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Summary of main recommendations

Radiotherapy service providers:

  • Risk assessments must be completed when implementing new technology and techniques. This is made clear in the NRIG IGRT report.1
  • Training workbooks for MV/kV planar imaging and 3D volumetric imaging are desirable.
  • The roles and responsibilities within local protocols must be reviewed for those individuals justifying non-planned imaging dose to ensure that they are in-line with IR(ME)R Legislation and guidance. 2,3
  • It is important that all centres regularly review their IR(ME)R procedures in terms of training records for entitled practitioners and operators (for IGRT) .2,3
  • The use of document templates is recommended to ensure continuity in the format of local protocols and work instructions.
  • All providers to have access to and use of the eLearning for Healthcare (e-LfH) IGRT module 4 as part of local training and competency programmes.
  • A database of interesting patient cases that can be used as a training aid to help assess troubleshooting skills should be compiled.
  • Developments in applications training must be driven by service providers and reflect local pathway requirements.
  • Protected time needs to be provided for the IGRT team including the lead imaging radiographers, clinical radiographers and physicists to enable the development and implementation of IGRT training programmes as recommended in the NRIG IGRT report.1
  • IRMER requires that an assessment of patient dose is undertaken. Imaging doses should be recorded for each patient as a total concomitant exposure received during planning and treatment (Regulation7, 3(b) of IRMER) .2
  • Audit of patient set up error data must become routine practice to help inform local planning margins and justify on-treatment image verification frequency.

NHS England specialised commissioning:

  • Clearer guidance for IGRT tariffs is required, in particular that which relates to the use of the ‘Adaptive’ code Y91.4.
  • A new code is required for IGRT linked to levels of complexity as outlined in the NRIG IGRT report.1
  • Future guidance relating to IGRT coding needs to be less ambiguous to avoid misinterpretation and to ensure that its application is standardised.

Radiography education providers:

  • Radiotherapy service providers must work with local Higher Education Institutions to develop the minimum requirements to enable new radiographers to be fit for purpose to undertake IGRT as outlined in the Education and Career Framework. 5
  • Volumetric image analysis and decision making skills need to be developed during the undergraduate and post graduate pre-registration  programmes via a standardised IGRT curriculum.
  • All education providers are advised to adopt the IGRT training framework outlined in Appendix 7.

 Radiotherapy Physics -  Education and Training:

  • The NRIG IGRT Report recommends establishing IGRT champions from each professional group. Although many centres have physicists nominated for or specifically appointed to IGRT roles it is accepted that many physicists in this position have never received formal training in imaging. It is recommended that stronger emphasis on IGRT is introduced into professional training programmes, possibly at Accredited Expert Scientific Practice (AESP)  or Higher Specialist Scientific Training (HSST level) under the Modernising Scientific Careers programme. In addition, support for physicists to participate in relevant CPD activities is strongly encouraged.
  • Closer working between physicists working in radiotherapy and diagnostic imaging departments is recommended with the emphasis being on mutual collaboration rather than specific tasks being assigned to one group or the other.

Radiotherapy board (Joint professional bodies: SCoR, IPEM, RCR):

  • It is essential that the professional bodies continue to support the work funded by NCAT and not lose the momentum of change that has been established.
  • A follow-up survey to assess the progress that has been achieved with regards to IGRT implementation is advisable after 12 months.
  • There is an appetite for ongoing and accessible physics IGRT support, possibly via coordinated peer-to-peer mentoring at a regional model. As suggested in the NRIG IGRT Report, one option may be for this to be facilitated by the IPEM dosimetry audit network that is already well established.
  • Physicists are also encouraged to utilise the RT imaging special interest group (SIG) ‘Google’ forum, established by the SCoR and to utilise the medical-physics-engineering@jiscmail.ac.uk  listserver.
  • Additional work is required to develop protocols for the end to end optimisation of radiotherapy imaging processes.

Radiotherapy equipment manufacturers:

  • Applications support needs to include anonymised data sets or possible access to on-line web demonstrations (modular e-learning) for group learning and discussion of non-standard cases for training, reducing the use of phantoms.
  • Remote terminal access for off-line review and IGRT training should be provided.
  • Access to data for systematic error and population trend analysis, including statistical analysis tools must be made available.

Radiotherapy trials

  • The IGRT component of any trial methodology must be clear.3 Work must continue with the Radiotherapy Trials Quality Assurance (RTTQA) group in developing an accreditation method for IGRT that is anatomically site specific.

Regulation 7 (4(d)) of IRMER requires there to be target levels of doses on those doses delivered for research purposes.  Links must be made with the National Research Ethics Services (NRES)  - http://www.nres.nhs.uk/about-the-national-research-ethics-service/development-of-the-research-ethics-service/

National IGRT Team

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