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Journal of the American Society of Radiologic Technologists

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Esophageal Cancer

Radiation TherapyPAGE 61

P E E R - R E V I E W E D A R T I C L E S

Incorporating VERT Technology

Into the Radiation Therapy

Classroom: A Case Study

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Bolus in Radiation Therapy:

The Versatility of Water

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Clinical Experiences of

Radiation Therapy StudentsPAGE 29

Volume 25, Number 1 Spring 2016

Radiation technology and software are just part of the cancer-fi ghting equation—and they can only reach their full potential when in the hands of the people who put them to use every day. That’s why we’re dedicated to working alongside you as the world of oncology continues to change. Because sophisticated treatment options, better insights and cohesive care are best achieved as a team.

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4 RADIATION THERAPIST, Spring 2016, Volume 25, Number 1

An Official JournalRadiation Therapist (ISSN 1084-1911) is an official scholarly journal of the American Society of Radiologic Technologists. It is published twice annually, in the spring and fall, at 15000 Central Ave SE, Albuquerque, NM 87123-3909. Standard-class postage paid at Albuquerque, NM 87123-3909, and at additional mailing offices. Printed in the United States. © 2016 American Society of Radiologic Technologists.

The research and information in Radiation Therapist are generally accepted as factual at the time of publication. However, the ASRT and authors disclaim responsibility for any new or contradictory data that may become available after publication. Opinions expressed in the journal are those of the authors and do not necessarily ref lect the views or policies of the ASRT.

Change of AddressTo change delivery address, notify the ASRT at least 6 weeks in advance. Address correspondence to ASRT Member Services, 15000 Central Ave SE, Albuquerque, NM 87123-3909; call 800-444-2778 from 8 AM to 4:30 PM Mountain time; fax 505-298-5063; or email [email protected]. ASRT members also can submit address changes online at asrt.org/myinfo.

Claims are not allowed for issues lost as a result of insufficient notice of change of address. ASRT cannot accept responsibility for undelivered copies.

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EditorialEditorial correspondence should be addressed to Radiation Therapist Editor at [email protected], 505-298-4500, or 15000 Central Ave SE, Albuquerque, NM 87123-3909. Letters of inquiry prior to finished manuscript production are encouraged and may be reviewed by the editor and the chairman of the Editorial Review Board.

The initials “R.T.” following proper names in this journal refer to individuals certified by the American Registry of Radiologic Technologists.

SubscriptionsMember subscription is $1.59 per year, included in ASRT member dues. Members who select radiation therapy as their continuing education preference receive 2 issues of Radiation Therapist and 4 issues of Radiologic Technology each year. Nonmember subscription of 1 volume of 2 issues is $40 for individuals and $45 for institutions within the United States. The rate for foreign individuals and institutions, including for those in Canada, is $74. Discounted rates apply to 2- and 3-year subscriptions and subscription agencies. A bundled rate is available for those interested in subscribing to both ASRT journals, Radiologic Technology and Radiation Therapist. For additional information, visit asrt.org/publications.

Single issues, both current and back, exist in limited quantities and are offered for sale. For prices and availability, visit asrt.org/store or call Member Services at 800-444-2778.

AdvertisingPublication of an advertisement in Radiation Therapist does not imply endorsement of its claims by the editor or publisher. For advertising specifically related to educational programs, ASRT does not guarantee, warrant, claim, or in any way express an opinion relative to the accreditation status of said program.

Rights ReservedAll articles, illustrations, and other materials carried herein are pending copyright under U.S. copyright laws, and all rights thereto are reserved by the publisher, the American Society of Radiologic Technologists. Any and all copying or reproduction of the contents herein for general distribution, for advertising or promotion, for creating new collective works, or for resale is expressly forbidden without prior written approval by the publisher and, in some cases, the authors.

Copying for personal use only through application and payment of a per-copy fee as required by the Copyright Clearance Center, under permission of Sections 107 and 108 of the U.S. copyright laws. Violators will be prosecuted.

Erratum In the “Radiation Therapy Reimbursement Update” Directed Reading, which appeared in the Fall 2015 issue, the end of the question number 8 stem should read “treatment delivery codes.” This question will not be used for grading. Thank you to the reader who alerted us to the error.

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I love the CE track and transfer service. I attend the OSRT conference each year in order to keep up with my CE credits. The ASRT does a great job of tracking them, accounting for them and sending them to ARRT for my registration. The turnaround time is great as I typically get them back much quicker than promised.

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ASRT tracks 88,865 continuing education credits each month for members. When you’re within two months of the end of your biennium, we begin sending your CE record to the ARRT. Learn more about the track and transfer service at www.asrt.org/trackandtransfer.

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Radiation Therapist Editorial Review BoardChairman Amy A Heath, MS, R.T.(T)[email protected] of Wisconsin Hospital and Clinics, Madison, Wisconsin

Vice ChairmanMegan Trad, PhD, MSRS, R.T.(T) [email protected] State University, San Marcos, Texas

MembersLinda Alfred, MEd, MBA, R.T.(T) [email protected] York, Brooklyn, New York

Lisa Bartenhagen, MS, R.T.(R)(T)[email protected] of Nebraska Medical Center, Omaha, Nebraska

Sherry Bicklein, MHI, R.T.(R)(T) [email protected] Doisy College of Health Sciences, St Louis, Missouri

Mellonie Brown-Zacarias, MET, R.T.(T), [email protected] Technologies University, Louisville, Kentucky

Jessica A Church, MPH, R.T.(R)(T), CMD [email protected] Sturt University, Wagga Wagga, New South Wales

Radiation Therapist Journal Staff Lisa Kisner, scientific publications managerLisa Ragsdale, scientific journal editorJulie Hinds, associate editorSherri Mostaghni, associate editorKathi Schroeder, director of communicationsNatasha Rosier, radiation therapy managerKatherine Ott, senior professional development editorEllen Lipman, director of professional developmentMarge Montreuil, graphic designerTaylor Henry, graphic designerLaura Reed, graphic design manager

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SubmissionsSubmissions from radiation therapy professionals and researchers are encouraged. Visit asrt.msubmit.net to upload a manuscript. Author guidelines are available at asrt.org/authorguide.

Doralene Deokielal, BS, R.T.(R)(T)[email protected] Mary’s Hospital, Grand Junction, ColoradoJason Dixon, MA, R.T.(T) [email protected] Cancer Care Alliance, Proton Therapy Center, Seattle, WashingtonKathy Kienstra, MAT, R.T.(R)(T) [email protected] College of Health Sciences, St Louis, MissouriJulie Lasley, MSA, R.T.(R)(T) [email protected] College of Health Sciences, Memphis, TennesseeBrandon Lausser, MS, R.T.(T)[email protected] Fellow Designate, Houston, TexasBenjamin Morris, R.T.(R)(T)(CT)[email protected] Medical Center Branson, Branson, MissouriCory Neill, MS, R.T.(R)(T), [email protected] Cancer Center, Carson City, Nevada

An R.T.’s Best Friend!ASRT’s JobBank® is the source for job seekers in the radiologic sciences.

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9RADIATION THERAPIST, Spring 2016, Volume 25, Number 1

Contents

Volume 25, Number 1 Spring 2016

P E E R - R E V I E W E D A R T I C L E S

Incorporating VERT Technology Into the Radiation Therapy Classroom: A Case StudyLinda Schinman, Megan Trad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Bolus in Radiation Therapy: The Versatility of WaterAmara Miescke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Clinical Experiences of Radiation Therapy Students: A Qualitative Case Study Using PhotovoiceMegan Trad, Clarena Larrotta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

D I R E C T E D R E A D I N G A R T I C L E S

Electronic Health RecordsRosann Brauer Keller . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Esophageal Cancer Radiation TherapyBryant Furlow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

C O L U M N S Editor’s Note

Registry Changes Make Life Easier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Bookshelf

Take Charge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Writing & Research

Polishing Your Professional Portfolio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87Global Outlook

Achtung Strahlenschutz! Beer, Bratwurst, and Cancer Care . . . . . . . . . . . . . . . . . . . . . 89In The Clinic

Three-dimensional Imaging for High-Dose-Rate Cervical Brachytherapy . . . . . . . . . . . 92Patient Care

Treating Patients With Autism Spectrum Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Advances in Technology

Advances in Technology With Brainlab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101Teaching Techniques

Cognitive Apprenticeship Strategies in Clinical Education . . . . . . . . . . . . . . . . . . . . . 103RE: Registry

Preparing for Continuing Qualification Requirements . . . . . . . . . . . . . . . . . . . . . . . . 106Case Summary

Radiation Therapy for Treatment of Craniopharyngioma . . . . . . . . . . . . . . . . . . . . . . 108Backscatter

Ductal Carcinoma in Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

This symbol indicates expanded online content .

O N T H E C O V E R

In “Digital Therapy, Esophageal,” ASRT graphic designer Taylor Henry used binary code to depict a radiation treatment plan for esoph-ageal cancer. This abstract view demonstrates how treatment plans, medical imaging, and patient infor-mation are stored on a computer as 1s and 0s. Binary code makes up the electronic health records medi-cal professionals use daily.

10

Editor’s Note

RADIATION THERAPIST, Spring 2016, Volume 25 Number 1

Lisa Kisner, BA, CQIA, ELS

Registry Changes Make Life Easier

The American Registry of Radiologic Technologists (ARRT) recently announced some changes, and astute readers will notice the results of those changes on the Directed

Reading post-tests beginning with this issue. The first change is an extension of the expiration date. Now, Directed Readings are available for 3 years and will be eligible for an additional 3-year renewal, making them potentially available for 6 years. Previously, the post-tests were available for 2 years, so members will have more f lexibility to take the quizzes when it is most con-venient or beneficial to them.

The second change will surely brighten the day of many journal readers. Under previous ARRT require-ments, 20 post-test questions were needed for 1 Category A or A credit, 25 were needed for 1.5 cred-its, 30 for 3 credits, and so on. The latest ruling simpli-fies the post-tests for continuing education providers and readers: 8 questions per credit. This change virtu-ally cuts the number of questions you have to answer by half, without reducing the credit amount.

The third change is another fairly significant one: The ARRT now allows registered technologists to repeat educational activities for credit, as long as they are not repeated in the same biennium. That means you may access your favorite Directed Reading articles—or perhaps ones you struggled with—and earn credits again. To do so, simply choose an article from your list at asrt.org/drquiz, and purchase a new quiz at 15% off

the original cost of the course, or $8.50 per credit. Of course, all Directed Reading quizzes published during your current membership period are still free the first time you take them.

These 3 changes should help you get more from your membership and make meeting ARRT requirements easier than ever. Happy reading and credit earning!

Lisa Kisner, BA, CQIA, ELS, is the scientific publications manager for the American Society of Radiologic Technologists. She also serves as the staff liaison for the Radiologic Technology and Radiation Therapist Editorial Review Boards.

For additional information, check out the ASRT Scanner story at asrt.org/as.rt?BvrzKx or contact [email protected].

http://www.asrt.org/as.rt?BvrzKx


Bookshelf

Take Charge

The Cancer Solution: Taking Charge of Your Life With Cancer.Westman JC. 2015. 298 pages. Archway Publishing. www.archwaypublishing.com. $38.

For this book, the author drew from his experience and expertise to create a guide that empowers patients with cancer

to take control of their lives. The Cancer Solution also helps health care providers better anticipate patients’ questions and become better resources for their patients.

Westman explains the basics of chemotherapy, radia-tion therapy, and surgery along with the outcome goals associated with these treatments. He describes how to navigate medical terminology and questions patients might bring to postdiagnosis appointments, including those regarding the personal health record mobile appli-cation, MyChart (Epic), advance directives, power of attorney, the history of cancer, and even where cancer cells come from.

Information on alternative therapies is presented alongside information on research grants and clini-cal trials. The book describes therapies that have been successful in other countries and preliminary stages of clinical trials, as well as the politics behind funding for research in the United States. After reading this book, patients might feel more empowered to ask questions

about alternative and complementary medicine vs tradi-tional treatment options.

Health care providers might appreciate the politi-cal research and expertise presented in this handbook. The last 4 chapters highlight key organizations involved in furthering knowledge in the field of cancer in the United States and the coinciding financial and political barriers to progress. This information seeks to answer typical questions, from why multiple medications have the same goal (ie, antinausea) to why there is no cure for cancer as of yet.

However, some information presented is specious. For example, Westman writes that cancer is the leading cause of death in the world but gives no citation to sup-port the statement. Generalizations and lackadaisical editing—excessive spelling and grammatical errors—litter the book, making this handbook less than profes-sional and therefore difficult to rely on fully.

Overall, the information might be helpful for patients seeking answers after their cancer diagnosis. Most of the information is concise and written in simple language that can be understood easily by the general public. With some thorough editing and fact check-ing, this book could shine as a reference for patients. Caregivers and health care providers also might find the information helps them to better serve their patients.

Brittani Woods, BS, R.T.(T)United Hospital SystemsPleasant Prairie, Wisconsin


Peer Review

Incorporating VERT Technology Into the Radiation Therapy Classroom: A Case Study

machine by using the available technology and defin-ing our safety standards.

Administering radiation therapy is complex and requires the constant use of critical thinking skills, along with technical precision.1 Often, there is a discon-nect between the classroom and the clinic in radiation therapy education because it is difficult to teach com-plex treatment procedures in a lecture or classroom format, and each clinic has different expectations of the students.2,3 As clinics become busier, students need a safe environment in which to practice and gain confi-dence in skills; however, most educational programs do not have access to linear accelerators for students’ use.

Over the past few years, Virtual Environment Radiation Therapy (VERT) technology has been used to bridge the gap between the classroom and the clinic, helping concepts come alive and increasing student confidence.2-4 VERT is a 3-D linear accelerator simulator

As a therapist, clinical instructor, and private pilot, study author Linda Schinman recogniz-es similarities between radiation therapy and aviation. Aviation safety is dependent on a

pilot’s level of awareness and ability to stay ahead of the airplane. This is accomplished through competency-based training, simulations, currency checks, adher-ence to checklists, and real-world experience. The same level of spatial awareness and skill can be applied to patient setups and treatment delivery. In addition, positioning the isocenter inside a patient is a 3-D con-cept similar to knowing the position of an airplane in space. In f light, it is imperative not to let your circum-stances outwit your ability to control the airplane. Similarly, as professionals, we should not let our cir-cumstances or technologies precede our competence or ability to provide quality care in a safe manner. In other words, Schinman advises us to stay ahead of the

Linda Schinman, MBA, R.T.(T)(CMD)Megan Trad, PhD, MSRS, R.T.(T)

Background A disconnect between classroom and clinic often exists because it is difficult to teach complex treatment procedures in a lecture or classroom format, and each clinic has different expectations of students. Research has indicated that students feel immense pressure to learn the patient care side of radiation therapy while also mastering the psycho-motor skills necessary to administer radiation treatments.

Discussion A case study research design was used to assess student learning with Virtual Environment Radiation Therapy (VERT) technology in a radiation therapy course. Students indicated the practice of determining setup errors and mak-ing the corrections was most helpful in developing and improving skills. This research demonstrated improved technical communication and competence after using VERT technology, consequently improving safety and quality in the radiation therapy workplace.

Conclusion Although simulated practice can never replace the invaluable experience of working with real patients, 3-D VERT technology can help bridge the gap between the classroom and the clinic and enhance the student’s skill set, which the literature states is a major issue facing educators.

Keywords radiation therapy, radiation therapy education, Virtual Environment Radiation Therapy, virtual simulation in radiation therapy education

13

Peer Review

RADIATION THERAPIST, Spring 2016, Volume 25, Number 1

Schinman, Trad

Many health care professions have been investigat-ing the use of virtual simulators to enhance students’ learning, develop problem-solving and reasoning skills, increase self-confidence, and improve clini-cal judgment.7-9 Simulation is an effective teaching tool in today’s health care classroom; however, little research has been done on the radiation therapy class-room. Lasley and Ganley described VERT technology and documented the findings of other fields, stating that VERT allows students to learn the basics in the classroom and therefore be better prepared for more advanced learning in the clinic.10 By graduating better-prepared radiation therapists, patient safety also is increased, which is a top priority in this field.6

Lozano discussed effective training strategies and the importance of clear communication to minimize errors and increase safety in patient care.6 The ever-increasing complexity of treatment equipment and plans means the responsibilities of educators are increasing. For students to be fully ready to enter this field at graduation, they must do more than simply set up patients appropriately; they must understand the rationale for each step they take in the treatment process. Because of this, Lozano stated, “future research must harness the ability of cur-rent technology, as well as find ways to apply the founda-tions of knowledge that keep practitioners personally involved in the treatment process and ensure safe patient care.”6 The ability of VERT technology to allow students to visualize the beam and the effects it has on the tumor and nearby critical structures and to personally manipu-late the machinery has the potential to greatly affect their knowledge of the body and to increase precision and accuracy in their work as radiation therapists.

Although simulated practice will never replace what students learn while working with real patients in the clinical environment, it has the capability to increase skill levels and competence. Simulation also offers hands-on experience at the learner’s pace while not infringing on the patient’s or therapist’s time. One study evaluating students’ experience with an immersive visualization environment showed that 93% of students reported feeling more confident in their technical skills after working in the virtual environ-ment.3 They also reported that the experience was both “realistic and enjoyable,”3 which indicates that this type of learning environment might better meet the needs

projected in the classroom that includes hand-operated pendants to control the machine.4 Although VERT technology is relatively new to health care, it rapidly has become an effective teaching tool providing a solution for many programs that struggle to find resources to train students in the classroom.3,4

When incorporating VERT technology into a radia-tion therapy program, it is best to realign the entire curriculum to obtain the greatest amount of benefit. This case study describes one radiation therapy pro-gram’s attempt to restructure its current curriculum to incorporate VERT technology and to evaluate the results. The research question guiding this case study was “How can VERT technology be used to increase student skill sets in the cognitive, psychomotor, and interpersonal domains?” To investigate the findings of previous research regarding the use of simulators in health care education, we conducted an online litera-ture search using PubMed and EBSCOhost, with the key terms virtual simulation in health care education, simulation in education, and virtual simulation in radia-tion therapy education.

Review of the LiteratureVertual, the company that created VERT technology,

was founded in 2007.4 More than 100 installations have been performed worldwide, and 14 are in the United States.4 VERT allows students to safely learn treatment procedures in a noncritical environment, encourages the development of psychomotor (hand-eye coordina-tion) skills by allowing students to physically manipulate the machinery, and fosters a greater understanding of treatment planning and anatomy.4 The 3-D technology allows students to visualize the radiation beam as it exits the treatment head and moves through the body, giving students a visual sense of “spatial anatomy, organs at risk, beam paths, and dose distribution.”3

Research indicates that students feel immense pres-sure to learn both the patient care side of radiation ther-apy while mastering the psychomotor skills necessary to administer treatments.3,4 This pressure, coupled with the burden clinical therapists carry to stay on time and mini-mize treatment delays,5 can lead to students’ inability to fully master clinical concepts. Radiation therapists must be fully trained and competent at the time of graduation to ensure the safety of their future patients.6

14

Peer Review



of this generation of students as opposed to learning through lecture or on phantoms.

Other researchers emphasize the need for a more patient-centered approach to teaching and worry that focusing too much on technology and not on develop-ing patient care and empathy skills can lead to lower patient satisfaction.11 A balance between teaching tech-nical skills and soft skills will produce well-rounded therapists by the time they graduate. Therefore, adapt-ing the curriculum to incorporate technology such as VERT needs careful planning and consideration.12 Educators must take into consideration the goals they aim to achieve with use of the technology, as well as how they want it to affect students’ clinical practice.12 This study focused on the 3 domains recognized by the American Registry of Radiologic Technologists (ARRT) in its Scope of Competence Assessment: cognitive, psychomotor, and interpersonal.13 These assessment criteria ensure that students are trained to use critical thinking to make judgments, communicate clearly, and execute corrections precisely and accurately.

MethodsA case study is a type of research in which a particu-

lar phenomenon that has occurred in an intrinsically bound group is investigated.14 Data come from a specific population experiencing the event and representing a unit of analysis.14,15 We assessed a group of radiation therapy students enrolled in a simulation course that incorporated a unique curricular intervention offered only to these particular students. The purpose was to assess student learning and demonstrate how the 3-D VERT simulator could be used to bridge the gap between classroom and clinic learning and enhance students’ skill set. Data were obtained through a pre-test and post-test examination. Both assessments were divided into the 3 domains identified for analysis: cog-nitive, psychomotor, and interpersonal.

A convenience sample of 9 first-year radiation therapy students enrolled in the Principles of CT Simulation course at a 2-year, associate-degree program in Bellevue, Washington, participated in the study. The course was using the VERT system; therefore, other teaching vari-ables could be minimized. Because the sample size was small, a pilot study was not conducted. All students were required to participate, and participation was part of the

students’ overall grade. This course was chosen for inves-tigation of VERT because it had learning objectives tied to outcomes and the program curriculum, which related to the skills required to be a competent radiation thera-pist such as emphasizing the importance of spatial aware-ness in radiation therapy and identifying inconsistencies between the treatment plan and daily patient setup.

The students were advised that they would be pre-tested on course content at the beginning of the course and would be given a post-test at the end of the quar-ter. Course content, including VERT concepts, was delivered through lecture, and the students were given the opportunity to work with the VERT technology individually or in small groups throughout the quarter. Students also were encouraged to ask questions and apply the concepts in the clinical environment.

The pretests and post-tests were created by the instructor using the guidelines of the ARRT Scope of Competence Assessment (see Table 1). Each domain was purposely covered in class throughout the semes-ter. For the cognitive and interpersonal domains, the students’ grades were assigned according to the course rubric (see Table 2); for the psychomotor domain, the number of seconds it took students to make a shift after a command was recorded.

As it pertained to this study, the cognitive domain referred to critical thinking skills and the ability to make sound judgments. This domain was assessed using images with induced setup errors, for which students were required to determine the direction, amount, and type of correction needed.

As it pertained to this study, the interpersonal domain was considered the ability to verbalize thoughts and clearly communicate a necessary correction. Students in this course learn that not everyone interprets images the same way. Therefore, learning to clearly articulate thoughts using medical terminology is an important skill that improves team communication and effectively prevents errors. The interpersonal domain was assessed by determining students’ abilities to clearly communicate the needed correction in their responses.

For the cognitive and interpersonal domains, students were presented with 4 sets of images, consisting of 2 trans-lational errors and 2 rotational errors. The rubric used for these 2 domains contained a total of 8 possible points, and a score of 8/8 points resulted in a score of 100%.

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The psychomotor domain was assessed using hands-on timed testing to evaluate the student’s ability to make an accurate shift after a given command. A simu-lated patient with skin markings was positioned in the virtual environment on the treatment table. Lasers were projected onto the patient to represent the isocenter. Because placing a ruler on the patient is not an option in a virtual environment, students were limited to using the digital readout for precision in measurement. However, the students could see the patient and table moving as if they were in a treatment vault.

For the assessment, students were asked to shift a patient in a certain direction, such as 2 cm superior or 1.5 cm lateral. The students then had to follow the command and make the shift in the direction they believed was

accurate. The instructor recorded the amount of time in seconds that it took each student to complete the move, using hand pendants and digital readouts. If the students moved in the wrong direction without realizing it, the instructor prompted them to correct the mistake and included the extra time in the assessment.

Throughout the course, students were able to prac-tice with the VERT technology and develop the ability to make a judgment for correction of simulated errors. Students’ scores are reported for both the pretest and post-test to document the change in knowledge.

ResultsPretest and post-test scores were obtained from

the 9 students for all 3 domains. The figures provide

Table 1

American Registry of Radiologic Technologists Scope of Competence Assessment13

For each procedure, candidates are expected to demonstrate competence in the cognitive, psychomotor, and interpersonal domains. This table offers a general guide to competence assessment in each of the 3 domains. It is recognized that most activities actually fall into more than 1 domain.

Cognitive domain As part of providing treatment, candidates should demonstrate their understanding of concepts related to anatomy, physiology, pathology, and dose to critical structures. Candidates should also recognize complications and adverse effects commonly associated with each treatment procedure. If facilities have a limited number of treatment options, candidates should also describe alternative treatment procedures (eg, intensity-modulated radiation therapy, image-guided radiation therapy, or stereotactic therapy) and explain how those procedures might apply to a given case.

Psychomotor domain Candidates should demonstrate competence in performing activities such as verifying treatment param-eters, setting up the treatment unit, positioning the patient, monitoring the patient during treatment delivery, and documenting treatment delivery.

Interpersonal domain Candidates should demonstrate ongoing sensitivity to and compassion for each patient’s physical and emotional well-being and interact with members of the radiation therapy treatment team.

Table 2

Rubric for the Cognitive and Interpersonal Domains

0 points 1 point 2 points

Student does not state correct direction or amount of needed correction. Also does not communicate the procedure to a fellow therapist.

Student indicates correct direction and amount of needed correction but does not communicate the procedure.0.5 point deducted for incorrect direction or amount.

Student indicates correct direction and amount of needed correction and clearly communicates to a fellow therapist the procedure to make the correction in the treatment room.

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examples of pretest and post-test problems for each of the domains. Students’ ages ranged from 20 to 45 years, and there were 3 male and 6 female students.

Cognitive DomainDuring the pretest, 67% of students demonstrated

the ability to state the correct direction and amount of shift necessary on the first set of translational errors, and 100% demonstrated the ability on the second set. Forty-four percent of the students demonstrated the ability to state the correct direction and amount of shift on the first set of rotational errors, and 61% demon-strated it on the second set (see Table 3). These results indicate that rotational errors pose more of a challenge than translational errors.

For the post-test, 89% of students demonstrated the ability to state the correct direction and amount of shift necessary on the first set of translational errors, and 78% demonstrated it on the second set. Fifty-six percent of the students demonstrated the ability to state the correct direction and amount of shift on the first set of rotational errors, and 67% demonstrated it on the sec-ond set (see Table 3).

From pretest to post-test, there was some improve-ment on the translational sets and moderate improve-ment on the rotational sets. Because the image sets varied in treatment areas, such as the thorax or pelvis, the level of difficulty could be related to the student’s familiarity with patient anatomy, as well as isocenter placement.

Psychomotor Timed AssessmentThe purpose of the timed test was to simulate the

pressure of the real-world clinic environment and to assess psychomotor skills. Two command shifts were given for both the pretest and post-test. During the pretest for the first rotational shift command, 4 stu-dents (44%) made the move in less than 20 seconds, 3 (33%) made it in 20 to 29 seconds, 1 student made it in 30 to 39 seconds, and 1 student made the move in 40 to 49 seconds. For the second shift command, 5 (56%) students made the move in less than 20 sec-onds, and 4 (44%) made it in 30 to 39 seconds (see Figure 1).

During the post-test for the first command shift, 1 student made the move in less than 10 seconds, 3 (33%) made it in 10 to 19 seconds, 4 (44%) made it in 20 to 29 seconds, and 1 made it in 30 to 39 seconds. For the second command shift, 1 student made the move in less than 10 seconds, 6 (67%) made it in 10 to 19 seconds, and 2 (22%) made it in 20 to 29 seconds (see Figure 2).

The amount of time it took students to complete the shift varied greatly. This could be because of uncer-tainty about which direction to move or how much to move, moving in the wrong direction and taking extra time to make a valid correction, or students second-guessing themselves. Nonetheless, there was moderate improvement in overall speed and confidence between the pretests and post-tests.

Table 3

Scoring for the Cognitive and Interpersonal Domainsa

Domain Set Pretest (%) Post-test (%)

Cognitive First translational 67 89

Second translational 100 78

First rotational 44 56

Second rotational 61 67

Interpersonal First translational 78 89

Second translational 67 78

First rotational 44 89

Second rotational 67 89aFour image sets were used to test the cognitive and interpersonal aspects of translational and rotational errors. Each image set was assigned a total of

2 points, for a total of 8 possible points; therefore, 8/8 = 100%. Both pretests and post-tests are shown for comparison.

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Interpersonal DomainDuring the pretest, 78% of

students demonstrated the ability to clearly communicate the move necessary to correct the setup on the first set of translational errors, and 67% demonstrated it on the second set. Forty-four percent of students demonstrated the abil-ity to clearly communicate the move on the first set of rotational errors, and 67% demonstrated it on the second set. These results indicate that there was moderate room for improvement in com-munication.

During the post-test, 89% of students demonstrated the abil-ity to clearly communicate the move necessary to correct the setup on the first set of trans-lational errors, and 78% dem-onstrated it on the second set. Eighty-nine percent of students demonstrated the ability to clear-ly communicate the move on the first set of rotational errors, and 89% demonstrated it on the sec-ond set (see Table 3). The post-test indicates major improve-ment in the students’ ability to communicate, especially in the sets involving rotational errors, which require repositioning the patient as opposed to shifting the table.

VERT was used to create images and to simulate pitch error in the pelvis. Figures 3 to 5 show examples of how a rotational setup error can be mistaken for a translational error. Translational moves are along 3 planes: lateral, longitudinal, and vertical. Rotational moves are referred to as pitch, yaw, and roll.

1st shift

2nd shift

Num

ber o

f Stu

dent

s

Psychomotor Timed Post-Test

Seconds

6

5

4

3

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Figure 2. The post-test results for the psychomotor domain show that the majority of shifts were made between 20 and 30 seconds; some were less than 10 seconds. Compared with Figure 1, shifts were faster.

1st shift

2nd shift

10 10-19 20-29 30-39 40-49

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Figure 1. The pretest results of the psychomotor, or hands-on, timed testing show that the majority of shifts were made between 20 and 50 seconds.

10 10-19 20-29 30-39 40-49

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Translational errors can be corrected by making shifts in lateral, lon-gitudinal, or vertical planes. Rotational errors rotate along an axis; therefore, they must be cor-rected by repo-sitioning the patient along the lateral, longitu-dinal, or vertical axis. Pitch cor-rections are made on the lateral axis; the most common errors involve the mandible or a pelvic rock-ing motion. Roll corrections are made along the longitu-dinal axis, such as rolling a patient during triangulation, and yaw corrections are made along the vertical axis, usu-ally requiring moving the patient’s hips or shoulders (see Figure 6).

Misalignment in pitch along the lateral axis (com-mon with the mandible and pelvis) might appear to be a superior or inferior discrepan-cy when solely viewing from the anteroposterior dimen-sion. For example, compare the pelvis in Figure 4 with that in Figure 5. Additional projec-tions, such as those illustrated in Figure 3, or 3-D images help to differentiate between

Figure 3. In the clinic, this image is known as kV-kV match overlay. Conventional port films cannot be overlaid. Green and purple mismatch displays pelvic tilt error, or “pitch.” Images courtesy of the author.

Figure 4. Anteroposterior (AP) view, with the pelvis in the correct setup position (no translational or rota-tional error). Image courtesy of the author.

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Students indicated that the practice of determining setup errors and making the corrections was most helpful in developing and improving skills. In-depth discussions often followed activi-ties dealing with communica-tion errors as a result of varying perspectives, department jargon, and designation of machine coordinates, which indicated that the students were engaged in the learning and were starting to make connections between didac-tic and clinical learning. Although simulated practice can never replace the invaluable experience of working with real patients, it bridges the gap between the class-room and the clinic, which the literature states is a major issue facing educators.2,7

Use of VERT technology in the classroom demonstrated radiation therapy students’

improvement in technical communication and com-petence. Although the findings are not unique, the purpose of this study was to determine whether VERT technology is suitable as a teaching tool in the radiation therapy classroom. Major limitations of this study were the small sample size and that data were collected after only one quarter. Because this class represented the typical size of a radiation therapy class, the size served its purpose; however, in future research, monitoring a larger group of students would be ideal. In addition, this was an initial examination into the use of VERT to determine how much students learned from the soft-ware. Future research could compare a control group at another institution that does not use VERT with a group that uses VERT and conduct statistical analysis between the 2 groups. Future research also could be geared toward finding other courses that might benefit from VERT technology, creating more images and sce-narios for students to practice on, and allowing licensed radiation therapists to use the equipment for refresher courses or continuing education.

a translational and rotational discrepancy. In this case, there is a pitch error in patient position. In other words, a longitudinal shift would not correct the error. Instead, the therapist should instruct the patient to readjust his or her pelvis by tilting toward or away from the ceiling.

DiscussionThroughout the quarter, students demonstrated

competency in many of the course’s learning outcomes using VERT technology to: Describe patient positioning strategies. Analyze the use of specific positioning devices. Increase accuracy and speed when making an

anatomical shift. Clearly communicate to a fellow radiation

therapist how to move the patient. Differentiate between a translational error and a

rotational error. Demonstrate how to correct for each error. Assess images. Evaluate shifts.

Figure 5. AP projection indicating a possible 1-cm superior to inferior error, which in actuality is a pitch error as shown in Figure 3. Image courtesy of the author.

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Linda Schinman, MBA, R.T.(T)(CMD), is associate professor for the radiation therapy program at Bellevue College in Bellevue, Washington.

Megan Trad, PhD, MSRS, R.T.(T), is associate pro-fessor for the radiation therapy program at Texas State University, San Marcos, Texas. Trad is vice chairman of the Radiation Therapist Editorial Review Board and can be reached at [email protected].

Reprint requests may be mailed to the American Society of Radiologic Technologists, Communications Department, at 15000 Central Ave SE, Albuquerque, NM 87123-3909, or emailed to [email protected].

© 2016 American Society of Radiologic Technologists

AcknowledgmentsThis project was funded by a Bellevue College Foundation

minigrant. Vertual, Ltd, granted permission to publish this article.

References1. Lozano RG. A review of literature: learning conditions of

radiation therapists. Radiat Ther. 2012;21(1):7-17.2. Palmer C, Naccarato N. Differences in radiation therapy staff

and students’ perceptions of clinical teaching characteristics. J Radiother Pract. 2007;6(2):93-102.

3. Bridge P, Appleyard RM, Ward JW, Philips R, Beavis AW. The development and evaluation of a virtual radiotherapy treatment machine using an immersive visualisation environ-ment. Comput Educ. 2007;49(2):481-494.

4. Vertual. The flight simulator for linacs. http://www.vertual.eu /products/vert. Accessed September 16, 2015.

5. Ash D, Barrett A, Hinks A, Squire C; Royal College of Radiologists. Re-audit of radiotherapy waiting times 2003. Clin Oncol. 2004;16(6):387-394.

6. Lozano RG. Characterizing a culture of training and safety: a qualitative case study in radiation oncology. Radiat Ther. 2013;22(2):139-153.

7. Rogers L. Developing simulations in multi-user virtual envi-ronments to enhance healthcare education. Br J Educ Technol. 2011;42(4):608-615. doi:10.111/j1467-8535.2010.01057.x.

8. Mason PB, Turgeon BM, Cossman JS, Lay DM. The use of technology and perceptions of its effectiveness in training physicians. Med Teach. 2014;36(4):333-339. doi:10.3109/0142159X.2014.887837.

