Advanced Brachytherapy Techniques

Details

Title

Advanced Brachytherapy Techniques

Type

Stage Two

Module code

HPE113

Requirement

Optional

Module objective

By the end of this module the Clinical Scientist in HSST will be able to analyse, synthesise, evaluate and critically appraise the theoretical underpinning of the safe and appropriate use of advanced brachytherapy techniques and their application in therapeutic clinical practice. The Clinical Scientist in HSST will be able to identify advantages and limitations of the standard and innovative practices in the treatment of advanced brachytherapy, including:

• Factors influencing the choice and appropriateness of imaging.
• Limitations of different equipment, techniques and computer modelling of applicators.
• Complex treatment planning and optimisation, identification of dose parameters most relevant for clinical practice (tumour and organs at risk), and opportunities for dose escalation.

They will be expected to justify the imaging process and advise on the balance of resources against benefit with respect to advanced brachytherapy and understand the benefits of audit and clinical trials, including governance and ethical issues. The Clinical Scientist in HSST will also be expected to contribute to the development of brachytherapy on a local, national and international level by, for example, contribution to protocols, audit, trials, etc. They will be expected to have an awareness of key areas of active research and development in brachytherapy, including techniques.

Knowledge and understanding

By the end of this module the Clinical Scientist in HSST will be able to analyse, synthesise and critically apply their expert knowledge with respect to advanced brachytherapy techniques, including:

• Range of sources and isotopes, and their properties.
• Legislation relating to the specification, purchase, clinical use, keeping, transportation, removal and disposal of brachytherapy sources.
• The types of commissioning tests that are required when implementing advanced brachytherapy.
• Quality assurance programmes for comprehensive quality control of brachytherapy equipment.
• Treatment-planning algorithms for brachytherapy dose calculation.
• Empirical dosimetry systems (e.g. Paris, Manchester).
• Intracavitary, intraluminal and interstitial methods.
• Guidelines for target and organ at risk definition (e.g. GEC-ESTRO for gynaecological brachytherapy).
• Common sites, including cervix and prostate (both temporary and permanent implants).
• Evidence-based rationales for selecting appropriate methods of imaging for volumetric determination and treatment plan evaluation.
• Verification and quality control of brachytherapy treatments.
• The impact of human factors with regard to patient safety in the use of medical devices that use ionising radiation or radioactive materials.
• The principal relevant imaging modalities, e.g. CT, ultrasound, MRI, planar X- rays.
• Radiosensitisers, and commonly used drugs.

Dosimetry

• Quantities and units used in brachytherapy.
• Different methods of source specification.
• Instrumentation used for source measurement and calibration.
• Dosimetry formalisms and Codes of Practice (including AAPM TG43).

Applicator modelling (reconstruction) and treatment planning

• Uncertainties in applicator and source positional reconstruction, and their impact on dosimetry.
• Define the goals of dose optimisation.
• The factors that have to be considered when evaluating a brachytherapy treatment plan.
• Methods of dose optimisation using different applicators, source patterns and for different clinical sites.
• Dose targets and constraints for tumour target volumes and critical organs at risk.
• Dose optimisation, plan evaluation and dose modification.

Radiobiology

• Influence of dose rate effects, including low, pulsed, medium and high dose rate.
• Summation of external beam and brachytherapy treatments.

Logistics

• The logistics of imaging with applicators in situ and other patient care-related issues.
• The care of the patient needed pre-, during and post-brachytherapy procedures.
• The possible complications of each procedure and their management.
• The specific clinical and emergency issues relating to high-dose rate brachytherapy.
• The specific clinical and emergency issues relating to low-dose rate seed implants.
• Transport regulations and safe processes for ordering/storing and removing/disposing of brachytherapy sources.

Technical and clinical skills

The Clinical Scientist in HSST will perform, adapt and master the technical skills and clinical understanding necessary to critically evaluate the clinical implications of actions in the following areas and make an informed decision and provide advice, to include an understanding of the accuracy and precision of brachytherapy dosimetry and will:

Commissioning

• Design and carry out a commissioning programme for clinical brachytherapy protocols and equipment.
• Apply UK guidelines for low-dose rate brachytherapy considering the ramifications for low-dose rate source calibration.
• Identify typical issues that may arise when commissioning three-dimensional imaging.
• Identify typical issues that may arise when commissioning clinical applicators for image-guided brachytherapy.

Calibration and quality control

• Apply current dosimetry codes of practice for brachytherapy.
• Perform and advise on calibrations of brachytherapy sources.
• Design a quality assurance (QA) programme appropriate to your centre’s implementation of a particular type of brachytherapy.
• Participate in local and national audit.
• Design protocols and perform quality control (QC) for all principal relevant imaging modalities, e.g. CT, ultrasound, MRI, planar X-rays.
• Verify local brachytherapy treatments by measurement and/or independent calculation.

Applicator modelling (reconstruction) and treatment planning

• Identify the potential pitfalls that may arise during applicator reconstruction.
• Reconstruct brachytherapy applicators using CT, MRI and ultrasound.
• Practice safe use of the optimisation tools and recognise their limitations.
• Identify the most useful dose parameters for different clinical applications.
• Assess a brachytherapy treatment plan.
• Modify the prescribed dose, considering all options when the brachytherapy treatment plan is suboptimal.

Radiobiology

• Evaluate the use of appropriate radiobiological parameters.
• Calculate the equivalent dose for different dose-fractionation schedules.
• α/β ratio and its relevance to tumours, acute and late-responding tissues.
• Calculation of biological effective dose (BED).

Radiation protection of patients and staff

• Advise all relevant staff groups on the safe working practices regarding brachytherapy procedures, including post-implant scenarios.
• Liaise with all relevant staff groups and external inspectors and advisers to sure safe and secure working practices in brachytherapy.
• Provide advice to patients regarding risks associated with their implanted brachytherapy sources.

The Clinical Scientist in HSST will be expected to reflect on the challenges of applying research and innovative technologies to practice in relation to these procedures and suggest improvements, building on a critique of available evidence, encouraging participation in clinical trials, and organising and participating in local and national audit. The Clinical Scientist in HSST will also be required in partnership with the clinical team to identify areas of current practice that could be improved, and design and evaluate a suitable intervention based on a critical review of evidence to improve practice.

By the end of this module the Clinical Scientist in HSST will demonstrate the clinical and scientific skills necessary to safely set up, implement and oversee management of an advanced brachytherapy clinical service and will:

• Accurately report data needed for a clinical study.
• Design a clinical study involving brachytherapy.
• Work with a multidisciplinary team in an operating theatre for brachytherapy procedures.
• Communicate effectively within the multidisciplinary team.

Attitudes and behaviours

By the end of this module the Clinical Scientist in HSST will consistently demonstrate the attitudes and behaviours necessary for the role of a Consultant Clinical Scientist and will:

• Adhere to, accept and work within current governance requirements applicable within an organisation, raising concerns when necessary.
• Collaborate with a group of peers with an interest in improving clinical and scientific outcomes.
• Collaborate with multidisciplinary groups on local, national and international levels with the aim of improving clinical and scientific outcomes related to brachytherapy.
• Promote the importance of innovation in service and/or delivery, including the contribution of research and innovation in advanced brachytherapy delivery in the NHS, business and the UK economy.
• Display an objective and unbiased approach.