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  • br document was for a four tier skills mix model

    2022-04-29

    
    document was for a four-tier skills mix model for radiog-raphers, which will lead to a more flexible workforce. At Addenbrooke’s Hospital (Cambridge, UK), VBT delivery was chosen as the ideal service to pilot this (±)-Baclofen model.
    The Addenbrooke’s radiographer-led VBT service was implemented in 2007. Initially, assessment and applicator placement for the first VBT treatment was carried out by an oncologist; subsequent treatments were carried out by radiographers independently. Since 2010, the entire service, including the initial assessment and all treatments, has been conducted by radiographers without an oncologist present.
    The aim of this study was to evaluate the safety and effectiveness of exclusively radiographer-led delivery of VBT without image guidance. To our knowledge, this is the first series to report clinical outcomes after VBT as adjuvant treatment for endometrial cancer delivered entirely within a radiographer-led service.
    Please cite this article as: Buckley H et al., Clinical Outcome of Exclusively Radiographer-led Delivery of Postoperative Vaginal Vault Brachy-therapy for Endometrial Cancer e The Addenbrooke’s Experience, Clinical Oncology, https://doi.org/10.1016/j.clon.2019.06.018
    2 H. Buckley et al. / Clinical Oncology xxx (xxxx) xxx
    Materials and Methods
    Study Population
    This was a single-centre retrospective study of patients with stage IeIIIC1 endometrial carcinoma receiving adju-vant high dose rate VBT, delivered entirely by a radiogra-pher, between 1 January 2010 and 31 December 2016. Eligible patients were identified from an electronic radio-therapy database. Patients with IIIC2 disease, carcinosar-coma or recurrent disease, and those requiring whole vaginal brachytherapy, were excluded.
    All patients were surgically staged according to the 2009 International Federation of Gynaecology and Obstetrics (FIGO) classification. Routine pelvic lymphadenectomy was not carried out; however, clinically suspicious pelvic or para-aortic nodes were removed.
    The standard protocol was to offer VBT alone to patients who met the PORTEC-1 criteria of ‘high risk’, i.e. age 60 years with stage IB grade 1e2 tumours or any patient with IA grade 3 disease [1]. Patients with stage IB, grade 3, stage IIeIIIC1 and non-endometrioid histology were offered adjuvant pelvic EBRT þ VBT (from 2015, only patients with cervical stromal involvement were offered VBT after EBRT). Patients with non-endometrioid cancers (serous, clear cell or mixed) were also offered adjuvant chemotherapy. The final choice of treatment for each patient was agreed through shared decision-making.
    Radiotherapy
    Pelvic EBRT was delivered using a four-field technique defined on bony landmarks. The standard target volume extended from the L5/S1 junction superiorly to the lower border of the pubic symphysis inferiorly. Laterally, the target volume extended to 1 cm beyond the pelvic brim. The anterior border of the target volume was mid-pubis sym-physis, whereas the posterior border was 2e3 cm anterior to the sacral hollow, with a maximum width of about 10 cm. The total dose was 45 Gy in 1.8 Gy fractions delivered over 5 weeks.
    VBT was delivered using a single channel, vaginal cylin-der applicator. Treatment was delivered using standard plans, treating the proximal 2 cm of the vaginal vault. The dose was 21 Gy in three fractions over 2 weeks for VBT alone or 7 Gy as a single fraction if given after pelvic EBRT, pre-scribed to 0.5 cm from the surface of the applicator. The choice of applicator diameter and length was decided clinically at the first insertion by vaginal examination and the use of vaginal sizers. No imaging was undertaken during the entire process.
    Competency Package
    An educational package was designed in collaboration with a higher education institute to provide evidence of academic knowledge, skills and expert practice at a master’s degree level. In-house training for vaginal examination and
    brachytherapy applicator sizing and insertion was provided by the oncologist; as part of the training, radiographers were required to observe five insertions and then to carry out five insertions under supervision followed by five un-supervised mentored cases. The scope of practice was limited to standard treatments only, i.e. adjuvant treat-ments to the top 2 cm of the vaginal vault.
    Initially, the competency package was confined to advanced and consultant radiographer practice only. In 2012, the programme was extended to include band 7 radiographers, on a rotational placement of 1 year or more, and responsibility for training and assessment was dele-gated to the advanced practitioner. Radiographers were required to update their knowledge and skills annually and to undertake a refresher if there was a gap in practice of more than 6 months.