Figure 6. Translational planes and rotational axes. AP-PA, anteroposterior-posteroanterior.

Sagittal

Coronal

Transverse

Sagittal

Coronal

Transverse

Sagittal

Coronal

Transverse

Sagittal

Coronal

Transverse

Sagittal

Coronal

Transverse

Coronal (Frontal) PlaneDivides the body into front and back portions.Yaw Rotation along the AP axis Bringing your ear close to your

shoulder

Sagittal PlaneDivides the body into right and left portions.Roll Rotation in the left-right axis Shaking your head indicating

“no”

Transverse PlaneDivides the body into upper and lower portions.Pitch Rotation in the SI axis Nodding your head indicating

“yes”

Sagittal planex-axis

Coronal planey-axis

Transverse planez-axis

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9. Chow M, Herold DK, Choo T-M, Chan K. Extending the technology acceptance model to explore the intention to use Second Life for enhancing healthcare education. Comput Educ. 2012;59(4):1136-1144. doi:10.1016/j.compedu.2012.05.011.

10. Lasley J, Ganley C. Virtual environment radiation therapy. Radiat Ther. 2015;24(1):105-106.

11. Trad M. Teaching communication skills and empathy through engaged scholarship. Radiat Ther. 2013;22(1):21-31.

12. Edelbring S, Dastmalchi M, Hult H, Lundberg IE, Dahlgren LO. Experiencing virtual patients in clinical learning: a phenomenological study. Adv Health Sci Educ Theory Pract. 2011;16(3):331-345. doi:10.1007/s10459-010-9265-0/.

13. American Registry of Radiologic Technologists. Primary certification: didactic and clinical competency requirements: radiation therapy. https://www.arrt.org/pdfs/Disciplines /Competency-Requirements/THR-Competency-Require ments.pdf. Published January 2014. Accessed March 15, 2015.

14. Merriam SB. Qualitative case study research. In: Qualitative Research: A Guide to Design and Implementation. 3rd ed. San Francisco, CA: Jossey-Bass; 2009:40-55.

15. Patton MQ. Designing qualitative studies. In: Qualitative Research & Evaluation Methods. 3rd ed. Thousand Oaks, CA: Sage; 2002:230-243.


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Background Bolus material is commonly used in radiation therapy to bring the radiation dose closer to the skin sur-face to treat superficial lesions. Many types of bolus can be used, each possessing advantages and disadvantages.

Discussion The literature review detailed 2 common types of bolus materials: water and Superflab. Analysis of 3 case studies revealed that in each case, the patient setup was unique and required creative bolus design. Water was found to be a versatile bolus option for all 3 cases.

Conclusion Using the correct type of bolus when treating a superficial lesion with radiation prevents underdosing the tumor and overdosing healthy structures. Radiation therapists should be aware of the types and uses of bolus to assess patients accurately and determine the most appropriate bolus material for treatment.

Amara Miescke, BS, R.T.(T)

Bolus in Radiation Therapy: The Versatility of Water

In 2015, it was estimated that more than 1.6 million Americans would be diagnosed with cancer.1 Radiation therapy, alone or with the use of surgery and chemotherapy, will be used in the treatment of

the majority of these cancers.2 Some cancers treated with radiation are superficial lesions.3 In such cases, bolus usually is needed to bring the radiation dose clos-er to the patient’s skin surface where the tumor is locat-ed.2-10 Bolus also might be needed for patients with sur-face irregularities to compensate for missing tissue and ensure a uniform dose is delivered to the tumor.2-4

Bolus is defined as a material that mimics the properties of tissue when interacting with the radia-tion beam.2,3,5,6 Many materials can be used as bolus in radiation therapy (see Box).2-10 Each type of bolus has distinct properties and possesses unique benefits and limitations. Radiation oncology professionals should be aware of the types of bolus materials and be able to select the best option for a patient’s treatment.

Radiation therapists are responsible for fabricating a bolus and placing it on the patient for each session. Although radiation therapists might be familiar with a bolus used at their facility, it is important to under-stand how each type of bolus material works and how it can be used in conjunction with another bolus. This

article reviews 2 common types and uses of bolus and highlights 3 cases where water is used in tandem with a second bolus material to achieve the most effective and accurate dosage for a patient.

Review of LiteratureExternal-beam radiation therapy typically works by

using megavoltage photons to treat deep tumors while sparing healthy skin.3,5,7 However, patients frequently

Box

Types of Bolus Used in Radiation Therapya

Alginate (eg, Jeltrate Plus [DENTSPLY International]) Hydrophilic polymers (eg, Super Stuff [Radiation Products Design Inc], Polyflex [DENTSPLY]) Modeling compounds (eg, Play-Doh [Hasbro]) Petroleum-based materials (eg, Aquafor [Beiersdorf]) Synthetic oil gels (eg, Superflab [CNMC Company], Superflex [Radiation Products Design Inc]) Tantalum wire mesh Thermoplastics (eg, Aquaplast [Qfix]) Uncooked rice WateraThis is not intended to be a complete list of all bolus materials.

Keywords radiation therapy, water, bolus, superficial lesions

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addition, water molds to the skin’s surface without any air gaps, filling in spaces and conforming to even the most irregular tissue cavities, such as the ear.3 Another benefit is that water bolus can be reproduced with little variation by filling a container, bag, balloon, or cavity with the same amount of water each time. Water bolus also can be used with other bolus materials to eliminate limitations created by using only one type of bolus. Finally, water is inexpensive, readily available, and requires little to no fabrication time.3

Despite its benefits, water cannot be used to treat all types of patient contours because of the difficulty of containing it.3 For example, it is easy to contain water in the ear canal, but it is impossible to contain it on a slop-ing surface such as a chest wall. Water bolus also can be uncomfortable for patients.3 Some patients might dislike or be unable to tolerate having their ear canal or other cavity filled with water repeatedly.

SuperflabSuperflab is a vinyl-based, synthetic oil gel sheet con-

sidered a tissue equivalent material (see Figure 1).3,5,6 Sheets of Superflab come in a variety of thicknesses, with

present with tumors close to the skin’s surface or directly on the skin.3 In these cases, the skin-sparing effect of megavoltage machines is unwanted because it will cause the beam to penetrate past the tumor.3 To treat these super-ficial lesions, a bolus is placed on the patient’s skin.2-10 The bolus acts as a layer of tissue that scatters and absorbs some of the radiation, bringing the dose closer to the sur-face.3,5 Because bolus acts like tissue, it also can be used to compensate for surface irregularities and air cavities, such as an ear canal, to create a more consistent surface area.2-4 A uniform surface area allows the radiation beam to penetrate evenly through the patient and gives a more homogenous dose to the entire tumor.2,4

Bolus was first used in the 1920s and routinely is used today.3,6 Studies show the most beneficial bolus materials2-6,10: Have the same density as soft tissue. Adhere to the patient’s skin without air gaps. Are easy to shape. Can be reproduced every day with little variation. Two common bolus materials used in the clinic are

water and Superflab (CNMC Company). Each one has unique properties with advantages and disadvantages. The more familiar radiation oncology professionals are with the different types and properties of bolus materi-als, the better their ability to select the best option for the patient’s treatment.

WaterWater is one of the oldest bolus materials still in use

today.3 It can be used in a variety of ways to achieve skin-sparing effects and dose homogeneity.3 One method that works well for lesions on extremities is filling a container with water and then submerging the lesion.3 To achieve this, the patient stands or sits and fully submerges his or her hand or foot in the water bath. Water also can be used as bolus by filling a bag or balloon with water and insert-ing it into a cavity.2,3 This technique is useful when treat-ing the orbit or nasal cavity.3 Finally, water can be used to fill cavities such as an ear canal or umbilicus. The water fills in the space where tissue is absent, allowing delivery of a homogenous dose to the target.3

The largest advantage of water bolus is that water has the same density as tissue, 1.0 g/cm3.3 This allows the radiation beam to penetrate water exactly as it pen-etrates tissue, making the dose distribution equal. In

Figure 1. A 30-cm square, 0.5-cm sheet of Superflab bolus. Image courtesy of the University of Wisconsin Hospital and Clinics.

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0.5 cm and 1.0 cm being the most common. Sheets are typically 30-cm square.5-7 Superflab is soft, malleable, semitransparent, and versatile.3,5 It conforms well to large, sloping surfaces with irregular contours and is ideal for areas such as the breast, chest wall, and neck.3,5,7 Superflab also can be laid on top of superficial skin lesions to bring the radiation dose closer to the surface where the lesion is located.3,5 Superflab is manufactured to a density of 1.02 g/cm3, which is close to the density of soft tissue (1.00 g/cm3), and attenuates radiation simi-larly.3,5 In addition, it can be washed and reused, does not dry out over time, and can be cut easily to the desired size and shape.3,5

One primary disadvantage of Superflab is that it can introduce air gaps between the bolus and the patient’s skin.3-5,7 When air gaps are present in a treatment field, the dose delivered to the patient’s skin is reduced.5,7 The bigger the air gap, the greater the decrease in surface dose.5,7 Thus, Superflab must adhere to the patient with minimal air gaps to avoid underdosing superficial lesions. The size of the field also impacts the effect of the air gaps.5,7 Larger fields have more scatter and for-ward penetration than smaller fields, making smaller fields more problematic and susceptible to reduced dos-age.5,7 Radiation therapists must pay special attention when placing the Superflab to ensure that minimal air gaps are created between the bolus and the patient’s skin. Ways to reduce air gaps include using a sticky bolus in tandem with Superflab so that it better adheres to the patient’s skin or using tape to help secure the Superflab to the patient.

Another disadvantage comes from the thickness of Superflab. Even though it is f lexible, it can be too thick and not f lexible enough to account for intricate, irregu-lar surfaces like the inside of an ear or between fingers without introducing significant air gaps.5

Case DescriptionsCase 1: Water and Superflab

An 82-year-old man had received a diagnosis of pro-gressive T-cell lymphoma, not otherwise specified, with large cell transformation and progressive disease in both hands. He was treated with a conventional linear accel-erator using 6 MV photons. He received 10 fractions, 2 Gy each, for a total of 20 Gy to each hand. A water bath lined with Superflab was used as bolus for each hand

to conform to the irregular contours of the extremity and increase the dose to the lesions. The water bath was constructed by placing a 1.0-cm sheet of Superflab in the bottom of a Plexiglas container and then filling the container with water. The Superflab provided a material for backscatter, which the physics staff determined was needed to give a homogeneous dose to the treatment area. Without the Superflab material, the hand would have been underdosed by approximately 7%.

For treatment setup, the patient placed his hand in the water bath and spread his fingers apart as far as possible. He then positioned his body toward the inferior por-tion of the water bath and turned his face away from the gantry to increase the distance between his body and the water bath and decrease the radiation that reached the rest of his body (see Figure 2). The container was filled with water to a depth of 9 cm, measured from the top of the Superflab sheet, not from the bottom of the con-tainer. Finally, the water bath was adjusted so the 100-cm source-to-skin distance fell on the surface of the water bath (see Figure 3). It was important to check the field

Figure 2. Patient positioned at the most inferior portion of the water bath with his face turned away from the gantry for the treatment of his right hand. The treatment of his left hand mirrored this setup. Image courtesy of the University of Wisconsin Hospital and Clinics.

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Case 2: Water and AquaphorAfter Mohs surgery, a 78-year-old woman with a

basal cell carcinoma of the triangular fossa of the left ear was treated with a conventional linear accelerator using 6 MeV electrons. She received 17 fractions, 3 Gy each, for a total of 51 Gy. A 5-cm custom electron cutout was used to define the radiation field. Water was used in conjunction with Aquaphor as a bolus for the left ear. The patient was positioned head first, lying on her right side. Water was used to fill her ear canal, and Aquaphor was used to fill the pinna of the ear so it was level (see Figure 5).

The patient was then aligned using the source-to-skin distance and field light. It was important that the source-to-skin distance was 105 cm because that is the standard distance used for electron irradiation at the treatment facility. It also was important that f lash was around the superior and lateral aspects of the ear, and inferiorly the field light ended at the level of the tragus. A piece of molded red wax was then positioned around the ear to reduce dose to healthy structures (see Figure 6). Once these steps were completed, treatment was delivered to the left ear.

Figure 4. An alternate view of the patient’s hand submerged in the water bath demonstrating the extent of this patient’s disease before treatment. Fingers are spread out as far as possible, and the red line around the patient’s hand indicates the treatment field light. Flash should be around all parts of the hand except the proximal portion where the hand meets the wrist. Image courtesy of the University of Wisconsin Hospital and Clinics.

Figure 3. Patient’s hand submerged in the water bath demonstrat-ing water depth and lateral laser position. Image courtesy of the University of Wisconsin Hospital and Clinics.

Figure 5. Water and Aquaphor bolus applied to the patient’s ear. The Aquaphor fills the pinna of the ear and makes the surface of the ear smooth and flat. The yellow wire outlines where the flash was laterally and superiorly, ending inferiorly at the level of the tragus. Image cour-tesy of the University of Wisconsin Hospital and Clinics.

light to make sure the entire hand was within the treat-ment field with additional flash around all parts of the hand except the most proximal region; this limited dose to the wrist and forearm (see Figure 4). Once these steps were completed, the treatment was delivered to the first hand and then all steps were repeated for treatment of the opposite hand.

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Case 3: Water and SuperflabA 71-year-old woman received a diagnosis of bili-

ary adenocarcinoma of extrahepatic origin with direct extension into liver parenchyma and positive margins at the time of surgical resection. She then developed a secondary malignant neoplasm of the retroperitoneum and peritoneum. Her umbilicus region was treated on a conventional linear accelerator using 6 MV photons. She received 10 fractions, 3 Gy each, for a total of 30 Gy. The umbilicus was treated using 2 photon beams: a right anterior oblique and a left anterior oblique.

Water was used in conjunction with a 5-mm sheet of Superflab as bolus to bring the dose closer to the sur-face lesion. The water conformed to the irregular con-tours of the inside of the umbilicus and a 5-mm sheet of Superflab covered her abdomen (see Figure 7). The patient then was aligned using the isocenters marked on her body. A final check was done with the field light to ensure the bolus was covering the entire field. Once these steps were complete, a physical wedge was put into place and the dose was delivered from the right anterior oblique. The wedge then was f lipped, and the dose was delivered from the left anterior oblique.

DiscussionCase studies allow radiation oncology profession-

als to understand how other facilities address diffi-cult cases, which they can use during similar patient

encounters. The case studies presented in this article demonstrate the benefits of water bolus when treating irregular contours. In Case 1, the water conformed to all parts of the hand equally and filled the irregular spaces between the fingers without any air gaps, help-ing to deliver a homogeneous dose to the patient’s lesions. In Case 2, the water, in addition to Aquaphor, filled in the irregular tissues of the ear without any air gaps for an evenly distributed dose to the lesion. In Case 3, the water filled the umbilicus so that once the Superf lab was placed on top, no air gaps existed, and an even dose was distributed to the lesion. All 3 cases demonstrate the benefits of using water as an inexpensive, readily available, and easy-to-fabricate bolus. The cases also exhibit how water can be used in conjunction with other bolus materials to optimize the patient’s treatment plan.

All patients were treated and noticed shrinkage in their lesions or decreased pain by the first scheduled follow-up visit. The most noticeable and rewarding example of this was witnessed with the patient in Case 1. The patient experienced a reduction in his lesions almost immediately, and by the end of his treatment, he had sig-nificantly less pain and increased mobility of his fingers.

Although these cases illustrate the many benefits of water as a bolus material, a few disadvantages were noted. In Case 1, the water bath was cumbersome and messy because of water spillage. Overall, this disadvantage was

Figure 7. Water was used to fill the umbilicus, and the Superflab was placed over the abdominal region. Image courtesy of the University of Wisconsin Hospital and Clinics.

Figure 6. Water bolus and Aquaphor applied to the patient’s ear and red wax positioned to protect the healthy structures around the ear. The black marks indicate where the field light was terminated inferiorly, at the level of the tragus. Image courtesy of the University of Wisconsin Hospital and Clinics.

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References1. American Cancer Society. Cancer facts and figures 2015.

http://www.cancer.org/acs/groups/content/@editorial /documents/document/acspc-044552.pdf. Published 2015. Accessed January 24, 2015.

2. Coleman AM. Treatment procedures. In: Washington CM, Leaver D, eds. Principles and Practice of Radiation Therapy. 3rd ed. St Louis, MO: Mosby Elsevier; 2010:158-179.

3. Vyas V, Palmer L, Mudge R, et al. On bolus for megavolt-age photon and electron radiation therapy. Med Dosim. 2013;38(3):268-273. doi:10.1016/j.meddos.2013.02.007.

4. Gerbi BJ. Radiation therapy using high-energy electron beams. In: Kahn FM, Gerbi BJ, eds. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:365-392.

5. Benoit J, Pruitt A, Thrall D. Effect of wetness level on the suitability of wet gauze as a substitute for Superflab as a bolus material for use with 6 MV photons. Vet Radiol Ultrasound. 2009;50(5):555-559. doi:10.1111/j.1740-8261.2009.01573.x.

6. Walker M, Cogen N, Menchaca D. Play-Doh and water-soaked gauze sponges as alternative bolus material for cobalt-60 teletherapy. Vet Radiol Ultrasound. 2005;46(2):179-181. doi:10.1111/j.1740-8261.2005.00033.x.

7. Khan Y, Villarreal-Barajas JE, Udowicz M, Sinha R, Muhammad W. Clinical and dosimetric implications of air gaps between bolus and skin surface during radiation therapy. J Cancer Ther. 2013;4(7):1251-1255. doi:10.4236/jct.2013.47147.

8. Huang KM, Hsu CH, Jeng SC, Ting LL, Cheng JC, Huang WT. The application of Aquaplast Thermoplastic as a bolus material in the radiotherapy of a patient with classic Kaposi’s sarcoma at the lower extremity. Anticancer Res. 2006;26(1B):759-762.

9. Hsu SH, Roberson PL, Chen Y, Marsh RB, Pierce LJ, Moran JM. Assessment of skin dose for breast chest wall radiotherapy as a function of bolus material. Phys Med Biol. 2008;53(10):2593-2606. doi:10.1088/0031-9155/53/10/010.

10. Vassil A, Pavelecky N, Magnelli A, Videtic G. General physics principles. In: Videtic G, Vassil A, eds. Handbook of Treatment Planning in Radiation Oncology. New York, NY: Demos Medical Publishing; 2011:1-14.

insignificant and could have been overcome with more careful handling. More significantly, the patient in Case 2 was unable to withstand the water bolus for the duration of the treatment. The sensation of water in her ear canal was intolerable, forcing the therapist to adjust the treat-ment setup. Although not suitable for this patient, water bolus in cavities, such as the umbilicus discussed in Case 3, benefits many patients. Oncology professionals have to assess each patient on an individual basis.

ConclusionFinding the correct type of bolus for the patient and

tumor location is an important step to treating superfi-cial lesions. If the correct type of bolus is not used, there is risk of underdosing the tumor and overdosing healthy structures.3 Bolus material comes in many forms, all of which possess unique benefits and limitations.2-10 Water can be an effective bolus in situations with irregular contours, but it is not practical for all patients because it needs to be confined and can be uncomfortable. No one type of bolus is significantly better than the others or works for all situations. Often, more than one bolus material is required. Radiation oncology professionals should understand the different types of bolus materi-als, how the materials can work together, and how to select the correct bolus for each treatment.

The bolus materials described here are some of the most common types. Newer types of bolus materi-als exist, but they do not offer many advantages over traditional bolus materials. Additional study of the many types of bolus materials, new and old, is needed. Radiation therapists have the important responsibility of constructing the bolus materials and placing bolus on the patient’s skin for each session.2,3 Therefore, they should be familiar with the different types of material available and become experts in using the materials pro-vided at their facilities.

Amara Miescke, BS, R.T.(T), is a recent graduate of the radiation therapy program at the University of Wisconsin – La Crosse. She works for Columbia Saint Mary’s Hospital in Milwaukee, Wisconsin. She can be reached at [email protected].

Grass-roots Advocacy Action Center Find contact information for your elected federal, state and

local offi cials. Contact your legislators and take action.

Check it out at www.asrt.org/takeaction.

State Legislative and Regulatory Tracking ToolASRT members can Access regulatory and legislative news by state or other

searchable criteria. Search pending and enacted legislation. Keep current on changes affecting your practice and

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Background A qualitative research study was implemented in a radiation therapy program in central Texas with 13 partici-pants to find out whether photovoice is an effective teaching strategy for Introduction to Radiation Therapy students.

Discussion Students documented and reflected on the patient–student journey during radiation treatment with the use of photovoice. Data were gathered through a demographic questionnaire, photovoice project pictures and captions, class discussions, student-written reflections, and field notes.

Conclusion Study findings demonstrated student learning about issues affecting patients with cancer and about the pri-mary goal of becoming a radiation therapist. By collecting the photographs, the students looked critically at the patients’ experience and learned that listening to patients’ stories was helpful in understanding their needs and struggles. This article presents an innovative strategy to teaching in this field.

Megan Trad, PhD, MSRS, R.T.(T)Clarena Larrotta, PhD

Clinical Experiences of Radiation Therapy Students: A Qualitative Case Study Using Photovoice

Photovoice is a teaching approach that employs photography and group discussion as a means for radiation therapy students to deepen their understanding of issues that affect patients with

cancer. Students collect photographs and describe the photograph’s significance based on interactions with their patients and the connections they make with theo-ry learned in the classroom. The Figure 1 vignette cap-tures the essence of the photovoice project implement-ed in an Introduction to Radiation Therapy course with 13 students. In this example, Karina used the picture of mints to report on an interaction with one of her patients. Photographs provided participating students with the opportunity to recall dialogue and experiences shared with their patients during their clinical work that were crucial to understanding what the patients were going through.

As explained by Pink, analyzing photographs implies the translation of visual evidence into verbal knowl-edge.1 Facts are embedded in photographs; carefully studying these facts allows researchers to produce knowledge that otherwise would be unavailable solely

Figure 1. The mints. “This picture represents an interaction I had with an 84-year-old male patient who was diagnosed with prostate cancer. He dreaded coming in for treatment because it was a daily reminder that he had cancer. He explained how he would always have 2 mints every day, 1 while he was sitting in the waiting room to be called for treatment and the other when he was being treated. He said he knew when the treatment was about to be over because that is when the mint would disappear in his mouth. I find this to be a unique cop-ing strategy. I felt a lot of sympathy for this patient because I knew he must have been in a lot of pain lying on the treatment table” (Karina). Image courtesy of the author.

Keywords photovoice, radiation therapy curriculum, teaching techniques

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through verbal interviewing.1 The aims of the photo-voice project were to explore an innovative teaching strategy that engages students in learning and encour-ages them to reflect on their clinical experiences, as well as to fulfill class objectives. Lecture is the most frequent teaching strategy used in introductory radiation therapy courses; however, it is important for students to have meaningful hands-on experiences and to reflect on those experiences for learning to be powerful.2

The Need for Engaging Teaching Strategies in Radiation Therapy

The methods used to educate students in radiation therapy programs vary from program to program; the American Society of Radiologic Technologists cur-riculum encourages creativity in instructional deliv-ery.3 All programs provide courses in patient care and ethics, and most courses are taught through lecture and fact memorization.4 Typically, hands-on, or expe-riential, curriculum is taught through clinical educa-tion. However, there is a push to integrate teaching techniques that actively involve students in the learning process and encourage them to become more reflective of their professional practice.2 As Greathouse and Dowd stated, “to become empathetic practitioners, students must learn how to put themselves in the patient’s place. They must learn to imagine the discomfort patients feel…the anticipation [patients] experience.”4 However, these are skills that cannot be taught sitting in a class-room taking notes.

A search of the literature in the ERIC, PubMed, and CINAHL databases showed little research about teach-ing techniques used in radiation therapy education to better engage students in their learning. Greathouse and Dowd encouraged the use of real-world experi-ences and an increase in students’ active participation in learning, but they did not offer strategies to implement these experiences in the radiation therapy curriculum.4 Other health care professions, such as nursing and med-icine, also have a need to instill empathy and patient care skills when training their students, and research-ers have investigated various strategies that seem to be productive in those fields.5,6 Both Webster and Winefield and Chur-Hansen used teaching strategies that encourage students to engage with patients.5,6 One strategy assigned students a patient with whom they

must build a relationship and asked students to reflect on that patient’s life and struggles. Another strategy was to conduct in-depth interviews on the patient’s life history and experience with disease. Both these strate-gies increased students’ empathy and provided health professions students with a broader understanding of a patient experiences.

Likewise, photovoice has been used in disciplines, such as anthropology, sociology, and history, as a means to increase empathy and as a participatory action research method based on health promotion principles and education for critical consciousness.7,8 Photographs acquired through a photovoice research project have the potential to empower study participants when they take the pictures and explain the meaning behind the image.1,8-10 In implementing this research project, the interest was in capturing the students’ clinical experiences. Asking the students to take photographs of meaningful events and instances illustrating their learning was an appropriate method by which to do this. As Haviland explained, photographs can be an accessible way into another person’s experience and an effective way to provide context for a project or event.7 Photographs can be an effective technique to get people’s attention and engagement in an idea or project.7 Asking the students to document their work at the clinic and reflect on the issues their patients faced during cancer treatment also requires that the students look critically at their clinical experience. As Haviland explained, photography allows researchers and their audiences to see the world in new ways and to make the invisible visible.7 The photovoice project was imple-mented as a teaching strategy to provide students the opportunity to be more reflective about their behavior and performance in the day-to-day activities of their clinical work experience.

MethodsThe research questions guiding this qualitative

study were: What can Introduction to Radiation Therapy

students learn from implementing a photovoice assignment?

How can the photovoice assignment help these students understand salient issues affecting patients with cancer?

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Participating students were asked to document and reflect on the patient–student journeys during radiation treatment with the use of photovoice. The assignment had the potential to help the students learn as well as to provide insight for the researchers.

SettingThe Introduction to Radiation Therapy course

offered in a radiation therapy program at a 4-year univer-sity in central Texas served as the setting for the study. The class had 13 students and is a required course for all students who enroll in the program. It is offered in the first semester of the program and introduces several con-cepts related to the profession such as principles related to cancer care, patient interaction, aspects of technology, and historical perspectives leading to current practices of cancer management. A variety of instructional strate-gies (eg, lecture, field-work discussion, and video analy-sis) are used in this course. However, the photovoice assignment aimed to help students understand salient issues that affect patients with cancer using a hands-on approach and building on student’s experiences working with clinic patients.

The Photovoice Assignment To start the assignment, the instructor explained

the usefulness of photovoice using an example picture of a patient’s reconstructive scar. She discussed the meaning of the photograph and provided a written reflection about the picture. The students were then asked to collect 1 photograph per week for 8 weeks and to document and reflect on salient issues that affect patients with cancer during radiation treatment. The students received a handout with the requirements for the assignment (see Box 1), a list of dos and don’ts for collecting images (see Box 2), and a consent form to obtain written permission from the patient to take a picture. The class met twice a week, and every Monday, students submitted 1 photograph electronically. Each photograph attempted to capture the essence of a mean-ingful story the students learned by communicating with the patients in the clinic. In addition, each student was required to create an electronic portfolio where he or she could upload photographs and share them with the instructor. Students used a variety of free photo-book Web sites (eg, Shutterfly, Snapfish, Walgreens).

ParticipantsA total of 13 students completed the assignment; 3

students (23%) were men and 10 (77%) were women. The ethnic diversity of the student population was as follows: white (n = 9, 69%), Hispanic (n = 3, 23%), and black (n = 1, 8%). All students were in their early 20s, with an average age of 21 years. In qualitative research, the sample size is relative to the conditions and characteristics of the research setting. In this case, the number of students in a typical radiation therapy class is small; therefore, this sample of 13 students was representative of the radiation therapy student popula-tion in an introductory course. Additional information about study participants relates to their lack of previous clinical work experience. When the project was first introduced, students seemed intrigued, and some were concerned about how they were going to obtain an interesting story and photograph each week.

Box 1

Project Requirements

Develop a portfolio documenting the photovoice project. Include a total of 8 pictures with corresponding captions. Write a cover letter presenting your project. Complete a midterm reflection on your progress with the project, indicate struggles or accomplishments, and describe images taken to this point. Write a final reflection and discuss your experience with the project, the process of obtaining the photographs, and your thoughts behind the images. Write a conclusion documenting (a) 3 things you would do differently or the same next time you implement this project, and (b) 3 things you learned from this experience.

Box 2

Dos and Don’ts for Collecting Images

Do take pictures of a variety of subjects (eg, people, inanimate objects, symbols). Do talk to patients to get their perceptions. Do reflect on what patients tell you and make meaning of it. Don’t obtain a picture of a person without consent. Don’t take pictures of patients or of yourself with a patient.

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Data SourcesFor data triangulation purposes, multiple data

sources were collected to add rigor to study findings and make sure data illustrating findings were strong.11 Data sources included a demographic questionnaire, photovoice project pictures and captions submitted electronically, class discussions and presentations, the student-written midterm and final reflections about the project, and researchers’ field notes. Every week in class, a few minutes were allotted to discuss the students’ clinical experiences and questions about the photovoice assignment. These discussions were recorded in writ-ing and became the study field notes. During this time, concerns and salient issues were discussed.

By the seventh week, the students completed a mid-term reflection in which they wrote about their progress, successes, and struggles in implementing the project. They also wrote and discussed the photograph captions submitted thus far. This was done during class while working in small groups. The students were expected to focus the captions on salient issues that affect patients with cancer and their learning journey working with the patients. Class discussions occurred throughout the semester and were helpful in capturing field notes. Often, impromptu class discussions occurred when a student would bring up the project or ask a question in regard to the project. Class presentations were scheduled after completion of the project. For the final reflection, students discussed, in writing, their experience with the project, the process of obtaining the photographs, and the overall learning experience.

Data Analysis Narrative analysis procedures helped in coding, gen-

erating themes, and triangulating findings.12,13 Creswell explained that in narrative inquiry, the researcher gath-ers data through stories told by the study participants to report on their experiences.14 Therefore, in this study, students were required to present the stories related to the photographs orally through a class presentation and through written captions narrating the meaning and relevance of the photograph. Also, to provide answers to the research questions, cases (individual student files containing the photographs and stories they collected) were created for each participating student. A spread-sheet was developed for each student, which included

all their photographs with the captions and stories, their reflections, and the field notes from class discussions and student presentations.

Next, open coding was performed to identify the pat-terns and themes common to the 13 cases. This process helped in deciding what data to use to provide relevant answers to each research question. Then, visual narrative inquiry steps were used to process, explore, and make meaning of the students’ experiences.15,16 Visual narrative analysis includes finding the images, devising categories for coding, coding the images, and analyzing the results.16

Researcher analysis of the photographic content taken by the participating students involved identify-ing captioned photographs that demonstrated the following characteristics: authenticity of the picture, a meaningful caption, evidence of the student–patient relationship, and an appropriate level of critical ref lec-tion. Authenticity of the picture meant the picture was captured by the student in the original setting and not staged or downloaded from the Internet. The messages and stories provided by the students in regard to an event or a discovery illustrated in the picture were reviewed for meaningfulness. The cap-tions were expected to ref lect the learning and inter-action between the student and the patient, and the student was expected to describe the issues affecting the patients and their needs. For critical ref lection, students were expected to discuss the meaning behind the picture, rather than just describe the image. The students also were expected to make a personal and professional connection based on the story and event shown in the photograph.

The 2 research questions guiding the study gave a focus to the analysis. Captioned images were sorted by which of the 2 questions was being answered. A third group was created to incorporate images that related to both questions. Finally, a table was developed to illustrate the most salient photographs and corresponding captions, and demonstrate what students, instructors, and research-ers can learn from using photovoice in a similar setting.

Ethical ConsiderationsInstitutional Review Board (IRB) approval was

obtained and all IRB guidelines were followed during implementation of the study. The project was graded on the basis of completion and not on the specific content

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felt overwhelmed by the amount of technical knowl-edge they needed to acquire quickly while building relationships and helping to ease the patients’ anxiety. The students were initially worried about being able to obtain a meaningful story and picture each week for the photovoice assignment. However, as they began work-ing in the clinic, they realized that each patient they encountered provided them with an opportunity for learning and reflection.

In agreement with the literature, the photovoice project encouraged the students to focus on the per-sonal side of the fieldwork in the clinic, where the tech-nical aspects of the profession often take precedence.5,6 Several students ref lected on the value of emphasizing patient communication in the clinic. As first-year radi-ation therapy students, they indicated that although there were many technical aspects to learn, they real-ized the importance of going beyond the technological facets of the profession to understanding the relevance of communication and empathy. For example, Adam wrote in his final ref lection:

provided by the student. The purpose of this was to have students focus on their learning and not their grade. Students also were encouraged to speak freely about their feelings about the project and were told that both positive and negative comments were helpful and desired.

Results and DiscussionStudent Learning From the Photovoice Project

The purpose of this project was to create a space for the students to engage in critical ref lection and to make the most of their clinical experience. The project was helpful in establishing connections between the clinical work and classroom pedagogy. A 2010 study suggested that the use of creative ref lective teaching strategies encourages students to gain a more holistic view of their patients.5

All names used in this article are pseudonyms to pro-tect the students’ identities. The Table synthesizes the primary lessons learned, as reported by the participat-ing students. Many students expressed concern about how to begin having conversations with patients. They

Table

Chief Lessons Learned by Study Participants

Sharla Working with the patient I should not just focus on the technology or the buttons I need to use; I need to remember there is a person on the table.

Edith Taking the pictures I didn’t know what to say. But, reflecting back to the specific patient I got into their shoes. Analyzing the pictures was useful in clinic too, I made connections to the patients I wrote about.

Adam It is not a traditional way of learning; it allows for experiencing something you would not have otherwise learned.

Karla It made me think from the patient point of view and how they’re affected by our actions and performance.

Ann I focused on the reasons why I’m here…to provide quality care for the patients. Learning the fundamentals of a new occupation, one can forget about that.

Hannah I was able to identify patients’ struggles throughout their experience with cancer. Sharing our stories in class, we also heard about successes and other patients.

Sam A picture portraying the patient can really be worth a thousand words.

Samantha I reflected about what I had learned daily at clinic and as a person. Every day there was a lesson to take away.

Ashley Engaging with patients I had not met yet just frightened me. The project made it necessary to work closely with patients.

Robin This was authentic. I had to actually describe the day and the state of my patients.

Kay I actively listened to the patients. I saw the importance of the patient–therapist bonding.

Darla This project gave me the extra push to talk to patients and connect with them.

Ronald The first few weeks of clinic I was nervous to talk. With the help of the therapists and the need to complete this project, I was able to break out of my shell.

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Edith reflected on the real reason for being in the clinic—to learn, to be respectful, and to be engaged in the patient’s journey:

I have enjoyed this learning experience, especially for our first semester in this program because it causes us to step outside our normal realm of thinking. Aside from studying for class and worrying about making a good impression in clinic, it is important to keep in mind the real reason we are there...to focus on the patient.

