Late effects of radiotherapy

by: Kay Leonard

Same role, different skills:

radiotherapy nursing across Europe

by: Birgitte Grube

Brachytherapy:exploring the role of nurses

by: Christina Andersen

Summer 2010

N U R S I N G A T T H E H E A R T O F P A T I E N T C A R E

RadiotherapyCare

Theme:

2

Editor-in-Chief:

Clair Watts

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Jim Boumelha

Editorial Assistants:

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EONS Secretariat:

Avenue Mounier 83, 1200 Brussels, Belgium

Phone: +32 (0)2 779 99 23

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EONS acknowledges AMGEN (Europe) GmbH,

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and SpePharm SAS France for their continued

support of the Society as sustaining members.

Print run: 2000 copies

Electronic version accessible

to 22000 EONS members

Design and production:

© 2010 HarrisDPI. www.harrisdpi.co.uk

Cover Photo:

ZEPHYR/SCIENCE PHOTO LIBRARY

Disclaimer

The views expressed herein are those of the authors

and do not necessarily reflect the views of the European

Oncology Nursing Society. The agency/company

represented in advertisements is solely responsible for

the accuracy of information presented in that

advertisement.

The European Oncology Nursing Society (EONS) does

not accept responsibility for the accuracy of any

translated materials contained within this edition of the

EONS Newsletter.

© 2010 European Oncology Nursing Society

EDITORIAL

3 New technologies, new skills, better knowledgeby Birgitte Grube & Mary Wells

LATEST NEWS

4 A message from the Board

6 EONS 7th spring congress

8 Icelandic volcano: Needs must when the devil drives

FEATURES

10 Late effects of radiotherapy

14 Same role, different skillsRadiotherapy nursing across Europe

20 Developments in radiotherapyQuestions and answers

24 3D accelerator in radiation therapy trainingFrom apprenticeship to virtual reality training

26 Brachytherapy: exploring the role of nurses

28 Caring for the skin during radiotherapy

30 Communicating better to prevent errorsand improve patient safety

The aim of the EONS Newsletter is to provide a written resource for European nurses working in cancer settings.

The content of the articles is intended to contribute to the growing body of knowledge concerning cancer care.

All correspondence should be addressed to the Editor-in-Chief at: eons.secretariat@cancernurse.eu

Contents Summer 2010

E d i t o r i a l

3

R adiotherapy is an extremely important treatmentmodality but, being of little interest to the phar-

maceutical industry, it is not always given the atten-tion it deserves. There are relatively few nurses workingin radiotherapy, and in many countries, the role of thenurse is less well defined than in other cancer specialties.Around 60% of all cancer patients currently undergo

radiotherapy. With new technologies emerging, greateruse of combined chemotherapy and radiotherapy andincreasing numbers of people developing or living withcancer, this number will rise in the coming years.In this Newsletter you can read about some of the

latest technological advances in radiotherapy as wellas the management of common side-effects and theexperience of the patient.When radiotherapy treatment is over, patients

continue to experience late side-effects whichcompromise the quality of their life and may beassociated with second malignancies. With survivalrates improving, it is crucial for nurses to understandthese effects so they can inform and support patientsafter treatment. The first article provides an overview oflate effects and includes an interview with Lars Hansen,who continues to experience effects many years later.Nurses working in radiotherapy have an extremely

important role to play informing and supporting the patientand relatives before, during and after treatment. In someEuropean countries, nurses are also responsible foradministering radiotherapy treatment. In our secondarticle,“Same responsibility, different skills —

radiotherapy nursing across Europe” on page 14, we takea tour round Europe to learn more about the role ofradiotherapy nurses in five different countries, bringing tolight many differences.One of the questions most commonly asked by nurses

is how to care for the skin during radiotherapy. Thearticle, “Caring for the skin during radiotherapy” on page28, summarises current thinking in this area. Lena Sharp,from Sweden, then describes the importance of effectivecommunication within the radiotherapy department,showing how patient safety can be improved.New technologies demand new skills and knowledge.

Annette Bøjen from Århus, Denmark, describes aninnovative training initiative — the 3D accelerator inradiation therapy training — set to equip nurses for newroles. Christina Andersen, also from Denmark, explainsthe importance of information, communication andhigh-quality care for patients undergoing brachytherapy.

This newsletter only scratches the surface of whatnurses need to know, but we hope to inspire you tolearn and understand more about patients’ experienceof radiotherapy. Nurses need to be proactive in educatingthemselves about new developments in treatment, or insupportive care or in symptom management. EONS isoffering a new module to improve nurses’ knowledgeand skills in radiotherapy, hoping to motivate morenurses to conduct research in this area too. Nurseshave a huge amount to contribute to radiotherapy care,and have the potential to take a leading role in clinicalresearch into the future.

Guest Editorial Birgitte Grube & Mary Wells

New Technologies, New Skills,

Better Knowledge

Birgitte Grube is Head of Education for Radiotherapy Nurses at Metropol University College in Copenhagen and is currently EONS President-elect

Mary Wells is a Senior Lecturer in Cancer Nursing at the University of Dundee, Scotland. Her clinical background is in radiotherapy care

The European Journal of Oncology Nursing, the official journal ofEONS known as EJON, made a splash last month at the SpringConvention by sponsoring for the first time the internet zone.“We wanted to let people know about EJON” said Alex Molassiotis,Professor of Cancer Care at the University of Manchester and Editor-in-Chief of the journal. “We are very proud that EJON is the officialjournal of EONS and we wanted to contribute to the SpringConvention. We felt that sponsoring the internet zone would be agood way to do this. As well as promoting the journal, it reallyhelped the delegates by enabling them to check for urgent emails”.EJON attracted a great interest from congress participants as itachieved another milestone. The journal published for the firsttime abstracts from oral presentations and posters in asupplement. Its publisher Sarah Jenkins noted the importance ofthis achievement and said, “The Proceedings Book waspublished in print for the delegates to the Spring Convention.It will also be published online and we expect the abstracts tobe widely read in Europe but also by subscribers in NorthAmerica and Asia. It was great to publish the ProceedingsBook as an official supplement of EJON and we look forwardto doing it again in the future”.

4

We have no doubt that ourbiennial Spring Convention in

The Hague was a resounding success.The event was memorable for manyreasons, not least the impact ofEyjafjallajökull, the Icelandic volcano.I was one of the many delegates whoseplans were severely disrupted by the ashcloud. As I was in Scotland the morningI was due to travel to The Hague, I wasone of the first people to feel the effects— my flight was cancelled and I wasunable to join the event. We are in aweto the many ingenious initiatives takenby participants to overcome the chaosand help each other hatch plans to make

their way back home.Our work on planning the 8th Spring

Convention which will be held at the endof April 2012 in Valencia is gatheringpace. Similarly, the ECCO 16-ESMO 35, tobe held from 23 till 27th September inStockholm next year, is coming closer. Weare introducing new procedures toregulate our capacity to maximise ourshare of the profit from this event whichrequires that we provide ECCO with up-to-date lists of national societies beingmembers of EONS. This will enable themto identify EONS members and calculateour share of the surplus funds. Since thiswill have an effect on our finances and

consequently our ability to carry out otherEONS activities, society assistance onproviding such lists is highly appreciated.

Your Board highly values contact withEONS members and, in addition to theAdvisory Council held annually, we areplanning to make personal contacts withnational societies and we will be glad topresent and discuss EONS at yournational meetings. In the meantime, don’tforget to keep yourself fully informedabout the latest news by accessing theEONS website athttp://www.cancernurse.eu/Ulrika Östlund

EONS Board Secretary

A Message from the Board

Learned Journal MakesImpact on Congress

25-28 April 2012

vAlenciA ,spAin

www.ecco-org.eu

save the Date

The european Oncology

nursing society presents:

EONS8_210x280_OK.indd 1 26-07-2010 11:06:33

Attending the spring convention againhighlighted for me the importance of

giving nursing an individual voice in thepolicy making process. Equally important isthe need to give a forum for discussion forthose of us coming from countries wheredevelopments in cancer nursing are not yetas established as for instance in Britain.Policy affects nurses and patients alike, asillustrated by Sara Faithful in the openingsession, when she stressed that cancernurses will probably be in short supply if, inthe years to come, we do not address theattractiveness of the profession. In addition,EU policy makes it easier fornurses to move around, whichcan only lead to a brain drain incountries with fewer resources.Patient mobility is governed by

more complex regulations, with freedom ofchoice closely tied to the ability to pay, atthe moment.Given the complexity of the issues involvedand the diversity of definitions and roles ofcancer nursing in different countries,discussing and comparing nationalachievements and stumbling blocks,searching for best practice models and a“European curriculum” will help cancernurses be heard in the policy-makingprocess, not only at the national but alsoat the supranational level.Petra Riemer-Hommel

A Voice in Policy Making

Bottom clockwise: Alex Lindenburgh

describes magnet hospitals; Anita Margulies

brings to life targeted therapy; Mary Gullatte

shares her recipes for leadership success;

Portuguese delegates explore a poster session

Centre: EONS President Sultan Kav,V&VN

President Marieke Schreuder-Cats and

EONS Past President Sarah Faithfull chair

the opening plenary session.

