung tumours. Performance was logged on a 25-item checklist for pre and post-procedure checks and treatment delivery tasks.

All eight students participated in the assessment with seven students (87·5%) achieving a pass grade at first attempt. The course team observed that participants demonstrated a range of skills and abilities and were able to compare and contrast individual approaches to patient positioning. Specific feed-forward action points were also highlighted as areas for students’ to focus on during their second placement. The project also identified logistical benefits for assessment teams.

While these experiences are a single snapshot, a VERT simulation-based summative assessment is feasible and identified benefits included controlled observation and structured feedback on individual performance and scheduling pressure reductions for clinical teams. However, more work is needed to determine the psychometric qualities and predictability of performance in more complex techniques.

Malignant spinal cord compression (MSCC) is a serious condition requiring urgent palliative radiotherapy to alleviate symptoms and avoid permanent paralysis. The aim of this project was to analyse the 30-day mortality rate post-palliative radiotherapy for MSCC patients to identify if radiotherapy can be safely omitted or the fractionation reduced in the poor prognosis group (patients likely to die within 30 days) by biomarkers and performance status (PS).

A retrospective audit was performed (July–December 2019) and data on treatment duration, date of death, biomarkers (C-reactive protein (CRP), albumin) and PS were collected using hospital patient management systems.

Hundred and one patients received palliative radiotherapy for MSCC in the 6-month period. The number of patients who died within 30 days was 17, representing 16·8% mortality rate. Rising CRP levels and poor PS indicated a poorer prognosis in this patient group.

Monitoring biomarkers and PS as standard throughout patients’ treatment is recommended to assess disease progression. Worsening PS and high CRP is an indicator of poor prognosis and early death, and therefore omission of treatment or a single fraction of radiotherapy is recommended.

There is abundant evidence of the comparative efficacy of single-fraction (SF) radiotherapy and multi-fraction (MF) radiotherapy when treating patients with bone metastases. Despite this, previous surveys have shown SF schedules to be underutilised.

To determine current patterns of practice in patients with bone metastasis and to investigate the factors that influence practice.

An electronic audit was performed amongst 46 physicians, within 7 hospital trusts in the UK. The audit comprised of four hypothetical cases in which consultants and registrars chose which dose and fractionation they would recommend and their reasons for this recommendation.

SF radiotherapy was the most common radiotherapy schedule in hypothetical cases 1, 3 and 4. SF radiotherapy was recommended by 65% of respondents in case 1, 47% in case 2, 89% in case 3 and 46% in case 4. For case 2, 50% proposed MF radiotherapy. For case 4, 22% of respondents recommended Stereotactic Body Radiotherapy (SABR). The following deciding factors were cited as influencing choice of an SF schedule: prognosis, published evidence, performance status and spinal cord compression.

The most common radiotherapy schedule selected was SF. However, there were inter-institution differences regarding the use of SF radiotherapy. Furthermore, the survey had shown that a third of respondents recommended an MF regime, despite evidence supporting the efficacy of an SF schedule.

To investigate whether a radiographer-led radiotherapy pathway can provide an efficient service for patients requiring treatment for symptomatic skeletal metastases.

A retrospective review of 425 courses of palliative radiotherapy was conducted. Data was analysed assessing diagnosis, dose/fractionation, time from referral to treatment, gender, age, inpatient/outpatient status and referring clinic location for radiographer- and clinical oncologist-led cohorts.

Patients aged ≥70 years were more likely to be planned by radiographers (n = 162/57, p < 0·001). Patients were more likely to be treated with 8 Gy in single fraction than with 20 Gy in five fractions (n = 279/136, p = 0·012). The median referral to treatment time in 8-Gy single-fraction prescriptions was 3 days for radiographer-led versus 7 days for clinical oncologist-led cohorts. In all patients and in 20 Gy in five-fraction prescriptions, it was 4 versus 8 days. A comparison of all prescriptions (p < 0·001), 8 Gy in single-fraction (p < 0·001) and 20 Gy in five-fraction prescriptions (p = 0·001) showed radiographer-led procedures as enabling faster access to treatment in each category.

A radiographer-led service can facilitate faster access to treatment than a clinical oncologist-led pathway for an appropriately selected patient caseload.

Accuracy and reproducibility of the patient’s position is crucial for successful delivery of radiotherapy (RT). Data on palliative patients’ set-up uncertainties are sparse. The aim of this study was to calculate set-up errors observed for palliative patients positioned using one skin mark (Group 1) versus three skin marks (Group 2) and to assess the accuracy of both approaches.