The students also expressed their anxiety about going into the clinic and not knowing how to begin conversa-tions or build relationships with the patients. Kay wrote in her final reflection: “This project has gotten me to engage and listen to the patient. I’ve had deeper conversa-tions with them. This helps build strong relationships; it helps them feel more comfortable and relieves their nervousness.” Likewise, the literature has discussed the importance of the work that the students do at the clinic related to the hands-on, experiential learning that takes place.2 Thus, the photovoice project was a way to bridge classroom learning with clinical work experience.

The in-class discussions with the students and their reflections indicated that the photovoice project helped them to re-evaluate the reasons for choosing the pro-fession and the role that the therapist plays in patients’ lives. The students stated that when they initially began working at the clinic, their first response was to focus on the technical aspects of the job. However, this proj-ect helped them to focus on the patient; they realized that this aspect of the profession holds equal or greater importance in their future work and that for the thera-pist to empathize with and relate to the patient, each person’s story and struggles must be heard.

Salient Issues Affecting Patients With Cancer To answer the second research question on how pho-

tovoice can assist students with gaining an understanding about salient issues affecting patients with cancer, the students’ midterm and final reflections were assessed. Students discovered that patients’ struggles were not only with the treatment and the adverse effects of treat-ment. They realized that a cancer diagnosis has the power to change every aspect of the patient’s life and

This project has helped me to think about what the patients are going through and not just the technical aspect of trying to learn how to perform the different tasks that are being taught at the clinic. It has forced me to be aware of my patient’s feelings and struggles so that I always treat them like human beings and not just a disease or a body part.

Similarly, Sharla stated in her final reflection:

So far in my time at the clinic, it is easy to get caught up in all the technology we are surrounded by and learning how to use it. You can forget there is an actual patient lying on the table. But when I ask patients about their days and they go into stories, I can see the therapists glaring at me. Not in a bad way really, but they get rushed sometimes and it’s hard to make a connection when you feel like you’re slowing down the treatment.

Students also spoke about the photovoice project giving them a broader scope of what it means to be a radiation therapist. To this effect, Greathouse and Dowd4 explained the need for students to be able to understand patients’ needs and lifestyles to become empathetic prac-titioners. The study participants realized that although it is important to deliver the treatment with precision and accuracy, they also have to create an environment that eases anxiety and provides an outlet for the patients to talk about what is important to them. Ann described this new view in her final reflection:

As a radiation therapist it is extremely important to provide quality care and always put the patient first. We have to be more than just the person treating the patient; we should be a reference and a source of comfort not just physically but, if possible, emotionally and mentally. Sometimes the therapist is all that the patient will have to fall back on when it comes to help, direction, and support. Being a therapist is more than just an occupation. There is an underlying duty to be there for someone else; this truly is a service job. We should be of service to the patient and their family as much as possible while remaining within our own scope of practice, and sometimes the first step is to simply start a conversation.

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and sometimes their driver’s licenses are taken away. This places an additional burden on the patient because now he or she has to rely on family and friends or public trans-portation. Edith reflected on her patients’ struggle with this situation:

It is crucial for patients undergoing radiation therapy to come to treatment every day, and some have to rely on transportation services if they cannot drive or do not have family who can help. Unfortunately, this is a big hassle and a source of stress for many patients. They have to call way in advance, and there are just not enough drivers and vans to provide transportation. One morning before the clinic opened, the transportation service dropped off a woman in a wheelchair and her caregiver—the temperature was 40 degrees, and they just left them outside. Patients deserve way better care than that; they are already dealing with enough.

The students also discovered that patients with cancer need support from others (eg, other patients) who can relate to what they are going through. Sam provided a photograph of an elderly man with a walker to symbolize one of his patients and gave it the following caption:

This photo was inspired by 2 prostate patients. These men had back-to-back treatment times so they would always see each other. Throughout their time of treatment they became very good friends and would joke with one another. They became support for each other and when one finally finished treatment the other waited for him to take him out to celebrate for finishing. These men showed me how we can find support in someone that we only see for 20 minutes a day and knows nothing else about them. They inspire me to be that person for someone else.

Students indicated that the project gave them a broader understanding of the how the patients’ lives were changed after diagnosis and helped them to under-stand that the demands of life do not stop when under-going treatment; the treatment actually adds to the demands. They also gained a better understanding of the importance of a support system, finding others who can relate to their situation, and how these individuals can be found anywhere and have the ability to reduce

that many patients struggle to maintain some sort of control over their lives. For instance, Robin wrote in her photovoice journal:

One of the biggest struggles patients have is maintaining control over their sense of normality. Especially in the female patients, I see a great emphasis on maintaining control over their bodies’ appearance such as hair or nails. Maintaining regular care and aesthetics of their appearance helps them feel like nothing in their life has changed, at least during that little moment when getting a manicure or hair appointment. Normality also presents itself in scheduling work and social life around the daily treatment and side effects. This helps them feel as though cancer has not completely disrupted their life.

Patients juggle responsibilities among family, work, and social obligations in addition to their treatments, and at times, these responsibilities can become overwhelm-ing. As explained by Haviland, collecting the photographs and writing the narratives to explain why the images were important provided the students with the opportunity to make the invisible visible7 and to look at their routines at the clinic using a more critical eye. In other words, stu-dents saw beyond the patients’ symptoms and treatment and realized that patients also are human beings just like the students. Darla witnessed this in her clinical practice and wrote about it in her photovoice journal:

Most patients are struggling with the cancer process and how it has affected their daily life. Sure there are those tough patients that don’t seem like it is really bothering them, that the treatment is just one more thing that they have to do, but many others are feeling overwhelmed. Some patients cry on the table because they thought it was their last treatment day and it wasn’t. I can understand how coming in for treatment is a real burden on the patient. I have seen some quit treatment because they just can’t handle the stress that the treatment brings to their lives.

Other students spoke about specific limitations that patients encounter because of their disease. Even small privileges are often taken away from patients with cancer. Many who have been placed on certain medications or have tumors in the brain are considered unsafe drivers

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assigned specific meaning to objects, such as a mint, a paper robe belt, or a puzzle in the waiting room. At first glance, these objects seem ordinary; however, the students learned that these objects served a purpose and held great meaning for the patients. The students also were able to ref lect on their daily routine at the clinic to remind themselves of the primary reasons they chose this profession.

The photovoice project encouraged ref lection on the part of the students, allowing them to gain a bet-ter understanding of salient issues that affect patients with cancer. The students spent time outside of clini-cal work ref lecting on the patients’ stories and learn-ing from them. Hopefully, these ref lection skills will transfer to other classes and projects throughout the program and their professional lives. The strategy of ref lecting through photography also could be a useful tool for practicing radiation therapists in helping to deal with their emotions or gaining a broader under-standing of the circumstances affecting their particu-lar patients.

the stress of the patient. Support from health care pro-fessionals and peers has been shown to be beneficial to patients in gaining knowledge about their illness and treatment, acceptance of their condition, coping strate-gies, and improved emotional state.17,18

Limitations and Future Research The study was implemented using a small number

of participants; it took place during one semester and in one course. Creating an electronic portfolio and a photobook required that some of the students spend time learning how to use the photobook Web site and build the portfolio. The students also had to have a digital camera or a phone that captured images. The largest limitation was the lack of readiness of the stu-dents to implement a self-directed project. Students struggled with the openness of what photographs to take, identifying what was important in the clinic set-ting, and practicing critical ref lection. These issues eventually were overcome, but the instructor needs to be prepared to provide plenty of explanation and guid-ance about these issues.

Future research could consist of conducting a longi-tudinal study that includes several cohorts of students implementing this project. This would yield more extensive results useful for transferability to other set-tings with similar health professions programs. Another idea for future research would be to study how the use of photography could assist practicing radiation thera-pists to develop empathy skills and help patients to deal with emotions and understanding of specific circum-stances that affect their lives.

ConclusionFigures 1-6 show salient student photographs and

the corresponding captions students provided to add meaning to the visual image. Both the photographs and captions support the idea that there are more effective teaching strategies than lecture to guide the learning journeys of radiation therapy students.

The photographs collected by the students, the captions they provided, and their written ref lections demonstrated the learning that took place through-out the semester about the issues affecting patients. By collecting the photographs, the students made the familiar strange by observing how their patients

Figure 2. Paper robe belt. “Every day, our patients put on a paper robe before treatment. Typically, patients throw them away. One patient, however, was asked by her children to bring home her belt every day so that they could decorate it. Every day she came to treat-ment with something added to the belt. She said that by the time she is done with treatment, her teenagers will have the whole belt bedazzled and sparkly. Seeing this and hearing how patients brag about their children and family members made me realize how important it is to have some sort of support system while going through something as tough as cancer” (Darla). Image courtesy of the author.

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Trad, Larrotta

Figure 6. Rosary and faith. “This patient comes into treatment every morning with his prayer books and Knights of Columbus jacket on. His faith keeps him going despite all the stress and pain of his chemo-therapy and radiation. I chose to take this picture of my rosary which I carry in my purse, because faith also keeps me going. I can relate to this patient. My father and grandfather are both members of Knights of Columbus and are strong role models in my life. I look up to this patient; I see that he believes his guardian angels are looking over him during his daily treatment” (Edith). Image courtesy of the author.

Figure 3. Transportation van. “It is crucial for patients undergoing radiation therapy to come to treatment every day. Some rely on trans-portation services to get them there if they cannot drive or do not have family who can help. This is a big hassle and stress, also for patients who have a handicap. They have to call way in advance. There are not enough drivers and vans for the many people in need of transporta-tion. One morning before the clinic opened, the transportation service dropped off a woman in a wheelchair and her caregiver—it was 40 degrees outside. Patients deserve better care! They are already dealing with enough as it is” (Edith). Image courtesy of the author.

Figure 4. Puzzle in the waiting room. “This is a 74-year-old man who has a passion for puzzles. He was diagnosed with prostate cancer but claimed not to be worried about it as long as he could come in every day and build the puzzle that is set out in the waiting room. If it would get ruined before it was finished he would be very angry that day dur-ing treatment. You could tell he truly enjoyed doing it. Reflecting back I thought I am always a very competitive person and I like to see the outcome of my work. So I understood his anger when the puzzle was messed up” (Kay). Image courtesy of the author.

Figure 5. Thank you card and tissues. “My first gift from a patient, a lovely thank you card and a pack of tissues labeled ‘Bless You.’ This gift was from one of our breast patients I got to know for the 2 days I was present for her treatment. On the second day, the doctor was taking a long time to prepare her treatment, and I was left alone in the room to visit with her. We talked about life and all the blessings it brings. I was amazed at how positive she was about her diagnosis. I returned the next week to find these two gifts left for me. You can make an impact in someone’s life in a short period of time” (Samantha). Image courtesy of the author.

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12. Glesne C. Becoming Qualitative Researchers: An Introduction. 4th ed. Boston, MA: Pearson; 2011.

13. Riessman CK. Narrative Methods for the Human Sciences. Los Angeles, CA: Sage; 2008.

14. Creswell JW. Qualitative Inquiry & Research Design: Choosing Among Five Approaches. 2nd ed. Thousand Oaks, CA: Sage; 2007.

15. Bach H. Visual narrative inquiry. In: Given LM, ed. The Sage Encyclopedia of Qualitative Research Methods. Los Angeles, CA: Sage Publications; 2008:940-950.

16. Rose G. Visual Methodologies: An Introduction to Researching With Visual Materials. 3rd ed. London, UK: Sage Publications; 2012.

17. Campbell HS, Phaneuf MR, Deane K. Cancer peer support programs. Do they work? Patient Educ Couns. 2004;55:3-15.

18. Gottlieb BH, Wachala ED. Cancer support groups: a critical review of empirical studies. Psychooncology. 2007;16(5):379-400. doi:10.1002/pon.1078.

Megan Trad, PhD, MSRS, R.T.(T), is associate professor for the radiation therapy program at Texas State University, San Marcos, Texas. Trad is vice chairman of the Radiation Therapist Editorial Review Board and can be reached at [email protected].

Clarena Larrotta, PhD, is associate professor for the Department of Counseling, Leadership, Adult Education, & School Psychology at Texas State University in San Marcos, Texas. She can be reached at [email protected].

Reprint requests may be mailed to the American Society of Radiologic Technologists, Communications Department, 15000 Central Ave SE, Albuquerque, NM 87123-3909, or emailed to [email protected].


References1. Pink S. Doing Visual Ethnography: Images, Media, and

Representation in Research. 2nd ed. London, UK: Sage; 2007. 2. Trad M, Larrotta C. Experiential learning at hospice: the

case of first year radiation therapy students. Radiol Sci Educ. 2014;19(2):3-13.

3. American Society of Radiologic Technologists. Radiation therapy professional curriculum. http://www.asrt.org/docs /educators/rtttransitionaldoc_012513.pdf. Published 2014. Accessed August 24, 2015.

4. Greathouse GF, Dowd SB. Using critical thinking to teach empathy. Radiol Technol. 1996;67:435.

5. Webster D. Promoting empathy through a creative reflec-tive teaching strategy: a mixed methods study. J Nurs Educ. 2010;49(2):87-94. doi:10.3928/01484834-20090918-09.

6. Winefield HR, Chur-Hansen A. Evaluating the outcome of communication skill teaching for entry-level medical students: does knowledge of empathy increase? Med Educ. 2000;34:90-94.

7. Haviland M. Creative documentation: using photography as a tool in action research. Stronger Families Learning Exchange Bulletin. 2004;5:10-15.

8. Wang C. Photovoice: a participatory action research strategy applied to women’s health. J Womens Health. 1999;8(2):185-192.

9. Close H. The use of photography as a qualitative research tool. Nurse Res. 2007;15(1):27-36.

10. Radley A, Taylor D. Images of recovery: a photo-elicitation study on the hospital ward. Qual Health Res. 2003;13(1):77-99.

11. Patton MQ. Qualitative Research & Evaluation Methods. Thousand Oaks, CA: Sage; 2002.


CEDirected Reading

The concept of computerizing medical records was first introduced in the 1960s. Initially, development and use of electronic health records was slow. However, changes in medical technology, consumer demand, and government initiatives, as well as the need to reduce health care costs while improving patient safety have created rapid growth in the use of electronic medical records in recent years. This article defines electronic health records and describes their evolution, benefits, implementation, and use in radiation oncology.

This article is a Directed Reading. Your access to Directed Reading quizzes for continuing education credit is determined by your membership status and CE preference.

After completing this article, the reader should be able to: Define and distinguish the terms electronic health record (EHR), electronic medical record,

and electronic personal health record. Describe the influences that have driven the development and adoption of EHRs. Discuss the role of government and nongovernmental organizations in EHR expansion. List benefits and challenges associated with EHRs. Explain the privacy and safety safeguards required for EHR use. Describe the implementation and use of EHRs in radiation oncology.

Rosann Brauer Keller, MEd, R.T.(T)

Electronic Health Records

On August 29, 2005, Hurricane Katrina slammed into the U.S. Gulf Coast, destroying beachfront towns in

Mississippi and Louisiana.1 More than 1800 people lost their lives and nearly 1 million were displaced. When the levees were breached in New Orleans, 80% of the city was under water. Although a mandatory evacuation order had been issued the day before the hur-ricane hit, 20% of the city’s 500 000 res-idents were stranded in place without food, water, or power.

Patients had to be evacuated from about 2 dozen local hospitals because of loss of power, water, and sewage service.2 Many of these patients were separated from their medical records during the evacuation. When they arrived at receiv-ing hospitals, vital information about their diagnoses, medical histories, and medications was not available to medical personnel unless the patients could sup-ply that information themselves.

Of the New Orleans area residents who voluntarily evacuated, tens of thousands required urgent care and more than 200 000 had chronic medi-cal conditions that needed attention once they reached evacuation centers.3 Many had left home without medical documents or medications in the rush to evacuate. Many more were later unable to obtain their medical records because their health care facilities and physicians’ offices had been f looded. Clinicians had to care for ill and unfa-miliar patients without access to their medical records.

The exact number of immediate deaths attributed to Hurricane Katrina will never be known, but it is estimated to be between 971 and 1170.4 There is also no way to determine the latent morbidity and mortality of survivors and evacuees that occurred as a conse-quence of having their care interrupted or terminated because of lack of access to their medical records.


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and any functional benefits resulting from having an EHR.8 A broader definition describes EHRs as:

any information relating to the past, present or future physical/mental health, or condition of an individual which resides in electronic system(s) used to capture, transmit, receive, store, retrieve, link and manipulate multimedia data for the primary purpose of providing healthcare and health related services.9

The term electronic medical record frequently is used synonymously with EHR. There are, however, signifi-cant differences between them. The term electronic medical record was used initially because the first elec-tronic records were used primarily by physicians for recording information about their own patients. They were truly digital versions of the patient’s medical chart used in a physician’s office.10 They contained the medi-cal and treatment history of patients cared for by one physician or medical practice site. The information was not accessible to the patients themselves, nor could it be shared with other health care providers unless it was printed out to be hand-delivered or sent by mail or fax.

In contrast to electronic medical records, EHRs are intended to focus on the total health of the patient and are more interactive. Information can be shared with any authorized care provider, regardless of health care orga-nization. Patients can access their own records and test results. The EHR emphasizes a team approach to health care, including the patient, clinicians, and support staff.

A personal health record, sometimes called an elec-tronic personal health record, is an electronic application patients can use to maintain and manage their own health information.11 Unlike EHRs, in which data is primarily entered and accessed by health care providers, the personal health record is controlled by the individ-ual patient. Patients determine what is included in their personal health records such as contact information, family medical history, immunization records, medica-tion lists, or personal recollections of medical encoun-ters. Personal health records are separate from and not substitutes for a health care provider’s legal medical record. Patients determine whether information in the personal health record is shared with care providers or family members. Personal health records were created to help individuals take a more active role in their own health and wellness.12

While most patients and health care providers in Katrina’s wake were frustrated by the inability to access patient files, more than 38 000 veterans and their physicians in Louisiana, Mississippi, and the Florida panhandle were able to get all their records, prescrip-tions, and test results. Patient information was available for every patient treated at the Southeast Louisiana Veterans Health Care System in New Orleans. The health care system’s use of a computerized patient record system ensured all patient medical information could be accessed by any Veterans Affairs physician in the nation.5

Disaster situations, such as Hurricane Katrina, dem-onstrate the vital importance of being able to access patient medical records at any time from anywhere. The computerized patient record system used by the United States Department of Veterans Affairs (VA) proved the capability of electronic health records (EHRs) to meet the data needs for continuity of care, even in the worst of conditions. In addition to the capability of immediate access to information in any circumstance, EHRs have other anticipated benefits, including increased efficien-cy, reduced costs, and improved patient safety.

As society has embraced the digital tools of the infor-mation age, it is imperative for health care providers to do the same. The health care system in the United States continues to move into the technological age with the rest of the world, and EHRs are becoming an integral part of every patient’s health care experience.

Defining Electronic Health RecordsNo universally accepted definition of an electronic

health record exists. The simplest description comes from the U.S. Office of the National Coordinator for Health Information Technology, which defines an EHR as a digi-tal version of a paper chart.6 The Centers for Medicare & Medicaid Services (CMS) refined that definition to be an:

electronic version of a patient’s medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that person’s care under a particular provider, including demographics, progress notes, problems, medica-tions, vital signs, past medical history, immunizations, laboratory data and radiology reports.7

Generally, EHRs can be considered any part of a patient’s medical record that is stored on a computer


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It is fairly easy for individuals to create and access a personal health record. They do not need to be in electronic format. Patients who do not feel comfortable using computers or other electronic devices can main-tain paper-based personal health records.13 Personal health records also can be stand-alone files in which patients store their data on an Internet site, their own computers, or other digital data storage devices. Forms for electronic personal health records commonly are made available by health insurance plans, health care providers, employers, and independent vendors. Often personal health records are linked to a health care orga-nization’s EHR, allowing patients to access their infor-mation through a secure portal.

History of Electronic Health Records

The concept of computerizing medical records has been around for more than 50 years, but widespread use of electronic medical records occurred only over the past 10 years.8 The idea of recording patient informa-tion electronically instead of on paper was introduced by Lawrence Weed, MD, in the late 1960s.14 In 1976, Weed collaborated with the Medical Center Hospital of Vermont to develop the Problem-Oriented Medical Information System. Around the same time, a few other academic medical centers developed clinical informa-tion systems, the predecessors of EHRs, for their own use.15 The Lockheed Corporation developed one of the earliest systems, which was noted at the time for its fast processing speed and flexibility in support-ing the diverse needs of many users at a single site.16 Concurrently, the University of Utah, in collaboration with 3M, began developing one of the first clinical deci-sion support systems, called Health Evaluation through Logical Processing.

In 1968, Massachusetts General Hospital, in partner-ship with Harvard University, developed and imple-mented COSTAR, the Computer Stored Ambulatory Record. The first adoption of the system was at the Harvard Community Health Plan, which had 9 care facilities.16 Because of COSTAR’s modular design, individual care sites only needed to install a partial set of modules to meet their needs. For example, schedul-ing modules and medical records modules could be installed without billing modules, if a site desired. This increased the overall efficiency of the system.15 Another

advantage of COSTAR was the f lexible vocabulary that recognized multiple terms for the same medical condi-tion and associated brand name medications with their generic equivalents.16 This allowed COSTAR to accom-modate variations in terminology among individual health care providers and institutions.

The federal government’s involvement with EHRs began in the 1970s, when the VA began to develop VistA, the Veterans Health Information Systems and Technology Architecture, formerly known as the Decentralized Hospital Computer Program. VistA is used at more than 1500 care sites within the Veterans Health Administration, including every Veterans Affairs medical center, community-based outpatient clinic, and community living center.17 In addition, VistA is avail-able to care providers not affiliated with the Veterans Administration or Veterans Health Administration through the Freedom of Information Act.

The software developed for VistA is grouped into the categories of system/database management, admin-istrative management, and clinical management.16 The system/database management software supports, devel-ops, and maintains VistA. Administrative management software supports all hospital administrative tasks, including scheduling, and the clinical management software supports clinical information delivery in the laboratory, pharmacy, and other departments such as surgery, medicine, cardiology, and oncology.

The VA also developed the Computerized Patient Record System (CPRS) as an application of VistA. CPRS supports clinical decision making and allows users to enter, review, and update patient information; order tests and procedures; request and track consultations; enter progress notes, diagnoses, and treatments for each patient encounter; and enter discharge summaries.18

Because 60% of all physicians educated in the United States have rotated through VA facilities for some por-tion of their training, VistA and CPRS are thought to be the most widely used EHRs in the country.19

Because of the groundbreaking development of the VistA information system, the VA and Veterans Health Administration were recipients of the 2006 Innovations in American Government Award by the Ash Institute of the John F Kennedy School of Government at Harvard University.20 This award pro-gram recognizes and promotes excellence and


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redundancy in ordering tests, reduce medical costs, and prevent unnecessary procedures. Information on patient diagnoses, allergies, and medications should improve patient safety and increase the efficiency of medical care.

The Results Management function refers to the ability to electronically access laboratory test results and medi-cal imaging reports quickly and easily.23 Computerized results provide health care practitioners with information when and where it is needed. Reducing the delay in access to this information allows for quicker recognition and treatment of medical problems. Automated displays of previous test results make it possible to reduce redundant and additional testing. Electronic results allow for bet-ter interpretation and easier detection of abnormalities, ensuring appropriate follow-up care. Access to electronic consultations and patient consent forms can improve care coordination among multiple providers, as well as between the provider and patient.

Computerized Order Entry/Management capability improves workflow processes by eliminating the problems associated with illegible handwriting and lost orders.23 In addition, related orders can be generated simultaneously, duplicate orders can be detected, and the time required to fill orders can be reduced. Computerized provider order entry (CPOE) systems have been shown to reduce the number of errors in medication dose and frequency, adverse events due to drug allergies, and drug interac-tions. CPOE systems also diminish the costs of preprinted forms and ensure that prescribing practices are consistent with a facility’s established formulary.

Decision Support systems enhance clinical perfor-mance in the areas of medication prescribing, disease

creativity in the public sector. It provides grant money to promote sharing of successful government innova-tions with nongovernmental organizations.21

Over the years, some individual institutions devel-oped EHRs for their own use, and a small number of vendors began to offer systems for sale, but there was little interest in moving away from paper-based medical records. The fairly recent interest in and motivation for adopting EHRs by almost all health care providers in the United States came about when the American Recovery and Reinvestment Act of 2009 was signed into law by President Barack Obama. This law provided government support for development of a national EHR system.

Key Capabilities of EHRs

The U.S. government’s role in the transition from paper-based to electronic charts began with a report published by the Institute of Medicine (IOM), an inde-pendent, nonprofit organization that researches health and health care concerns and makes recommendations to policymakers and the public.22 Most studies carried out by the IOM are mandated by the U.S. Congress or commissioned by federal and independent agencies.

The 1991 IOM report titled “The Computer-Based Patient Record: An Essential Technology for Health Care” called for elimination of paper-based patient charts within 10 years to make important patient data readily available and useable to health care providers.16,23 Following that report, progress toward implementing EHRs was still slow, with only a few health care settings adopting EHRs. There were technical challenges, as well as policy, organizational, and financial challenges. No functional model for an EHR system existed, nor was there much incentive to develop one.

In 2003, the IOM issued “Key Capabilities of an Electronic Health Record System,” a report requested by the U.S. Department of Health & Human Services (HHS). This report identified 8 categories of core func-tions an EHR should be able to perform to promote bet-ter safety, quality, and efficiency in health care delivery (see Box 1).23

The Health Information and Data function of an EHR should have a defined data set that includes items such as medical diagnoses, medication lists, allergies, clinical narratives, test results, and demographics.23 The ability to access laboratory test results can eliminate

Box 1

Institute of Medicine Categories of Core Functionalities

23

1. Health Information and Data2. Results Management3. Order Entry/Management4. Decision Support5. Electronic Communications and Connectivity6. Patient Support7. Administrative Processes8. Reporting and Population Health Management


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errors in health care delivery.24 Using extrapolated data, the report stated that at least 44 000 and perhaps as many as 98 000 deaths each year in the United States were due to preventable medical errors. Beyond the costs related to the loss of human life, the report discussed the estimated expenditures associated with the additional care neces-sitated by errors and costs to patients in terms of lost income, productivity, and disability. Patient trust in the health care system and health care providers and custom-er satisfaction by both patients and health care profession-als also were diminished by medical errors. As the health care system and the services provided by the system have become more complex, the opportunities for error have increased. The report recommended establishing systems to make it hard for people to do the wrong thing and easy for them to do the right thing. It also was recommended that information about patients, medications, and treat-ments be available at the point of patient care. In short, the IOM suggested a computer-based record would help to implement both recommendations.

Because of extensive media coverage, the report received attention from the health care industry and the public.25 Health care institutions, insurers, govern-ment agencies, nongovernmental organizations, and health care consumers responded to the report by tak-ing action. Health care consumers began asking more questions, getting more information about their care, and requesting access to their medical records. The fed-eral government appropriated funding for patient safety research, and nongovernmental agencies issued reports about patient safety issues.

Despite this call for improved patient safety, recent data indicate medical errors are now the third leading cause of death in the United States behind heart disease and cancer.26 A study published in 2013 determined that between 210 000 and 400 000 patients experience preventable harm that contributes to their deaths.27

EHRs and Health Care Costs The year before the IOM report was published, a

group of large employers who purchased employee health care plans met to discuss how to improve afford-ability and quality of health care. These founders of the Leapfrog Group realized that employers were spending billions of dollars on health care for their employees but could not assess its quality or cost or compare health

prevention, diagnosis and management of illness, and detection of adverse events and disease outbreaks.23 Computer reminders and prompts have been shown to improve preventive practices in the areas of vaccinations and cancer screenings, as well as improve drug selection and dosing, and screening for drug interactions.

Communication among health care team members and other care partners is enhanced with the Electronic Communications and Connectivity function of EHRs.23 Improved communication enhances patient safety and quality of care. Email and Web messaging facilitate communication between providers and with patients. Telemedicine allows patients access to care provid-ers when travel to offices or hospitals is not possible because of distance, disability, or illness. Providers also can consult with peers to share expertise.

EHRs can play a role in Patient Support.23 For exam-ple, patients can access computerized educational mate-rials. In addition, telemonitoring that uses electronic devices can display self-testing results and self-care behaviors of patients at home.

The Administrative Processes of health care insti-tutions become more efficient with the use of EHRs, enabling better and more timely service to patients.23 Appointments can be scheduled electronically. Electronic authorization and prior approvals for reimbursement pur-poses eliminate delays in care. Insurance eligibility can be verified immediately to improve access to services and expedite payment with minimal paperwork.

The Reporting and Population Health function of EHRs assists health care institutions in meeting the reporting requirements at federal, state, and local levels for data on public health, patient safety, and quality of care.23 Computers eliminate manual abstracting of data, which can be labor intensive, time consuming, and fraught with potential for errors.

Despite this general guidance from IOM regard-ing EHRs, and the recognition by both the public and private sectors of the need to improve quality of health care and reduce costs, there has been little incentive for the development and implementation of such systems.

Medical Errors and the Need for EHRsIn 1999, the IOM published a report titled “To Err

Is Human: Building a Safer Health System,” which described the need to improve patient safety by reducing


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records at least once in the past year, and 55% of respon-dents accessed them 3 or more times per year.34

As health care consumers have become more comfort-able with sharing and accessing sensitive health informa-tion securely on the Internet, many want to access their medical information and use that information to make decisions about their personal care.35 EHRs make patient access to their personal medical records possible.

Government Influence on EHRsPresident Bill Clinton issued an executive order in

1998 to establish the Quality Interagency Coordination Task Force to ensure all federal agencies involved in purchasing, providing, studying, or regulating health care services would work in coordination and with the common goal of improving the quality of health care.36 In response to the 1999 IOM report, in 2001 the U.S. Congress allocated $50 million annually for patient safe-ty research to the Agency for Healthcare Research and Quality, the lead federal agency for health care safety.8 President George W Bush, through a 2004 executive order, created the Office of the National Coordinator for Health Information Technology (ONC) under the HHS. The purpose of Executive Order 13335 was to “provide leadership for the development and nationwide implementation of an interoperable health information technology infrastructure to improve the quality and effi-ciency of health care.”37 The executive order identified the responsibilities of the national coordinator as developing, maintaining, and directing the implementation of a stra-tegic plan to guide nationwide application of interoper-able health information technology in public and private health care sectors to reduce medical error, improve quality, and increase value for health care expenditures. At that time, the president called for the majority of Americans to have interoperable EHRs within 10 years.38

The American Recovery and Reinvestment Act of 2009 included the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act promoted the adoption and meaning-ful use of health information technology by offering financial incentives to physicians and hospitals for dem-onstrating meaningful use of EHRs up until 2015 and penalties for failure to demonstrate such use.39

When David J Brailer, MD, PhD, was appointed as the first national coordinator, he outlined a strategic

care providers and institutions.28 Following the release of the IOM report in 1999, the Leapfrog Group began to work to provide more market reinforcement for the quality and safety of health care. The organization now helps employer members provide incentives and rewards to the best-performing hospitals, either directly or through their health plans.29 One of the means to reduce health care costs advocated by Leapfrog was the use of CPOE systems, a component of most EHRs. This recommendation was based on studies looking at the costs associated with adverse drug events.30 In 2007, the IOM Committee on Identifying and Preventing Medication Errors issued a report that estimated at least 1.5 million preventable adverse drug events occur in the United States each year.31 This estimate was based on research showing that 380 000 to 450 000 preventable adverse drug events occur in hospitals each year, with another 800 000 occurring annually in long-term care facilities, both of which were considered to be underes-timates. The IOM report also discussed the additional health care costs related to injuries caused by adverse drug events in hospitals. A conservative estimate was calculated to be $3.5 billion in 2006.

Aside from a reduction in care costs because of medi-cation errors, additional savings from the use of EHRs in large hospitals have been estimated to range from $37 million to $59 million over a 5-year period.32 Some of these cost savings occur as a result of automating time-consuming and labor-intensive paper-based activi-ties such as transcription, chart pulling, storage, coding, and billing. Reducing duplicate medical tests and proce-dures also reduces costs.

Consumer Demand for Electronic Medical Information

Technology has changed the way people communi-cate and access information. According to a 2014 Pew Research Center survey, 87% of adults in the United States use the Internet, 90% of adults own a cell phone, and 58% own a smartphone.33 Further, 72% of Internet users said they researched health information online in the past year. An additional 31% of cell phone users and 52% of smartphone users indicated they used their phones to access medical or health information. Another national study indicated that more than 4 out of 5 patients with online capabilities accessed their medical


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appropriate, authorized, and timely access to and use of electronic health information to benefit public health, biomedical research, emergency preparedness, and quality improvement.

The strategies were characterized by a commitment to include both the private and public sectors; concern for reliability, confidentiality, privacy, and security in the exchange, use, and storage of electronic health information; and the focus on the health care consumer as an essential participant in achieving the plan’s goals (see Box 3).

Since the publication of these first 2 strategic plans, the ONC has issued updated strategic plans for 2011 to 2015 and 2015 to 2020. In each of these plans, the ONC continued to commit itself to promoting the adoption of information technology in health care set-tings, enabling the interoperability of information and advancing the safety and quality of care for patients.

framework that included 4 major goals, each with a cor-responding set of strategies (see Box 2).38 The first goal was to inform clinical practice. This goal centered on bringing EHRs directly to clinical practice, consequently reducing medical errors and duplicate work. Achieving this goal would enable clinicians to focus their energy and effort on improving patient care. The strategies developed to reach this goal included incentivizing EHR adoption, reducing the risk of EHR investment for clini-cians who attempted to change their clinical practice and office operations using EHRs, and promoting diffusion of EHRs in rural and underserved areas.

The second goal was to connect clinicians to allow them to share information and move patient data from one point of care to another. To achieve this goal, the ONC proposed strategies to foster regional collabora-tions, develop a national health information network, and coordinate federal health information systems.

The third goal was to personalize care by allowing individuals to manage their own health and wellness and assist them in making personal health care deci-sions. The strategies developed to accomplish this goal included encouraging the use of personal health records, improving consumer choice by providing infor-mation on clinicians and health care facilities, and pro-moting the use of remote communication technologies such as telehealth systems.

The final goal was to improve the health of resi-dents of the United States by collecting timely, accu-rate, and detailed information to allow evaluation of health care delivery and reporting of data to public health officials, researchers, and clinicians. The strat-egies for this goal included unifying public health surveillance architectures, streamlining quality and health status monitoring, and accelerating research and dissemination of evidence.