6

L A T E S T N E W S

7

When the leaders of EONS and the USOncology Nursing Society (ONS) discussedwhether to use material from the ONSLeadership Development Institute in twoworkshops at the conference, the consensuswas a clear yes. The collaborative effort,chaired by their respective presidentsSultan Kav and Brenda Nevidjon, showedthat leadership has universal themes,despite the diversity of countries and theirhealthcare systemsMary Gullatte from the US and Sara Faithfullfrom the UK combined lectures, group

activities, and fun exercises toengage participants. Beingasked to draw a pig in oneof the case studies raisedmany chuckles, but it

proved how smallgroups can identify

system barriers and solutions to them.Making a clear distinction between Englishand American phrases and colloquialisms ledto an animated session engaging participantsto help each other clarify information. In theword choice exercise, the result was a colourthat described characteristics of the person.Participants were given a piece of ribbon forthe dominant and second colour, and worethem in their name tag. It was a fun way toreflect on one’s leadership characteristicswith none being right or wrong.Throughout the conference, I learnedsomething new in each session and enjoyedbeing in a community of oncology nurses.The subsequent challenge posed by thevolcano and the resilient response by nursesmade this conference unique and gave usall many great stories to tell.Brenda Nevidjon

Left clockwise:

Lawrence Drudge-

Coates shares the

impact of prostate

cancer; the chill-out zone

at the Scheveningen

beach party; Roderick

van den Bergh explains

the impact of prostate

cancer; Novice

researcher Beate Senn

receives her prize; ONS

and EONS Board

members relax post-

congress at the

Keukenhof gardens

BRINGING BACK THE 3 PSBrenda Nevidjon, US ONS President, kicked off the session bydescribing the concept of ‘Magnet’ hospitals, used in the US inthe 80s, to stop nurses leaving and to attract new trainees.Based on five model components, this programme gave priority toachieving higher performance where nurses were given positionsin every management level.

Alex Lindenburg, Nurse Manager at the Vlietland Hospital inthe Netherlands, used power points with music and fireworks toshow how the ‘Magnet’ principle was used to bring back the 3 Ps,Passion, Pleasure and Professionalism. He called for action“Think Big, start Small, but just Do it!”Erwin Humer

Reflectingon Leadership

8

Thousands of years ago the Vikings charged in all overEurope, not known for their good manners. This April, a

smaller horde of Vikings, once again, were on the move, braving thewrath of Eyjafjallajökull to roam back home, again with noimprovement on the manners.Around thirty Vikings, known today as Scandinavians, were amongthe 670 participants stuck in the Hague after attending a Springconvention — with beautiful houses, good bars and eateries, and nicefolks — not a bad place to be marooned in. At first the plan was to renta bus, but there was no room for the Danes — actually it had all to dowith feuds between footballing nations! The Swedes and Norwegianstook the coach to Copenhagen then reached home by train. ThreeDanes were left behind. A profiteering agency demanded €1500 torent them a car. In the end, a lovesick husband came to the rescue. Hedrove for 12 hours, spent one night in the Hague and drove themback. An award has now been named after the gallant husband.Birgitte Grube

The Vikings and the volcano

The EONS congress was such a wonderful opportunity to seeold friends,make new ones, and learn so much.Who wouldhave guessed that a volcano with an unpronounceablename would impact on our journey? As one who travels agreat deal, I should be prepared for such mishaps. This one,however, stretched the limits of previous experiences, but Ilearned new lessons and reinforced old ones.There were four of us from the United States who bandedtogether to hatch ways to get back home.“Strength innumbers,”became our motto. By facing together a commonordeal, we were able to support each other and make thebest of a stressful predicament.We experienced the goodhearts of so many people time and again. Everyone at theconference was helpful and so concerned about our well-being.We were grateful for that extension of caring.Creativity was rife as delegates set out to search for everypossible option to get home. Key to it all was a positiveattitude and a flexible approach. Technology is amazingand helped us to stay in contact with family and workcolleagues.We were stuck, so we set out to turn it into anadventure and took every opportunity to see more of theNetherlands.We visited Delft, Amsterdam’s museums andUtrecht, and we became experts on the Hague’s transitsystem and the Dutch train system.Luck was with us, and we were able to rebook our travel asthe skies began to open up.We were all able to headhome on the following Thursday, so no one had to be “thelast woman standing”. All in all, it will be an unforgettableconference with many wonderful, lasting memories,despite the antics of Eyjafjallajökull.Paula Rieger

Turning Lemons Into Lemonade

When Eyjafjallajökull came to life in Iceland this

spring, it left thousands of travellers stranded and

shocked. Among them were hundreds of participants

at EONS 7th Spring Convention in The Hague.

For many, their home journeys became the stuff

of travellers’ tales.CarlosAraujo

Icelandic volcano:Needs must when the devil drives

L A T E S T N E W S

9

The Spring Convention in thedream flowerland of The

Netherlands left us with unforgettablememories. But what will remain etched onthe mind of our delegation from Turkey wasthe incredible trip to get back homefollowing the widespread disruption causedby the Icelandic volcano. At first, Icelandseemed to us very far, but as the ash cloudhurriedly spread all over Europe we soonrealised the world indeed is very small.Even though the sky was sunny and clearover the Hague, all flights were cancelledindefinitely. No tickets were available fortrains or buses, no cars to rent, noalternative plans, not even hotelreservations for some of us — it was a realcrisis. Then came a glimmer of hope whenwe discovered we could rent a bus thatwas on its way back to Turkey havingbrought participants from Turkey to theHannover Fair. By midnight on April 19th,38 Turkish delegates boarded the bus at anempty Schiphol airport, which wasdeserted and desolate.That was the beginning of our longjourney, the most exciting and

adventurous experience for many of us,which for two and half days took us acrossGermany, Austria, Italy and Greece. Naturewas still asleep in the Northern Alps, butwe were delighted to see it waking upwhen we reached Italy. While driving nearInnsbruck, we suddenly realised we hadto race against the clock to catch the lastferry for Greece, leaving Italy at 7 pm.After a mad dash throughout Italy,breaking the speed limits, and having tospend hours on our mobiles to persuadethe port authorities in Ancona to delaydeparture of the ferry by half an hour, wemanaged to board on time. It was aluxurious nine-floor cruiseship, withglittering facilities — bars, casino,swimming pools and shopping malls. Ourdelightful cruise on the Adriatic Sea endedat Igoumenitsa in Greece at around noon.Our last leg in Greece was a dream — weenjoyed a beautiful spring sunshine, awonderful fish and wine dinner at Kavala,and crossed the Turkish border at aroundmidnight. By Wednesday noon, we werefinally all safely back home.Nurgun Platin

CRISIS, ADVENTURE AND A HAPPY END

Took a tramto catch a trainto catch a bus

to catch a coachto catch a ferryto catch a taxi

to catch a trainto catch a trainto catch a taxi

to catch a trainto be picked upto get to my car

to get home.Simon Roxborough

‘I’ve beentravelling

so long’

Just like the hundreds of ourcolleagues attending congress,we in the Greek delegation tookthe awful news in our stride. Ourone food for thought was to findthe quickest means to get backhome.We hatched two plans —one was to travel by roadthrough Croatia, Serbia andFYROM — which neededpassports — and the other was togo via Italy and take a ferry.Only three of our 10-strongdelegation group hadpassports, so we jumped at theoffer from the Croatiancolleagues to travel with themon a bus organised by theirtravel agency.We just had to

pay the driver.We started at thecrack of dawn on Sunday, anddrove endlessly along themotorways, stopping every fourhours for the driver to rest. OurCroatian friends, in particularBarcka who spoke English, werevery hospitable and polite andmade us feel we were all onefamily, the big family ofoncology nurses.On arrival in Croatia, we weretreated to coffee, as we did nothave any Croatian Cuna. Barckahelped us all the way through,even taking us to the station andmaking sure we took the rightcoach to Belgrade with enoughprovisions for the trip. Barcka, our

heartfelt thanks! We could nothave made it without you.From there on, things went pear-shaped. The very slow train wetook from Belgrade was terrible.The toilets were dirty and, asthere were no facilities, we couldnot get a drink for over 20 hours.When we finally reachedThessaloniki, we weredevastated to learn that theconnecting train was not due toleave for another five hours, sowe had to rent a car. Five hourslater, we were home after 56hours on the road — a bigexperience, but let’s all hope itwon’t happen again.Dimitrios Papageorgiou

56 hours on the road

Radiotherapy is the cornerstone of moderncancer management with an estimated50˗60% of all people with cancerreceiving radiation either alone or in

combination with surgery and or chemotherapy at somepoint.1,2 Advances in radiotherapy planning andtreatment techniques, such as three-dimensionalplanning and intensity modulated radiotherapy, havereduced acute and late toxicities3 but, because ofimproved early detection and survival rates, we areseeing a wide range of chronic morbidities in long-termcancer survivors.

