ESTRO 2024 Congress report

Online adaptive radiation therapy (ART) is rapidly becoming an integral part of clinical practice in radiation oncology. It brings a vast array of new possibilities to personalise precision radiation therapy for our patients while providing exciting opportunities for the role expansion of each radiation oncology discipline. The development of systems that adapt the treatment plan based on daily anatomy, using not only MRI images but also cone beam computed tomography (CBCT), promises to revolutionise the daily clinical practice of radiation therapists (RTTs) in the near future. The ESTRO 2024 programme was a clear demonstration of this, as it highlighted both the crucial importance of the development of online ART in radiotherapy and the growing role and advanced skills required of RTTs.

This was emphasised by the theme that was chosen for the RTT pre-meeting course “Online Adaptive Radiotherapy: Skills and Knowledge for RTTs”, which introduced a series of interesting topics that were explored further in the various congress sessions on online ART from the RTT perspective. In the course, Elizabeth Joyce from the Royal Marsden Hospital (UK) and Lykke Kildegård Johansen from Rigshospitalet in Copenhagen, Denmark, emphasised the evolving role of RTTs in online ART, highlighting the resource-intensive nature of these workflows and the need for multiple professionals to ensure competency. They explained that online ART workflows generally fell into two categories, each dictating the skills required by RTTs: multidisciplinary (MDT)-led workflows and RTT-led workflows. They underscored the importance of evaluating current and proposed responsibilities during role changes to identify and address any gaps through a more structured approach to training. The presentations highlighted the importance of interprofessional support and continuous learning within MDTs and stressed that the adaptation of roles required a supportive environment in which team members could learn from one another and collectively enhance their skills. Reijer Rutgers from UMC Utrecht (The Netherlands) described comprehensive training programmes for RTTs that prepared them to manage the complexity of MR-guided treatments. This training enabled RTTs to take on more responsibilities, reducing the need for the constant presence of oncologists and physicists and resulting in 85% of treatments being managed by RTTs. Additionally, it was highlighted that, thanks to plan adaptation, patient comfort was prioritised over daily reproducibility, which eliminated the need for tattoos or laser systems for proper positioning. These discussions demonstrated how the daily clinical practice of RTTs with online ART systems were evolving, shifting from ensuring correct positioning reproducibility to ensuring optimal treatment plan optimisation and selection.

The first panel discussion of ESTRO24 began with a focus on multidisciplinarity in the context of ART, in a session titled "Role Definition in ART: Who Does What and When Do They Do It?" This session allowed experts in ART to share insights and experiences from various disciplines. A diverse panel from Australia, Canada, The Netherlands, Scotland and Italy highlighted the roles of different disciplines, technological advancements, and future directions in both offline and online ART environments. Among them, two RTTs, Amanda Moreira (Canada) and Aileen Duffton (Scotland), shared their testimonies. Dr Moreira discussed the structured offline adaptation process at Princess Margaret Hospital and the comprehensive training programme that enabled RTTs to adjust the contours of the target and organs-at-risk (OARs) to facilitate RTT-led workflows. Dr Duffton emphasised the importance of a multi-professional team and a structured framework of training and competencies to ensure safe and effective ART. This is because RTTs need a lot of additional information to make decisions, such as knowledge of typical aspects of contouring and planning. However, the level of RTT knowledge varies greatly between countries. In some countries, such as Australia, training includes dosimetry, making the transition to adaptive workflows somewhat easier because the basic knowledge is already present. In other countries, this represents a challenge, so specific training programmes are necessary to bridge the gaps and ensure safe decision-making.

During the conference, various presentations highlighted the increasing involvement of RTTs in adaptive workflows. For example, in the RTT track session "Novel Approaches in Treatment Planning," Bethany Williams from the Royal Marsden NHS Foundation Trust (UK) and Marjolein Hilberts from the Catharina Hospital in Eindhoven (The Netherlands) demonstrated that, with adequate training, RTTs could perform online contouring tasks to a standard comparable to that of clinicians, significantly improving operational flexibility. In the first case, an initial evaluation of online contouring for bladder magnetic resonance image-guided radiotherapy (MRIgRT) was presented, while in the second, a quantitative analysis of online contouring for prostate MRIgRT was provided.

The impact of these new tasks on RTT professionals was evidenced by the fact that online ART was also a focal topic in the RTT track session "Advanced Role Development for RTTs," in which contributions from outside Europe were presented. This demonstrated the global relevance of the topic. Meegan Shepherd from Northern Sydney Cancer Centre (Australia) investigated whether virtual radiation oncology-led workshops improved RTT contouring accuracy and confidence for pelvic OARs on CT and CBCT datasets. Dr Shepherd found that virtual education significantly improved contouring accuracy for the rectum and bowel bag, and showed that there was a positive correlation between self-reported and actual accuracy, indicating that confidence may align with competence. Robbie Beckert from Siteman Cancer Center at Washington University (USA) conducted a study on the implementation of advanced practice RTTs (APRTs) who specialised in adaptive contouring. The results demonstrated that APRTs were effective in reducing the time spent on contouring and total treatment. The study showed that task shifting to APRTs could significantly alleviate the workload on physicians, which would enhance the overall efficiency of ART without compromising treatment quality.

In conclusion, ESTRO 2024 underscored the pivotal role of RTTs in the advancement of online ART. Through comprehensive training and a supportive multidisciplinary framework, RTTs are equipped to handle increasingly complex tasks, significantly enhancing the precision and efficiency of adaptive treatments. This evolution not only optimises patient care but also heralds a new era of professional development and responsibility for RTTs in the dynamic field of radiation oncology.

Claudio Votta

Radiation therapist

Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
ESTRO P&I focus group