In 2008, with a new national coordinator, the ONC updated the strategic plan for 2008 to 2012. This plan had 2 goals: patient-focused health care and population health. These goals were organized around the core themes of privacy and security, interoperability, adoption, and col-laborative governance.40 The patient-focused health care goal was to promote electronic health information access and use by health care providers, patients, and their desig-nees to achieve higher-quality, more cost-efficient, patient-focused care. The goal of population health was to enable

Box 2

Summary of Goals and Strategies for National Adoption of Health Information Technology from the Office of the National Coordinator for Health Information (ONC) 2004

38

Goal 1: Inform clinical practiceStrategy 1. Incentivize EHR adoption.Strategy 2. Reduce risk of EHR investment for clinicians who purchase EHRs to reduce risk, failure, and partial use of EHRs.Strategy 3. Promote EHR diffusion in rural and underserved areas.

Goal 2: Interconnect cliniciansStrategy 1. Foster regional collaborations.Strategy 2. Develop a national health information network.Strategy 3. Coordinate federal health information systems.

Goal 3: Personalize careStrategy 1. Encourage use of personal health records.Strategy 2. Enhance informed consumer choice to select clinicians and institutions based on what they value, includ-ing but not limited to the quality of care providers deliver.Strategy 3. Promote the use of telehealth systems.

Goal 4: Improve population healthStrategy 1. Unify public health surveillance architectures.Strategy 2. Streamline quality and health status monitoring.Strategy 3. Accelerate research and dissemination of evidence.


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Despite the promotion of EHRs by the ONC, there has been little incentive for health care practitioners and insti-tutions to invest financial, time, and personnel resources to develop and adopt health information technology. With the passage of the HITECH Act of 2009, HHS was given the authority to establish programs to promote health information technology, including EHRs and private and secure electronic health information exchange. Individual sections of HITECH provide HHS’s directive to improve privacy and security provisions for exchange and use of electronic health information and establish grant and loan programs to assist providers in effectively adopting and using EHR technology. The HITECH Act also estab-lished the Medicare and Medicaid incentive programs for providers to adopt, implement, upgrade, and demonstrate meaningful use of certified EHR technology.41

To receive an incentive payment, eligible profession-als (see Box 4) must demonstrate use of an EHR that is

certified for the incentive programs.42 The ONC estab-lished a certification program to test and verify that health information technology products meet estab-lished standards for a structured data format and other criteria for technological capability, interoperability, functionality, and security. Certification provides confi-dence that health information technology products and systems are secure and interoperable.

Meaningful use must be documented to receive the incentive payments. The ONC defined meaningful use as the use of certified EHRs for improving quality, safe-ty, and efficiency of health care and reducing health dis-parities; engaging patients and their families; improving care coordination and population and public health; and maintaining privacy and security of patient health information.43 The stated purpose of the meaningful use incentive was to improve individual patient clinical and population health outcomes, increase transparency

Box 3

Health Information Technology Goals and Objectives 2008-2012 From ONC40

Goal 1Patient-Focused Health Care

Objective 1.1: Privacy and Security

Facilitate electronic exchange, access, and use of electronic health information, while protecting the privacy and security of patients’ health information.

Objective 1.2: Interoperability

Enable the movement of electronic health information to support patients’ health and care needs.

Objective 1.3: Adoption

Promote nationwide deployment of EHRs and personal health records and other consumer information technology tools.

Objective 1.4: Collaborative Governance

Establish mechanisms for multistakeholder priority setting and decision making.

Goal 2Population Health

Objective 1.1: Privacy and Security

Advance privacy and security policies, principles, procedures, and protections for information access in population health.

Objective 1.2: Interoperability

Enable exchange of health information to support population-oriented uses.

Objective 1.3: Adoption

Promote nationwide adoption of technologies to improve population and individual health.

Objective 1.4: Collaborative Governance

Establish coordinated organizational processes supporting information use for population health.


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who has not had time to become a meaningful user, having insufficient Internet access, or in case of natu-ral disasters. Hardship exceptions are valid for 1 year, except for newly practicing professionals, who are grant-ed 2-year exceptions.

EHR BenefitsThe use of EHRs and the ability to share informa-

tion electronically promises to create a health care system that provides higher quality and safer care for patients. Some of the recognized benefits of EHRs are care coordination, safety, improved processes, clini-cal decision support, improved care management, and reduced malpractice.48

Because EHRs are not physical objects that only can be in one place at one time like paper charts, they can be available immediately wherever and whenever an authorized care provider needs them. In addition, they can be used by more than one person at a time. Chart pulling is eliminated, and reports no longer need to be copied, mailed, or faxed. The capability to retrieve rapidly and exchange information efficiently allows enhanced coordination of patient care.

Handwritten notes in paper records can be illegible, leading to misinterpretation of clinical care notations, physician orders, and medication and treatment orders. Paper-based reports might not be filed in the chart promptly, or they might be filed in the wrong part of the chart and inaccessible to the care provider, potentially causing clinical decisions to be made with incomplete information. Both of these are potential sources of medical error that affect patient well-being.49

Although the safety of patients is paramount, main-taining the physical safety of paper records is also neces-sary. A considerable amount of patient data can be lost if paper charts are damaged through careless handling or the deterioration of paper over time. Paper also is sus-ceptible to damage from fire and water.50

The limitations of paper-based charts affect the pro-cess of health care, which includes both medical and business practices. Paper records require large, secure areas for storage. They must be kept organized for easy location but also must have limited access and some type of logging system to record access and removal.50

The capability to retrieve diagnostic test reports and prescription records from EHRs can lower health care

and efficiency, deliver more robust research data on health systems, and empower individuals.

Specific objectives were established for eligible pro-fessionals and hospitals to qualify for the CMS incen-tive payment. To ease the transition into EHR use, the objectives were established in stages. Stage 1, rolled out in 2011, focused on the functionality of EHRs, requiring demonstration of the ability to capture patient data and share data with patients or other health care providers. In 2014, stage 2 required documentation of advancement in clinical practice, such as using CPOE, clinical decision support systems, and giving patients secure online access to their health information. Stage 3, originally scheduled to begin in 2016, has been delayed until 2017. The final rules regarding stage 3 are being developed; however, it is expected that providers will be required to demonstrate advanced use of EHRs and improved outcomes.44

The American Recovery and Reinvestment Act mandated financial penalties in the form of payment reductions to eligible professionals and hospitals that were not meaningful users of certified EHR technol-ogy under the Medicare EHR Incentive Program.46 In October 2014, payment reductions for hospitals were initiated. Nonmeaningful use hospitals now receive a reduced annual payment update for their Medicare inpatient services. Beginning in January 2015, CMS began to apply penalties to eligible professionals for fail-ing to adopt and successfully demonstrate meaningful use of certified EHR technology according to the estab-lished timelines.47 This penalty decreases the Medicare physician fee schedule payment for covered professional services by 1% each year, with a maximum payment adjustment of 5% after 2018. CMS allows eligible hos-pitals and providers to apply for hardship exceptions to the meaningful use rule under some specific circum-stances such as being a newly practicing professional

Box 4

Eligible Professionals for EHR Incentive Program45

Doctors of medicine or osteopathy (MD or DO)Doctors of dental surgery or dental medicine (DDS or DDM)Doctors of podiatry (DPM)Doctors of optometry (OD)Chiropractors (DC)


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intra-office communication, reduce “chart chasing” activities, and make it easier for health care providers and support staff to comply with regulations. Patients have quicker access to their records, easier access to patient education materials, and faster turnaround times for returned messages and prescription refills.

Privacy and Security IssuesOne of the biggest concerns associated with EHR

use is maintaining confidentiality of patient data. Health information privacy rights are protected by the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA required the Secretary of the HHS to develop regulations to protect the privacy and security of health information.58 The HIPAA Privacy and Security Rules were published in response to this mandate. The Standards for Privacy of Individually Identifiable Health Information, better known as the HIPAA Privacy Rule, established national standards to protect certain health information. The Security Standards for the Protection of Electronic Protected Health Information, also known as the HIPAA Security Rule, created a set of national standards to protect certain health information that is stored or transferred in electronic form. The HHS Office for Civil Rights is responsible for enforcing both the Privacy Rule and the Security Rule.

Health care organizations required to follow HIPAA rules are called covered entities. These organizations include health plans, health care providers, and health care clearinghouses (see Box 5).59 Health care clear-inghouses are organizations that process nonstandard health information received from one entity into a standard format for transmission to another entity. An example of a health care clearinghouse is a business that transmits insurance claims and billing information between a hospital and an insurance company.60,61

The HIPAA Security Rule is intended to allow cov-ered health care entities to adopt new electronic technol-ogies to improve the quality and efficiency of health care while protecting the privacy of each individual’s health information. While the Privacy Rule protects against disclosure of individually identifiable health informa-tion, called protected health information, the Security Rule covers a subset of that data. Electronic protected health information is defined as all individually identifiable

costs by reducing service duplication.14 It is estimated that administrative costs account for 25.3% of total hospital expenditures in the United States, a far higher percentage than in other developed nations.51 EHRs can reduce redundant paperwork, interface with coding and billing programs, and reduce the time spent by health care providers and support staff in locating, photocopy-ing, and filing records. All of this allows care providers more time to focus on direct patient care.

A clinical decision support system (CDSS) is:software designed to be a direct aid to clinical decision-making, in which the characteristics of an individual patient are matched to a computerized clinical knowledge base and patient-specific assessments or recommendations are then presented to the clinician or the patient for a decision.52

CDSSs support the practice of evidence-based medicine, which allows integration of the best available research evidence with clinical expertise and patient values.53 These systems can provide alerts such as warn-ing prescribers about patient drug allergies or potential drug interactions. CDSSs also can deliver reminders to providers and patients, for example, when follow-up appointments need to be scheduled or prescriptions need to be refilled. More sophisticated CDSSs provide clinical care guidelines, condition-specific order sets, focused patient data reports, diagnostic support, and contextually relevant reference materials.54 Benefits of using CDSSs are increased quality of care, reduced errors and adverse events, and improved efficiency.

According to a 2010 study, patients in the United States have seen an average of 18.7 different physicians during their lifetimes.55 For patients 65 years and older, the aver-age increases to 28.4, including primary care physicians, specialists, hospitalists, and urgent care providers. EHRs enhance the capability to coordinate and manage patient care by allowing care providers to communicate with each other easily and share patient-related information.

Well-designed and appropriately used EHRs can reduce the risk of malpractice by providing clinical alerts and reminders; improving aggregation, analysis, and communication of patient information; and gather-ing all relevant patient information in one place.56

Other potential benefits of EHRs are improvement in job and customer satisfaction.57 EHRs can improve


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become more common.59 One notable case occurred in May 2006, when the personal information of more than 26 million veterans and American military personnel was stolen when a VA employee’s home was burglarized and his personal laptop computer stolen. Although the employee had authorized access to VA databases for a work project, he was not authorized to have the data on a personal computer at home.62 In January 2015, Anthem, the second largest health insurance provider in the United States, discovered that hackers had broken into a database containing up to 80 million records.63 These are 2 examples of many health care database breaches that have occurred in the past decade. Ninety-one percent of all health care organizations have report-ed at least one data breach in the past 2 years, and it is estimated that the health care industry accounted for 42.5% of all data breaches over the past 3 years.64

HIPAA regulations were designed for the health care system and processes that existed in the 1990s. Because the HITECH Act anticipated the massive expansion in

health information an entity creates, receives, maintains, or transmits in electronic form.58

In general, the Security Rule requires covered entities to safeguard the confidentiality, integrity, and availability of all electronic protected health information they cre-ate, receive, maintain, or transmit; identify and protect against reasonably anticipated threats to the security and integrity of information; guard against reasonably anticipated prohibited uses or disclosures; and ensure compliance by their workforce.58 Confidentiality refers to making sure electronic protected health information is not disclosed or made available to unauthorized people. Integrity of electronic protected health information is maintained by ensuring information is not altered or destroyed in an unauthorized manner. Availability refers to electronic protected health information being acces-sible and useable on demand by any authorized user.

The HIPAA Security Rule requires 3 basic protec-tions: administrative, physical, and technical safeguards.59 Administrative safeguards are internal organizational policies and procedures and maintenance of security measures that protect patient health information. Physical safeguards protect physical equipment from being stolen or rendered inoperable, and technical safeguards protect against electronic threats such as hackers who would steal or maliciously alter data (see Box 6).

As technology evolved and health care entities began to move away from paper-based systems to share and store medical information, data breaches started to

Box 5

Health Insurance Portability and Accountability Act (HIPAA) Covered Entities

59

Health PlansHealth insurersHealth maintenance organizationsCompany health plansMedicare and Medicaid

Health Care ProvidersPhysicians and dentistsClinics and hospitalsPsychologistsChiropractors Nursing homesPharmacies

Health Care Clearinghouses

Box 6

HIPAA Security Rule Required Safeguards 58,59

Administrative Safeguards

Security management processes to identify and analyze potential risks and implementation of measures to reduce vulnerabilities.Security personnel designated to be responsible for develop-ing and implementing security policies and procedures.Information access management that limits uses and disclo-sures to the minimum access necessary to perform duty.Workforce training and management.Evaluation of security policies and procedures.

Physical Safeguards

Facility access and control, limiting physical access to facilities.Workstation and device security policies and procedures covering transfer, removal, disposal, and reuse of electronic media.

Technical Safeguards

Access control that restricts access to authorized personnel only.Audit controls for hardware, software, and transactions.Integrity controls to ensure data is not altered or destroyed.Transmission security to protect against unauthorized access to data transmitted on networks and via email.


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transferred to the treatment unit from simulator or treat-ment planning system computers. Some R&Vs captured parameters used on the first day of treatment to use as a reference for subsequent treatments.

At treatment time, sensing hardware on the treat-ment unit detected collimator, gantry, and table posi-tions and relayed those values to software that com-pared the intended and actual settings.69 A warning that required human intervention to override was issued if there was a mismatch exceeding tolerance levels.

R&Vs were developed to reduce the risk of daily treat-ment errors.70 Over the years their importance and neces-sity in the safe and efficient delivery of modern radiation therapy has been proved.68 Technical advancements since the 1990s have transformed simple R&Vs into sophisticated treatment management systems capable of automatically setting many treatment parameters, such as field size and shape and collimator and gantry positions, with minimal intervention by the radiation therapist.

Traditionally, R&Vs have been unique to radiation oncology and have only contained data related to daily patient treatment. Similarly, radiation oncology treat-ment planning systems usually have been set up as separate entities containing only data related to patient dose calculations. Access to patient clinical data, such as pathology and laboratory reports or consultation and progress notes, was not part of these systems. Nor were patient demographics and scheduling information accessible with these systems.

For years radiation oncology departments typically generated and used department-specific paper charts.71 These charts contained daily treatment records and treatment planning data in addition to demographic and disease-specific information for each patient. Almost all of the information contained in the chart was inaccessible to health care practitioners outside the radiation oncology department.

As computer systems were integrated into radiation oncology departments, different systems were devel-oped for different tasks, such as treatment delivery, treatment planning, scheduling, and billing. Some of these systems were introduced by radiation therapy equipment vendors and others were created in-house to meet the needs of specific institutions. In many instances, even within the radiation oncology depart-ment, it was difficult to obtain all the data on a

the exchange of electronic protected health information that would come with meaningful use of health informa-tion technology, the scope of HIPAA privacy and security protections needed to be broadened. The final HIPAA Omnibus Rule, issued in 2013, expanded many privacy and security requirements to cover business associates of covered entities that receive protected health information. Maximum penalties for noncompliance were increased and clarification was made regarding when breaches of unsecured health information must be reported to the HHS.65 A breach is considered an impermissible use of disclosure under the Privacy Rule that compromises the security or privacy of personal health information.66

Covered entities must now notify individual patients upon discovery of a breach, and the media and HHS must be notified when more than 500 patients are affected. HHS must investigate data breaches to determine whether they were caused by willful neglect, defined as the conscious, intentional failure or reckless indifference to the obligation to comply with HIPAA regulations.67

The final rule allows patients to ask for a copy of their EHR in electronic form, prohibits the sale of indi-viduals’ health information without their consent, and allows individuals who pay cash for their medical care to instruct providers not to share information about their care with their health plans.

EHRs in Radiation OncologyRadiation oncology is a health care discipline

that always has relied on cutting-edge technologies. Historically, these technological advances created a need for more accurate ways to monitor and record daily radiation treatments.68 Some of the first uses of comput-ers in radiation oncology were introduced in the 1980s. To ensure the accurate and safe delivery of daily radia-tion treatments, record and verify systems (R&Vs) were developed to check treatment parameters set by radiation therapists.68,69 When treatment parameters were matched and approved by the computer, the treatment could be delivered and the treatment settings recorded.

R&Vs were computerized systems added to individual treatment units designed to capture treatment param-eters using sensors and compare them with intended parameters before treatment was initiated. The intended parameters were entered either manually or automatically


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particular patient at once because the different systems did not communicate with each other.69,70

In the 1990s, radiation oncology vendors began to introduce electronic medical records systems that inte-grated R&Vs with treatment planning, scheduling, work-flow management, and document storage.69 Radiation oncology departments began to adopt these new oncol-ogy information systems even before the HITECH incentives were put in place. Today, most radiation oncol-ogy facilities use an EHR system.72 In a 2012 study that surveyed 40 academic institutions and private practices, all respondents indicated they used an electronic R&V, and 81% said they used at least one EHR system.73

Varian’s ARIA and Elekta’s MOSAIQ are 2 com-monly used systems in radiation oncology. Both have been certified for stage 2 meaningful use.74,75 ARIA enables the radiation oncology department to connect with pathology, radiology, pharmacy, lab, and billing departments.72 It also links and provides access to the patient’s treatment chart and images, treatment plan-ning modules, physician modules, the R&V, and EHR. The radiation oncology information system can inter-face with the medical oncology information system, which allows medical and radiation oncologists the ben-efit of coordinating care and the capability to determine the patient’s phase of treatment at any given time.

MOSAIQ also can centralize radiation and medical oncology patient data into a single user interface that can be accessed by multidisciplinary team members in various locations.72 It is interoperable with a wide range of treatment planning and treatment delivery systems.

System IntegrationUsually, individual radiation oncology information

systems have been specifically designed for radiation oncology. Some have interoperability with other oncol-ogy systems, but typically they have not been easy to integrate with hospital- or enterprise-wide information systems. This has been one of the challenges to EHR adoption. Historically, individual hospital departments have used stand-alone systems selected to meet their individual needs.76 This “best of breed” approach has resulted in hospitals having a collection of systems rath-er than one system for the entire hospital. Developing a single integrated system for an entire health care organization requires connecting each department’s

software installations to the others in a manner that operates seamlessly. Much of the difficulty encountered with EHR system setup is a result of trying to mesh several systems to create one that operates well for all users. To create an interoperable health care environ-ment, 4 areas of EHR technology need to be addressed: the way computer applications interact with the users, the way systems communicate with each other, the manner in which data are processed and managed, and the methods consumer devices and applications, such as mobile devices, integrate with other systems.77

The struggle to interweave currently used systems that have multiple and noncommunicative EHRs has led many health care systems to switch from a multiple vendor to a single comprehensive vendor approach.78 Epic Systems Corporation currently leads the market in the sale of integrated software for large health care orga-nizations. The EpicCare Inpatient Clinical Systems, based on software developed at Massachusetts General Hospital in 1968, had more than 50% of new large hospital contracts in the United States in 2014 and was reported in 2013 to have included at least partial health information on 50% of the U.S. population.79 Epic’s suc-cess has been attributed to its single product solution, better physician buy-in, standardization of governance and processes, reduced demand on information tech-nology staff for customization or best of breed solu-tions, built-in integration across institutions, and com-pliance with meaningful use regulations.

The biggest advantage of using a single-vendor product is that data flow is more reliable because the same technical platform is used across a health care system. This enables better workflow management.80 Disadvantages to a single product include an inability to meet the specialty requirements of individual health care disciplines and the potential downtime of the entire sys-tem when upgrades are needed to one part of the system.

Current Trends in EHR Use

Despite the factors driving EHR use, not only in radiation oncology but the entire health care industry, some concerns about potential hazards remain, and many health care providers are still not adopting EHRs.

Each year the ECRI Institute, an independent non-profit organization that researches approaches to improv-ing patient care and safety, issues a report that identifies


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cations. Additional research should focus on areas of needed improvement related to the implementation and use of EHRs.

In a 2014 study released by the ONC, 8 in 10 physi-cians reported they were using an EHR or planned to adopt one.83 More than half of the physicians who indicated they planned never to adopt EHRs cited a lack of financial resources as one reason for their deci-sion. Other reasons frequently cited for nonadoption of EHRs were lack of time and staff and security and privacy concerns. Fewer physicians indicated that an EHR system suited to the needs of their specialty was not available.

The adoption of EHR systems by nonfederal acute care hospitals increased more than fivefold between 2008 and 2013.84 In 2013, 59% of hospitals were using a basic EHR system, and 93% of hospitals possessed a certified EHR technology that met meaningful use requirements.

Adoption of EHRs continues to rise. Hospitals and physicians are responding to market and policy pres-sures and are investing time and resources toward adop-tion.85 However, there is still much to be done. Ongoing effort is needed to achieve HITECH’s purpose of build-ing a nationwide health information infrastructure with the ultimate goal of improving health care delivery and population health outcomes in the United States.

Rosann Brauer Keller, MEd, R.T.(T), earned a bachelor of science degree in radiation therapy technology in 1982 and a master of education degree in instructional technology in 1985 from Wayne State University in Detroit, Michigan. In 2013, she earned a certificate in health information administration from the University of Toledo. She now is assistant professor for the radiation therapy technology program at Wayne State University.



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potential sources of danger to health care consumers from health technology. The “Top 10 Health Technology Hazards for 2015” report identified 2 hazards related to the use of EHRs: data integrity and cybersecurity.81 The report acknowledged that when EHRs function well they provide the information clinicians need to make appro-priate and accurate treatment decisions. However, when faults exist, incomplete, erroneous, or outdated informa-tion ends up in the patient’s record, potentially leading to poor treatment decisions and injury to the patient. The integrity of data in health information technology sys-tems can be compromised in many ways and can be dif-ficult to recognize and correct once compromised. Some examples of data integrity issues cited in the report are the entry of one patient’s data in another patient’s EHR, missing data or delayed data delivery, default values being used by mistake or fields being prepopulated with incor-rect information, and outdated or inappropriate informa-tion being copied and pasted into new reports.

The other hazard identified by the ECRI Institute’s report is insufficient protections for medical devices and systems.81 Networking and connectivity of medical devices increases the devices’ susceptibility to malware and malicious attacks. Although the report indicated there is little evidence to date of direct harm to patients from poor cybersecurity, patient safety must always be a consideration when addressing the vulnerability of health information systems. The U.S. Food and Drug Administration noted that, just like other computer systems, medical devices are susceptible to security breaches. When medical devices are connected to hospi-tal networks, other medical devices, or the Internet, that vulnerability increases, potentially leading to equipment malfunctions, disruption of health care services, inap-propriate access to confidential patient information, or compromised data integrity within the EHR.82

Since the IOM recommended the use of EHRs and other health information systems in 1991, studies have focused on their benefits and successes, not potential risks. The ECRI Institute report noted that technology hazards can arise from many different sources, such as poorly configured systems, incomplete data, improper malware protection, inadequate device maintenance, design f laws, quality issues, and failure of devices to perform as they should.81 It is important to recognize hazards and address them before they become compli-


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29. How Leapfrog works. Leapfrog Group Web site. http://www .leapfroggroup.org/about_leapfrog/how_leapfrog_works. Accessed July 2, 2015.

30. First Consulting Group. Computerized Physician Order Entry: Costs, Benefits and Challenges. http://www.leapfroggroup.org /media/file/Leapfrog-AHA_FAH_CPOE_Report.pdf. Published January 2003. Accessed July 2, 2015.

31. Institute of Medicine. Preventing medication errors. http://iom.nationalacademies.org/~/media/Files/Report%20Files /2006/Preventing-Medication-Errors-Quality-Chasm-Series /medicationerrorsnew.pdf. Published July 2006. Accessed June 2, 2015.

32. Benefits of EHRs: medical practice efficiencies & cost sav-ings. Health IT Web site. http://healthit.gov/providers -professionals/medical-practice-efficiencies-cost-savings. Updated March 20, 2014. Accessed July 6, 2015.

33. Health fact sheet. Pew Research Center Internet Science & Tech Web site. http://www.pewinternet.org/fact-sheets /health-fact-sheet/. Accessed July 6, 2015.

34. Leventhal R. Patients value online EHR access, trust tech over paper. Healthcare Informatics Web site. http://www .healthcare-informatics.com/article/patients-value-online -ehr-access-trust-tech-over-paper. Published December 11, 2014. Accessed August 10, 2015.

35. Accenture. Consumers with chronic conditions believe the ability to access electronic medical records outweighs concern of privacy invasion. https://www.accenture.com/us-en/~ /media/Accenture/Conversion-Assets/DotCom/Documents /Global/PDF/Industries_11/Accenture-Consumers-with -Chronic-Conditions-Electronic-Medical-Records.pdf. Published 2014. Accessed July 6, 2015.

36. U.S. Department of Health & Human Services. Quality Interagency Coordination (QuIC) Task Force. Archive AHRQ Web site. http://archive.ahrq.gov/quic/about/clinton establish.htm. Accessed July 10, 2015.

37. Bush GW. Executive Order 1335 of April 27, 2004. Federal Register. 2004;69(84):24059-24061. http://www.gpo.gov /fdsys/pkg/FR-2004-04-30/pdf/04-10024.pdf. Published 2004. Accessed July 27, 2015.

38. Thompson TG, Brailer DJ. The decade of health information technology: delivering consumer-centric and information-rich health care. http://www.providersedge.com/ehdocs/ehr _articles/the_decade_of_hit-delivering_customer-centric _and_info-rich_hc.pdf. Published July, 2004. Accessed July 27, 2015.

39. Health Information Technology for Economic and Clinical Health (HITECH) Act. Healthcare IT News Web site. http://www.healthcareitnews.com/directory/health-infor


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others by far. Health Aff. 2014;33(9):1586-1594. doi:10.1377 /hlthaff.2013.1327.

52. Sim I, Gorman P, Greenes RA, et al. Clinical decision support systems for the practice of evidence-based medicine. J Am Med Inform Assoc. 2011;8(6):527-534.

53. Evidence-based medicine tutorial: definition of evidence-based medicine. Florida State University College of Medicine Web site. http://www.med.fsu.edu/index.cfm?page=medical informatics.ebmTutorial. Accessed August 10, 2015.

54. What is clinical decision support (CDS)? Health IT Web site. http://www.healthit.gov/policy-researchers-implementers /clinical-decision-support-cds. Updated January 15, 2013. Accessed June 11, 2015.

55. Survey: patients see 18.7 different doctors on average. Practice Fusion Web site. http://www.practicefusion.com/pages/pr /survey-patients-see-over-18-different-doctors-on-average .html. Published April 27, 2010. Accessed August 10, 2015.

56. Benefits of EHRs: improved diagnostics and patient outcomes. Health IT Web site. http://www.healthit.gov/providers-pro fessionals/improved-diagnostics-patient-outcomes. Updated March 19, 2014. Accessed June 11, 2015.

57. Introduction to electronic health records (EHRs). American Academy of Family Physicians Web site. http://www.aafp.org /practice-management/health-it/product/intro.html. Accessed June 9, 2015.

58. Summary of the HIPAA security rule. U.S. Department of Health & Human Services Web site. http://www.hhs.gov/ocr /privacy/hipaa/understanding/srsummary.html. Accessed July 10, 2015.

59. Hutfless B. Health information privacy. In: Hoyt RE, Yoshihashi A, Bailey N, eds. Health Informatics: Practical Guide for Healthcare and Information Technology Professionals. 5th ed. Raleigh, NC: Lulu.com; 2012:169-181.

60. Covered entities and business associates. U.S. Department of Health & Human Services Web site. http://www.hhs.gov/ocr /privacy/hipaa/understanding/coveredentities/. Accessed August 20, 2015.

61. Patient’s guide to HIPAA-Learning about HIPAA: which health care entities must comply with HIPAA? World Privacy Forum Web site. https://www.worldprivacyforum.org/2013 /09/hipaaguide9-2/. Accessed August 20, 2015.

62. Department of Veterans Affairs Office of Inspector General. Review of issues related to the loss of VA information involv-ing the identity of millions of veterans. http://www.va.gov/oig /pubs/VAOIG-06-02238-163.pdf. Published July 11, 2006. Accessed August 1, 2015.

63. Loria G. HIPAA breaches: minimizing risks and patient fears. Software Advice Web site. http://www.softwareadvice.com /medical/industryview/hipaa-breaches-report-2015/. Published March 12, 2015. Accessed August 20, 2015.

64. Weisman S. Another health care data breach. USA Today. http://www.usatoday.com/story/money/personalfinance/20 15/07/24/steve-weisman-health-care-data-breach/30593661/. Published July 25, 2015. Accessed August 20, 2015.

65. New rule protects patient privacy, secures health informa-tion. U.S. Department of Health & Human Services Web site. http://www.hhs.gov/news/press/2013pres/01/20130117b .html. Published January 17, 2013. Accessed August 13, 2015.

66. Office of the National Coordinator for Health Information Technology. Guide to privacy and security of electronic health information: Chapter 7 breach notification, HIPAA enforcement, and other laws and requirements. http://www .healthit.gov/sites/default/files/pdf/privacy/privacy-and -security-guide-chapter-7.pdf. Accessed August 20, 2015.

67. Health information privacy: breach notification rule. U.S. Department of Health & Human Services Web site. http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnoti ficationrule/index.html. Accessed August 20, 2015.

68. Colonias A, Parda DS, Karlovits S. A radiation oncology based electronic health record in an integrated radiation oncology network. J Radiat Oncol Inform. 2011;3(1):3-11.

69. Miller AA. Electronic medical record. In: Stardschall R, Siochi RAC, eds. Informatics in Radiation Oncology. Boca Raton, FL: CRC Press; 2013:27-38.

70. International Atomic Energy Agency. Record and verify systems for radiation treatment of cancer: acceptance testing, commissioning and quality control. http://www-pub.iaea.org /MTCD/Publications/PDF/Pub1607_web.pdf. Published 2013. Accessed February 24, 2016.

71. Kirkpatrick JP, Light KL, Walker RM, et al. Implementing and integrating a clinically driven electronic medical record for radiation oncology in a large medical enterprise. Front Oncol. 2013;3:69. doi:10.3389/fonc.2013.00069.

72. Bolan C. Radiation oncology’s data-intensive climate links the OIS to EHRs. Applied Radiation Oncology. http://applied radiationoncology.com/articles/radiation-oncology-s-data -intensive-climate-links-the-ois-to-ehrs. Published June 1, 2013. Accessed August 20, 2015.

73. Shen X, Dicker AP, Doyle L, Showalter TN, Harrison AS, DesHarnais SI. Pilot study of meaningful use of electronic health records in radiation oncology. J Oncol Pract. 2012;8(4): 219-223. doi:10.1200/JOP.2011.000382.

74. Varian Medical Systems’ ARIA oncology information system certified for use to demonstrate stage 1 and 2 “meaningful use“ of an electronic health record. Varian Medical Systems Web site. http://investors.varian.com/2014-07-22-Varian-Medical -Systems-ARIA-Oncology-Information-System-Certified-for -Use-to-Demonstrate-Stage-1-and-2-Meaningful-Use-of-an -Electronic-Health-Record. Published July 22, 2014. Accessed August 20, 2015.


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75. Elekta’s MOSAIQ oncology information system receives stage 2 meaningful use certification. Elekta Web site. https://www .elekta.com/press/2a031205-cafb-4020-8b4d-f5ab467ed020 /elekta-s-mosaiq-oncology-information-system-receives-stage -2-meaningful-use-certification.html. Published June 11, 2014. Accessed August 20, 2015.

76. The myth of hospital EHR integration: why can it be so dif-ficult? Practice Fusion Web site. http://www.practicefusion .com/blog/search/The+myth+of+hospital+EHR+integration. Published January 3, 2012. Accessed August 20, 2015.

77. What is EHR interoperability and why is it important? Health IT Web site. http://www.healthit.gov/providers-professionals /faqs/what-ehr-interoperability-and-why-it-important. Updated January 15, 2013. Accessed August 20, 2015.

78. Conn J. Narrowing it down: systems seeking single supplier for interoperability. Modern Healthcare. http://www.modern healthcare.com/article/20130921/MAGAZINE/309219970. Published September 21, 2013. Accessed August 20, 2015.

79. Koppel R, Lehmann CU. Implications of an emerging EHR monoculture for hospitals and healthcare systems. J Am Med Inform Assoc. 2015;22(2):465-471. doi:10.1136/amiajnl-2014 -003023.

80. Single vendor vs. best of breed for ambulatory EMR strategy. Digitized Medicine Web site. http://www.digitizedmedicine .com/2009/08/single-vendor-vs-best-of-breed-for-ambulatory -emr-strategy.html. Published August 29, 2009. Accessed August 20, 2015.

81. ECRI Institute announces top 10 health technology hazards for 2015. ECRI Institute Web site. https://www.ecri.org/press /Pages/ECRI-Institute-Announces-Top-10-Health-Technol ogy-Hazards-for-2015.aspx. Published November 25, 2014. Accessed July 24, 2015.

82. Cybersecurity. U.S. Food and Drug Administration Web site. http://www.fda.gov/MedicalDevices/DigitalHealth/ucm373 213.htm. Updated December 2, 2015. Accessed January 4, 2016.

83. Heisey-Grove D, Patel V. Physician motivations for adoption of electronic health records. Health IT Web site. http://www .healthit.gov/sites/default/files/oncdatabrief-physician-ehr -adoption-motivators-2014.pdf. Published December 2014. Accessed June 3, 2015.

84. Charles D, Gabriel M, Furukawa MF. Adoption of electronic health record systems among U.S. non-federal acute care hos-pitals. http://www.healthit.gov/sites/default/files/oncdata brief16.pdf. Published May 2014. Accessed June 3, 2015.

85. Adler-Milstein J, DesRoches CM, Furukawa MF, et al. More than half of U.S. hospitals have at least a basic EHR, but stage 2 criteria remain challenging for most. Health Aff. 2014;33(9):1664-1671. doi:10.1377/hlthaff.2014.0453.


Directed Reading Quiz

continued on next page

1. According to the Centers for Medicare & Medicaid Services, an electronic version of a patient’s medical history that is maintained by the provider over time and can include all of the key administrative clinical data relevant to that person’s care under a particular provider defines a(n):a. electronic health record (EHR).b. electronic medical record.c. personal health record.d. radiation oncology information record.

2. An electronic medical record contains the medical and treatment history of patients cared for by one physician.a. trueb. false

3. An electronic application that allows patients to maintain and manage their own health information is called a(n): a. medical chart.b. electronic medical record.c. personal health record.d. radiation oncology information record.

4. The recent motivation for adopting EHRs in the United States is the:a. Institute of Medicine (IOM).b. Leapfrog Group.c. Office of the National Coordinator (ONC).d. American Recovery and Reinvestment Act.