Late effects of radiation occur months to years after theend of treatment and are a major concern not only forpaediatric cancer patients but also for adults treated forcancer.1 While there is data on the late radiationmorbidity for children treated for cancer, there is limiteddata on late effects in adults treated for cancer.

Swift developments in planning and new techniques continue to

make radiotherapy one of the most successful cancer therapies.

Associated late effects however can cause major problems to

patients ranging from pain and fatigue to second malignancies.

Late Effectsof Radiotherapy

Kay Leonard

10

Late effect

System-specific

Second cancers

Functional changes

Cosmetic changes

Associated co-morbidities

Examples

Damage, failure or premature aging of organs,immunosuppression or compromised immunesystems and endocrine damage

Increased risk of certain cancers associated withthe primary cancer and a second cancer associatedwith cytotoxic or radiological cancer therapies

Lymphoedema, incontinence, pain syndromes,neuropathies and fatigue

Amputations, ostomies, skin and hair changes

Osteoporosis, arthritis, scleroderma andcardiotoxic effects

Table 1. Classification of late effects4

Corbis

F E AT U R E

LATE EFFECTS OF CANCER TREATMENTMany patients treated for cancer now have multi-modaltherapy and this combination of therapies is oftenassociated with late effects. Generally, chemotherapyresults in acute toxicities that can persist, whereasradiotherapy leads to consequences that are notimmediately apparent.4 Examples of late effects oftreatment are shown in Table 1. Radiotherapy is alocalised treatment affecting tissues mainly within theconfines of the radiation field. Late effects ofradiotherapy are specific to the area treated and manifestin two ways as late effects on normal tissues (LENT) anddevelopment of radiation-induced second malignancies.1

ASSESSMENTLate effects from radiotherapy evolve over time and aregraded according to severity.5 The ability to quantify andscore late effects is a challenge, but there are assessmenttools to assist us, such as the RTOG/EORTC’s (RadiationTherapy Oncology Group/European Organisation forResearch and Treatment of Cancer) late morbidity systemand the National Cancer Institute’s (NCI) CommonTerminology Criteria for Adverse Events (CTCAE).6

The CTCAE is a grading system developed byconsensus that incorporates acute morbidities andLENT. The system is designed to provide an assessmentof complications from all cancer modalities and

includes subjective, objective, management andanalytical (SOMA) criteria for each organ or tissue.1 TheCTCAE (version 4.02) uses five grades (1-5) to describethe severity for each adverse event (see Table 2). Thescale includes an additional set of scores to evaluate thepatient’s view of quality of life after treatment.Instrumental Activities of Daily Living (ADLs) refer topreparing meals, shopping for groceries or clothes, usingthe telephone, managing money, etc. Self-care ADLsrefer to bathing, dressing and undressing, feedingoneself, using the toilet and taking medications; theyexclude the bedridden patient. Specific criteria forindividual late effects are also available. Table 3contains the National Cancer Institute’s CommonTerminology Criteria for Adverse Events (CTCAE)version 4.02 for the assessment and grading ofxerostomia (dry mouth), a common and debilitating sideeffect of radiotherapy to the head and neck.

Although toxicity grading scales are useful, they areunable to portray the day-to-day experience of patientsliving with late effects. The following interview illustratesthe impact of radiotherapy on all aspects of life, long aftertreatment is over.

Details of the references cited in this article can be accessed at

www.cancernurse.eu/communication/eons_newsletter.html

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Mild: asymptomatic or mild symptoms; clinical or diagnosticobservations only; intervention not indicated

Moderate: minimal, local or non-invasive intervention indicated;limiting age-appropriate instrumental ADL

Severe or medically significant but not immediately life-threatening:hospitalisation or prolongation of hospitalisation indicated;disabling; limiting self-care ADL

Life-threatening consequences: urgent intervention indicated

Death related to adverse event

Table 2. Five grades describe the severityfor each adverse event

See NCI’s CTCAE version 4.02

Adverse event

Definition

Grade

1

2

3

4

5

Dry mouth

Disorder characterised by reduced salivary flow in theoral cavity

Symptomatic (e.g. dry or thick saliva) withoutsignificant dietary alteration: unstimulated salivaflow > 0.2ml/min thick

Moderate symptoms: oral intake alterations (e.g. copi-ous water, other lubricants, diet limited to purees and/orsoft, moist foods); unstimulated saliva 0.1˗0.2 ml/min

Inability to adequately eat and drink orally, tubefeeding or TPN (total parenteral nutrition) indicated:unstimulated saliva <0.1ml/min

No grade available

No grade available

Table 3. Assessing and grading xerostomia

See NCI’s CTCAE version 4.02

Late effects of radiation occur after treatment iscompleted and are a major concern not only forchildren but also for adults treated for cancer

11

12

I am 56 years old, married with two grownup children. I teach computing to youngadults at a business college. I wasdiagnosed with cancer in 2001. When Ifirst went to my doctor, he thought that itmight all be due to stress. I insistedsomething was wrong and he sent me toa specialist who found something in myneck. From there on, I had some biopsiesdone and they found a cancer on thebase of my tongue. Since I wasconsidered to be young and fit, theytreated me with 33 fractions ofradiotherapy.During the treatment, I found it reallydifficult when things got slowly worse andworse every day. Also, you cling to thehope that, when the radiotherapy is allover, you will get better again. I waspretty well informed but I still didn’t graspthe whole thing. During the thick ofthe crisis a lot of the informationgot lost or clogged up, so youcan’t actually use it. There is a lotsaid about patients’ rights to beinformed, but all of this has a ratherabsurd side-effect — the healthprofessionals are forced tointegrate patients into a decision-making process that they can’tpossibly cope with.For instance, at the beginning Iwas informed that if I wasn’t eatingsufficiently, a feeding tube might be agood idea. But it’s only after the doctorconfronted me about my loss of weight,three weeks into my treatment, that Iunderstood the fact that they wereanxiously waiting for me to say it was ok,and they got desperate before I did. Hadthey waited for me to get desperate and

started the process off, I think I wouldhave died. Before the end of the wholeprocess I lost about 40kg, about a third ofmy weight, during my treatment andwithin the first month after. I am an eternaloptimist so whenever they asked me howmuch I had eaten, I probably told themwhat I ate on a good day or what Ihoped to eat tomorrow.I had been told about the side-effects —bleeding wounds in the throat, vomiting,pain, etc — but I didn’t talk much about itbecause everybody knows it’s going tohappen. Also, when I wasn’t feeling verymuch in pain, I was trying not to focus onthose things.The feeding tube went in about threeweeks into treatment and it improved thesituation almost immediately. For onething I actually got the medication I

needed — the pain killers as well as thefluid and calories. I became morerelaxed as I didn’t have this fightingfeeling all the time.If I had been able to contribute to thedecision properly I think I would havesuggested the tube a week or two beforeand I think it might have saved me some

of the long-term effects. I eventuallystarted eating again about four to fivemonths after the end of the treatment. Mymother had made some very soft food forme at Christmas. It was the first time Ichewed something and I couldn’t do itwithout chewing my tongue or the side ofmy cheek as well — it was pretty pathetic.But it was a real milestone — it wassymbolic.One of the most important things wasgetting back to work. Coming back aftera year, the pupils had all changed sothey didn’t know me and they just treatedme like anybody else. That was reallyimportant, it still is — being an active partof something again instead of being likea glass sculpture in the corner, marked“fragile”. I was very fortunate too becausemy employers really supported me.

There were some difficult timesthough. I had been living withmy partner for many years, andthe whole thing put ourrelationship under strain. I thinkshe felt she could best supportme by nursing me, but if therewas something I did not need atthe time it was being nursed. Ididn’t want to be helped to thetoilet, because when I couldn’tdo anything else, at least Icould go to the toilet on my

own. I didn’t understand how important itwas for her to contribute. I just wanted totake the worry away from her becauseshe was the one who was having theworst time, not me. Within a year of megetting well again, we were drifting awayfrom each other and parted not muchlater — I am not saying it was the reason,

INTERVIEW: SURVIVING CANCER – THE DIFFICULT ROAD TO FEELING NORMAL AGAIN

Lars Hansen, who received radiotherapy for a cancer at the base of his

tongue, talked to Mary Wells about how the treatment affected many

aspects of his life, long after treatment was over.