Displacements in the left–right (L–R) and superior–inferior (S–I) directions were retrospectively analysed for 175 sites treated with a course of fractionated palliative RT. Population mean, systematic and random errors were calculated in both directions for patients positioned with one and three skin marks. Frequency of deviations was also examined for both groups.

The population mean, systematic and random errors for Group 1 and 2 for the L–R direction were 0·0, 4·4, 4·8 and 0·4, 3·1 and 3·3 mm, respectively, and in the S–I direction: 0·1, 3·4, 4·2 and 1·2, 2·7 and 3·3 mm, respectively. Frequency of images within the clinical tolerance of 5 mm was 47·1% for Group 1 and 65·9% for Group 2.

Three skin marks are recommended for patients receiving a fractionated course of palliative RT, as it reduces set-up error, reduces the number of gross displacements (>10 mm) and increases the number of displacements within the clinically acceptable tolerance of 5 mm.

To examine patient satisfaction with a Clinical Specialist Radiation Therapist (CSRT) in a palliative radiotherapy clinical environment.

A one-point dissemination design captured satisfaction scores from patients who did (n=19) and did not (n=14) receive palliative care from the CSRT. The ‘Patient Satisfaction Questionnaire’ included six common questions and four additional questions for patients seen by a CSRT. T-tests compared results from common questions and mean values, standard deviations were also calculated.

For questions ‘I was told everything that I want to know about my condition’ and ‘I felt that the problem that I came with was sorted out properly’, those who received care from the CSRT scored significantly (p<0·05) higher than those that did not (p=0·033, 0·037). For CSRT-specific questions, 89% of participants felt the experience with the CSRT was excellent, 78% strongly agreed/agreed having a CSRT on the care team was important, and 89% of participants strongly agreed/agreed having a CSRT on the care team was important to patients’ understanding of treatment.

Patients receiving care from the CSRT had better understanding of treatment and an excellent experience with the CSRT. This interaction provided more opportunities to address patient questions/concerns, thus alleviating patient anxiety, increasing satisfaction with care, and demonstrating how new roles can develop new models of care within the current healthcare system.

Imaging protocols are implemented to identify and minimise set-up errors. A crucial component to the success of these protocols is staff compliance.

This is case report describing a retrospective review of radiation therapists’ compliance to a palliative imaging protocol in a single large institution in one calendar year.

The review showed a non-compliance to protocol for 8% of treatments. The most frequent protocol deviation was a failure to calculate the mean set-up displacement after 2/3 days of consecutive imaging.

Despite the presence of institutional evidence-based palliative imaging protocol unwanted deviations in practice can occur.

Malignant spinal cord compression (MSCC) is a serious condition requiring urgent palliative radiotherapy to alleviate symptoms and avoid permanent paralysis. This audit compares the number of patients treated for MSCC before and during Covid-19, their treatment regimes and 30-day mortality rates to assess if the pandemic affected the treatment and the number of patients referred for palliative radiotherapy.

A retrospective audit was performed (July–December 2019) and 101 patients were treated for MSCC, an average of 17 patients per month. A further audit was undertaken during Covid-19 (March–May 2020) and 36 patients were treated for MSCC, an average of 12 patients per month in this shorter cohort.

The results have demonstrated fewer patients presenting during the pandemic and this may be due to patients not wishing to utilise the National Health Service (NHS) during this time. It also highlighted the need to reduce the treatment duration to minimise hospital attendance and lessen the potential for exposure to Covid-19.

Educating patients at risk of MSCC is essential and all cancer patients should be counselled on symptoms and what to do if they occur. Ensuring clinicians know the warning signs and the referral pathway for MSCC is also key to ensure early presentation and early referral for treatment.

Radiation-induced nausea and vomiting (RINV) is a common side effect of single fraction palliative radiotherapy. Patients experiencing RINV have significantly reduced quality of life and a prescription of prophylactic antiemetics, principally 5-HT3 antagonists, is recommended. There is a growing body of evidence relating to indications for this, but as yet there are no national guidelines.

A retrospective audit aimed to determine the extent to which patients at high and moderate emetogenic risk receiving single fraction radiotherapy were prescribed prophylactic emetic medication in line with the current evidence base.

A total of 60 patients were included in the audit; of these patients, 50 were consented for the risk of nausea and/or vomiting. Prophylactic antiemetics were only prescribed to 28 (46·7%) of all audited patients. Out of the 50 patients who provided informed consent, only 24 (48%) were prescribed an antiemetic prior to their treatment.

Antiemetic prescribing for single fraction patients at moderate to high emetogenic risk at a large regional centre is underutilised in relation to published evidence. Amended guidance and further audits are recommended to ensure that this patient group is best supported.