5. Telemedicine is an example of which core function of EHRs?a. Population Health Managementb. Health Information and Datac. Electronic Communication and Connectivityd. Decision Support

6. “To Err Is Human: Building a Safer Health System” is a report issued by the:a. IOM.b. U.S. Department of Health & Human Services

(HHS).c. ONC.d. Leapfrog Group.


To earn continuing education credit: Take this Directed Reading quiz online at www.asrt.org/drquiz. Or, transfer your responses to the answer sheet on Page 60 and mail to ASRT, PO Box 51870, Albuquerque, NM 87181-1870.

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*Your answer sheet for this Directed Reading must be received in the ASRT office on or before this date

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11. According to the article, which of the following is an example of an administrative safeguard as required by HIPAA?a. limiting physical access to facilitiesb. training and management of the workforcec. restricting access to only authorized personneld. establishing policies covering the transfer and

disposal of electronic media

12. Whenever a data breach affects more than 500 patients, HITECH requires notification of:

1. area physicians.2. the media.3. the HHS.

a. 1 and 2b. 1 and 3c. 2 and 3d. 1, 2, and 3

13. One of the earliest uses of computers in radiation oncology was to:a. check treatment parameters.b. digitize portal images.c. create electronic medical records.d. computerize order entry.

14. Examples of EHR data integrity concerns identified by the ECRI Institute include:

1. missing data or delayed data delivery.2. prepopulating of data fields with incorrect

data.3. outdated data being copied and pasted into

new reports.


7. The ONC for Health Care Information Technology was created by an executive order by:a. Bill Clinton.b. Barack Obama.c. George W Bush.d. Ronald Reagan.

8. Which act gave the HHS the authority to establish programs to promote health information technology?a. Health Information Technology for Economic

and Clinical Health (HITECH)b. Freedom of Informationc. American Recovery and Reinvestmentd. Health Insurance Portability and Accountability

Act (HIPAA)

9. Which of the following is a requirement for demonstrating meaningful use?

1. improving care coordination2. maintaining privacy and security of patient

heath information3. engaging patients and their families


10. Which software application supports the practice of evidence-based medicine?a. EHRb. record and verify systemc. computerized provider order entryd. clinical decision support system

✁

Carefully cut or tear here.




CEDirected Reading

Esophageal cancer often is asymptomatic until it has advanced or metastasized to distant organs, limiting treatment options. The 2 most common forms are squamous cell carcinomas that appear in the upper or midesophagus and esophageal adenocarcinomas that tend to occur lower in the esophagus or at the gastroesophageal junction. Since the 1980s higher rates of esophageal adenocarcinomas have been reported. Radiation therapy has emerged as a standard treatment and palliative therapy for esophageal cancer. This article introduces readers to the biology, epidemiology, diagnosis, staging, and treatment of these most common forms of esophageal cancer.

This article is a Directed Reading. Your access to Directed Reading quizzes for continuing education credit is determined by your membership status and CE preference.

After completing this article, the reader should be able to:Discuss trends in the histology, imaging, and treatment of esophageal cancer.Identify components of esophageal anatomy relevant to diagnostic imaging of cancer.Compare the available evidence bases for adjuvant and neoadjuvant radiation therapy.List risk factors for the 2 leading types of esophageal cancer.Discuss the definitive, neoadjuvant, and palliative roles for external-beam

radiation therapy.

Bryant Furlow, BA

Esophageal Cancer Radiation Therapy

Squamous cell carcinoma (SCC) was the predominant form of esophageal cancer until the 1980s, and remains so in most of

the world and among certain patient populations. But since the 1980s, for rea-sons that are not entirely clear, the United States, England, and Australia have seen a dramatic shift in the etiology of esophageal cancers, to a predominance of esophageal adenocarcinomas. Because esophageal cancers tend to be asymp-tomatic until tumors are advanced and have invaded adjacent organs, regional lymph nodes, and frequently, distant organs such as the brain and lungs, these malignancies tend to be diagnosed at advanced and highly lethal stages.

Radiation therapy is playing an evolving and expanding role in man-aging esophageal cancers, and now is widely considered to be a definitive treatment modality and alternative to radical surgery in some cases. The risk of cardiopulmonary toxicities associ-ated with radiation fields that include nontarget cardiac and respiratory tissue

has prompted development of more tumor-contoured radiation therapy tech-niques such as 3-D conformal radiation therapy and intensity-modulated radia-tion therapy (IMRT) that help to mini-mize irradiation of healthy tissues while delivering therapeutic radiation doses to tumors and involved lymph nodes.

Functional AnatomyThe esophagus appears to be simply

a muscle-lined tube that connects the pharynx to the stomach (see Figure 1).1 Approximately 18 cm to 26 cm long in adults, its extent is functionally demar-cated by muscular upper and lower esophageal sphincters that control the entry of food and liquid into the esoph-agus, and their exit from the esophagus into the stomach.1

The esophagus is not a uniform, straight tube; it is subtly curved in the coronal and anteroposterior planes, and has 3 constrictions at approximately 15, 23, and 40 cm from the incisor teeth.1,2 Some of these landmarks correspond with other structures through which


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Abdominal esophagus – the portion between the diaphragmatic hiatus (T10) and the stomach (at T11), adjacent to the liver, where smooth muscle fibers predominate.1,2 The endoscopically visible boundary between the abdomi-nal esophagus and stomach mucosa is called the Z-line.1

The lumen of the cervical and thoracic esophagus usually is compressed or col-lapsed but expands to accommodate swal-lowed boluses of food.1 The lumen wall of the abdominal esophagus is open and round, even in the resting state.1

The esophageal sphincters are made up

of cartilage and 3 layers of muscle fibers with complex nerve supplies.1,2 Normally, the sphincters play impor-tant roles in preventing stomach acid from reaching the esophagus, pharynx, and mouth.1 However, sphincter dysfunction can lead to the upward migration of stomach bile and acid into the esophagus, a condition known as gastroesophageal reflux disease (GERD). Chronic GERD-associated tissue damage to the esophageal mucosa can contribute to tissue and cell changes that might lead to esophageal adenocarcinoma tumorigenesis.4 Disease-related upper esophageal sphincter dysfunction is known as oropharyngeal dysphagia and is associated with dif-ficulty swallowing.1 The lower esophageal sphincter is made up of esophageal muscle fibers and diaphragm muscle, which normally helps to raise the pressure within the esophagus and help prevent backflow of stomach contents into the upper esophagus.1

The esophageal wall is made up of muscle strata sandwiched between an external adventitia layer and

the esophagus passes; for example, the organ’s antero-posterior curvature accommodates the contours of the cervical and thoracic vertebral column, the second con-striction occurs where the esophagus crosses the aortic arch and left main respiratory bronchus, and the third at the point where it crosses the diaphragm.1,2 The third curve turns to the left at the gastroesophageal junction.1

The gross anatomy of the esophagus is divided into 3 anatomic regions or segments: Cervical esophagus – the portion ranging from the

back of the pharyngeal cavity to the suprasternal notch (at the level of T1), alongside the trachea, and in which striated muscle fibers predominate.1,2

Thoracic esophagus – the portion between the suprasternal notch and the diaphragmatic hiatus (T10), where involuntarily controlled smooth muscle fibers predominate.1,2 The thoracic esopha-gus is frequently further divided into the upper and middle thoracic esophagus.3

Figure 1. Anatomic regions of the adult esophagus: the cervical, upper and middle thoracic, and lower (abdominal), with corresponding axial computed tomography (CT) images showing locations of esophageal cancer as described in the 7th edition of the TNM staging manual. Reprinted with permission from Hong SJ, Kim TJ, Bum K, et al. New TNM staging system for esophageal cancer: what chest radiologists need to know. Radiographics. 2014;34:1735.Abbreviations: GEJ, gastroesophageal junction; UES, upper esophagus.


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internal mucosa and submucosa tissue layers.1 A thin layer of connective tissue known as the lamina propria is situated immediately beneath the epithelial cells of the lumen surface. The epithelium and lamina propria are collectively referred to as the mucosa. A layer of muscle cells known as the muscularis mucosae sepa-rates the lamina propria from the submucosa. A serosa membrane layer that lines the stomach and distal gas-trointestinal (GI) tract does not exist in the esophagus, and the absence of the membrane could contribute to the rapid spread of tumors in esophageal tissues and to complications in treating esophageal cancer.1,5 The innermost lumen-facing mucosa typically is made up of squamous epithelial cells.

Esophageal musculature, referred to as the muscularis propria, is made up of a thin outer layer of longitudinally oriented muscle fibers and an internal layer of laterally oriented muscle fibers that circumvent the mucosa and submucosa of the esophagus.1 The inner muscle fibers of the muscularis propria perform the swallowing motion as a tightly coordinated sequence of peristaltic contrac-tions moving food from the pharynx to the stomach.1 Accessory muscle fibers also anchor the esophagus to adjacent structures such as the left respiratory bronchus.1 Close anatomic associations between the esophagus and adjacent structures allow esophageal tumors to spread not only through the blood and lymph systems but also directly into neighboring organs including the aorta and heart, vertebrae, trachea, bronchi, and lungs.3,5,6

Various arteries supply blood to the cervical, thoracic, and abdominal esophagus.1,2 Similarly, esophageal blood drains from the submucosal tissues into different veins.2 The extensively interconnected immune lymphatic node and drainage system of the esophagus is situated in the mucosa, which can hasten the spread of tumor cells along the length of the esophagus and to distant organs.2

PathobiologyEsophageal cancer is one of the most aggressive

and lethal types of cancer.7 Although benign esopha-geal neoplasms are fairly common, they rarely are symptomatic, and therefore seldom diagnosed.8 The vast majority of symptomatic esophageal neoplasms are malignant.8 These tumors appear to be associated with sources of chronic tissue inf lammation.7 Chronic inf lammation of the squamous epithelium triggers

cellular dysplasia and tumorigenesis.6 Inf lammation of esophageal tissues can be caused by repeated con-sumption of swallowed toxic, caustic, or scalding agents—or in the case of esophageal adenocarcino-mas, by chronic GERD.7

Malignancies of the esophagus typically begin in the mucosa and then grow to invade underlying layers of the esophagus and other tissues and organs.9 In addi-tion to direct invasion of adjacent tissues and organs, esophageal tumors can spread via the lymph system and the bloodstream, causing metastatic tumors to emerge in the liver, lungs, bone, brain, iris of the eye, and other organs.5,6,10,11 Primary tumors in the esophagus also can invade the aorta, respiratory system, and vertebrae. Patients with these invasive tumors are not considered candidates for surgical tumor resection.3

Esophageal malignancies can be histologically diverse and genetically heterogeneous. The most com-mon types of esophageal cancers are epithelial malig-nancies: SCC, which also is called epidermoid esopha-geal carcinoma, and esophageal adenocarcinoma.12 There are histological variants of SCC including spindle-cell carcinoma, verrucous carcinoma, squamous papil-loma, and basaloid squamous cell carcinoma.8,13 About 1% of esophageal cancers are neuroendocrine neo-plasms.8 Other rare nonepithelial malignancies of the esophagus include the smooth-muscle tumors called leiomyomas, along with leiomyosarcoma, lymphoma, melanoma, and neurofibroma.8 SCC usually begins in the cervical or thoracic esophagus but can occur in the abdominal esophagus as well.9 Conversely, 75% of esophageal adenocarcinoma cases originate in the abdominal esophagus.6,8

Untreated chronic GERD can lead to Barrett esophagus, a condition in which normal, f lat squa-mous epithelial cells are replaced by a columnar mor-phology epithelium.6 Columnar epithelial cells are more rectangular than typical f lat, squamous cells. For reasons not yet well understood, chronic GERD can cause epithelial cells to undergo metaplasia and become less organized and more abnormal in appear-ance.6,14,15 In Barrett esophagus, metaplasia leads to the formation of goblet cells, a process sometimes called intestinalization.15 Whether the presence of goblet cells is required to confirm a diagnosis of Barrett esopha-gus is controversial, but the cells’ presence in a biopsy


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Epidemiology Esophageal carcinomas emerge in the tissues of the

esophagus but can spread to distant organs throughout the body. Because early-stage esophageal cancers are frequently asymptomatic, diagnosis commonly is made only after tumors are at an advanced stage and patients have a poor prognosis.12 As a result, esophageal cancers are highly lethal malignancies, and are associated with a 5-year survival rate following diagnosis of only 17.9%.9 The National Cancer Institute combines statistics on esophageal cancers of different histologic types, but other research indicates that survival rates are higher for patients in the United States with esophageal adenocar-cinoma than they are for esophageal SCC.3

The age-adjusted incidence rate for esophageal can-cer is 4.4 per 100 000 Americans, and mortality rates are 4.2 per 100 000.9 In the United States, nearly 17 000 new cases of esophageal cancer are diagnosed each year, and more than 15 000 people die from esopha-geal cancer in the United States annually, representing approximately 1% of all cancer diagnoses and 2.6% of all cancer deaths.9 In 2012, an estimated 35 781 people with esophageal cancer were living in the United States.9 Overall, an estimated 0.5% of people living in the United States will receive a diagnosis of esophageal cancer in their lifetimes.9

Most (59.9%) of the esophageal cancers occurring in the United States are adenocarcinomas, and an estimated 85% of patients with this cancer are men.8,20 SCC was the most common form of esophageal carcinoma in the United States, as it still is in most of the world outside of Australia and the United Kingdom.5,7 However, begin-ning in the 1980s, the incidence rate of esophageal adeno-carcinomas has increased and the cancer subtype has overtaken esophageal SCC in the United States, United Kingdom, and Australia.5,21 This shift has been geograph-ically uneven, with SCC remaining the most common form of esophageal cancer in most of the rest of the world and among black men in the United States.5 The epide-miology of this shift from SCC to esophageal adenocarci-noma predominance in these countries remains unclear.5

Most patients learn of an esophageal cancer diag-nosis during mid- or late adulthood, after age 44 years, and the median age of those with the disease at death is 69 years.9 Rates are markedly higher among men than women, at 7.6 cases per 100 000 men vs 1.7 cases per

sample is widely considered a diagnostic criterion.16 Barrett metaplasia, in turn, can evolve through pro-gressively severe stages of dysplasia and tumorigen-esis.17 Histologically assessed dysplasia is believed to ref lect underlying genetic or genomic changes.14

Dysplasia is an indicator of esophageal adenocarci-noma risk, but its endoscopic assessment is subjective and can be problematic. Up to 3% of patients with low-grade esophageal dysplasia develop esophageal adenocarcinoma tumors each year, although estimates vary, partly because of the poor reliability of identifying low-grade dysplasia in patients with Barrett esopha-gus.14 Interobserver agreement among pathologists is lower than 50%.14 Among patients with low-grade dys-plasia confirmed by expert pathologists, the annual risk of progression to high-grade dysplasia or esophageal adenocarcinoma has been reported at 9%.14 Esophageal adenocarcinoma incidence rates are higher among those patients who develop high-grade dysplasia, who have Barrett esophagus longer than 10 years, or who have esophagitis and Barrett esophagus.14 In more than half of cases, initial endoscopic findings of low-grade dyspla-sia are not confirmed with follow-up endoscopy, but it is unclear if this is due to a biological reversal of dysplasia or simply an ongoing failure to detect dysplasia.14 The resulting uncertainty has complicated efforts to develop screening protocols.

High-grade dysplasia is believed to be an interme-diate step between low-grade dysplasia and tumori-genesis.14 Patients with high-grade dysplasia face a risk of developing esophageal adenocarcinoma that averages up to 11.8% per year, or 59% over 5 years, according to one study.14 However, meta-analysis of data pooled from multiple studies found lower incidence rates (6% per year) of esophageal adeno-carcinoma associated with high-grade dysplasia.18,19 Authors of one of the meta-analyses found that men with high-grade dysplasia and Barrett esophagus are twice as likely as women to have the condition prog-ress to esophageal cancer.18

The anatomic extent of Barrett esophageal metapla-sia, particularly in the abdominal esophagus, is associat-ed with increased risk of esophageal adenocarcinoma.6 However, most patients with esophageal cancer have no medical history of Barrett esophagus at the time of cancer diagnosis.6


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alcohol and tobacco use each independently increase the risk of esophageal SCC, there is some evidence that heavy consumption of both tobacco and alcohol has a syner-gistic effect on SCC risk—an effect that multiples rather than simply adds to overall risk.5,23 This could be because alcohol is a solvent and increases epithelial cell uptake of tobacco carcinogens such as nitrosamines, aldehydes, phenols, and polycyclic hydrocarbons.6 Dietary intake of nitrosamines such as those found in some canned veg-etables and fish also is associated with SCC.6

Certain bacterial or viral infections appear to modu-late esophageal cancer risk, as well. Chronic infection with the bacteria Helicobacter pylori, which has been confirmed to increase risk of gastric cancers, is associated with a doubling of risk of developing esophageal SCC. Helicobacter pylori appears to have an inverse relationship with some esophageal disease, however, actually decreas-ing risk of developing Barrett esophagus and esophageal adenocarcinomas.4,5,22

100 000 women.9 Hispanics, Asian/Pacific Islanders, and American Indians tend to have lower rates than whites or blacks (see Figure 2).9

At diagnosis, approximately 21% of patients with esophageal cancer have tumors that are localized at their primary site; 31% have already spread to regional lymph nodes; and 38% have metastasized to distant organs.9 Another 11% are of undetermined state at diagnosis.9 The corresponding 5-year relative survival rates for patients based on stage of the cancer at diagnosis are9: Localized esophageal cancer – 40.4%. Regional lymph node involvement – 21.6%. Metastatic disease – 4.2%.

Risk FactorsTobacco smoking is a major risk factor for both

esophageal SCC and esophageal adenocarcinomas.14,22,23 The combination of alcohol use and tobacco smoking is believed to underlie 90% of SCC cases.4,7,23 Although

Number of New Cases Per 100 000 People by Race/Ethnicity & Sex: Esophageal Cancer

SEER 18 2008-2012, Age-Adjusted

All Races

White

Black

Asian/Pacific Islander

American Indian/Alaska Native

Hispanic

Non-Hispanic

Men Women

7.6

8.0

7.6

3.6

4.9

5.2

7.9

1.7

1.7

2.5

1.0

1.6

1.0

1.8

Figure 2. The incidence rates of esophageal cancer among men and women of different ethnicities in the United States. Image courtesy of National Cancer Institute Surveillance, Epidemiology, and End Results Program. http://seer.cancer.gov/statfacts/html/esoph.html. Accessed August 31, 2015.


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esophageal SCC also could be associated with occupa-tional exposures to asbestos, carbon black (eg, among chimney sweeps or dockyard workers), sulfuric acid, textile dye work-associated perchloroethylene exposure, and polycyclic aromatic hydrocarbons associated with asphalt work. Esophageal adenocarcinoma risk appears to be elevated for people who are exposed to lead and sulfur-containing chemicals in the occupational setting.23,24 Based on limited available evidence, the International Agency for Research on Cancer has clas-sified occupation in the dry cleaning and rubber indus-tries as a risk factor for esophageal cancers.24

Elevated risks of esophageal SCC are reportedly associated with exposure to ionizing radiation, includ-ing exposure among Japanese survivors of atomic bomb fallout, and among patients who have undergone radiation therapy for the treatment of breast cancer or ankylosing spondylitis.23 Breast radiation therapy has not been found to increase the risk of esophageal adeno-carcinoma, however.23

Genetic and Epigenetic Risk FactorsThe advent of high-throughput, rapid genetic sequenc-

ing and genome-wide DNA sequencing is revolutionizing the understanding of the molecular epidemiology of can-cers and tumor formation, progression, and metastasis. For example, alterations in the gene-encoding enzymes involved in alcohol metabolism appear to increase esoph-ageal SCC risk, and SCC tumors frequently have muta-tions in the RB1, CDKN2A, PIK3CA, NOTCH1, and NFE2L2 genes.5,13 SMAD family member 4 (SMAD4) mutations are found in high-grade esophageal dysplasia and esophageal adenocarcinoma cells.13

Genome-wide sequencing also should hasten the iden-tification of molecular biomarkers that will help identify patients at particular risk for poor prognosis or who are likely to benefit from a particular type of treatment.25 Although no candidate biomarker for esophageal cancer risk or prognosis has yet been validated, aberrant expres-sion of the tumor protein p53 (TP53) gene appears to show promise as a biomarker of progression from nondys-plastic epithelia, or low-grade dysplasia, into high-grade dysplasia and esophageal adenocarcinoma. Both overex-pression and underexpression of TP53 increase the risk of progression to malignancy from low-grade dysplasia.13,14 Other biologically plausible candidate gene mutations and

Some studies, but not others, suggest that Epstein-Barr virus might be associated with esophageal can-cers.16 Despite a significant role for oncogenic human papillomavirus (HPV) in SCC incidence in parts of Asia, Africa, and South America, HPV infections appear to play a negligible role in esophageal cancers in the United States.23

Diet also might play a role in SCC risk. Malnourish- ment and low body mass index (BMI) are associated with increased esophageal SCC risk worldwide.23 Eating high levels of dietary fats might increase esophageal SCC risk.23 Consumption of fruits and vegetables appears to be associated with a reduced risk of both esophageal SCC and adenocarcinoma.23 Regular consumption of hot teas or beverages containing alcohol could increase SCC risk through chronic thermal damage to the esophageal mucosa.7,23 The International Agency for Research on Cancer has identified regular consumption of extremely hot yerba mate tea, a traditional drink in South America, as “probably carcinogenic.”23

Risk factors for esophageal adenocarcinomas are less well understood but include GERD and Barrett esopha-gus.4,14,22,23 However, because the incidence of esophageal adenocarcinomas is relatively low, even seemingly dra-matic associations between a risk factor such as Barrett esophagus and esophageal adenocarcinoma can affect relatively few patients. Accordingly, although the risk of esophageal adenocarcinoma is up to 100 times higher among people with a history of Barrett esophagus than for those who have not had the condition, fewer than 5% of patients diagnosed with esophageal adenocarci-nomas have a history of Barrett esophagus.6

Whereas reduced BMI is associated with increased risk of SCC, increased BMI is considered to be a risk factor for esophageal adenocarcinoma.23 For example, obesity is associated with up to 7 times the risk for esophageal adenocarcinoma compared with individu-als who fall in the lowest quartile of BMI calculation, possibly because obesity can contribute to the develop-ment of GERD.23 The association between esophageal adenocarcinoma and obesity is strongest for abdominal obesity.6 Fat cells and inflammatory cells within fat deposits secrete proinflammatory cytokines that might contribute to tissue inflammation in other organs.6

Some occupational exposures might contribute to esophageal cancer risk, particularly SCC.23 For example,


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esophagus, and 93% of esophageal adenocarcinoma cases are not detected by current screening strategies.6,21 With the rise in esophageal adenocarcinoma incidence rates beginning in the 1980s, attempts have been made to institute screening for Barrett esophagus among patients diagnosed with GERD, along with surveillance endoscopy of patients with Barrett esophagus for early detection of esophageal adenocarcinoma; however, these screening efforts have not led to earlier detection of esophageal adenocarcinoma.21

Mucosal high-grade dysplasia is associated with an elevated risk of esophageal adenocarcinoma, but high-grade dysplasia is not always extensive enough or read-ily differentiated from low-grade dysplasia in Barrett esophagus for reliable detection during surveillance endoscopy.14,17 Effective detection of dysplastic areas often requires examination of much of the internal lumi-nal surface area of the esophagus.17 By the time dysplasia is extensive enough to be detected with endoscopy, malignancies are frequently already present, limiting the opportunity for prevention or early intervention.14

Sampling error during endoscopy has led to prom-ulgation of the Seattle biopsy protocol recommenda-tions.14 Adherence to the Seattle protocols would dramatically improve detection rates for high-grade dysplasia and esophageal adenocarcinoma, but adher-ence rates appear to be low (51%) where the protocols have been implemented.14

Various endoscopic imaging methods have been proposed to better detect epithelial dysplasia, including chromoendoscopy with contrast or stain agents such as methylene blue, indigo carmine, or Congo red, to dif-ferentiate normal esophageal mucosa from intestinalized epithelia.17 Narrowband endoscopy and autofluores-cence imaging methods also are under investigation. Narrowband endoscopy uses nonwhite light sources to detect columnar and dysplastic epithelia.17 Despite efforts to develop alternative endoscopic modalities such as these, traditional white-light-based endoscopy remains the standard for assessment of the esophageal mucosa, including endoscopic surveillance and screening efforts.

Authors of a meta-analysis of the progression of dyspla-sia to esophageal adenocarcinoma in patients with Barrett esophagus have cautioned that the cost-effectiveness of surveillance will remain uncertain until patients with the highest cancer risk can be reliably identified for targeted

molecular pathways have been implicated in esophageal cancers and are undergoing further study.13

Genomic alterations other than genetic mutations can contribute to esophageal cancer processes. For example, aneuploidy, which is having an abnormal num-ber of chromosomes in a cell, and epigenetic changes to certain genes, a condition called hypermethylation, appear to drive progression of Barrett esophagus to high-grade dysplasia and esophageal adenocarcinoma.13 Epigenetic changes do not entail mutations in the DNA sequence of a gene, but instead involve the attachment chemicals on a genetic sequence to up-regulate or down-regulate expression of that gene.

PreventionAvoiding tobacco and alcohol reduces the risk of

esophageal cancers.4 Regular consumption of nonsteroi-dal anti-inflammatory drugs (NSAIDs) such as aspirin is associated with a modest chemopreventive effect against the risk of both esophageal SCC and adenocarcinoma.4 The potential benefits of NSAIDs must be balanced, however, with increased risk of GI tract bleeding, myo-cardial infarction, heart failure, and stroke.4 Despite the relationship between GERD, Barrett esophagus, and esophageal adenocarcinoma, the evidence base is not yet robust enough to determine whether surgical or pharma-cologic management of GERD would reduce the risk of esophageal adenocarcinoma.4

According to an assessment from the National Cancer Institute, radiofrequency ablation of Barrett esophagus with high-grade dysplasia can help eradicate both dysplasia and intestinal metaplasia and reduce the risk that the diseases will progress to esophageal adeno-carcinoma.4 However, the effect of the preventive mea-sure on patient survival has not been established and radiofrequency ablation entails potential harms such as esophageal stricture and upper GI tract hemorrhage.4

ScreeningEsophageal cancer and Barrett esophagus screen-

ing and surveillance efforts are controversial.4,16,26 The National Cancer Institute has concluded that balanced evidence suggests screening would have little to no effect on U.S. mortality rates from esophageal cancer.4 No screening protocol is in use for esophageal adeno-carcinoma among patients diagnosed with Barrett


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surveillance.18 With the advent of genome-wide DNA sequencing and epigenetic characterization of patient and tumor genetics, however, it is widely anticipated that the genetic mutations and molecular pathways of esophageal adenocarcinoma and SSC tumorigenesis, disease progres-sion, and metastasis will become much better understood in the future.21 This technology will allow the develop-ment of clinically meaningful diagnostic and prognos-tic molecular and genomic biomarkers for patient risk stratification. Such tools are expected to improve early detection of dysplasia and tumorigenesis associated with Barrett esophagus, as well as differentiation of high-risk and low-risk dysplasia.21 Biomarkers also can help identify which patients are likely to benefit from particular tar-geted therapies.

DiagnosisProgressive difficulty or discomfort in swallowing,

or dysphagia, is the most common clinical presentation for patients who are ultimately diagnosed with esopha-geal adenocarcinoma and SCC; dysphagia typically emerges rapidly over just a few months.5,7,20 Swallowing food often is more difficult than swallowing liquids for patients with dysphagia, at least initially. In advanced cases, however, even swallowing liquids can be chal-lenging.7,20 Dysphagia in esophageal cancer usually is related to tumor mass in the abdominal esophagus vs oropharyngeal dysphagia, which is associated with upper esophageal sphincter dysfunction.20

Patients also frequently present with fatigue and less commonly with upper GI tract pain or bleeding.7,20 In patients with SCC, recent weight loss and history of tobacco and alcohol use are common; weight loss is not a common clinical presentation among patients with esophageal adenocarcinoma.5

Differential diagnosis of dysphagia involves exclud-ing caustic or radiation injury, tuberculosis, esophagitis, scleroderma, hiatal hernia, aortic aneurysms, or none-sophageal malignancies such as lung cancer or lympho-ma.7 Confirmation of a diagnosis of esophageal cancer involves endoscopy with biopsy.7 Upper GI endoscopy is the initial diagnostic procedure for suspected esopha-geal cancer.7 Esophagogastroduodenoscopy or endo-scopic biopsy with ultrasonographic guidance leads to definitive diagnosis of esophageal cancer from histo-pathological analysis of tumor tissue. The biopsy tissue

sample also provides important tumor staging infor-mation, such as proximal and distal tumor extent and involvement of adjacent organs.5,7 Bronchoscopy can help assess respiratory tissue involvement of tumors in the thoracic esophagus.6 Endoscopy can be complicated by disease-related esophageal strictures and obstruc-tions of the esophageal lumen by tumor mass.5

StagingTreatment options for esophageal cancer depend on

how advanced the malignancy is at diagnosis. Therefore, tumors are staged following endoscopic biopsy and diag-nosis of esophageal cancer. At the time of diagnosis, only approximately 25% of patients with esophageal adenocar-cinoma have localized tumors; most patients already have advanced-stage disease; in 50% of cases the advanced disease includes distant metastases.20

The American Joint Committee on Cancer has endorsed the tumor, node, and metastasis (TNM) stag-ing system to assess prognosis and treatment options for patients with esophageal cancer (see Figure 3).3,5,6,20,27,28 In this system, the T stage represents the extent of pri-mary tumor invasion of the esophageal wall and, in more advanced T stages, through the esophageal wall into adjacent structures.3 N stage refers to the involvement of tumor cells in the regional lymph nodes (see Figure 4).3 M stage refers to the spread of esophageal tumors to dis-tant organs; M0 means no distant organ or bone metastat-ic tumors exist, whereas M1 represents metastatic disease being detected in one or more distant organs.3

An updated seventh edition of the TNM stag-ing system for esophageal cancer was released in 2009, ref lecting advances in diagnostic imaging and treatment planning, and an improved evidence base regarding treatment outcomes (see Table 1).29 For example, the updated system differentiates T4a, or surgically resectable, tumors from T4b tumors, which are not resectable; these 2 types of tumors previously had been grouped together as T4.3,28,29 Lymph node (N) staging was updated from ref lecting the pres-ence (N1) or absence (N0) of tumor involvement in regional lymph nodes to ref lecting how many nodes are involved (N0-N3) to indicate the prognostic sig-nificance of this information.29 Finally, the update has simplified metastatic disease (M) staging to exclude regional lymph node status criteria and instead to


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Figure 4. Regional lymph nodes according to the seventh edition of the staging manual for esophageal cancer. The posterior mediastinal lymph node (3P) is not shown here. Reprinted with permission from Hong SJ, Kim TJ, Nam KB, et al. New TNM staging system for esophageal can-cer: what chest radiologists need to know. Radiographics. 2014;34(6):1729.Abbreviations: 1L, left supraclavicular; 1R, right supra-clavicular; 2L, left upper paratracheal; 2R, right upper paratracheal; 4L, left lower paratracheal; 4R, right lower paratracheal; 5, aortopulmonary; 6, anterior mediastinal; 7, subcarinal; 8L, lower paraesophageal; 8M, middle paraesophageal; 9, pulmonary ligament; 10L, left tracheo-bronchial; 10R, right tracheobronchial; 15, diaphragmat-ic; 16, paracardial; 17, left gastric; 18, common hepatic; 19, splenic; 20, celiac.

EpitheliumBasement membraneLamina propria

Muscularis mucosae

Submucosa

Muscularis propria

Adventitis

Pleura

N1 1-2N2 3-6N3 7 Aorta

M1

M1

T3

T4a

T1aT1b

T4b

T2

Figure 3. A. Drawing illustrates the revised TNM staging system for esophageal cancer (7th edition). B. Endoscopic sonogram shows the normal esophageal wall, with 5 alternating hyper- and hypoechoic layers (arrowheads). The hyperechoic layer between the hypoechoic inner and outer mus-cularis propria (*) is the inner muscular connective tissue layer and sometimes is seen prominently. Reprinted with permission from Hong SJ, Kim TJ, Nam KB, et al. New TNM staging system for esophageal cancer: what chest radiologists need to know. Radiographics. 2014;34(6):1724.

A B


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ref lect only metastatic spread of esophageal cancer to distant organs (see Figures 5 and 6).3,29

The updated staging system has reportedly improved postsurgical prognostic risk-stratification of patients.30 However, noninvasive preoperative staging remains challenging and can be imprecise.31 The accu-racy of computed tomography (CT) chest image tumor depth staging is 50% to 80%, according to the National Cancer Institute.31 Endoscopic ultrasonography is more accurate (85%-90%) at tumor staging because it

Table 1

Comparison of the Sixth and Seventh Editions of TNM Staging System for Esophageal Cancer3

Category Sixth Edition Seventh Edition

Tumor (T) Tis: carcinoma in situ Tis: high-grade dysplasia

T1: invasion of lamina propria, muscularis mucosae, or submucosa

T1: invasion of lamina propria, muscularis mucosae (T1a), or submucosa (T1b)

T2: invasion of muscularis propria T2: invasion of muscularis propria

T3: invasion of the adventitia T3: invasion of the adventitia

T4: invasion of adjacent structures T4: invasion of adjacent structures

T4a: resectable (pleura, pericardium, or diaphragm)

T4b: unresectable (aorta, vertebral body, or trachea)

Lymph Node (N) N0: absent N0: absent

N1: present (any number) N1: 1-2 regional lymph nodes

N2: 3-6 regional lymph nodes

N3: 7 regional lymph nodes

Metastasis (M) M0: absent M0: absent

M1a: cervical lymph node (in upper esophageal cancer) or celiac lymph node (in lower esophageal cancer)

M1: present

M1b: all other distant metastases

Figure 5. T4b tumor with tracheobronchial invasion. Axial contrast-enhanced CT image at the level of the tracheal bifurcation and the main-stem bronchi shows diffuse wall thickening in the midesophagus (*), a finding later confirmed to be esophageal cancer. Direct tumor extension into the left main bronchus is seen (arrow). Reprinted with permission from Hong SJ, Kim TJ, Nam KB, et al. New TNM staging system for esophageal cancer: what chest radiologists need to know. Radiographics. 2014;34(6):1728.