There is a lot said about patients’

rights to be informed, but health

professionals integrate patients

into a decision-making process

that they can’t possibly cope with

13

F E AT U R E

but it was something our relationshipcouldn’t carry. My daughters wentthrough quite a hard time too, they werepretty afraid.When I turned fifty and my colleagueshad arranged a small party for me, Imade a speech and I said “I have asmall thing I would like from you. Pleasestop treating me like something special,please start teasing me and calling menames like you used to — I am out of myquarantine now, please don’t ask everytime you see me ‘How are you now?’ Ihave had all the attention I need, pleasedon’t do it anymore”. There was a lot oflaughter, and it was quite a big turningpoint for me.From the day you are told you are free ofdisease, that’s when you feel you haveno support. You feel left to your owndevices and this is when you feel quiteisolated. After my treatment I wentaround having lost weight, with sunkeneyes, broken teeth, and you have noidea how easily people stigmatise youfrom the way your face looks. The disgustin their eyes was immediately visible —they must see me as just another streetbum, an alcoholic. I am not a verysensitive person but it really shocked me.The dietitian helped me along the way.Every time you eat it’s an unpleasantphysical experience so you become likean anorexic. You get very good atmaking up excuses for forgetting to eat.Somehow when you forget to eat, youare less hungry and it becomes a viciouscircle — you really have to say to yourself“this won’t do”. That’s where my dietitianwas really important — I thought “I haveto do this because I can’t go back and

tell her I didn’t even try”.So you have a sort of extramarker in your life, somestandards you try to keepup because someone isexpecting it from you —and more than a goodprofessional, she has to bea very good person too sothat you don’t want todisappoint her.Even now, I can’t eattoast, or boiled potatoes.Spicy food and spirits areout of the question — it’s like drinkingpetrol and sets your throat on fire, unableto taste for a long time. I can only eatsmall pieces of bread, a small bit at atime, making sure I have something todrink so it doesn’t get stuck. Eatingsocially is difficult too. It’s OK in a familycontext, but in other situations you haveto tell people you have a problem, andeven then, other people will only eat andtalk if they see you eating and talking.You have to get on with it, if you don’t,you become socially isolated.The combination of eating and teethproblems is the most difficult. The surfaceof my teeth is very corroded and full ofcaries, the teeth break really easily and Ilose teeth every now and then from theback. I have very little saliva and despitespecial treatment with fluoride and specialtoothpaste, it’s going to be a long-termproblem. But it is kept at bay as best aspossible by my dentist.You can’t just haveany dentist; but you need someone withexperience of irradiated teeth. Recently hebecame concerned about the pain andpressure I felt in my jaw, which he thought

may be due toosteoradionecrosis. Heundertook a smalloperation and hissuspicion turned out tobe correct. He removedtwo teeth and a bridge,and cut away part ofthe lower jaw, and nowit seems to be undercontrol. I just hope itdoesn’t recur.Second most importantis the fatigue. I can

work, I have no problems with quality oflife but I can’t keep up with people of thesame age and I quickly run out of steam.I can’t stay up late and I have to gohome and sleep after working for threeto four hours. I have to plan in a differentway — if I am away, I have to find a spaceto rest. Even people who know me wellkeep forgetting that, as I do myself. It’snot so much a tragedy but it is a limitation.I was used to doing quite a lot of sport,but now I can’t run or cycle longdistances, my mouth gets too dry. It’s notso much the physical aspects, it’s thesocial aspects that are important. Painpasses, pain goes away, but not beingable to participate in what you want to,that feels pretty tough.My message to nurses is “Keep doingexactly what you are doing. Please bepatient with us when we can’t rememberwhat you have told us four times already— and keep seeing us as the very differentindividuals we are. Oh, and please forgiveus for not having the strength to comeback later and tell you what wonderfulsupport you’ve been giving!”

“I am out of my

quarantine now,

please don’t ask

every time you

see me ‘How

are you now?’”

14

Across Europe, there are wide differences in how radiotherapy

nurses are trained, as well as in their responsibilities. A quick trip

around Europe, touching down in Scotland, Belgium, France, Italy

and Turkey, brings to light the different roles across Europe.

Birgitte Grube

Same Role,Different Skills

Radiotherapy nursing across Europe

Whether nurses are involved insupporting patients throughtreatment, advising them aboutthe treatment process, managing

side-effects, or administering the treatment itself, theyplay an essential role in improving the experience ofpatients undergoing radiotherapy.One of the key areas is the treatment of side-effects

and supportive care, an area where nurses in thefuture will need to assert themselves and continue todevelop research and their knowledge of evidence-based care and treatment of side-effects in patients.Across Europe, there are substantial differences in

the educational requirements, tasks, functions, skillsand working environments of radiotherapy nurses.One of the most fundamental differences is that, inDenmark, Belgium and Sweden, the radiotherapynurses administer the radiotherapy treatment in closecollaboration with radiographers, physicists andradiologists. In most other European countries, onlyspecially trained Radiation Therapists (RTT) havedirect responsibility for the final administration of aprescribed course of radiation therapy. The RTT is anintegral member of the multidisciplinary team involvedin the total process. The role of the cancer nurse in theteam in these countries is in supportive care.Sc

iencePhotoLibrary

F E AT U R E

15

Marie Paule Gardes is a nurse at the Institute forCancer Research and Treatment, Candiolo, Turin,Italy, where she has been working for seven years.

She is also president of the AIIRO italian nurses'association of radiooncology. She explains that thenurses in Italy are not involved in administeringradiotherapy treatment, which is done byradiographer technicians. The role and responsibilitiesof radiotherapy nurses lie mainly with the preventionand management of side-effects, supportive careand rehabilitation of the patient.Marie Paule sees the nurse as a key link in the chainof care, and an essential part of the multidisciplinaryteam. There are many other clinicians involved withthe patient, for example dietitians, psychologists andpain service staff, etc. The nurse’s role is to advise thepatient and promote their best interests.There is currently no nationally recognisedqualification for radiotherapy nurses in Italy saysMarie Paule but the Association is striving toachieve this.Continuing education is left to everyone to acquirethemselves. This is important, because every yearnurses have the duty to acquire an obligatoryupdating with a formal examination, and if this is notsufficient they find it difficult to continue in their work.“The biggest challenges I’m facing working inradiotherapy, is the ability to see a patient who canfinish his/her treatment without or with only minimalside-effects.” she says.“I feel very satisfied working in radiotherapy.When Istarted in this job there was no nursing assistanceand I had to build it up in all its sectors (includingbrachytherapy). It has been very difficult because,as I said, our training does not give us anyknowledge of radiotherapy and its side-effects. Ibegan to study radiotherapy, its treatments and itsside-effects so that I understood more.”Marie Pauletook the initiative to survey the needs of patients foreach type of treatment and she drew up guidelinesto prevent problems.“The best results we had were inoral and breast cancer. Before this we had manypatients with oral cancer with SNG or PEG formucositis (light or severe). Now there’s only a veryfew of them with problems.”

BENVENUTO IN ITALIA

Françoise says “Providing information to patients prior to anytreatment is very important, in reducing anxiety and promoting self-confidence. For a number of years, nurses have provided ‘counseling’to patients at the time of diagnosis, and this is now being extended toother important time points during the cancer journey, including thestart of radiotherapy.” Many cancer centres in France, she says, haveset up this type of counseling in their radiation oncology department.“The service in Strasbourg has been running since November

2009. Three radiotherapy assistants were trained to providecounseling to patients with breast and head-and-neck cancers. “ByJune 2010, the service will also be available to patients withgynaecological cancers” says Françoise. “The counseling takes placethe same day as the dosimetry CT scan, after the medicalappointment. The radiotherapy assistants use a slide presentationwith simple comprehensible text illustrated by photographs toexplain what will happen during the different stages of theradiotherapy”. The points of information covered include:

Katleen Luyten is Head Nurse in Radiotherapy at anOncology Ward in Leuven, Belgium. Katleen hasworked as a licensed practical nurse in radiotherapysince 1998 and is now also a Head Nurse. She explainsthat in Belgium, radiotherapy can be administered bynurses and by radiation technologists (RTT), but theyhave different roles.

Both are involved in planning patients on the simulator,under the supervision of a radiotherapist. Some haveresponsibilities in preparing immobilisation devices,customised shielding, electron cutouts and bolus material.RTTs carry out daily control checks on the simulator andassist with 2D, 3D, 4D, IMRT, total body irradiation (TBI) andelectron plans, ensuring that treatment prescription sheetsare correct and radiation doses are verified. They treatpatients each day, performing all quality assurancechecks, and ensuring treatment plans are followedaccurately. RTTs are also involved with preparing patientsfor brachytherapy, assisting with the brachytherapyprocedure and simulating the patient.In addition to these roles, RTTs perform a very importantfunction in relation to patient education, providing

information about radiotherapy and its side-effects,monitoring the condition of patients’ skin, and referring onto other clinicians, as necessary, including social workers,dietitians, psychologists, sexologists, relaxation therapistsand medical staff.They are also often involved in radiation protectioncommittees, and in research, depending on theirexperience and qualifications. To work as a nurse inradiotherapy in Belgium, says Katleen, you need adiploma in nursing or medical imaging technology.Additionally, nurses must undertake a diploma inradioprotection. In some areas, RTTs are directly involvedwith the teaching of new RTTs. All newly qualified RTTs aregiven a mentor for around two years.Katleen sees the biggest challenges working inradiotherapy as:� Patient satisfaction� Patient safety� Radioprotection� Keeping up to date in such a rapidly evolving field.The greatest reward, she says, is the gratitude of thepatients, and participating in the total picture of aRT treatment.

BIENVENUE EN BELGIQUE – WELKOM BELGIË

BIENVENUE EN FRANCE

16

Françoise Charnay-Sonnek is from the Department ofCancer Surgery, Centre Paul Strauss, Strasbourg, France.She is also an EONS Board member.

TheSwedish

SocietyforNursesinCancerCare

17

F E AT U R E

DOSIMETRY CT SCAN:Point tattoos are made by the radiotherapy assistant during thedosimetry scan in order to ensure the same position ismaintained every day of the treatment. It is important for thepatient to know that the tattoos will fade over time and can beremoved by a skin specialist after the treatment, if desired.

DELINEATION:The radiation oncologist marks out the area to be irradiated andthe healthy organs that need to be shielded.

DOSIMETRY:The physicist determines the dose prescribed by the radiationoncologist which will be fractionated over several sessions. Thedosimetry is then once again verified and validated by thephysicist and the physician.

TREATMENT:The position the patient will have during the dosimetry scanwill be the same during the treatment and it is essential that

they remain still. The first session lasts about 30 minutes andthe following ones about 15 minutes. The machine can be loud,so music is used to make this time as comfortable as possible.Control images are made every day before delivering treatmentto verify the correct position of the patient. It is important toinform the patient that the treatment is painless.During the second treatment session, a dosimetry in vivo is

performed in order to be sure that the delivered dose is the right one.

FOLLOW UP:The radiotherapy assistant informs the patient about the supportavailable from dietitians, psychologists, social workers, painspecialists and others. Advice is also given about side-effects, inparticular caring for their irradiated skin and managing fatigue.Elysabeth Rieger, Headnurse of the Radiotherapy department,

says that patients’ feedback about the pre-treatment counselingservice has been encouraging. “Patients say they are satisfiedwith the information received and that they feel less anxious asa result of being able to understand more about their treatment.”

She has undertaken a Masters Degreelevel education and is a qualifiedindependent nurse prescriber. Janicecurrently manages a small team ofnurses who provide weekly on-treatmentreview for patients undergoingradiotherapy, to monitor symptoms andimprove quality of life.“It has beenrecommended since at least 19951 thatpatients receiving radiotherapy shouldbe routinely reviewed and their toxicitiesassessed,” says Janice. A recent report,Towards Safer Radiotherapy,2

recommends that ‘each centre shouldhave an agreed policy for systematicreview of patients on treatment’. Untilrecently, medical staff were responsiblefor reviewing patients on treatment, butspecially trained nurses andradiographers are increasingly takingon this role. She adds, however,“thatwhile the ability of nurses to successfullymanage on-treatment review has beendemonstrated in studies,3 the

experience in Dundee has shown that itcan be difficult for radiotherapy nurseswho are single postholders to respondto patients’ needs promptly andthoroughly.”“Within our Cancer Centre, the servicewas difficult to maintain with only onenurse available to undertake reviews ofpatients receiving radiotherapy. Inaddition, we recognised that two groupsof patients with complex needs (thosewith head-and-neck cancer and braintumours) had no Clinical NurseSpecialist (CNS) support.” Theseproblems were addressed by setting upa nursing team to provide CNS input tothe head-and-neck and neuro-oncology patient pathways and toundertake the non-medicalradiotherapy reviews. Called theRadiotherapy Support Team, the nursingteam consists of four qualified oncologynurses, who provide cross cover for eachother so as to ensure that patients are

supported throughout their pathway.“Asa result,” says Janice,“the nurses gainexperience in a variety of roles andhave time to maintain their professionaldevelopment.”Although Masters Degree levelmodules are available for UK nursesundertaking radiotherapy on-treatmentreview, not all radiotherapy nurses canaccess these modules and Janice’steam recognised that nurses working inradiotherapy needed a framework forpractice to support their roles. In a jointproject with NHS Education Scotlandand a Cancer Nurse Consultant fromthe North of Scotland, a capabilityframework was developed. The aim ofthis framework, entitled ‘RadiotherapyOn Treatment Review’ is to providerobust, measurable capabilities toidentify the knowledge and skillsrequired to underpin safe, competentand consistent practice in this fieldof care.4

WELCOME TO SCOTLAND

Janice Fletcher, Macmillan Clinical Nurse Specialist, Radiotherapy/Neuro-Oncology, atNinewells Hospital in Dundee, Scotland has been a radiotherapy nurse for 10 years.

18

“Little has been published regardingthe specific role of nurses in radiationoncology.” Fatima explains.“Traditionally, nursing in radiationoncology has been overshadowed bythe technical aspects of the therapyand highly trained professionals whoremain part of the treatment today,including physicians, physicists,dosimetrists, and therapists.” Her studyidentified five broad nursingresponsibilities: patient care (theprimary responsibility), education, administration,research, and consultation.5-7

The target population for this study consisted ofnurses currently practising in the field of radiationoncology (both outpatient and inpatient). Based on theliterature, a semi-structured questionnaire wasdeveloped to elicit information related to the role of thenurse. The instrument consisted of a six-page, self-administered questionnaire with both fixed-choice andopen-ended questions regarding respondents’demographic and professional characteristics, practicesettings, employment characteristics and nursing tasksincluding patient care (36 items), patient and familyeducation (32 items), administrative (17 items) andresearch responsibilities (4 items).In February 2005, a questionnaire, cover letter, and

return envelope were mailed to members. Forty-fourcentres were identified (17 private and 27 governmentinstitutions) and asked about whether they employednurses. A total of 124 responses were eligible forevaluation from 17 centres that are all publicinstitutions. Of those, 24 (19%) were members of theOncology Nursing Association of Turkey (TONA).Mean age was 36 years (21‒55); 56% had an

associate degree in nursing, 78% were staff nurses,68% worked at an inpatient clinic, and 61% hadspent more than five years in radiation oncology. Themajority of respondents (60%) worked 40 hours per

week, whereas 27% worked 45 hours. The majoritydid not receive specific education. Although 68% ofrespondents (n=84) stated that they had procedures/guidelines, most did not specify; 27% have guidelineson skin care. Most of them were involved in patientsand family teaching (87%), but only 21% of them hadspecific provision for education and 30% of them usedwritten educational materials (Table 1).The most frequently cited patient care activities

were administering medications and supportingpatients and families during procedures. Less citedactivities were obtaining medical history andperforming physical assessment.Patient teaching activities included mostly explaining

radiation procedures and nutrition, and least frequentlysexual counseling. Only 10% of respondents wereinvolved in nursing research related to this area.Radiation oncology nursing is a sub-specialty in

evolution. This survey is the first detailed description ofthe nurses’ role in radiation oncology in Turkey. Furtherresearch should be focused on the importance of the roleof educators in radiation oncology and should providesupport for an exploration of how patient education andsupport influence patient outcomes in radiation oncology.

This study was presented at the EONS-6 Congress, Geneva.

Details of the references cited in this article can be accessed at

www.cancernurse.eu/communication/eons_newsletter.html

Fatma Gundogdu is president ofthe Turkish Oncology NursingAssociation in Ankara, Turkey.She carried out a study todetermine demographic andprofessional characteristics,working conditions, roles andresponsibilities of nurses inradiation oncology clinics.

TÜRKIYE’YE HOS GELDINIZ

Receiving specific education and sources (n= 173)*

In-service educationConferences (oncology nursing; radiation oncology; breast cancer)Courses (chemotherapy; radiotherapy; gynecologic oncology; sexuality)Not received

Availability of guidelines/procedures for nursing practice (n=84)*

Skin careMouth careAdministration of drug and blood productsOther (chemotherapy, CVC care, patient and family education)

Involvement in patient and family teaching

Provisions for education

Availability of written educational materials

n (%)

60 (34.7)47 (27.2)17 (9.8)49 (28.3)

n (%)

23 (27.4)19 (22.6)13 (15.5)18 (21.5)

108 (87.0)

26 (21.0)

37 (30.0)

Table 1. Access to specific education and guidelines,and involvement in patient and family teaching

*Some items may

have multiple answers

The European Journal of Oncology Nursing is ranked 30th out of 62 journals in the ‘Nursing’ subject category with a 2008 Impact Factor of 0.976! © Thomson Reuters Journal Citation Reports, Science Edition (2009)

We are delighted with this result, and hope that you share our confi dence that this new Impact Factor will add to EJON’s excellent reputation.

The European Journal of Oncology Nursing is an international journal which publishes research of direct relevance to patient care, nurse education,management and policy development.

With 95,257 articles downloaded from EJON in 2009, we can guarantee that our authors’ work will be widely read by the international oncology nursing community. Why not join our community of authors by submitting your next manuscript to EJON?

Find the guide for authors and submit online athttp://ees.elsevier.com/yejon

EJON is proud to be the offi cial journal of the European Oncology Nursing Society.