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Fine-needle aspiration with endoscopic ultrasonog-raphy guidance for lymph node (N) staging can offer highly-accurate N staging and, unlike radiographic images, cytologic confirmation of the presence of meta-static tumor tissue within nodes.3 Reports have shown up to 93% sensitivity, or true-positive rate, and 100% specificity, or true-negative rate, for use of the fine-needle biopsy technique.31

Fludeoxyglucose (FDG) 18 positron emission tomog-raphy (PET)-CT shows promise in metastatic disease staging.31 FDG 18 PET-CT also is used widely for post-treatment restaging and monitoring.32 However, CT and PET-CT can miss small metastatic tumors in the liver and lungs.28 For that reason, some institutions still use minimally invasive surgical thoracoscopy or staging lapa-roscopy to assist in tumor staging for some patients.28

displays the esophageal wall tissue layers as alternating hypoechoic and hyperechoic strata, helping physicians to differentiate T1, T2, and T3 primary tumors.3,31 In endo-scopic ultrasonography, the esophageal wall has 5 distinct layers. Layer 2 (the lamina propria and muscularis muco-sae) and layer 4 (muscularis propria) are hypoechoic and the other layers are hyperechoic.3 Layer 3, which is hyper-echoic, is the submucosa.3 The absence of a hyperechoic layer 3 suggests a T1b-stage primary tumor.3

Endoscopic ultrasonography also offers superior accuracy to CT for regional lymph node staging; stud-ies have shown an accuracy rate of 70% to 80% for endoscopic ultrasonography vs 50% to 70% for CT at staging regional nodes.31 CT is the most accurate imag-ing modality, however, for detecting T4 tumors that have invaded adjacent anatomy.3

Figure 6. A. Unexpected metastatic disease (TNM stage M1) detected with axial positron emission tomography (PET)-CT as unanticipated fludeoxyglucose (FDG) uptake in the left cerebellum of the patient’s brain (arrow). B. FDG uptake also is seen in the primary tumor in the midesophagus (arrowhead), a finding later confirmed to be esophageal squamous cell carcinoma, and in the mediastinal lymph nodes; fewer than 7 nodes represents N2 disease. Reprinted with permission from Hong SJ, Kim TJ, Nam KB, et al. New TNM staging system for esophageal cancer: what chest radiologists need to know. Radiographics. 2014;34(6):1732.

BA


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To optimize the strengths of each of these diagnostic imaging modalities, preoperative staging typically is multimodality in nature, using images acquired with CT, endoscopic ultrasonography, and FDG 18 PET-CT (see Figure 7).3 For example, on CT, a wall of a distend-ed esophagus with asymmetric thickening to greater than 5 mm might indicate the presence of a T1- or T2-stage esophageal tumor; however, these tumors fre-quently must be evaluated using follow-up endoscopic ultrasonography or PET-CT.3

Histological cell type and grade also are relevant to a patient’s prognosis and treatment options. Esophageal adenocarcinoma and SCC tumors can be difficult to distinguish from one another with structural diag-nostic imaging, but their location in the esophagus can provide an important diagnostic indication.8 SCC tends to occur in the cervical or thoracic esophagus, whereas esophageal adenocarcinoma usually occurs in the abdominal esophagus.3,5,8 Physicians determine the location of a tumor in the esophagus by its upper extent or periphery, not the center of its volume or mass.3

The updated TNM staging system includes biologic activity, or namely histologic tumor grade, to help differentiate SCC from esophageal adenocarcinoma. Grade 1 refers to tumors with good histologic dif-ferentiation, grade 2 to moderate differentiation, and grade 3 to poor differentiation.3 Grade 4 is reserved for undifferentiated tumors.28 Tumor grades correlate with stage. For example, a T1a tumor is likely to be grade 1,

Figure 7. Imaging modalities have different strengths in staging esophageal cancers, so staging typically involves several modalities. These CT, endoscopic ultrasonography, and axial PET-CT images of a T1a esophageal tumor illustrate the strengths of a multimodality imaging strategy. A. Axial contrast-enhanced CT image at the level of the right pulmonary artery shows a suspicious small nodular lesion in the midesophagus (arrow), a finding that is not easily substantiated without endoscopy. The lesion was later confirmed to be squamous cell carcinoma. B. Endoscopic ultrasonogram shows an irregularly shaped nodule (arrow) and preservation of the hyperechoic third layer (submucosa; arrowheads). C. Axial PET-CT image at the same level as figure A shows no definite FDG uptake in the primary tumor. Reprinted with permission from Hong SJ, Kim TJ, Nam KB, et al. New TNM staging system for esophageal cancer: what chest radiolo-gists need to know. Radiographics. 2014;34(6):1725.

B

C

A


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whereas a T1b tumor is likely to be grade 2 or grade 3.3 As with tumor stage, increasing tumor grade is associ-ated with poorer patient prognoses.3

TreatmentEsophageal cancer treatment depends on disease stage

and patient history. Treatment recommendations can involve surgery only, chemotherapy, external-beam radia-tion therapy, or a combination of these therapies.20,32-34 In contemporary clinical practice, treatment planning usually involves an interdisciplinary and multimodal approach, with individual patients’ treatment plans designed for their particular esophageal cancer subtype.3

Traditionally, surgical resection (esophagectomy) with lymphadenectomy was the primary esophageal cancer treatment, with chemotherapy and radiation therapy in adjuvant and palliative roles.3 Although sev-eral surgical techniques have been used, survival and tumor recurrence rates remain comparably poor among these approaches, prompting development of alterna-tive treatment strategies.3,5 Minimally invasive esopha-gectomy appears to be associated with a lower patient mortality rate and improved postsurgical quality of life compared with conventional open esophagectomy.5

Chemotherapy typically includes cisplatin or car-boplatin plus 5-fluorouracil.20 The evidence base for adjuvant chemotherapy in treating esophageal cancer is relatively scant and equivocal, leading some research-ers to recommend that the therapy be used primar-ily when histology and other clinical signs suggest a high likelihood of metastatic disease.28 The National Comprehensive Cancer Network (NCCN) does not recommend adjuvant chemotherapy for patients diag-nosed with SCC, and recommends adjuvant chemother-apy for patients with esophageal adenocarcinoma only if they have received induction radiation therapy.28,35 The NCCN recommends neoadjuvant concurrent external-beam radiation therapy (for a total of 45-50.4 Gy) and chemotherapy for patients undergoing resection for locally advanced esophageal adenocarcinoma.35

In recent years, neoadjuvant combined chemo-therapy and radiation therapy have become more widely used, particularly for patients with locally advanced, or stage T1-T3, esophageal cancer.3,5,36 Neoadjuvant che-motherapy and radiation therapy are associated with superior patient survival times compared with surgery

alone, and although toxicities vary among studies, this approach has been shown to result in comparable patient morbidity and mortality compared to neoadju-vant chemotherapy alone.20,37-39

For stages Tis and T1a esophageal SCC or stage N0/M0 esophageal adenocarcinomas, endoscopic tumor resection or ablation alone now is preferred to open surgical resection, particularly when tumors are grade 1 or grade 2 and smaller than 3 cm in diam-eter.3,20,40 Endoscopic mucosal resection of foci is per-formed for these early-stage tumors; tumor tissue is removed, along with adjacent Barrett esophagus and regions of high-grade dysplasia that could become foci of progression to tumorigenesis and tumor recur-rence.35,40 Endoscopic submucosal dissection is appro-priate for tumors at stage T1b or more advanced.40 Patients undergoing endoscopic tumor resection who have residual Barrett esophagus or high-grade dyspla-sia frequently (in up to 30% of cases) have tumor recur-rence.20 Therefore, endoscopic eradication therapy is sometimes recommended following endoscopic tumor resection to remove residual Barrett esophagus that might conceal high-grade, tumorigenesis-prone dys-plasia.20 These patients also are candidates for periodic endoscopic surveillance to detect recurrences.35

Surgical resection with or without neoadjuvant che-motherapy with radiation therapy generally is preferred for stage T1b, T2, T3, and T4a tumors.3 For patients with cervical esophageal tumors, the larynx is removed along with the esophagus, which means that patients permanently lose their ability to speak.41 Combined chemotherapy and radiation therapy is preferred for patients with nonmetastatic (M0) T4b-stage tumors.3

By definition, patients with any distant metastases (M1) are candidates only for palliative therapy.3 The therapy might include modalities that treat or destroy the tumor, but with the goal of easing symptoms and improving quality of life rather than prolonging a patient’s life.33 Endoscopic ablative laser therapy some-times is included in a palliative care plan.33

In addition to standard chemotherapy drugs, a newer targeted therapy aimed at the erb-b2 receptor tyrosine kinase 2 (ERBB2) has shown promise against some metastatic (M1) esophageal cancers. The targeted ther-apy involving trastuzumab (Herceptin), is used along with palliative chemotherapy regimens.42 Ramucirumab


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option, even for patients with resectable esophageal cancers when patients wish to preserve esophageal func-tion. It has been found that required salvage surgery for persisting or recurrent tumors following the combination therapy offers similar patient outcomes to surgery.41

Radiation therapy without chemotherapy also is a treatment option, particularly among patients with met-astatic disease or elderly patients with advanced-stage cancers and poor performance status.41

The evidence base for neoadjuvant and adjuvant therapy for resectable esophageal cancer is evolv-ing.5,34,37,38 Neoadjuvant chemotherapy and radiation therapy followed by surgical resection is a standard of care for locally advanced esophageal cancer.37 Long-term results from the neoadjuvant chemoradiotherapy for esophageal cancer followed by surgery study (CROSS) clinical trial were published in August 2015 in The Lancet Oncology and showed that 5-year overall survival rates among patients with esophageal SCC and esophageal adenocarcinomas undergoing neoadjuvant chemotherapy and radiation therapy are superior to those for patients who have surgery alone.38

The CROSS study’s 23-day therapy regimen involved chemotherapy with intravenous carboplatin and pacli-taxel, delivered concurrently with external-beam radiation therapy delivered in 23 daily fractions of 1.8 Gy, 5 days per week for a total dose of 41.4 Gy.38 The authors reported that local-regional and distant disease progression were significantly reduced by neoadjuvant chemotherapy and radiation therapy, with prolonged local-regional control.38 The CROSS regimen was associated with a better toxicity profile than the popular regimen of 45 Gy plus 5-FU and cisplatin, but most of the patients in the study had distal abdominal-esophageal tumors or tumors at the gastro-esophageal junction, which means radiation fields includ-ed less nontarget respiratory tissue than has been the case in previous studies, which included a higher proportion of cervical-esophageal and thoracic-esophageal cancers.34

Despite the promising CROSS study findings, it remains unclear whether neoadjuvant chemotherapy and radiation therapy is beneficial in early-stage esophageal cancer; only 17% of CROSS study participants had stage T1 or T2 tumors, and a separate randomized trial has found increased risks of postoperative deaths associated with neoadjuvant chemotherapy and radiation therapy among these patients.34,46 Furthermore, other researchers

(Cyramza), another targeted agent, sometimes is used as a second-line therapy after tumor recurrence in patients whose primary tumors occurred at the gastro-esophageal junction.42 Both targeted agents have been approved by the U.S. Food and Drug Administration (FDA) for patients with esophageal cancer. The investi-gational targeted agent alisertib also has shown promise in early clinical trials against gastroesophageal adeno-carcinoma as well as other types of cancer.43

Photodynamic therapy with the photosensitizing agent porfirmer sodium (Photorin) has been approved by the FDA for palliative treatment of symptoms arising from Barrett esophagus or obstructive esophageal tumors.44

Radiation TherapyRadiation therapy is an important component of the

interdisciplinary treatment of esophageal cancers, play-ing 4 potential roles for patients: Primary or definitive radiation therapy and chemo-

therapy, with or without surgery, intended to cure.45

Neoadjuvant radiation therapy with or without chemotherapy, delivered before surgery to poten-tially improve the surgery’s effectiveness.41,45

Adjuvant radiation therapy, with or without chemotherapy, delivered after surgery to destroy micrometastatic tumor cells not removed during surgery.41

Palliative radiation therapy as short-course radia-tion therapy or brachytherapy, with or without chemotherapy, to ease pain or other symptoms that can degrade the quality of a patient’s life, administered to patients with incurable, meta-static cancer.41

Surgery remains the preferred treatment for cura-tive therapy when esophageal tumors are resectable.41 However, combined radiation therapy and chemo-therapy has emerged as a viable treatment alternative with curative potential for patients with unresectable, locally advanced esophageal cancer, or patients who are otherwise not deemed candidates for definitive surgical treatment.41,45

A meta-analysis of trial data has shown similar sur-vival times and nearly similar mortality rates for patients who received surgery or chemotherapy and radiation therapy for esophageal SCC.45 Definitive chemotherapy and radiation therapy also is an emerging treatment


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volumes specific to each patient: the gross tumor volume (GTV), clinical target volume (CTV), and the planning target volume (PTV). These 3 volumes make up a portion of the total irradiated volume; however, the total irradi-ated volume is defined as the entire tissue volume receiv-ing a significant amount of the prescribed radiation dose, usually 50% of the target dose (see Table 2).

The GTV commonly used for esophageal treatment includes the primary tumor (GTVp) of the esophagus and also can include regionally involved lymph nodes (N1), referred to as GTVn.41,47 For planning purposes, any unresectable enlarged nodes usually are included in the GTV as well.41 Radiation oncologists might elect to include any subclinical regional nodes, or nodes of uncer-tain status, in the planning volumes.49 Elective radiation field coverage beyond the GTVp and GTVn is intended to ensure adequate coverage of possible, but unconfirmed, micrometastasis.47 However, little evidence supports including the regional lymph node bed in the treatment field.49 In one systematic review, the authors concluded that for patients with cervical esophageal cancer, lymph node irradiation fields should be extended to include the tracheal bifurcation.49

The CTV includes a region of presumed microscopic malignant spread around the margins of the discernable

have noted that not all CROSS study participants received benefit from the neoadjuvant therapy, showing that, to date, there is no single accepted neoadjuvant approach to treating early-stage esophageal cancer.34

Radiation Therapy Planning Radiation therapy involves planning based on

imaging to deliver therapeutic doses of external beam radiation to destroy malignant cells while minimizing irradiation of healthy, nontarget tissues near tumors or along radiation beam pathways to minimize toxicity and morbidity. Imaging is used to delineate radiation therapy target volumes.41,47 Treatment planning involves CT, endoscopic ultrasonography, and PET-CT.

CT scans for radiation therapy planning simulation are acquired with the patient in supine or prone position on the table, and protocols typically require CT slice acquisitions of less than 5 mm.47 The supine position is preferred for patients with pulmonary comorbidities such as chronic obstructive pulmonary disease, and entails use of a mold or other patient immobilization device.47 The patient should be instructed to raise his or her arms if the tumors are located in the gastroesopha-geal junction or thoracic esophagus.47

The ongoing challenge for developing a treatment plan is ensuring the best dose conformity to target volumes, while minimizing dose to healthy tissue. Theoretically, all tumor cells could be eradicated with the use of radiation, but only if no radiation is subse-quently delivered to healthy tissues. It is inevitable that some degree of healthy tissue is included when devising treatment plans. This requires the total prescribed ther-apeutic dose for the treatment volume to be divided and administered in smaller doses over the course of mul-tiple fractions. For example, instead of delivering a total prescribed treatment dose of 60 Gy to 70 Gy in a single treatment, the dose is administered in 1.8 Gy to 2.0 Gy daily fractions until the full dose is administered.41

Radiation therapy planning target volumes are com-monly delineated using diagnostic imaging. For patients with esophageal cancer who are being treated with radia-tion, the data obtained from esophagogastroduodenosco-py, endoscopic ultrasonography, CT, FDG PET-CT, or a combination of imaging examinations is used to delineate the treatment planning target volumes.48 Planning tradi-tionally involves the delineation of 3 treatment planning

Table 2

Typical Target Volumes for Treatment Planning of Esophageal Lesions

41,47,49,50

Volume Definition

Gross tumor volume (GTV)

GTVp primary esophageal lesion GTVn GTVp regionally involved lymph nodes

Clinical target volume (CTV)

CTVp GTV 2-4 cm proximal and distal marginsCTVn+s GTV subclinical regional lymph nodes

Planning target volume (PTV)

PTV CTV 1-2 cm proximal and distal 0.5-1 cm laterally

Irradiated volume GTV CTV PTV and any tissue receiving a significant amount of the prescribed dose

Abbreviations: p, includes primary lesion; n, includes regionally involved lymph nodes; s, includes subclinical regional lymph nodes.


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esophagitis frequently leads to dysphagia, dehydration, and malnutrition, necessitating intubation and nutritional support.51 Radiation-induced strictures also are common, typically beginning 4 weeks after initiation of therapy, and often can be treated with endoscopic dilation.52

When esophageal tumors have directly invaded adja-cent structures such as the trachea or bronchus, irradia-tion and necrosis of the tumors can cause the worsening of fistulas between the esophagus and the respiratory system.52 This sometimes leads to discontinuation of esophageal radiation therapy and necessitates surgical intervention or intubation.52

Radiation pneumonitis might occur 6 weeks follow-ing the initiation of radiation therapy when radiation fields include lung tissue.47 Recording FDG uptake levels in PET-CT before initiating therapy recently was proposed as a prognostic biomarker that could help stratify risk in patients who are under consideration for esophageal radiation therapy.53

Another emerging and serious concern is late radiation-associated heart disease, particularly for patients with radiation fields that include the cardiac ventricles, namely those targeting distal abdominal esophageal tumors or tumors of the gastroesophageal junction.51,55 Up to 10.8% of patients having radiation therapy for esophageal cancer develop cardiac toxicities including pericardial effusion, ischemic heart disease, and heart failure.55,56 Radiation-induced myocardial fibrosis has been noted among patients undergoing definitive radiation therapy for primary tumors and involved regional lymph nodes when the patients received total radiation doses of 60 Gy to 70 Gy with a median total dose of 66 Gy.57

Radiation Therapy TechniqueUsing conformal radiation therapy (CRT), usually

3-D CRT and intensity-modulated radiation therapy (IMRT) treatment techniques, for esophageal cancer radiation therapy minimizes the total irradiated volume to exclude respiratory and cardiac tissues as much as pos-sible and reduces cardiopulmonary toxicities.57 A multi-leaf collimator often is used to shape the radiation beams using small leaves; in IMRT, these leaves can be adjusted between and during delivery of treatment fields varying beam intensity to different components of the irradiated volume. Combination external-beam and intraluminal

lesion, or GTV.47 Margin definitions vary; however, one published standard defines the CTVp as the GTVp plus 2-cm to 4-cm proximal and distal margins. An alternate definition of the volume is based on data that suggests that microscopic disease spread can be captured within the CTVp in 94% of patients when 3-cm margins are used.41 While the inclusion of regional lymph nodes is dependent on the location of the esophageal lesion, CTVn is defined as the GTVn plus up to 0.5-cm circum-ferential margins. For esophageal SCC, elective irra-diation of involved subclinical regional lymph nodes, or CTVns, is defined for every primary lesion.41 The regional lymph nodes included in CTV vary depend-ing on the esophageal location of the target tumors (see Figure 4). Residual tumor outside the CTV following neoadjuvant chemotherapy and radiation therapy is a proposed prognostic factor that can predict patient sur-vival in esophageal cancer.50

Patient immobilization techniques are used to mini-mize respiratory and other patient motion issues; how-ever, a safe margin is added to the CTV to account for respiration and other patient motion, setup errors, and internal target volume (ITV) or the interfraction chang-es in tumor and nontarget anatomy that occur during treatment (eg, trachea, bronchi, stomach, vessels). This additional margin is added to the CTV, which defines the PTV. For patients with esophageal cancer, the PTV is defined as CTV plus 1-cm to 2-cm proximal and dis-tal margins, and 0.5-cm to 1-cm margins laterally.41

The total irradiated volume encompasses all of these volumes (GTV + CTV + PTV), and represents any amount of tissue that receives a significant amount of the prescribed radiation dose, usually 50%. Any dose to tissues that qualify as the irradiated volume should be recorded.

Adverse EffectsEven with fractionation, however, planning must

accommodate radiation dose constraints. Radiation and combined chemotherapy and radiation therapy toxici-ties often are dose limiting, resulting in disruption or discontinuation of therapy. Patients undergoing radia-tion therapy or combined therapy for esophageal cancers frequently experience diarrhea, nausea, and vomiting.51 Radiation esophagitis also is common, typically starting 2 to 4 weeks after radiation therapy begins.51 Radiation


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Furlow

brachytherapy also has been proposed and validated in small, preliminary patient cohort studies as an alternative to combined chemotherapy and radiation therapy.58

Three-dimensional CRT treatment planning allows direct target-volume identification and delineation using CT scan images, with CT scan data transferred directly from the scanner to treatment planning software.47 Scan data are used to identify and delineate the radiation therapy volumes using 3-D CRT planning software. Once the volumes are defined and contoured, the radiation oncologist and medical dosimetrist collaboratively deter-mine optimal beam-path arrangements to achieve planned contours and radiation doses—a process called forward planning.47 In contrast, IMRT planning employs inverse planning software to determine beam path arrangements given the desired tumor dose and goals for sparing healthy tissue outlined by the radiation oncologist in the radiation therapy prescription.47

Neoadjuvant combined chemotherapy and radiation therapy delivers a median total dose of 50.4 Gy. IMRT treatment plans are associated with significantly lower rates of weight loss and high-grade toxicities, compared with 3-D CRT.59 Contouring guidelines for esophageal and gastroesophageal junction cancer IMRT were published in 2015.60 Despite a relatively young evidence base for these newer techniques (especially IMRT), researchers have concluded that whenever possible, 3-D CRT or IMRT should be employed for radiation therapy components of esophageal cancer treatment to minimize healthy tissue irradiation.51,57

Proton beam therapy is an emerging radiation therapy modality still in research and clinical evaluation stages for patients with esophageal cancer.41 Because of the ener-gy-deposition profile of protons, this therapy should be able to better spare healthy nontarget tissues in external radiation beam paths than photon beam radiation ther-apy techniques. Preliminary studies of neoadjuvant pro-ton beam conformal radiation therapy with a total dose of 50.4 Gy suggest a low rate of serious toxicity, but this approach to esophageal cancer radiation therapy remains investigational as of fall 2015 and awaits additional pro-spective studies involving larger numbers of patients.41

Palliative Radiation TherapyPalliative radiation therapy helps alleviate dyspha-

gia, hematemesis, and other symptoms among patients

with metastatic or unresectable esophageal cancer, and usually is recommended when endoscopic ablation has been unsuccessful or is not an option.61 Other indica-tions for palliative radiation therapy include painful metastatic tumors; brain metastases causing neurologic signs and symptoms such as headache, seizure, or weak-ness; airway obstruction; and shortness of breath.

Palliative radiation therapy regimens vary; published total radiation doses range from 20 Gy to 64 Gy, delivered in fractionation schedules ranging from 5 to 20 fractions.41,52 For example, one published palliative radiation therapy regimen for elderly patients with dysphagia involves a total dose of 20 Gy delivered in 5 fractions.61 The exact pre-scribed dose reflects patient performance status, prognosis, comorbidities, and tumor location.52 The CTV for pallia-tive external beam radiation therapy typically includes a 5-cm longitudinal margin on both ends of the esophagus from the tumor margins and 2-cm lateral margins.52

Careful clinical monitoring of the patient throughout the course of palliative radiation therapy is important, with particular attention to the possibility that irradiation could worsen rather than relieve dysphagia.52 This treat-ment is associated with radiation esophagitis and tissue edema around the target tumors.52

For palliative radiation therapy after tumor recur-rence, when treatment has been unsuccessful—or when a patient’s life expectancy is considered to be less than 6 months—endoscopic placement of tumor-conformal radioactive brachytherapy seeds also can be attempted to deliver a sustained radiation dose to tumor tissue.62 Brachytherapy is used to treat well-delineated, small-volume lesions situated close to radiosensitive nontarget tissues; large irradiated or treated volumes require exter-nal-beam radiation therapy.41,61 Self-expanding metal stent placement followed by brachytherapy can provide rapid relief from dysphagia, compared with 2 or more weeks from brachytherapy seed placement to symptom relief in the absence of stents.63 Placement of self-expandable stents combined with brachytherapy shows promise in early studies on palliative therapy for dysphagia. However, hemorrhages occurred in some patients who had previous esophageal radiation therapy.64

ConclusionAs the population ages, the number of cases of esopha-

geal cancer will climb. Genome-wide and epigenetic


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6. Napier KH, Scheerer M, Misra S. Esophageal cancer: a review of epidemiology, pathogenesis, staging workup and treatment modalities. World J Gastrointest Oncol. 2014;6(5):112-120. doi:10.4251/wjgo.v6.i5.112.

7. Gatenby PAC, Preston SR. Oesophageal cancer. Surgery (Oxford). 2014;32(11):588-593.

8. Lewis RB, Mehrotra AK, Rodriguez P, Levine MS. Esophageal neoplasms: radiologic-pathologic correlation. Radiographics. 2013;33(4):1083-1108. doi:10.1148/rg.334135027.

9. SEER stat fact sheet: esophageal cancer. National Cancer Institute Surveillance, Epidemiology, and End Results Program Web site. http://seer.cancer.gov/statfacts/html /esoph.html. Accessed August 2, 2015.

10. Dhakal S, Lema GMC, DiLoreto DA Jr, Katz AW. Esophageal metastasis to the iris effectively palliated using stereotactic body radiation therapy and adjuvant intravitreal chemo-therapy: case report and literature review. Case Rep Oncol. 2012;5(3):639-643. doi:10.1159/000345955.

11. Zhang P, Feng P, Zheng X, Wang YZ, Shan GP. Cerebellar, brainstem, and spinal cord metastases from esophageal can-cer following radiotherapy: a case report and literature review. Oncol Lett. 2014;8(1):253-257.

12. Esophageal cancer for patients: overview. National Cancer Institute Web site. www.cancer.gov/types/esophageal. Accessed July 6, 2015.

13. Lam AK. Introduction: histological differences. In: Saba NF, El-Rayes BF, eds. Esophageal Cancer: Prevention, Diagnosis and Therapy. Switzerland: Springer International; 2015:25-40.

14. Runge TM, Abrams JA, Shaheen NJ. Epidemiology of Barrett’s esophagus and esophageal adenocarcinoma. Gastroenterol Clin North Am. 2015;44(2):203-231. doi:10.1016/j.gtc.2015.02.001.

15. Oh DS, DeMeester TR. Barrett’s esophagus: epidemiology and pathogenesis. In: Jobe BA, Hunter JG, Thomas CR, eds. Esophageal Cancer: Principles & Practice. New York, NY: Demos Medical Publishing; 2009:47-52.

16. Dunbar KB, Spechler SJ. Controversies in Barrett esophagus. Mayo Clin Proc. 2014;89(7):973-984. doi:10.1016/j.mayocp .2014.01.022.

17. Pollack MJ, Chak A, Das A. State of the art in esophageal imaging: endoscopic technology and evaluation of esopha-geal mucosa. In: Jobe BA, Hunter JG, Thomas CR, eds. Esophageal Cancer: Principles & Practice. New York, NY: Demos Medical Publishing; 2009:145-152.

18. Yousef F, Cardwell C, Cantwell MM, Galway K, Johnston BT, Murray L. The incidence of esophageal cancer and high-grade dysplasia in Barrett’s esophagus: a systematic review and meta-analysis. Am J Epidemiol. 2008;168(3):237-249. doi:10.1093/aje/kwn121.

19. Rastogi A, Puli S, El-Serag HB, Bansal A, Wani S, Sharma P. Incidence of esophageal adenocarcinoma in patients with

sequencing tools are leading to new insights into the molecular pathways and risk factors for esophageal tumor-igenesis, progression, and metastasis. As these pathways become better understood, new prognostic biomarkers and therapies will emerge that can better assist in devel-oping treatment strategies unique to patients and their tumors’ biology. Ongoing clinical research also will help identify which diagnostic, staging, and treatment tech-niques are best suited for different patient populations. Technological innovation, including advanced radiation therapy equipment and planning software, also likely improves the targeting and optimization of therapeutic radiation dose that can be delivered to tumors while bet-ter sparing healthy, nontarget tissues, reducing adverse effects of radiation.

New Mexico-based medical writer Bryant Furlow, BA, is a regular contributor to Radiologic Technology, Radiation Therapist, The Lancet Oncology, OncoTherapy Network, and several other clinical oncology and cancer news publications. He reports on oncology, medical imaging, radiation therapy, and pulmonology.

Reprint requests may be mailed to the American Society of Radiologic Technologists, Communications Department, 15000 Central Ave SE, Albuquerque, NM 87123-3909, or emailed to [email protected].


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41. Ito Y. Radiation therapy. In: Ando N, ed. Esophageal Squamous Cell Carcinoma: Diagnosis and Treatment. Tokyo, Japan: Springer; 2014:227-249.

42. Targeted therapy for cancer of the esophagus. American Cancer Society Web site. http://www.cancer.org/cancer/esophagus-cancer/detailedguide/esophagus-cancer-treating-targeted-therapy. Updated March 2, 2015. Accessed August 11, 2015.

43. Melichar B, Adenis A, Lockhart AC, et al. Safety and activity of alisertib, an investigational aurora kinase A inhibitor, in patients with breast cancer, small-cell lung cancer, non-small-cell lung cancer, head and neck squamous-cell carcinoma, and gastro-oesophageal adenocarcinoma: a five-arm phase 2 study. Lancet Oncol. 2015;16(4):395-405.

Barrett’s esophagus and high-grade dysplasia: a meta-analysis. Gastrointest Endosc. 2008;67(3):394-398.

20. Rubenstein JH, Shaheen NJ. Epidemiology, diagnosis, and management of esophageal adenocarcinoma. Gastroenterology. 2015;149(2):302-317. doi:10.1053/j.gastro.2015.04.053.

21. Reid BJ, Paulson TG, Li X. Genetic insights in Barrett’s esophagus and esophageal adenocarcinoma [published online ahead of print July 10, 2015]. Gastroenterology. 2015; 149(5):1142-1152.e3. doi:10.1053/j.gastro.2015.07.010.

22. Schneider JL, Corley DA. A review of the epidemiology of Barrett’s oesophagus and oesophageal adenocarcinoma. Best Pract Res Clin Gastroenterol. 2015;29(1):29-39. doi:10.1016/j .bpg.2014.11.008.

23. Brown LM, Devesa SS. Epidemiology and risk of esophageal cancer: clinical. In: Jobe BA, Hunter JG, Thomas CR, eds. Esophageal Cancer: Principles & Practice. New York, NY: Demos Medical Publishing; 2009:103-113.

24. Charbotel B, Fervers B, Droz JP. Occupational exposures in rare cancers: a critical review of the literature. Crit Rev Oncol Hematol. 2014;90(2):99-134. doi:10.1016/j.critrev onc.2013 .12.004.

25. Yoon H, Gibson MK. Molecular outcome prediction. In: Jobe BA, Hunter JG, Thomas CR, eds. Esophageal Cancer: Principles & Practice. New York, NY: Demos Medical Publishing; 2009:771-782.

26. Gordon LG, Mayne GC. Cost-effectiveness of Barrett’s oesophagus screening and surveillance. Best Pract Res Clin Gastroenterol. 2013;27(6):893-903. doi:10.1016/j.bpg.2013 .08.109.

27. Hagen JA. Revisions in the staging system for esophageal cancer. In: Jobe BA, Hunter JG, Thomas CR, eds. Esophageal Cancer: Principles & Practice. New York, NY: Demos Medical Publishing; 2009:189-209.

28. Berry MF. Esophageal cancer: staging system and guide-lines for staging and treatment. J Thorac Dis. 2014;6(suppl 3):S207-S289. doi:10.3978/j.issn.2072-1439.2014.03.11.

29. Leavitt BJ. Invited commentary on “New TNM staging sys-tem for esophageal cancer.” Radiographics. 2014;34(6):1740-1741. doi:10.1148/rg.346140237.

30. Zahoor H, Luketich JD, Weksler B, et al. The revised American Joint Committee on Cancer staging system (7th edition) improves prognostic stratification after minimally invasive esophagectomy for esophagogastric adenocarcinoma [published online ahead of print May 10, 2015]. Am J Surg. 2015;210(4):610-617. doi:10.1016/j.amjsurg.2015.05.010.

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radiation treatment of esophageal cancer? Radiother Oncol. 2015;114(1):85-90. doi:10.1016/j.radonc.2014.11.037.

56. Umezawa R, Ota H, Takanami K, et al. MRI findings of radiation-induced myocardial damage in patients with oesophageal cancer. Clin Radiol. 2014;69(12):1273-1279. doi:10.1016/j.crad.2014.08.010.

57. Ling TC, Slater JM, Nookala P, et al. Analysis of intensity-modulated radiation therapy (IMRT), proton, and 3D conformal radiotherapy (3D-CRT) for reducing periopera-tive cardiopulmonary complications in esophageal cancer patients. Cancers (Basel). 2014;6(4):2356-2368. doi:10.3390 /cancers6042356.

58. Aggarwal A, Harrison M, Glynne-Jones R, Sinha-Ray R, Cooper D, Hoskin PJ. Combination external beam radiother-apy and intraluminal brachytherapy for non-radical treatment of oesophageal carcinoma in patients not suitable for surgery or chemoradiation. Clin Oncol (R Coll Radiol). 2015;27(1):56-64. doi:10.1016/j.clon.2014.09.001.

59. Freilich J, Hoffe SE, Almhanna K, et al. Comparative out-comes for three-dimensional conformal versus intensity-modulated radiation therapy for esophageal cancer. Dis Esophagus. 2014;28(4):352-357. doi:10.1111/dote.12203.

60. Wu AJ, Bosch WR, Chang DT, et al. Expert consensus con-touring guidelines for intensity modulated radiation therapy in esophageal and gastroesophageal junction cancer. Int J Radiat Oncol Biol Phys. 2015;92(4):911-920. doi:10.1016/j .ijrobbp.2015.03.030.

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64. Liu N, Liu S, Xiang C, et al. Radioactive self-expanding stents give superior palliation in patients with unresectable cancer of the esophagus but should be used with caution if they have had prior radiotherapy. Ann Thorac Surg. 2014;98(2):521-526. doi:10.1016/j.athoracsur.2014.04.012.

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55. Beukema JC, van Luijk P, Widder J, Langendijk JA, Muijs CT. Systematic review: is cardiac toxicity a relevant issue in the




1. Gastroesophageal reflux disease (GERD) can result from dysfunction of the esophageal:a. sphincter.b. mucosa.c. submucosa.d. serosa.

2. Esophageal malignancies appear to be associated with which of the following?

1. chronic inflammation2. caustic agents3. chronic GERD


3. Malignancies of the esophagus typically begin in the:a. sphincter.b. mucosa.c. submucosa.d. serosa.

4. Patients with esophageal cancer often have a poor prognosis because:a. the cancer is so difficult to treat.b. patients fail to report symptoms.c. early-stage disease is typically asymptomatic and

therefore undetected.d. the tumors are difficult to detect on existing

medical imaging.

5. Esophageal cancers are associated with a 5-year postdiagnosis survival rate of ______%.a. 6.7b. 12.4c. 17.9d. 24.3


Read the preceding Directed Reading and choose the answer that is most correct based on the article.

To earn continuing education credit: Take this Directed Reading quiz online at www.asrt.org/drquiz. Or, transfer your responses to the answer sheet on Page 86 and mail to ASRT, PO Box 51870, Albuquerque, NM 87181-1870.