For more information on the journal and links to online submission visit:

www.ejoncologynursing.com

is ranked 30th out of 62 journals in the ‘Nursing’ subject category with a

that you share our confi dence that this new

international journal which publishes research of direct

Editor-in-Chief: Professor A. Molassiotis

OUR FIRST IMPACT FACTOR!

20

Radiotherapy technologies and techniques are

developing at a brisk pace. These Qs and As present

an overview of the main innovations and their

implications for the management and care of patients.

Alastair Munro, Harry Bartelink, Lena Sharp and Mary Wells

Developmentsin RadiotherapyQuestions and Answers

How do new technologies in ra-diotherapy contribute to im-

proving cure and control?New technologies aim to deliver ahigher radiation dose to the tumour,whilst at the same time decreasing thedose to critical organs and tissues,thereby improving the therapeuticratio. This can be defined as the ratiobetween the dose required to pro-

duce unacceptable toxicity and that re-quired for therapeutic effect.1

What are some of the problems withintroducing new technologies in radio-therapy?Introducing new technologies into radio-therapy is, in many senses, simply tooeasy. There are plenty of manufacturerstrying to market new equipment, but thisdoes not mean that it will be used effec-tively. Specialist staff need time to com-mission and calibrate the equipment andclinical staff need to become familiar withthe new equipment, whilst maintainingthe delivery of the current service.Some of the new technologies (IMRT,

IGRT, particle therapy, IORT) have not yetbeen subjected to rigorous evaluation.They are marketed on the basis of whatthey promise clinically, and there is someemerging evidence that the theoretical ad-vantages have been translated into clinicalimprovements. The task of fully evaluat-ing them will, however, take at least thenext decade.

What is the difference betweenIMRT and IGRT?IMRT (intensity modulated radiotherapy)allows the specific area of the cancer to betargeted, using 3- or 4-dimensional confor-mal radiotherapy. According to what can

I N T E R V I E W

21

be seen on a CT scan, high doses of radia-tion can be delivered to a very precise area,without causing damage to critical organslike the spinal cord or the salivary glands,etc. This means that patients experiencefewer long-term side-effects such as drymouth resulting from salivary gland dam-age. IMRT therefore allows the patient tobe given a higher and more effective dosewhilst sparing normal tissues.One of the problems is the movement

of the organs during radiotherapy. An-other new technique, called image guidedradiotherapy (IGRT), enables a CT scan tobe taken while the patient is beingtreated, allowing the radiotherapy treat-ment to be altered according to the pa-tient’s position. It is very useful inpatients with lung cancer (where breath-ing patterns can slightly alter the positionof the cancer during treatment), and thosewith prostate cancer (where the positionof the prostate can change slightly be-tween treatments as a result of bladderfilling or air within the rectum).

What is IORT?IORT stands for intraoperative radiother-apy. The idea of delivering radiotherapy toa tumour, or tumour bed, under direct vi-sion at the time of open surgery has alwaysbeen an attractive concept. The treatmentcan be precisely directed to the target with-out the need for elaborate techniques in-volving imaging, delineation of targetvolume, simulation and verification. Whatyou see is exactly what you get. Vulnera-ble normal tissues can be physically ex-cluded from the area that is treated. Theadvantage from the patient’s point of viewis convenience. A single treatment, givenduring an operation that they would behaving in any event, can replace a pro-

Some of the new technologies have not yet been subjected

to rigorous evaluation... The task of fully evaluating them will,

however, take at least the next decade.

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tracted course of treatment as anoutpatient.Until recently, the problem hasbeen with the practicalities. Ei-ther an anaesthetised patient withan open wound has to be movedto a radiotherapy department fortreatment on a linear accelerator,or a specially shielded operatingtheatre has to be built with a lin-ear accelerator within it. Howeverthere are many new approachesthat now make intraoperative ra-diotherapy feasible. These includehigh-dose-rate interstitial after-loading, portable linear accelera-tors with electron beam treatmentfacilities and limited shielding re-quirement — the PRS device (pho-ton radiosurgery), a fully portabledevice about the size of an electricdrill that produces 50 kV X-rays.Clinical trials of IORT are un-

derway for a variety of tumours.The most widespread use at pres-ent is as an alternative to post-operative breast radiotherapy inwomen treated with lumpectomyfor early breast cancer.

What are the advantagesof proton therapy?Proton therapy is particularly use-ful for tumours at specific sites,for example tumours of the base ofthe skull, and its advantages arepurely physical. The particles stopabruptly at a certain depth withinthe body, which can be directedby an appropriate choice of beamenergy. Biologically, protons have much thesame effect, for any given dose, as X-rays.Protons are particularly suitable for treatingtumours which lie at depth but immedi-ately above a sensitive normal tissue, suchas the brainstem or spinal cord.The absolute number of patients who

might benefit from proton therapy is rela-tively small. This is because of the rarity ofthe tumours for which protons offer spe-cific advantage. In Europe, about one pro-ton therapy facility is probably required per5 million population. This implies that pro-

ton therapy should be located at specialisedreferral centres, and is not necessary forevery radiotherapy department.

What other trends and techniquesare important?Over the years, there have been a numberof developments in fractionation (fre-quency of dose administration). Probablyone of the most important is CHART (con-tinuous hyperfractionated accelerated ra-diotherapy), whereby the overall radiationdose is delivered over a shorter number of

days because patients are treatedthree times a day, seven days aweek. The rationale for hyper-fractionation (radiotherapy givenseveral times a day) is thatsmaller doses per fraction can beadministered, which, in theory,reduces the late effects of treat-ment. The rationale for accelera-tion (radiotherapy administeredover a shorter period of timeoverall) is that tumour cellsare unable to proliferate dur-ing the radiotherapy course.Randomised trials of CHARThave shown statisticallysignificant improvementsin the survival of patientswith lung cancer, butCHART requires consid-erable resources to im-plement and is notwidely available.Combining radiother-

apy with chemotherapy and/ortargeted therapies is another im-portant development, which hasbeen shown to improve localcontrol and survival in a numberof cancers.

When radiotherapy is combinedwith chemotherapy or targetedtherapies, can you give a lowerdose of radiotherapy?No. The effect of radiotherapy ismore certain than the effect of thechemotherapy or targeted therapy.So adding drug treatments to ra-diotherapy still means that the pa-

tient receives the same dose.

Are the side-effects of radiotherapy thesame as they have always been?Yes and no. Because we are using muchmore combined modality therapy, patientsoften experience a greater range of side-ef-fects, different patterns of toxicity and moresevere acute side-effects overall. Also, be-cause many of the treatment combinationsare new, we have not had enough time tounderstand the long-term effects of thesetreatments.

22

Figure 1. Main side-effectsof radiotherapy by site

BRAINIncreased intracranial pressure —headaches, vomiting, dizziness, hairloss, fatigue, sleepiness, cognitivechanges

HEAD & NECKOral mucositis, xerostomia (drymouth), dental decay leadingto osteoradionecrosis (lateeffect), dysphagia & eatingproblems, pain, speechdifficulties

CHEST/BREASTOesophagitis, radiationpneumonitis (lateeffect), cardiacdamage (late effect),lymphoedema(late effect), brachialplexus damage (late effect)

ABDOMENNausea and vomiting

PELVISCystitis and other urinary problems,proctitis, abdominal discomfort,diarrhoea, radiation enteritis (lateeffect), sexual problems, infertility(late effect)

All AREASFatigue

Skin reactions

23

to die anyway, and if smoking is one of thefew enjoyments left to them, why shouldwe deny them their few last pleasures?However treatment nowadays ismore likelyto be successful and patients are livinglonger with, and beyond, cancer. We haveevidence that continued smokingmakes theside-effects of treatment worse and, at thesame time, makes treatment less likely to besuccessful. Continuing to smoke will there-fore have a double adverse effect on thetherapeutic ratio.

The diagnosis of cancer provides animportant opportunity for interven-tion in terms of public health. If wecan encourage and support patientsso that they are able to stop smok-ing, we could extend this to theirfamilies and friends and they, too,might stop smoking. This is theconcept of using the diagnosis ofcancer as a “teachable moment”.Research studies have shown

that nurse-led smoking cessationinterventions can be effective in a

range of patient groups.3 Inter-ventions are based on the ‘5 A’sapproach’ — Ask, Advise, As-

sess, Assist, Arrange follow-up — and onmotivational interviewing. Even simplyasking patients if they smoke and encour-aging them to think about giving up is animportant start.

How can nurses improve their knowl-edge of radiotherapy side-effects?EONS has recently launched an on-linemodule for nurses (http://www.eonslearn-ing.com ). This four-week course will in-clude video presentations, lecture notes,weblinks, activities and discussion boards,facilitated by four EONS members whohave expertise in radiotherapy care — SaraFaithfull, Birgitte Grube, Lena Sharp andMary Wells. The course will cover whypeople develop side-effects to radiotherapy,patient experiences, management of side-effects and changing practice. The on-linemodule is being piloted for a small numberof nurses working in radiotherapy acrossEurope, but EONS hopes to roll it out sothat it becomes more widely available. Asample page can be seen in Figure 2.