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6. Esophageal adenocarcinoma has overtaken squamous cell carcinoma (SCC) as the predominant form of esophageal cancer among which populations?a. U.S. black menb. Australian residentsc. Hispanic womend. most of the world

7. The combination of ______ and ______ is believed to underlie 90% of SCC cases.a. tobacco smoking; dietb. tobacco smoking; alcohol usec. alcohol use; obesityd. obesity; diet

8. Which of the following might reduce the risk of disease progression of Barrett esophagus with high-grade dysplasia but has not been established to affect patient survival?a. surgeryb. endoscopic mucosal resectionc. radiofrequency ablationd. brachytherapy

9. ______ is the initial diagnostic procedure for suspected esophageal cancer.a. Abdominal computed tomography (CT) b. Positron emission tomography–CT c. Upper gastrointestinal endoscopyd. Open surgical biopsy

10. SCC tends to occur in the ______ esophagus.1. cervical2. thoracic3. abdominal


11. The evidence base for ______ is scant and equivocal.a. adjuvant chemotherapyb. brachytherapyc. intensity-modulated radiation therapy (IMRT)d. chemoradiotherapy

12. Neoadjuvant ______ is associated with superior patient survival times compared with surgery alone.a. chemotherapyb. brachytherapyc. IMRTd. chemoradiotherapy

13. According to the article, the U.S. Food and Drug Administration has approved which targeted agents for treating patients with esophageal cancer?

1. trastuzumab2. alisertib3. ramucirumab


14. Radiation therapy without chemotherapy potentially is an option for patients with:

1. advanced age and cancer stage.2. metastatic disease.3. advanced age and poor performance

status.




15. CT scans for radiation therapy planning simulation for esophageal cancer typically are acquired with patients in the supine or prone position in slices of less than ______ mm.a. 2b. 5c. 7d. 10

16. Radiation pneumonitis can occur ______ week(s) following the initiation of radiation therapy when radiation fields include lung tissue.a. 1b. 2c. 4d. 6

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Writing & Research

Linda Alfred, MEd, MBA, R.T.(T)

Polishing Your Professional Portfolio

Professional portfolios typically are used by those vying for careers in writing, music, and advertis-ing. Although they seldom are used by radiation oncology professionals, a portfolio can help turn

an interview into a job offer. A professional portfolio gives an employer a thorough understanding of a job can-didate’s accomplishments. It provides tangible examples of an applicant’s finest work. A portfolio does not replace a résumé or curriculum vitae (CV), but it includes such documents. In a niche field such as radiation therapy, a portfolio can help with a career transition or promotion by showcasing skills such as leadership, organization, pro-fessionalism, empathy, and multitasking. In addition, portfolios are a feasible tool to help medical professionals demonstrate competency in their current jobs.

Elements of a PortfolioPortfolios reflect the evolution of career objectives

and track personal development. They serve as an example of organizational skills and establish attention to detail. A professional portfolio might include: Title page. Table of contents. Mission statements. Short- and long-term goals. Résumé or CV. Cover letter. Employee evaluations. Transcripts. Lists of references.

The contents can be fine-tuned based on the type of career being sought, and materials should be added or subtracted based on their level of relevance to the intended position. Contents must be organized, per-tinent, and accurate. Included items also should be neat, professionally formatted, and free of grammatical errors. A statement of originality indicating the port-folio is an original work and cannot be copied without permission may be included.

Artifacts are an extension of the aforementioned portfolio elements. They are examples that support knowledge attained or a skill set or competency that a candidate possesses. Artifacts include: Certificates of achievement or other awards. Career summary and goals. Letters of recommendation or testimonials. Newspaper or online articles highlighting

achievements. Images documenting relevant activity. Training certificates from vendors. Relevant personal activities. Spreadsheets supporting cost containment or rev-

enue generation. Professional certifications. Lists or evidence of professional development and

training activities. Evidence of volunteer work. Each artifact should serve as tangible proof of a skill,

achievement, personal trait, or knowledge set that will benefit the intended employer.


Writing & ResearchPolishing Your Professional Portfolio

employer of interest. The portfolio would be brought to the interview—or provided via a link—to fill relevant gaps of content not part of the résumé or cover letter.

The Interview ProcessKnowing when and how to use a portfolio is as

important as deciding on its elements. A single portfolio will not be ideal for all interviews. The portfolio needs to reflect the job description and the applicant’s goal of obtaining employment. An employer might not want to see a portfolio, but having the information ready is nec-essary. The portfolio is not handed to the interviewer for him or her to peruse. As the applicant addresses a ques-tion, appropriate artifacts in the portfolio can be pro-duced to support the answer given. The right informa-tion must be given at the right time to the right person.

Be prepared to leave a copy of the portfolio at the conclusion of an interview. Consider having it on a thumb drive if the prospective employer does not want a paper copy. A link to an online version can be sent again in a “thank you” email.

ConclusionPortfolios are used in many careers. Many areas

of radiation oncology and other medical professions require a unique and varied skill set that could benefit from the use of a portfolio. Cover letters, résumés, and, in some venues, CVs are part of the professional portfo-lio but cannot provide tangible evidence. The portfolio supports and validates the information in the résumé and, to a lesser degree, the cover letter. Its contents can act as a crucial differentiator, especially when applicants with similar skills are vying for the same position.

Creating a portfolio is considered a professional development process. It is reflective in nature and helps map professional growth and keep career goals on track. With it potential employers easily see a candidate’s growth and visualize how his or her continued develop-ment could benefit their bottom line.

Linda Alfred, MEd, MBA, R.T.(T), is sales manager for BMSi in Oklahoma City, Oklahoma, and a member of the Radiation Therapist Editorial Review Board. She may be reached at [email protected].

Constructing a PortfolioHistorically, a portfolio was in a binder or notebook

and featured a collection of index inserts and page pro-tectors. Just as the clinic has transitioned from paper charts to electronic health records, the interview process must keep up with technology. A digital copy of a profes-sional portfolio speaks to a candidate’s adaptability and comfort with technology. A portfolio that is electronic also is easier to keep current and distribute. When creat-ing a digital portfolio, the candidate must consider what technology is easiest for the employer. If documents are not formatted as common file types (eg, .pdf or .jpg), a potential employer might be unable to review them. Various Web sites offer assistance with online portfolios.

Not all employers accept digital portfolios. A port-folio available in muliptle formats demonstrates profes-sional f lexibility and could make a difference in a hiring decision. Tabs or dividers that reflect the table of con-tents are key in a nondigital portfolio, and high-quality copies should be used instead of original documents.

Regardless of the format, a portfolio should focus on a core objective and be easy to read and creative with-out clouding the message. A candidate should use space efficiently and exclude materials that are confidential or do not support the core objective.

Deciding What to PresentThe objective for the intended position determines

whether a portfolio or other materials are most appro-priate. When considering which to use, consider that a: Cover letter, typically less than a page in length,

introduces the applicant to the prospective employ-er. It notes which job is of interest and why the applicant is a good fit. The intent of the cover letter is to compel the recruiter, hiring agent, or employer to read the résumé and contact the applicant.

Résumé, usually 1 or 2 pages in length, offers a snapshot of a person’s education, work history, and other achievements.

CV is more relevant to professionals with an aca-demic background and includes teaching experi-ence, degrees, research, and scholarly activity. The length varies but can exceed 15 pages.

The professional portfolio can include a résumé, CV, or both. Most job applicants would send a résumé to an


Global Outlook

Christina Nitecke

Achtung Strahlenschutz! Beer, Bratwurst, and Cancer Care

Germany, known to many for its beer and brat-wurst, is one of the leading economic powers in Europe.1 Its centuries of history and the natural beauty of the Bavarian Alps and the Rhine River

Valley also make Germany a popular tourist destination. In addition to its universal health care and free college education,2,3 Germany is active in radiation therapy tech-nology development. For example, the world’s largest gan-try for an ion beam accelerator unit resides in Heidelberg, Germany, harnessing the power of heavy ions such as car-bon, oxygen, and helium.4 In addition, Deutsches Krebsforschungszentrum, the German equivalent to the American Cancer Society, employs more than 1200 scien-tists working to find a cure.5 It was my pleasure to have the opportunity to immerse myself in the German culture and to explore the many facets of this fascinating country.

The SparkMy exposure to the land of beer and bratwurst began

when I was young. I attended the Milwaukee German Immersion School in Wisconsin from kindergarten through fifth grade. I continued to speak German and study German culture in high school and then studied German language and radiation therapy in college. In my junior year of college, I studied abroad in Marburg, Germany. During this time, I observed more than 30 hours of radiation therapy. Not only did my German language skills improve during that time, but I also was able to integrate my passion for radiation therapy into my curriculum.

While abroad, one of my primary goals was to com-pare and contrast the German cancer care system with the radiation therapy observation I completed in the United States. Before my observation in Marburg, I observed 40 hours of radiation therapy in Wisconsin for my entrance into the radiation therapy program at the University of Wisconsin – La Crosse. Although I did not know the intricacies of radiation therapy, these hours provided me with enough procedural awareness and occupational vernacular to understand the basic steps of radiation therapy treatment. In Germany, I was unable to witness every aspect of radiation therapy, but the experience provided me and my German colleagues with insight and understanding into our 2 cultures, increasing our affinity toward one another.

Welcome to MarburgThe majority of my observation hours took

place at the Marburg and Giessen University Clinic (Universitätsklinikum Gießen und Marburg). I met with the 2 lead radiation oncologists, Rita Engenhart-Cabillic, MD, and Hilke Vorwerk, MD. In Germany, radiation therapy technologists are called medical technical assis-tants (MTA). Large emphasis is put on the technical assistant status, primarily because radiation therapy is not considered a bachelor’s study, unlike in the United States. In the United States, radiation therapists can be taught through a variety of programs such as accredited bach-elor’s degree programs, vocational training, or technical schools. In Germany, to gain MTA certification, a student


Global OutlookAchtung Strahlenschutz! Beer, Bratwurst, and Cancer Care

must complete 3 years of study and learn dosimetry and nuclear medicine in addition to radiation therapy. All students must complete a 1-year internship in their final year of study.

The TourIn the German cancer care system, a patient visits

4 main areas throughout the treatment process. I vis-ited each subdepartment in the same order as would a patient. Similar to radiation therapy in the United States, the treatment processes in Germany differ from department to department. The first stop was the sec-retarial headquarters. This was one of the largest proce-dural differences between the German and U.S. health care systems. Germany’s universal health care system offers care to all people no matter their socioeconomic status. Private care is an option for many; however, it is not necessary because the AOK-Bundesverband (gener-al medical insurance) covers a vast majority of medical procedures. When patients arrive at the cancer clinic, they present the secretary with their universal health care identification card. Their information is noted, and when the bill for treatment is determined, it is sent to the patient to pay out of pocket. The health insur-ance company then processes a refund for the patient. If the universal health care does not cover the treatment, the patient is not reimbursed. This happens rarely, and those who need extra coverage can get it through private insurance companies. Typically, patients with cancer pay minimal fees for treatment because they are sup-ported by the government, even if they are unemployed.

The outpatient department, known in German as ambulanz, is where patient appointments are sched-uled. Patients create a plan for treatment that best fits their schedule. Nurses and medical assistants work in this area conducting regular check-ups with patients throughout their course of treatment. Nurses in the outpatient department handle blood sampling, adverse effects, and complications management to ensure the patient is faring well during treatment. Patient files containing basic health and insurance information are completed at this stage and passed onto the radiation therapists for computed tomography planning.

Similarities exist in the computed tomography plan-ning process between the 2 countries. After a physician makes a diagnosis and prescribes a dose, the MTA

proceeds with planning (dosimetry is not a separate profession). Immobilization devices and thermoplastic masks are made, similar to those in the United States. An MTA acquires a series of images to ensure all angles are visualized and makes temporary markings on the patient’s skin to ensure consistent future setups. After the planning images are acquired, an oncologist checks them, adds notes to the plan and then gives them to the physicist to begin dose calculation. Patients who receive chemotherapy and radiation simultaneously are required to stay at the hospital as inpatients during treatment.

The University of Marburg clinic is a moderately sized hospital with 3 linear accelerators that perform intensity-modulated radiation therapy and stereotac-tic treatments.6 Brachytherapy also can be performed using iodine 125 seeds, planned with VariSeed (Varian Medical Systems).6 The treatment setups I observed were for patients with brain cancer, and there were approximately 3 MTAs per machine. Similar to the United States, patients are assigned to be treated with certain machines based on their type of cancer. Each machine has a specialty that allows for the most accu-rate treatment of a particular anatomic area.

The MTAs answered my questions and even shared that the average MTA earns roughly between €35 000 and €40 000 per year, which is equivalent to approxi-mately $39 000 to $44 000, as of February 2016.

One difference that came as a shock during my observation of the radiation therapy equipment was that no audio system was in place to allow communica-tion with the patient during treatment. It surprised me because such a system is considered a safety precaution in the United States. Despite this, the radiation therapy station setup was similar to the setups I had seen in the United States.

Coming Full CircleI cherished the opportunity to peer into the daily

operations of a German cancer care clinic. It allowed me to reflect on what I saw in the United States and to understand that globally, cancer care is progressive and technically advanced. The differences in language and culture are no barrier to fighting such a debilitating and traumatic disease. The common goal of eradicating cancer and bringing comfort to those suffering from it


Global OutlookNitecke

is something that brings all cancer care teams together, near and far. Cancer knows no distance…but neither do its opponents.

Christina Nitecke is a student in the University of Wisconsin – La Crosse radiation therapy program. She can be reached at [email protected].

References1. Nuechterlein D. Europe’s leading economic power is Germany.

Daily Progress Web site. http://www.dailyprogress.com/news /europe-s-leading-economic-power-is-germany/article_7bb78a e3-5203-528b-ae2a-103b3ad92196.html. Published June 13, 2010. Accessed December 7, 2015.

2. International health systems. Physicians for a National Health Program Web site. http://www.pnhp.org/facts/international _health_systems.php?page=all. Accessed December 7, 2015.

3. Denhart C. There is no such thing as a free college education. Forbes Web site. http://www.forbes.com/sites/ccap/2014/10/0 3/there-is-not-such-thing-as-a-free-college-education/#14e7cc 3e4c6e. Published October 3, 2014. Accessed January 28, 2016.

4. Heidelberg ion-beam therapy center (HIT). Universitäts Klinikum Heidelberg Web site. http://www.klinikum.uni -heidelberg.de/First-heavy-ion-gantry.112987.0.html?&L=en. Accessed October 26, 2015.

5. About us. German Cancer Research Center Web site. https://www.dkfz.de/en/index.html. Updated September 9, 2015. Accessed October 26, 2015.

6. Geräteausstattung. Universitätsklinikum Marburg Web site. http://ukgm.de/ugm_2/deu/umr_rth/3808.html. Accessed October 26, 2015.


In the Clinic

Three-dimensional Imaging for High-Dose-Rate Cervical Brachytherapy Treatment Planning

Lauren Hein, BS, R.T.(T)

Cervical cancer is the third most common cancer in women worldwide.1 The current standard of care for early-stage node positive or locally advanced cervical cancer is external-beam radi-

ation therapy with concurrent chemotherapy, followed by high-dose-rate cervical brachytherapy.1,2 Typically, external-beam radiation therapy delivers treatment to the pelvic lymph nodes, parametria, and the gross tumor.3 Next, high-dose-rate cervical brachytherapy is administered to act as a boost to the primary tumor area, improving overall disease control and prognosis.3

Intracavitary cervical brachytherapy involves the insertion of a tandem applicator through the cervix to the uterine fundus, while 2 ovoids are placed on either side of the cervix in the lateral vaginal fornices.3 The radioactive source is then afterloaded into the applica-tors to deliver a uniform dose to the upper vagina, cer-vix, and uterus.3 The organs at risk during the brachy-therapy procedure are the bladder, rectum, and sigmoid colon.2 These organs move daily, so localization and dose verification are crucial steps in the brachytherapy treatment planning process.4

Historically, 2-D orthogonal radiographic images were used for treatment planning.2 However, these 2-D images do not provide accurate information for treat-ment planning because soft tissue cannot be visualized.2 This can cause an underdose to the tumor, as well as an overdose to the surrounding healthy tissue.2 Three-dimensional imaging for cervical brachytherapy treat-ment planning is necessary to delineate the soft tissue

around the applicators and to ensure proper dose dis-tribution during treatment.2,4,5 Computed tomography (CT), magnetic resonance (MR) imaging, and ultraso-nography each offer benefits and limitations for cervical brachytherapy treatment planning.

The success of cervical brachytherapy depends on accurate identification and localization of the uterus, cervix, and residual disease, as well as accurate place-ment of the tandem and ovoid applicators within the uterine canal.3 The organs at risk move around the implanted applicators and radiation source, making their location and dose evaluation critical and influen-tial in the treatment planning process.4 Knowing the movement of the organs at risk can help to limit the uncertainties and potentially detrimental consequences of overdosing these sensitive organs.4

Conventional brachytherapy traditionally was based on clinical examination and 2-D point-based plan-ning using orthogonal images to locate bony anatomy to perform the dose calculations and prescriptions.2 Because 2-D orthogonal images do not show soft tis-sue, treatment planning using the 2-D images leads to inadequate target coverage, insufficient dose delivery, and a larger percentage of treatment failure.2 Other limi-tations associated with treatment planning from 2-D images include unknown planned treatment volume coverage and visibility, limited opportunity for f lex-ibility of the dose distribution to the planned treatment volume, and unknown spatial relationship between the applicator and the surrounding organs at risk.2,5 Many

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studies determined that, although 2-D image-based brachytherapy planning provides good local control for early-stage disease, it also leads to underdosing the tumor and overdos-ing the rectum and bladder, causing inaccu-rate target coverage and overall tumor con-trol.1,2,8 A benefit of taking orthogonal radio-graphs for planning is that radiation therapists do not need special training or further educa-tion to use the equipment and create adequate images. These images can be taken easily, and the units needed already are present in radia-tion oncology departments.

Using 3-D imaging techniques for cervical brachytherapy treatment planning can help to localize the disease site, visualize the planned treatment volume, identify the organs at risk, and alter the target volume dose coverage to be more conformal for each patient.2,4,5 Three-dimensional image-based brachytherapy planning offers visualization of the tumor and adjacent organs, which allows for improved target coverage, local control, and reduced late toxicity.2 These images also make it possible to see the brachytherapy applicator position itself, making the images superior to 2-D orthogonal images for treatment planning.5 Soft-tissue imaging also enables focus on the geometry of the applicator and the relation-ship of the tandem to the surrounding anat-omy, whereas radiographs only capture the applicator geometry and not the surrounding tissue.9 Newer advances in 3-D imaging—which include those in CT, MR, and ultraso-nography—are used in cervical brachytherapy treatment planning.2 Three-dimensional planning also allows information from multiple imaging modalities to be fused to create even better, more detailed images.5

Computed TomographyUsing CT images for cervical brachytherapy treat-

ment planning was first introduced circa 1980 and is becoming more common in practice (see Figure 1).5 A study that compared 2-D imaging with 3-D CT brachytherapy planning determined that CT planning significantly improved local and regional relapse-free

survival after treatment.8 CT also showed a significant decrease in grade 31 urinary and gynecologic toxici-ties, including urinary frequency, urgency, dysuria, hematuria, and pelvic pain.1,8 Another disadvantage of 2-D imaging planning is that it cannot detect uterine perforation at the time of tandem and ovoid placement.1 CT planning increases the diagnosis of perforation and avoids overtreatment of the fundus and lower uterine segment.1 Three-dimensional treatment planning offers other clinical advantages in addition to dosimetric advantages, such as1:

Figure 1. Transverse (A) and sagittal (B) computed tomography images. Images courtesy of the authors.

A

B


In the ClinicThree-dimensional Imaging for High-Dose-Rate Cervical Brachytherapy Treatment Planning

difficult, making MR necessary. Ideally, each brachy-therapy implant should be followed by MR imaging with the applicator in situ and a new dose plan.5,11 The work by these organizations helped advance the use of soft-tissue imaging with an emphasis on using MR for cervical brachytherapy treatment planning.7 Within the past 10 years, the fusion of CT and MR images was required to identify both the source position and all relevant soft tissue. It now has been shown that MR images alone could fulfill both functions with the use of a contrast agent to identify the dummy source

Confirmation of applicator placement. Decreased organs at risk dose for

patients with a small cervix. Accountability for sigmoid colon dose. Improved coverage for large volume dis-

ease while maintaining organ dosimetry.Because the sigmoid colon is a mobile

organ, its toxicity in relation to the dose received cannot be assessed through 2-D radiographic images; however, 3-D-based dosimetry offers more organ sparing and a better dose estimation to the organs at risk, ultimately reducing tissue toxicity.10

One limitation of CT-based planning is the possible overestimation of tumor volumes, resulting in an increased dose to adjacent healthy tissue.5 This limitation causes some to argue that MR is a more accurate imaging technique than CT. However, when compar-ing CT with MR-based planning, the images showed that tumor height, thickness, and total volume measured by CT were not sig-nificantly different compared with the MR volumes.1 Subsequently, in centers where logistical reasons make MR-based brachy-therapy not feasible, organs at risk and target contour can be made with CT images because they offer comparable dose volume results.2

Magnetic Resonance ImagingMR-based brachytherapy offers enhanced

anatomy and tumor recognition when used for treatment planning (see Figure 2).7 CT images provide only limited soft-tissue defi-nition in the area of interest, whereas MR offers a greater soft-tissue definition through nonion-izing image acquisition.9 MR images have been found to be better than those from CT because they can help assess the tumor size within an accuracy of 0.5 cm and are capable of assessing parametrial extension correctly 77% to 96% of the time.5 Because of these benefits, some professionals argue that MR is superior to CT for cervical brachytherapy treatment planning.5

The Groupe European de Curietherapie and European Society for Radiotherapy and Oncology acknowledged that tumor visualization on CT is

Figure 2. Transverse (A) and sagittal (B) magnetic resonance images. Images courtesy of the authors.

A

B

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include that it is nonionizing, quick, and reduces the dose to organs at risk without compromising the dose to the target volume.6,9

Although ultrasonography can be used on its own or in addition to 2-D radiography, it has limitations. The modality relies on physical contact with the patient to work correctly, which creates the potential for tissue deformation.6 Operators experienced with applicator geometry and pelvic anatomy are required to ensure that the images reflect the true dimensions of the applicator within the anatomical organ.6,9 Another fault with trans-abdominal ultrasound is the lack of a 3-D coordinate system or fixed frame of reference to help define the spa-tial location of the anatomy.6,7 Ultrasonography also does not offer volumetric analysis of the target coverage or dose to the surrounding organs, which is crucial in the treatment planning of cervical brachytherapy.6

ConclusionFuture advances will further improve the quality

and capabilities of cervical brachytherapy treatment planning. A multi-institutional international trial, EMBRACE, is underway to establish a standard for cervical cancer management in terms of tumor control, complications, dose specification, and a prospective assessment of quality of life.1 The trial aims to advance image-based brachytherapy and optimize its out-comes—potentially by mandating the use of soft-tissue 3-D imaging for treatment planning—to ensure each patient receives the most accurate treatment possible.1 Another advancement is BodyTom (Neurologica), a portable CT scanner that can be used to verify applica-tor and implanted catheter positions before treatment delivery every day, without having to physically move the patient.12 This scanner can help eliminate any error or uncertainty caused by patient transportation to and from the imaging rooms and the high-dose-rate suite during the procedure.12,13

Traditional orthogonal radiography remains the most commonly used imaging modality for planning cervical brachytherapy treatments where the incidence of cervi-cal cancer is high.6,7 However, soft-tissue imaging for cervical brachytherapy is increasing in some advanced economies and well-resourced departments.7 Although incorporating soft-tissue imaging into brachytherapy programs is a slow process because of the limited avail-

position.12 Although some professionals argue that the applicator placement and material cause distor-tions in the magnetic field scan of up to 1 cm (leading to clinically significant dose errors),12 data indicates that the distortions measured in the presence of MR-compatible applicators were small enough to vali-date the use of MR for gynecological brachytherapy planning and verification.5 This argument also can be used for CT image catheter distortions, but it has been proven that these errors were as small as 0.5 mm to 1 mm or less for both CT and MR images.12

Although MR provides excellent soft-tissue images, disadvantages include the expense of MR machines and limited access for many clinical centers.7 The machines also are not suitable for patients with implanted metal devices or for obese patients or those with severe claustro-phobia because of the machine’s small bore size.7 Another disadvantage is that CT and MR scans usually are taken first and then the patient is transported to the high-dose-rate room where the dose is delivered, making it chal-lenging to ensure applicator position stability because of patient movement.7,9 An alternative imaging modality that is more readily accessible and affordable is necessary.7

UltrasonographyTransabdominal ultrasound for image-based plan-

ning is cost effective, widely available, and has been found to have no significant differences in dosimetry compared to MR planning, with 90% local control rate for cervical brachytherapy.1 Studies show that transab-dominal ultrasound can be substituted for MR in defin-ing the target volume, outlining the cervix and uterus, as well as planning and verifying for conformal cervical brachytherapy treatment.7 Ultrasonography can be used to select the appropriate applicator size and to guide tandem and ovoid placement during the procedure.7 Ultrasonography use during applicator insertion has been shown to decrease the rate of uterine perforation because of the real-time images produced, whereas CT and MR images only determined whether the uterus had been perforated and cannot detect it beforehand.7

Ultrasonography is accessible, portable, and can be used within the brachytherapy suite, eliminating the need to move the patient during the procedure, unlike CT and MR.9 Other benefits of transabdominal ultra-sound for cervical brachytherapy treatment planning


In the ClinicThree-dimensional Imaging for High-Dose-Rate Cervical Brachytherapy Treatment Planning

abdominal ultrasound imaging to identify the brachytherapy target in patients with cervix cancer. Int J Radiat Oncol Biol Phys. 2014;88(4):860-865. doi:10.1016/j.ijrobp.2013.12.004.

8. Katz A, Eifel PJ. Quantification of intracavitary brachy-therapy parameters and correlation with outcome in patients with carcinoma of the cervix. Int J Radiat Oncol Biol Phys. 2000;48(5):1417-1425.

9. van Dyk S, Narayan K, Fisher R, Bernshaw D. Conformal brachytherapy planning for cervical cancer using trans-abdominal ultrasound. Int J Radiat Oncol Biol Phys. 2009;75(1):64-70. doi:10.1016/j.ijrobp.2008.10.057.

10. Holloway CL, Racine ML, Cormack RA, O’Farrell DA, Viswanathan AN. Sigmoid dose using 3D imaging in cervical-cancer brachytherapy. Radiother Oncol. 2009;93(2):307-310. doi:10.1016/j.radonc.2009.06.032.

11. Haie-Meder C, Pötter R, Van Limbergen E, et al. Recommendations from Gynecological (GYN) GEC-ESTRO Working Group (I): concepts and terms in 3D image based 3D treatment planning in cervix cancer brachytherapy with emphasis on MRI assessment of GTV and CTV. Radiother Oncol. 2005;74(3):235-245.

12. BodyTom. NeuroLogica Web site. http://www.neurologica .com/products/bodytom. Accessed February 10, 2015.

13. Aubry JF, Cheung J, Morin O, Beaulieu L, Hsu IC, Pouliot J. Investigation of geometric distortions on magnetic reso-nance and cone beam computed tomography images used for planning and verification of high-dose rate brachytherapy cervical cancer treatment. Brachytherapy. 2010;9(3):266-273. doi:10.1016/j.brachy.2009.09.004.

ability of planning software, increased cost, and lack of optimal training, these programs have shown to improve the technical accuracy of implants, which leads to improved local control and decreased toxicity.1,6 These improvements also have a positive effect on the quality of life for the patients undergoing brachytherapy for cer-vical cancer.6 Ideally, a single imaging modality should be available for each brachytherapy fraction and provide good organ and applicator definition with the ability to delineate residual tumor.9 This modality should have good soft-tissue imaging capabilities and be widely available, portable, and economically attainable.6

Lauren Hein, BS, R.T.(T), recently graduated from the University of Wisconsin – La Crosse Radiation Therapy Program. She is a radiation therapist for Wheaton Franciscan Healthcare in Racine, Wisconsin.

References1. Vargo JA, Beriwal S. Image-based brachytherapy for cervical

cancer. World J Clin Oncol. 2014;5(5):921-930. doi:10.5306 /wjco.v5.i5.921.

2. Madan R, Pathy S, Subramani V, et al. Comparative evalua-tion of two-dimensional radiography and three dimensional computed tomography based dose-volume parameters for high-dose-rate intracavitary brachytherapy of cervical cancer: a prospective study. Asian Pac J Cancer Prev. 2014;15(11): 4717-4721. doi:10.7314/APJCP.2014.15.11.4717.

3. Banerjee R, Kamrava M. Brachytherapy in the treatment of cervical cancer: a review. Int J Womens Health. 2014;6:555-564. doi:10.2147/IJWH.S46247.

4. Mazeron R, Champoudry J, Gilmore J, et al. Intrafractional organs movement in three-dimensional image-guided adap-tive pulsed-dose-rate cervical cancer brachytherapy: assess-ment and dosimetric impact. Brachytherapy. 2015;14(2):260-266. doi:10.1016/j.brachy.2014.11.014.

5. Pouliot J, Sloboda R, Reniers B. Two-, three-, and four- dimen-sional brachytherapy. In: Venselaar JLM, Baltas D, Meigooni AS, Hoskin PJ, eds. Comprehensive Brachytherapy: Physical and Clinical Aspects. Boca Raton, FL: CRC Press; 2013:231-239.

6. van Dyk S, Schneider M, Kondalsamy-Chennakesavan S, Bernshaw D, Narayan K. Ultrasound use in gynecologic brachytherapy: time to focus the beam. Brachytherapy. 2015;14(3):390-400. doi:10.1016/j.brachy.2014.12.001.

7. van Dyk S, Kondalsamy-Chennakesavan S, Schneider M, Bernshaw D, Narayan K. Comparison of measurements of the uterus and cervix obtained by magnetic resonance and trans-


Patient Care

Chantel Harnois

Treating Patients With Autism Spectrum Disorder

Autism spectrum disorder (ASD), also known as autism, is a broad name given to differing categories of brain development disorders.1 Typically, children are diagnosed around

2 years of age1; however, diagnosis can occur later because children often are not in social situations where manifestations of the disorder become evident until they enter school.2 In 2014, the Centers for Disease Control and Prevention’s Autism and Developmental Disabilities Monitoring Network reported 1 in 68 chil-dren in the United States have ASD.3 This statistic is approximately 30% higher than in 2012, when 1 in 88 children were reported to have autism. Autism also is 5 times more common in boys than in girls.3 As autism becomes more prevalent, it is likely that more patients with the disorder will be seen in the radiation oncology department. To ensure that the best care is given to those individuals, radiation therapists should have a basic understanding of the disorder.

SymptomsThe primary symptoms associated with ASD are

poor communication, poor social interactions, and repetitive behaviors. Symptoms and severity vary among individuals.4 Mildly affected patients can live a relatively normal life, whereas those who are severely affected might be unable to speak or care for them-selves.4 Individuals with autism generally are slower to learn and interpret nonverbal and social communica-tion. They might have trouble controlling their emo-tions, which can lead to tantrums, outbursts, or aggression.4 Individuals with autism struggle to regulate

sensory input, which can lead to difficulty processing visual, auditory, tactile, olfactory, gustatory, movement, and positional stimuli.4 When individuals with autism deviate from their typical routine, they might become overwhelmed by stimuli, which can lead to a tantrum. Many individuals are hypersensitive to sensory infor-mation, whereas others are hyposensitive.4 The wide range of conditions that occur within ASD can result in a variety of symptoms among individuals.

TypesASD encompasses 4 primary categories that can be

linked to intellectual disability, difficulties in motor coor-dination and attention, and physical health issues 4: Autistic disorder. Childhood disintegrative disorder. Pervasive developmental disorder–not otherwise

specified. Asperger syndrome.Standardized guidelines can help detect autism in

children approximately 2 years of age.5 For example, lack of communication, such as no single words spoken before 18 months, is one criterion. Before these guidelines were developed, autism typically was diagnosed in school-aged children. Those with classic autistic disorder lack social awareness, limit attachment to others, avoid eye contact, need to maintain a routine, express repetitive behaviors, and have trouble communicating.5

Childhood disintegrative disorder, also known as Heller syndrome, is a rare condition that affects about 2 in 100 000 children.6 People with Heller syndrome show severe regression after several years of typical


Patient CareTreating Patients With Autism Spectrum Disorder

development, which sets them apart from other ASD conditions.7 At around age 2, individuals begin to lose social skills, communication abilities, language, play skills, motor skills, and bowel and bladder control.7

Pervasive developmental disorder–not otherwise specified occurs when a child or an adult is on the autism spectrum but does not fully meet the crite-ria of the other categories. This specific disorder is marked by significant changes in social and language development.8

Individuals with Asperger syndrome tend to func-tion at a higher level than do those with other forms of ASD.9 According to the National Institute of Neurological Disorders and Stroke, those with Asperger syndrome tend to communicate differently. They might talk with a lack of rhythm or in a monotone voice or have trouble controlling the volume of their voice in dif-fering environments.9 For example, they might talk as loudly in a library as they would on a playground. Those with Asperger syndrome tend to have poor social skills and limited interests and might only want to talk about a single interest of theirs.9

Rett syndrome is a controversial and rare genetic disorder that affects brain development primarily in women and girls.10 Some believe it is a category of ASD, whereas others believe it only presents similar symp-toms.11 Symptoms typically begin to develop at about 6 months of age and, similar to ASD, can lead to problems with movement, coordination, and communication.11

Caring for Patients Each person with ASD is unique, which makes it dif-

ficult to predict behavior during radiation therapy treat-ment and deliver patient-centered care. However, there are ways a radiation therapist can better communicate with patients with ASD. According to Levinson et al, physicians and other health professionals should strive to build healing relationships, provide information, respond to the patient’s emotions, manage uncertainty, make informed decisions, and enable patient self-management.12 Radiation therapists should adapt these skills to meet the needs of individuals with ASD to provide them with the best care possible.

Adults with autism typically do well with clear, step-by-step, written directions and pictures,13 but children require more help and preparation. Individuals with

autism might come into the treatment room and be unable to determine whether the radiation therapist is there to help or harm them.13 Radiation therapists should introduce themselves before treatment and let the patient get to know them in and out of the treatment room.13 Patients also might be frightened by immobilization devices or the linear accelerator. To them, these objects might be big, scary, and confining. It is important for patients to see the machines before their treatment day, and they should be told what will happen when they come in and how the treatments will benefit them.13 In addition, most patients with ASD are hypersensitive to light, sound, and touch.13 To help a patient who is hypersensitive, sound-blocking headphones and sunglasses can be used. If patients are sensitive to light touch, use deep touch when moving them and setting them up on the table.

To patients with autism, the world is uncertain and can cause them to experience avoidance and anxiety.13 Most patients require a consistent routine and experience anxi-ety when their schedules are disrupted.13 Maintaining the same appointment time, therapists, and treatment routine can provide a sense of familiarity and trust.

Even when taught about the benefits of radiation ther-apy treatment, children with ASD still might have trouble complying because they cannot predict what will happen to them.14 Law described a study conducted to help chil-dren with autism understand and cooperate with going to the dentist.13 In that study, the dentists used social stories, role-playing, and visual schedules to help children com-plete their dental examinations.13 These same techniques can be applied to radiation therapy.

Social stories describe and illustrate a patient under-going radiation therapy, what instruments are used, the purpose of the instruments, and what garments are worn during therapy.13 The social story includes pic-tures of similar-aged patients going to radiation therapy treatment. Social stories describe how patients might feel, how they should respond to social situations, and what they might experience.14 Patients with ASD might have a difficult time with face masks and immobiliza-tion devices, and social stories can prepare them. Social stories can take the form of printed handouts, slide presentations or any visual media using the third person point of view. Radiation therapists or the nursing staff can create these stories in whichever format works best for them and their patients.

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possibilities can help the therapist adapt to any situa-tion. Every patient is different; it is important to get to know patients before their start date to create a plan best suited to meet their needs.

ConclusionWhen working with patients with ASD, it is cru-

cial to understand their unique qualities. Staff should explain what will happen in concrete terms and use pic-tures, schedules, written directions, and social stories to prepare patients for the treatment. Radiation therapists also should be prepared for behavior to vary from day to day. They should understand that not every person on the spectrum is the same, and what works for one patient might not work for another. If it is known that a patient with ASD is scheduled for treatment, therapists should do research on examples of social stories so they can create one, and they also should do research on the patient’s medical history to get a better understand-ing of his or her needs. After doing research, radiation therapists can create a social story for him or her. It is good for radiation therapists to know the patient’s level of severity and specific sensitivities so that they can tai-lor their interactions to each patient. The use of visual supports and literal language will be helpful. When therapists know how to adapt their communication, it will benefit the patient, the radiation therapist, and the hospital.

Chantel Harnois is a radiation therapy student at the University of Wisconsin – La Crosse in La Crosse, Wisconsin.

References 1. Communication problems in children with autism spectrum

disorder. National Institute on Deafness and Other Communi-cation Disorders Web site. http://www.nidcd.nih.gov/health /voice/pages/communication-problems-in-children-with -autism-spectrum-disorder.aspx. Accessed June 4, 2015.

2. Lauritsen M. Autism spectrum disorders. Eur Child Adolesc Psychiatry. 2013;22(suppl 1):S37-S42. doi:10.1007/s00787 -012-0359-5.

3. How common is autism. Autism Science Foundation Web site. http://autismsciencefoundation.org/what-is-autism/how -common-is-autism. Accessed June 1, 2015.

4. Autism Speaks. About autism. https://www.autismspeaks .org/sites/default/files/sctk_about_autism.pdf. Published 2012. Accessed June 3, 2015.

The visual schedule outlines the examination steps, the setup process, when the therapists will leave the room, and when the therapists will treat the patient. The patient can check off each step as it is completed. Visual schedules help individuals with ASD predict what is going to happen through images. It teaches them how others act, how they should act, and what they can expect. It helps take away the uncertainty of the unknown by showing them what is coming their way.14

In role playing, patients act out their role or the thera-pist’s role. This helps patients to better understand what the radiation therapist is doing and what is expected of them. If a patient is afraid of having a mask made for them, a radiation therapist can have the patient help make an Aquaplast (Qfix) mask for one of the patient’s family members. This enables the patient to see how a mask is made and that it is safe because his or her family member is wearing it. If this is not possible, the patient can watch one of the therapists lie on the table. This helps take some of the unknown out of the process as well.

When treating patients with ASD, it is important to remember that people with autism have difficulty interpreting sensory information.15 They are concrete thinkers and interpret language literally; therefore, when speaking with a patient with ASD, it is best to avoid sarcasm and use straightforward communica-tion. Therapists should pay attention to all the ways autistic patients communicate, including nonverbal clues, such as visible frustration and body language, and distinguish between what a patient will not do and what he or she cannot do. Patients with ASD typically are visually oriented; therefore, it can be helpful to focus on and build off their strengths.15 To prevent anxiety, a therapist should speak in simple words to make sure the patient understands.15 A radiation therapist can prepare for treatment and avoid problem situations by knowing the patient’s anxiety triggers. There will be instances in which the plan will falter, and the patient will have a difficult time. If this happens, one strategy the radiation therapist can use is to draw stick figures on a piece of paper while explaining what he or she needs the patient to do. Keeping an open mind and anticipating all

To learn more about and view example social stories visit http://carolgraysocialstories.com/.

http://carolgraysocialstories.com/


Patient CareTreating Patients With Autism Spectrum Disorder

5. Autistic disorder. Children’s Hospital of Wisconsin Web site. http://www.chw.org/medical-care/child-development -center/developmental-disorders/pervasive-developmental -disorders-pdd/autistic-disorder/. Accessed June 1, 2015.

6. Bernstein B. Childhood disintegrative disorder. Medscape Web Site. http://emedicine.medscape.com/article/916515 -overview. Updated February 12, 2014. Accessed February 3, 2016.

7. Childhood disintegrative disorder. Mayo Clinic Web site. http://www.mayoclinic.org/diseases-conditions/childhood -disintegrative-disorder/basics/symptoms/con-20026858. Revised March 6, 2013. Accessed June 1, 2015.

8. PDD-NOS. Autism Speaks Web site. https://www.autism speaks.org/what-autism/pdd-nos. 2015. Accessed June 1, 2015.

9. Asperger syndrome fact sheet. National Institute of Neurological Disorders and Stroke Web site. http://www .ninds.nih.gov/disorders/asperger/detail_asperger.htm. Published November 6, 2014. Accessed June 1, 2015.

10. Rett syndrome. Mayo Clinic Web site. http://www.mayo clinic.org/diseases-conditions/rett-syndrome/basics /symptoms/con-20028086. Accessed June 1, 2015.

11. Rett syndrome and autism. Research Autism Web Site. http:// researchautism.net/autism-issues/conditions-related-to-autism /rett-syndrome-and-autism.2015. Accessed February 3, 2016.

12. Levinson W, Lesser C, Epstein R. Developing physician communication skills for patient-centered care. Health Aff. 2010;29(7):1310-1318. doi:10.1377/hlthaff.2009.0450.

13. Law B. Everything is unexpected. ASHA Lead. 2015;20(1): 42-48. doi:10.1044/leader.FTRI.20042015.42.

14. Cosgrave G. Social stories. Educate Autism Web site. http://www.educateautism.com/social-stories.html. 2015. Accessed June 2, 2015.

15. Notbohm E. Ten Things Every Child With Autism Wishes You Knew. 2nd ed. Arlington, TX: Future Horizons; 2012.


Advances in Technology

Katherine Weiner, BS, R.T.(T)

Advances in Technology With Brainlab

Technological advances are vital to radiation therapy and health care alike. New technology and equipment offer patients ever-improving treatment options. One company that has been

innovating within the medical field is Brainlab. Brainlab has created software and hardware for use across the field of radiation therapy including the areas of treat-ment planning, monitoring, and verification. ExacTrac X-Ray is Brainlab’s patient position monitoring system. Its 2 in-room kilovolt x-ray units produce instant radio-graphs that are displayed on a monitor with proprietary 6-D fusion capabilities. Six-dimensional fusion allows for the correction of rotational deviations between the simulation and setup positions (see Figure 1).1

ExacTrac is unique in that it makes imaging and monitoring patient movement possible throughout an entire treatment session. Radiographic images can be obtained independently from the gantry position or couch angle. Intrafractional deviations in patient posi-tion thus can be detected and displayed for the user immediately. This valuable feature lessens the prob-ability of a geographical miss due to patient motion, internal anatomical changes, or a combination of these factors.1 Such precision allows for the safe delivery of radiation therapy treatments without the necessity of performing daily or weekly cone-beam computed tomography scans.

ExacTrac’s precision is based on monitoring and verifying a patient’s internal anatomy (see Figure 2). To do this, image fusion can be performed based on

bony anatomy or implanted fiducial markers. Image fusion based on fiducial markers is useful when there is tumor motion or difficulty visualizing the target. In these instances, ExacTrac can detect the implanted fiducial markers automatically and adjust for any motion using 6-D fusion. The use of implanted fiducial markers expands ExacTrac’s functionalities to allow for treatments of lesions in various areas of the body.1

The selective anatomical fusion feature is another function of ExacTrac. Selective anatomical fusion allows the user to select and define a volume of interest that

Figure 1. ExacTrac’s 2 in-room kilovolt x-ray units mounted above the treatment table. Image courtesy of Brainlab.

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Katherine Weiner, BS, R.T.(T), earned her degree in radiation therapy from Saint Louis University. She has 4 years of experience as a radiation therapist and works for SCCA Proton Therapy Center in Seattle, Washington. She can be reached at [email protected].

Reference1. ExacTrac X-Ray. Brainlab Web site. https://www.brainlab

.com/en/radiosurgery-products/exactrac/. Accessed December 10, 2015.

focuses on the most relevant anatomy for patient align-ment. At the same time, this allows the user to exclude areas of nonrigid objects, such as the ribs. Precise patient setups are achieved by concentrating on the anatomy most closely associated with the target and excluding areas that are not. Patient setups stay consistent because ExacTrac is programmed to store the selected volume of interest from day to day for each patient’s treatment.1

Coupled, the features of ExacTrac allow for the deliv-ery of highly accurate radiation therapy and radiosur-gery treatments. Stereotactic submillimetric precision makes ExacTrac’s frameless radiosurgery system pos-sible. Frameless radiosurgery provides a patient-friendly alternative to conventional head rings. Instead of the conventional head rings, the ExacTrac frameless radio-surgery system uses a 3-piece, noninvasive mask that is compatible with many vendor couch tops.

Brainlab’s software and equipment is built for ease of use and compatibility between systems. ExacTrac spe-cifically can integrate fully with Varian and Elekta linear accelerators. This integration results in a smooth work-flow that provides advanced care to patients. Although ExacTrac is not fully compatible with Siemens linear accelerators, its integration further extends the capabili-ties of these machines as well. In addition, ExacTrac functions with electronic health record systems ARIA (Varian) and MOSAIQ (Elekta). This allows for easy assimilation of the advanced technology.1

As with any new technology, the adaptation of Brainlab means that there is a learning curve for every-one involved. Although ExacTrac is intuitive with gener-ally simple acclimation, time must be spent developing processes, procedures, and protocols to go along with the system. For example, ExacTrac does not provide soft-tissue imaging capabilities, which means that imag-ing guidelines might need to be revised. The inability to display soft tissue also might require the use of fiducial markers for certain treatments. These are some of the possible challenges introduced with the integration of ExacTrac, but challenges are a part of any new technol-ogy and should not overshadow the advantages.

Brainlab continues to create improvements in the fields of radiation therapy and radiosurgery. The com-pany joins others to advance health care and improve the standard of care in the medical field.

Figure 2. ExacTrac X-Ray monitor is used to detect submillimetric shifts based on internal anatomy, which allows for the correction of deviations between simulation and setup positions. Image courtesy of Brainlab.


Teaching Techniques

Julie Lasley, MSA, R.T.(R)(T)

Cognitive Apprenticeship Strategies in Clinical Education

Historically, learning a trade meant a master offered his or her apprentice good reasons for performing a task one way or another. The mas-ter explained and demonstrated what should be

done based on principles that govern the action, or the master might have said very little, allowing the student to learn through practice and imitation.1 At first, the appren-tice might not have known why the procedure should be done a certain way, but as he or she gained experience, the rationale became apparent.

Cognitive apprenticeship in the radiation therapy clinic follows a similar format; however, instead of the apprentice learning an easily observed physical skill, the radiation therapy student learns a mental skill that is dif-ficult to demonstrate.2 Clinical instructors can use cog-nitive strategies to help students develop the thinking and reasoning they need to provide quality patient care.

Cognitive ApprenticeshipAccording to Collins et al, one of the oldest and most

natural ways to learn a skill is through apprenticeship.3 Children learn life skills by observing their parents. Couples learn to ballroom dance by observing their instructor. The medical resident observes the physician providing care to patients. This practice of the learner observing a behavior becomes the foundation for cogni-tive apprenticeship.2 However, cognitive apprenticeship is a challenging instructional approach in radiation therapy because the instructor must make his or her thought processes visible to the student.

Cognitive apprenticeship is a model for teaching intellectual skills.2,4 It emphasizes teaching learners how to think about what they are learning. Essentially, this instructional approach encourages radiation therapy students to become independent reflective constructors of knowledge. For example, simply thinking about a pre-vious clinical experience does not lend itself to reflec-tive thinking; radiation therapy students should ask themselves, “What can I do differently as a result of this experience for future clinical encounters?” and “What does the experience suggest to me about my strengths, weaknesses, and opportunities for development?” These pointed questions are essential to clinical learning.

Founded on the domains of reading, writing, and mathematics, cognitive apprenticeship provides the cognitive and metacognitive skills required for clinical competency in learning.2 In addition, cognitive appren-ticeship is rooted in the social constructivist theory, which encourages students to be actively involved in their learning. For example, when a radiation therapy student is engaged in a clinical discussion about a chal-lenging patient setup, knowledge is constructed. The student gains insight into the problem by actively work-ing through its solution. Instructors also should ensure the student’s problem or task is relevant to real-world situations that can occur in radiation therapy practices.5 Professions such as engineering, medicine, and educa-tional administration have adopted this model of learn-ing after recognizing the need for cognitive and metacog-nitive skills in employees.3

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StrategiesRadiation therapy students begin to take ownership

of their learning when 3 teaching strategies are applied. One strategy entails modeling the desired behavior or skill to be learned. For example, instructors can provide students with an opportunity to model the behavior appropriate for a meaningful discussion and to demon-strate how a discussion group should operate within the clinical arena. Instructors also should provide students with a picture of what the completed task should look like to build students’ confidence in leading discussions.6,7 Svinicki showed that students’ initial demonstration of a skill indicates that they are beginning to organize the information themselves.2 The instructor can refer to the final product while introducing the individual parts of a complicated radiation therapy setup.

Scaffolding is another teaching strategy that encour-ages students to own their learning. In this strategy, an instructor provides just enough support to allow students to progress through a task on their own. The instruc-tor fades into the background as the students master the concepts and skills unique to clinical radiation therapy. Although the instructor’s role diminishes, quality patient care is never compromised because instructors continue to follow accreditation standards of direct supervision.

The strategies of modeling and scaffolding can be used in tandem. The initial learning task is modeled by the instructor, which makes the learning task visible and allows students to observe success. As the radiation ther-apy student becomes more skilled, layers of scaffolding (ie, instructor support) are removed, giving the student more responsibility until a level of mastery is reached.6 Svinicki recommended making the student’s first task an easy one and offering encouragement along the way.2 Asking questions or giving clues or feedback to students about their progress adds further support to the scaffold.

A third teaching strategy used with cognitive apprenticeship is coaching or mentoring.5 An instruc-tor coaches as he or she walks around the classroom observing students or interacting with student groups and providing feedback. Similarly, radiation therapy instructors can describe and discuss a patient’s treat-ment plan, which allows the instructor to share his or her thinking pattern with the student. When the instructor asks questions and provides feedback, stu-dents build on their strengths and identify gaps in their

thinking, which help them create personal learning goals for the next clinical experience.2

Learning the Art of ReflectionThese learning strategies are supported with reflec-

tion. Learning the art of reflection begins with helping students become aware of their own thinking. Tanner recommended reflective dialogue in the clinical arena.8 To inspire reflection and stimulate thinking, radiation therapy students can be asked, “Were any concepts learned in the clinic today confusing, challenging, or difficult to understand? If you were puzzled by the problem at first, how did you work it out?” Instructors might need to provide an “instant replay” of events or problems that occurred during a procedure to prompt reflection. Students can compare their problem-solving skills with those of their peers and clinical instructors by engaging in reflective dialogue about the topic.9

Student ReadinessRadiation therapy students become ready to advance

by performing increasingly diverse clinical tasks. Completing these tasks allows a student to become skilled at advanced concepts and able to distinguish between what will work and what will not work in a clinical situ-ation. Cognitive apprenticeship helps students create a repertoire of contextual associations that can be used to tackle new problems.3 In addition, a student’s readiness to progress is related to the confidence the instructor shows in the student’s preparation as a radiation therapy profes-sional.7 The instructor should use empathic responses, such as, “When I used to sit down to study as a student, I used a mapping technique; without this, I felt stressed. Would you consider trying a mind map for studying?” Using this nondirective approach produces growth in learning because the student can freely express emotions and gain deeper insight into the learning process.

Authentic LearningAuthentic learning in radiation therapy clinical

practicum courses requires that students produce rather than reproduce knowledge gained through real-life clinical experiences.10 For example, if an instructor wants radiation therapy students to have effective com-munication skills, providing them with an opportunity to practice in the clinic is necessary.

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exercises into learning activities that challenge students to think more broadly about what they are trying to accomplish. Cognitive apprenticeship invites the radia-tion therapy instructor to teach new treatment setups and to design students’ clinical experiences based on a complex set of skills involving thinking and reasoning, which form the cornerstone of high-quality patient care.

Julie Lasley, MSA, R.T.(R)(T), is program chair of radiation therapy and medical radiography for the Baptist College of Health Sciences in Memphis, Tennessee. She also serves on the Radiation Therapist Editorial Review Board. Lasley can be reached at [email protected].

References1. Crawford MB. Shop Class as Soul Craft: An Inquiry Into the

Value of Work. New York, NY: Penguin Press; 2009:72-170.2. Svinicki MD. Learning and Motivation in the Postsecondary

Classroom. Bolton, MA: Anker Publishing Company; 2004:61-227.

3. Collins A, Holum A, Brown JS. Cognitive apprenticeship: making thinking visible. The 21st Century Learning Initiative Web site. http://21learn.org/archive/cognitive-apprenticeship -making-thinking-visible/8/. Accessed June 26, 2015.

4. Merriam SB, Caffrella RS, Baumgartner LM. Learning in Adulthood: A Comprehensive Guide. San Francisco, CA: John Wiley & Sons; 2007.

5. Bates FM, Waynor WR, Dolce JN. The cognitive apprentice-ship model: implications for its use in psychiatric rehabilita-tion provider training. J Rehabil. 2012;78(1):5-10.

6. Darling-Hammond L, Austin K, Lit I, Martin D. Watch It, Do It, Know It: Cognitive Apprenticeship. Detroit, MI: Detroit Public Television and Crim Communications; 2003. http://learner.org/courses/learningclassroom/session_overviews /cog_app_home8.html. Accessed March 2015.

7. Leaver D. Clinical teaching skills for radiation therapy. Radiat Ther. 2012; 21(2):157-177.

8. Tanner KD. Promoting student metacognition. CBE Life Sci Educ. 2012;11(2):113-120. doi:10.1187/cbe.12-03-0033.

9. Fink LD. Creating Significant Learning Experiences: An Integrated Approach to Designing College Courses. San Francisco, CA: Jossey-Bass Education; 1984:102-154.

10. Ma YJ, Lee H. Incorporating an authentic learning strategy into undergraduate apparel and merchandising curriculum. J Experiential Educ. 2012;35(1):272-289.

11. Joyce B, Weil M, Calhoun E. Models of Teaching. 9th ed. Boston, MA: Pearson Education; 2009: 323-337.

If direct experiences are not available, authentic learning can be accomplished through indirect means such as simulation, case study, problem-based learn-ing, or role-playing.9 In role-playing, students translate human actions into the kind of activity for which the course is intended to prepare them. Furthermore, stud-ies on authentic learning have demonstrated positive outcomes related to communication, research skills, and teamwork.11

Diminished Instructor RoleOwnership of learning can be transferred from the

instructor to the student through a cognitive appren-ticeship model. The instructor continually builds the scaffold and reflects on how the student acquired a particular skill. Self-reflection allows the instructor to determine whether the student needs more scaffolds or whether some should be removed. According to Svinicki, the environment itself can provide necessary feedback when a student is performing a task.2 However, the student should not have to rely on the environment as the only source of feedback; instructors should pro-vide positive feedback or some students might become discouraged with their learning.2 Constructive feedback also is important. The instructor can provide specific information about a treatment technique. Pointing out students’ strengths should always come first, followed by suggestions for improvement.

In addition, instructors can ask students about their decisions to inspire reflection about their learning. An accurate diagnosis of the learner’s thought processes and skill levels is necessary to assess whether the proper level of scaffolding is in place. The instructor’s role can then be diminished but should continue to provide direct supervision for procedures.5 Cognitive appren-ticeship allows the subtle, underlying thought processes essential to radiation therapists to become visible to the learner. This strategy is not used to teach every topic, but it has been successful in teaching students complex tasks such as radiation therapy procedures.3

ConclusionThe ability to learn throughout life is the key to cogni-

tive apprenticeship. Radiation therapy instructors must consider the interconnectedness of myriad situations radiation therapy students will face and incorporate


RE: Registry

Preparing for Continuing Qualification Requirements

Lisa Bartenhagen, MS, R.T.(R)(T)

Advancements in technology and health care are leading to expectations of increased accountability and quality. Medical reim-bursements are being associated with quality,

safety, and satisfaction, and consumer and regulatory activities are changing the professional’s role across health care systems. The idea of “once certified, forever qualified” no longer meets the patients’ or the profes-sion’s expectations. In response to these changing expectations, the American Registry of Radiologic Technologists (ARRT) has joined a growing number of health care organizations implementing time-limited certifications. Time-limit restrictions will provide the profession a means to assess medical imaging and radia-tion therapy professionals’ knowledge at reasonable milestones during their career, thus helping to ensure quality of care for patients.

Time-limited certification is not a new concept. In 1986, for example, the American Board of Internal Medicine limited the duration and validity of issued certifications. At that time, 17 other specialty boards also required recertification of their professionals.1 In addition, the registered radiologist assistant program has participated in time-limited certification since its introduction in 2005.

Continuing Qualification RequirementsThe ARRT introduced the Continuing Qualification

Requirements (CQR) compliance process to reassess registered technologists’ and therapists’ knowledge.

Credentials earned in primary and postprimary programs on or after January 1, 2011, are time-limited to 10 years.2 However, CQR does not necessarily apply to all credentials. For example, if someone became cer-tified and registered in radiography before January 1, 2011, and then went on to earn a postprimary certifica-tion in computed tomography after January 1, 2011, then only the postprimary credential would be subject to CQR reassessment. The compliance period begins 3 years prior to the 10-year time-limited period. So, for those who earned certification and registration in 2011, the compliance period begins in 2018.

The ARRT is committed to making CQR compli-ance as simple as possible. Professionals will be able to manage the process through a portal on the ARRT Web site. There they can gather information, monitor their progress, and document their completed requirements. Three components comprise CQR: professional profile, structured self-assessment, and continuing education opportunities.

Professional ProfileThe profile enables registered technologists to dem-

onstrate how they have maintained their qualifications since the credential was awarded 10 years prior. It helps them highlight achievements by indicating the type and frequency of procedures being practiced. This exercise takes approximately 20 minutes to complete and provides a summary of how the clinical experiences of one profes-sional compare with those of others in that discipline.3

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The profile could reveal areas that need refreshing and provide optional clinical refreshers to expand both the breadth and depth of clinical experiences in those areas. These resources are free as part of the CQR process.

Awareness gained through completing the profes-sional profile will serve as the basis for moving into the second step of CQR, the structured self-assessment.

Structured Self-AssessmentThe structured self-assessment is a set of questions

covering material similar to the content specifications used to develop the initial certification exam. The ques-tions, typically multiple choice or sorted lists, will be scored. However, unlike the initial certification exam, the assessment is not pass/fail. It is used as a tool to evaluate strengths and weaknesses in knowledge and skills compared with the expected qualifications of someone becoming credentialed. Completing continu-ing education (CE) activities in the identified areas is the third component of CQR.

Continuing Education for CQRThe structured self-assessment results will docu-

ment 1 of 2 things: If no areas needing improvement are identified,

CQR is met. If improvement is needed in certain areas, the

content areas will be identified and CE will be assigned. Content and contact information will be provided to aid in accessing pertinent activities.

Any CE credits earned to comply with CQR will apply to regular biennial CE requirements. Registered technologists will have 3 years in which to complete the CQR process. If he or she is not successful within that time period, certification and registration will be discontinued, which could affect their ability to work, depending on state and employer requirements.

ConclusionUnderstanding how CQR fits into the overall certifi-

cation and registration process is fairly simple. Annual renewal and biennial CE reporting are important, so they remain part of the process to be completed as usual. CQR will provide the mechanism for indicating current qualifications 10, 20, or more years later.

Lisa Bartenhagen, MS, R.T.(R)(T), is the radiation therapy program director for the University of Nebraska Medical Center and serves on the Radiation Therapist Editorial Review Board. Bartenhagen is completing her third year on the Board of Trustees for the American Registry of Radiologic Technologists.

References1. Glassock RJ, Benson JA Jr, Copeland RB, et al. Time-

limited certification and recertification: the program of the American Board of Internal Medicine. The Task Force on Recertification. Ann Intern Med. 1991;114(1):59-62. doi:10.7326/0003-4819-114-1-59.

2. American Registry of Radiologic Technologists. Continuing qualifications requirements (CQR) [video]. ARRT Web site. http://www.arrt.org/videos. Accessed December 20, 2015.

3. What CQR (Continuing Qualification Requirements) Will Mean for You. St Paul, MN: American Registry of Radiologic Technologists; 2015.

For more information about CQR, visit the ARRT Web site at arrt.org.

http://arrt.org


Case Summary

Casey Johnson, BSCory J Neill, MS, R.T.(R)(T), CMDPeter Francis Rosser, R.T.(T)

Radiation Therapy for Treatment of Craniopharyngioma

challenging.3 Complete excision also does not appear to significantly decrease tumor recurrence.5 Conservative surgical resection with adjuvant or salvage external-beam radiation therapy has been shown to achieve local tumor control while avoiding the severe surgical and neurologic complications associated with gross total resection.2,6 Radiosurgery is restricted to small, solid tumor volumes, as well as to tumors with clear margins near critical cere-bral structures.6 The decision for complete or subtotal resection is determined based on patient medical comor-bidities and performance status.2

Case StudyA 29-year-old woman presented to her family physi-

cian complaining of intermittent headaches for 6 to 8 months followed by a constant headache. In addition, the patient reported significant changes in peripheral vision of the left eye and difficulty reading. The patient’s medi-cal history indicated a routine school eye examination performed at age 7, which showed blindness in the right eye. At that time, the patient was diagnosed with a cra-niopharyngioma and underwent surgical resection. The surgery did not restore vision and left her permanently blind in the right eye. Following the resection, the patient received routine magnetic resonance (MR) imaging scans for 7 years with no evidence of recurrence. Cases of craniopharyngioma often involve the pituitary stalk and hypothalamus, which causes significant hormonal imbal-ances in patients that usually are permanent.2 Therefore, since age 7, the patient received hormone replacement

C raniopharyngiomas represent less than 2% of all primary central nervous system tumors but are the most common intracranial nonglial tumors in children.1 Craniopharyngiomas typi-

cally exhibit a bimodal peak incidence in children aged 5 to 14 and in adults aged 65 to 74. From 2004 to 2008, there were 644 new cases of craniopharyngioma in the United States.2

This histologically benign tumor grows slowly within the sellar and parasellar region of the brain, often causing permanent endocrine disorders and vision impairment. Diagnosis largely is based on the physical components of the tumor (eg, solid, cystic, and calcified).3 The onset of symptoms typically is marked by visual disturbances and headaches due to intracra-nial pressure and compression of the optic chiasm.4,5 Craniopharyngiomas have the highest mortality rate of any pituitary-related tumor because of their propensity to impinge on surrounding neurologic and endocrine structures. Increased cardiovascular risks, hypothalam-ic damage, and reduced cognitive function also affect comorbidities and long-term survival.4,5

The limited number of studies related to craniopha-ryngioma treatment on a population scale make assess-ment of the long-term control of these tumors difficult.2 In addition, no clear evidence supports a “best” overall course of treatment for adult craniopharyngiomas. Gross total resection is the standard of care when critical struc-tures can be avoided, but the often irregular margins and cystic component of these tumors make complete excision


Case SummaryJohnson, Neill, Rosser

system (Philips). The MR images were registered to com-plement the treatment planning CT for accurate target delineation. Insurance restrictions prevented the use of intensity-modulated radiation therapy. To accommodate the insurance restrictions, the treatment planning team used forward planning, requiring the medical dosime-trist to create an effective treatment plan by manually modulating the dose. Additional segmented lateral beams were created to avoid critical structures including the left optic nerve (see Figure 1). The 3-D planning along with manipulation of the multileaf collimator within segment-ed fields allowed planning target volume coverage from 5 beam angles and 6 segments. The block-to-planning target volume margins were 1.5 cm.

The tolerance dose limit to the optic nerve is 5400 cGy, with some studies suggesting that doses up to 5900 cGy can reasonably avoid optic nerve neu-ropathy.7 The radiation oncologist required the left optic nerve maximum dose be limited to 5354.9 cGy, accounting for the slight possibility that radiation treat-ment might restore some vision to the left eye.

The treatment plan was evaluated and accepted. The actual dose at point “DP” from all beams was 5452.47 cGy (see Figure 2). The prescribed daily dose

therapy to address underactive thyroid and adrenal insufficiency, as well as desmopressin to regulate dia-betes insipidus.

An emergency department visit at age 29 prompted by complete loss of vision in the left eye led to the recur-rent diagnosis. MR images of the brain demonstrated a large cystic mass in the suprasellar region, with the nerve structures and optic chiasm not clearly visible. The patient then underwent a computed tomography (CT) scan without contrast, confirming a 2.5-cm World Health Organization grade 1 cystic tumor arising from the sella turcica, with a larger calcified component fill-ing the suprasella cistern. The tumor compressed the subfrontal region, the floor of the third ventricle, as well as the retro-orbital segments of the optic nerves and optic chiasm. The patient immediately underwent emergency resection. A frontotemporal approach was used in the pterional craniotomy to subtotally resect the tumor. This surgery used an intraoperative micro-scope with microdissection technique because of the close proximity of the tumor to the internal carotid artery. The cyst ruptured during the procedure and, coupled with the significant scarring from the previous craniotomy, limited the amount of the cyst wall removed.

Two months postoperatively, the patient was seen for a radiation therapy consult at an outpatient cancer center. The patient presented with complete blindness in both eyes, but maintained full ocular muscle con-trol. The patient reported intermittent bed-wetting, polyuria, fatigue, complete loss of smell, and difficulty sleeping following the surgery. She was advised that the blindness following the recent resection might be the permanent result of ischemic nerve damage from com-pression of the optic nerve fibers and optic chiasm. The patient also was informed of potential acute and chronic adverse effects (eg, local hair loss, fatigue, skin reaction, and swelling in the treatment area) related to radiation therapy and consented to treatment.

To begin the treatment planning process, a CT simula-tion was performed using 1-mm and 3-mm slices from the top of the skull to the base of the brain. The 1-mm slices were used through the proposed treatment vol-ume. The patient was lying supine with her hands at her sides and immobilized using a thermoplastic mask. The medical dosimetry team reviewed the CT images and transferred them into the Pinnacle treatment planning

Figure 1. Chosen beam angles to limit dose to critical structures. Image courtesy of the authors.


Case SummaryRadiation Therapy for Treatment of Craniopharyngioma

low vision in one eye. The treatment planning team incor-porated this into the dose tolerance and critical structures of the plan. Careful considerations were made to keep the dose as low as reasonably achievable given the patient’s age and existing endocrine dysfunction. The insurance limita-tions and location of the tumor also proved to be consider-able obstacles in regard to treatment planning. Ultimately, forward planning allowed for acceptable dose coverage while sparing critical structures in an effort to restore any amount of vision for the patient. At the time of treatment follow-up, the patient had not regained any vision and will continue to be monitored by a neurologist.

Casey Johnson, BS, is a radiation therapy student at the College of Southern Nevada in Las Vegas, Nevada.

Cory Neill, MS, R.T.(R)(T), CMD, is a medical dosime-trist for Carson-Tahoe Radiation Oncology in Carson City, Nevada. In 2015, Neill traveled to Yinchuan, China, as an ASRT Radiation Therapy Fellow. He is a member of the Radiation Therapist Editorial Review Board.

Peter Francis Rosser, R.T.(T), is a medical dosimetrist for Carson-Tahoe Radiation Oncology in Carson City, Nevada.

References1. Bunin GR, Surawicz TS, Witman PA, Preston-Martin S,

Davis F, Bruner JM. The descriptive epidemiology of cranio-pharyngioma. Neurosurg Focus. 1997;3(6):e3.

2. Zacharia BE, Bruce SS, Goldstein H, Malone HR, Neugut AI, Bruce JN. Incidence, treatment and survival of patients with craniopharyngioma in the surveillance, epidemiology and end results program. Neuro-oncology. 2012;14(8):1070-1078. doi:10.1093/neuonc/nos142.

3. Garnett MR, Puget S, Grill J, Sainte-Rose C. Craniopharyngioma. Orphanet J Rare Dis. 2007;2(1):18. doi:10.1186/1750-1172-2-18.

4. Erfurth EM, Holmer H, Fjalldal SB. Mortality and morbid-ity in adult craniopharyngioma. Pituitary. 2013;16(1):46-55. doi:10.1007/s11102-012-0428-2.

5. Parsons JT, Bova FJ, Fitzgerald CR, Mendenhall WM, Million RR. Radiation optic neuropathy after megavoltage external-beam irradiation: analysis of time-dose factors. Int J Radiat Oncol Biol Phys. 1994;30(4):755-763.

6. Zoicas F, Schöfl C. Craniopharyngioma in adults. Front Endocrinol (Lausanne). 2012;3:46. doi:10.3389/fendo.2012 .00046.

7. Habrand JL, Ganry O, Couanet D, et al. The role of radiation therapy in the management of craniopharyngioma: a 25-year experience and review of the literature. Int J Radiat Oncol Biol Phys. 1999;44(2):255-263.

of 180 cGy was delivered to DP using mixed energies of 6 MV and 15 MV for 30 fractions. Treating to the 99% isodose line allowed a maximum dose of 5354.9 cGy to the left optic nerve, while maintaining 98.05% coverage of the planning target volume (see Figure 3).

This unique case presented obstacles in several respects. Postsurgically, the patient was completely blind, but radiation therapy offered a slim possibility to restore

Figure 3. The 99% isodose cloud is shown in green. The blue contour represents the right optic nerve. The green contour represents the left optic nerve. The purple contour is the brainstem. Image courtesy of the authors.

Figure 2. The location of calculation dose point marked as DP. Image courtesy of the authors.

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