This article has been compiled using

presentations from the EONS-7 Congress

and discussions with the authors.

Details of the references cited in this article can

be accessed at www.cancernurse.eu/

communication/eons_newsletter.html

I N T E R V I E W

The online module

developed by EONS and

facilitated by experts in

radiotherapy care,

includes videos, lecture

notes, weblink and

discussion boards.

It covers patients

experiences, the

management of side-

effects and changing

practice. The module is

currently piloted across

Europe and will soon be

rolled out. In order to

access, an account can

be created by logging to

www.eonslearning.com

Clinac (R) iX linear accelerator

provides advanced

radiotherapy treatments.

What can nurses do to improveside-effects?It is very important that nurses improvetheir knowledge of radiotherapy side-ef-fects. Seeing a patient with severe toxicitysometimes makes nurses think treatmentought to be stopped. However, in mostcases, this is inadvisable as it will reducethe effectiveness of the treatment. Sup-portive care and symptom management,which enables the patient to continuehis/her treatment, should be the maingoal. The problem is that not enough evi-dence is available to guide the manage-ment of radiotherapy side-effects.The side-effects of radiotherapy tend to

affect the area being treated (Figure 1).Supportive care measures including nurs-ing and pharmacological interventions, in-formation/education and psychologicalcare are addressed in the book by Faithfulland Wells.2

Should we be encouraging patientsundergoing treatment for cancerto stop smoking?We used to take a negative approach to thisquestion, thinking that if people are goingIm

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24

In 2006 the Department of Radia-tion Oncology at Aarhus Hospital,

Denmark established a Learning Centrefor Radiotherapy.1 The Centre was readyfor use in 2007, but in order to overcomethe difficulties in training enough staff,radiation therapists/nurses in particular(see box on opposite page), it was neces-sary to develop new training methods.Taking advantage of the Danish Ministryof Health’s plans to expand in the radia-tion therapy field, the department se-cured funds from the Ministry of Healthto sign up to a two-year cooperationagreement with the Department of Com-puter Science at the University of Hull,England, UK.In this project, the department was

the first in the world using a 3D com-puter-animated simulator (3D acc) fortraining in radiotherapy.2,3 The 3D accis used for both theoretical and clinicaltraining. Because it is so new, there wasno educational knowledge or experi-ence to draw on when the projectbegan, and now three years later, evalu-ation is still needed.

THE LEARNING CENTREPlanning and delivering radia-tion therapy is a complexprocess involving physicians,physicists, radiographers andradiation therapists / nurses(RTTs). The starting point isthat specialists must be able tounderstand spatial relationships in the pa-tient’s anatomy. In the same way that pilotslearn flying using a simulator, it was thoughtthat itmust be possible to train planning andtreatment of radiation therapy in a simula-tor, too. In fact the data indicates that radia-tion nurses can get as much out of learningthrough simulation, as pilots can.The aims were to:� establish a Learning Centre with virtuallearning tools, to be used by all staffworking with radiation therapy;

� train an additional group of nurses to beradiation therapists;

� Explore the possibilities and limitations ofvirtual training in the 3D accelerator withthe results to be fed back to the Universityof Hull for developing the technology.

The Learning Centre consisted of a 3D acc,

an IT-laboratory with full scale computermatching the clinical facilities, a classroomand a study roomwith library.To achieve the best learning environment

it was agreed that:� educational material had to be clinical,actual and with anonymous patient data;

� exercises, training and learning could takeplace at the participants' pace (Figure 1);

� mistakes would be allowed but withoutrisk to patients;

� it would be possible to repeat practice;� there would be time for questions andreflection without ethical and timeconsiderations for patients;

� IT-programs in the Learning Centre hadto correspond exactly to those used inthe clinic, so they would be up to dateand relevant.

State-of-the-art new training methods are being used to help practitioners involved in the

delivery of radiotherapy, including nurses, strengthen their knowledge of treatment

planning using computer-controlled technology and virtual reality learning environment. A

3D computer-animated simulator was used in a groundbreaking training programme in a

joint initiative by Aarhus University Hospital and Hull University, England.

Annette Boejen

3D Accelerator in RadiationTherapy TrainingFrom apprenticeship to virtual reality training

Figure 1. Skill training with

the pendant. Students are

discussing the positioning

of the patient.

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F E AT U R E

25

TRAININGThe course for the project group consisted of12 weeks of theory, 13 weeks with clinicalvirtual reality learning and 20 weeks withclinical learning/training.In the 3D acc it was possible to train with

"transparent patients", flip and rotate themin all directions and see the beamdirections.The consequences of the treatment planningfor both tumour and the organs at risk couldbe visualised and discussed. (Figure 2)The IT-laboratory was established in col-

laboration with the accelerator firm Varian.Participants can be trained in IT-tools and getexerciseswith treatment planning and ImageGuided Radiation Therapy.The course covers a scientific approach on

how radiation therapy is carried out withcomputer-controlled technology combinedwith communication, care and observationof patients receiving radiotherapy. In thisway, there can be specific identification ofand interventionwith radiation-related side-effects. To strengthen participants' knowl-edge and understanding of these areas thestudents work with real anonymous patientcases. The cases consist of copies of the pa-tients’ medical chart, a treatment plan andtreatment cards. Treatment data are trans-mitted electronically to the IT lab and 3D ac-celerator. Participants work with pathology,prognosis, protocol treatment, side-effectsand management of these treatments. Exbooking of patients’ treatment time andplanning can be taught in the IT laboratory.Subsequently, the consequences of treat-ment planning can be examined by the 3Daccelerator. The studentswork in groups andteach each other through review and clini-cal example.Curative treatment often requires daily

treatments for 30-40 days, and patients needcare and information. The interpersonal rela-tionships and observation of patients for ex-ample, pains, weight loss and communicationcannot bewell taught in a virtual reality learn-ing environment. This part of the work areamust be learned in the clinical environment.A formal evaluationwith the project group

elicited very positive feedback:� "In the 3D accelerator, I have especiallylearned how fields are formed"

� "It’s possible to practise again and again"

� “Seeing doses in the organ at riskand the effect of wrong positioningin 3D is very instructive”

� “Amazing to find out what ishappening inside the patient”

� "I was able to think in 3D, I thought,but now I am much better!"

The immediate feedback from the tu-tors in the clinic was that the partici-pants in the project groupwere able tothink about dose planning in a three-dimensional perspective. All partici-pants passed the examinations and theexaminers assessed the participants as"at least at the same level as before." Furtherinvestigation and documentation are how-ever necessary.

WHAT NEXT?The project succeeded in doubling the train-ing capacity. The virtual reality learning en-vironment can now be considered as a newsupplementary educational component po-sitioned between theory and clinical train-

ing. Neither can be fully interchangeable.Systematised learning in the virtual realitylearning environment must be comple-mented by learning in the clinic with tutors.The evaluation and documentation of theparticipants' skills and competency levelachieved in the virtual reality learning en-vironmentmust be tested in the future. Thefirst systematic approach has started.The Learning Centre is nowused by all pro-

fessional groups to introduce them to newclinical features with the use of IT technology.

PERSPECTIVESThe collaborationwith theUniversity of Hullon the further development of 3D acceleratoris continuing. The system has subsequentlybeen installed in other clinics, both nation-ally and internationally, especially in Eng-land.4 The interesting point to debate is “Doestrainingwith a 3D virtual reality environmentgive greater competence?” Thisworkmust befurther developed and reviewed in the future.Working with the technology as a part of pa-tient education will also be included.

Details of the references cited in this article can

be accessed at www.cancernurse.eu/

communication/eons_newsletter.html

“Does training with a 3D virtual environment

give greater competence?”

Education for the radiation therapistmust qualify the student to performradiation therapy and care forpatients. The course takes placeover one year (equivalent to 60ECTS points) and is based on a 3½year health professional BachelorDegree. After finishing the trainingcourse the students are accreditedby the Danish Ministry of Health andare allowed to treat patients usingthe accelerators. They areconsidered contact nurses for thepatients. The course includes 12weeks of theoretical learning and33 weeks of clinical learning.

Radiation Therapist Training

Figure 2. Looking at beam direction and

organ at risk.

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Cancer patients have been treatedwith internal irradiation or brachy-

therapy since early in the past century. Ra-dium treatment, initiated by Marie Curie,paved theway for the afterloading techniquein the 1980s that used high / low dosebrachytherapy for the treatment of gynaeco-logical cancers. During the 1990s, the im-plantation technique and pulse-dose-rate(PDR)-brachytherapy allowed radical radia-tion treatment of a series of other cancers,including anal and oesophageal cancers.Brachytherapy is often administered in ad-dition to external radiation/chemotherapy,and applies a high level of radiation directlyto the tumour site while protecting the sur-rounding tissue. It’s aim is to optimise irra-diation and to minimise side-effects.

But while diagnosis, response and survivalrates, as well as the side-effects of radiationtherapy, are well described in the literaturelittle attention has been paid to the reac-tions and behaviors of cancer patients dur-ing stressful irradiation and the nurse’srole. Cancer nurses lack guidelines on bestclinical nursing practice in relation tobrachytherapy.Nursing care of cancer patients undergo-

ing brachytherapy is a balancing act betweentechnical, intensive and psychological sup-port tasks. Throughout what is only onecomponent of a more complex treatmentprocess, the nurse should be able to assess

where the task lies, and whether it is pro-viding comfort and security, advice or guid-ance. Before offering implantation, a doctorand a nurse evaluate whether the patient isphysically and psychologically able to copewith the treatment.A research project entitled “Brachyther-

apy’s influence on cancer patients” aimed atinvestigating the nurse’s rolewas carried outin the ward and in the out-patient clinic ofthe FinsenCenter at CopenhagenUniversityHospital, Rigshospitalet in Denmark.1

Christina Andersen

Brachytherapy:Exploring the Role of Nurses

Most European cancer centres today

routinely offer brachytherapy (a

radioactive implant) to supplement

external radiation and chemotherapy.

In an effort to improve the help and

support provided by nurses, a

Danish group recently conducted

a study looking at how patients

experienced this treatment. Univ

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F E AT U R E

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THE STUDYThe study aimed at understanding the PDR-brachytherapyprocess and thepatient’s experi-ence so as to improve nursing care and preventpsychosocial problems for patients when theyreceive this type of irradiation. The study, de-signed to be prospective, descriptive and ex-plorative, involved 40 cancer patients (19 withanal cancer and21with gynecological cancers),with a median age of 56 years, and combinedquestionnaires, interviews and observation.The patient’s experiencewith brachyther-

apy is described in the box below:

FINDINGSThe questionnairesPatients were surveyed on admission, duringtreatment and at discharge, and at three- andsix-months following treatment. The nursesinvolved with their care completed two ques-tionnaires, evaluating their ownwork, one fo-cussing on side-effects and the other oninformation.Ahighproportion, 85%of thepa-tients, proved knowledgeable about PDR-brachytherapy and its side-effects. The resultsshow that 74% were immobilised while 60%were confined to their bedswhile under treat-ment. No significant correlation was shownbetween frequency and degree of side-effects,diagnosis and length of stay.

The interviewTen patients participated in the interview

process six to eightmonths following internalirradiation. Semi-structured interviews high-lighted the patients’ views on their nursingcare and provided suggestions for improve-ments. Agreement between treatment expec-tations and actual experiences varied frompatient to patient, and common concernsemerged regarding having needles implantedinternally, and the long hours of treatment re-quiring bed confinement. One man with analcancer said “I thought that it [brachytherapy]would be horrifying when it wasn’t at all”. Awoman with cervical cancer stated: “I experi-enced a lot of pain … and was really afraid;really, really afraid”.

ObservationThe study combined pure observation withparticipant observation, and the main focusareas were time and communication. A totalof 172 hours were video-recorded involvingsix patients and 21 nurses, including completeinternal irradiation of five patients, of which42 hourswere studied for time and communi-

cation.The latter comprisedsevencategories, in-cludingsomatic, technical, social, existential andpsychological communication as well as smalltalk and silent presence. The nurses remainedwith the patients 27%of the total time availableforperforming tasksbetween treatment intervals.Themajorityof thenurses’ communicationwiththe patients concerned physical care (e.g. treat-ment, side-effects, nursing tasks). Despite thestress, the patients did not express any expecta-tions of receiving psychological support. Thevideo-recordings showed individual patterns ofbehaviour and coping.2

THE WAY FORWARDThe potential of brachytherapy is interna-tionally recognised and, although this studywas a major step, further evidence-basedstudies are needed.Communication between a nurse and a pa-

tient centers on psychological support, in-volving relaying information, communicatingwith patients, observing symptoms and side-effects, and leading rehabilitation courses.It is further suggested that:� a brachytherapy team follows the patientthroughout the treatment to enhance thepatient’s sense of security;

� international / national brachytherapycourses are given to develop qualitytreatment and care of the patient;

� an international brachytherapy networkbe set up to identify where and howbrachytherapy is administered in Euro-pean countries and influence quality andcompetence development of nursing inbrachytherapy. This network can create aforum for evaluation including expertsfrom nursing practice, management,education and research in brachytherapy.

Details of the references cited in this article can

be accessed at www.cancernurse.eu/

communication/eons_newsletter.html

Nursing care of cancer patients undergoing

brachytherapy is a balancing act between

technical, intensive and psychological support tasks

During summer 2009, Sara was diagnosed with cervical cancer. She was a socialworker and single mother to her 14-year old son. Two weeks followingtermination of external irradiation, Sara was admitted for implantation. Inaddition to fatigue, she experienced diarrhea, and soreness in the genital area.She felt nervous during the many hours of PDR-brachytherapy, when theobservation and nursing care can only be performed during pauses in thetreatment and she is partially isolated and immobilised, positioned on her side.Sixteen needles were implanted internally and she was to undergo 42 hours oftreatment, during which there were 34-minute pauses after each hour. Whilebeing treated, Sara watched television, spoke on the phone and had severalvisits from her son and sister. The brachytherapy went well but Sara experiencedphysical discomfort. She was thirsty, often requested ice-water and requiredmassage to her legs and lumbar region due to leg swelling. On removing theneedles, Sara experienced profuse bleeding at the injection sites and to avoidfurther bleeding, she was bedridden for another 24 hours.

One patient’s experience

28

Probably one of the most commontopics discussed by nurses working

in radiotherapy is how best to care forthe skin during radiotherapy treatment.Numerous surveys have shown that practicevaries considerably from hospital to hospi-tal, and that radiation skin care is not alwaysevidence-based.1 Given that up to 90% ofpatients undergoing radical radiotherapywill experience some sort of skin reaction,and increasing numberswill be treatedwithconcomitant chemotherapy and/or targetedtherapies, which exacerbate skin toxicity, itis vital that oncology nurses are well in-formed about the optimal management ofthe skin during and after radiotherapy.Although modern mega-voltage radiother-

apymachines have a ‘skin-sparing’ effect, theskin is still at risk of radiation damage. Newtechniques such as intensity modulated ra-diotherapy (IMRT) appear to be associatedwith less severe skin reactions, but such tech-niques are not employed universally acrossEurope. The most severe skin reactions arelikely to occur in patients having radiother-apy to the breast, head-and-neck or perinealarea, where skin folds rub together. Manyother factors can affect the severity of skin re-actions as summarised in Table 1.

RADIATION SKIN REACTIONSThe first stage of a radiation skin reaction iserythema, affecting 80-90% of patients andusually visible around 7-10 days after thestart of radiotherapy. Epidermal basal cellloss occurs after a dose of 20-25Gy, and the

inflammatory response, capillary dilatationand oedema cause the skin to appear red,inflamed and sometimes shiny in appear-ance. Patients complain of their skin feelinghot, itchy and uncomfortable. This erythe-matous stage often precedes drying andflaking of the skin, known as dry desqua-mation. The cumulative effect of furtherdoses of radiotherapy can then cause theskin to break down, leading to moistdesquamation. The severity of the skin re-action depends on the ability of the epider-mal cells to repair and repopulate. Skinreactions tend to worsen as treatment goeson, often reaching a peak during the firstweek after finishing radiotherapy. Patientsneed to be informed that this will happen,and health care professionals working inthe community must be provided with up-to-date information about the condition ofpatients’ skin and themost appropriate planof care once treatment is over.Unfortunately, moist desquamation reac-

tions provide an ideal route for infection andthey can also be very painful. However, thereis a great deal that oncology nurses can do toprevent further deterioration of the skin. Pa-tient education at all stages of the radiother-apy process is essential, as patients oftenbecome confused aboutwhat to do andwhatnot to do with their skin, and may be givenconflicting advice from different health pro-fessionals. To make matters worse, numer-ous ‘natural’ remedies are now available viathe internet or in shops, and there is little ev-idence to support their usefulness.Several guidelines have been produced

recently to guide best practice, and manyare available electronically (Care of Radia-tion Skin Reactions booklet, http://www.bc-cancer.bc.ca/HPI/Nursing/References/SupportiveCare/Radiation/default.htm; Skin Careof Patients Receiving Radiotherapy,http://www.nhshealthquality.org/nhsqis/files/20373_NHSQISBestPractice.pdf).There is now sufficient research evidence

Despite new techniques, skin is always at risk of radiation damage and patient

education at all stages is essential. Health care professionals must be provided

with up-to-date information and European radiation nurses are best placed to

help with risk assessment and patient education.

Caring For the Skin During Radiotherapy

Mary Wells

� Treatment factors, e.g. dose/fractionation, volume, technique, bolus,chemotherapy, targeted therapies, radiosensitisers.

� Physical factors, e.g. nutritional status, smoking, treatment site, skintype and integrity, haemoglobin.

� Genetic factors, e.g. reduced cellular DNA repair capability (ataxiatelangiectasia, hereditary nevoid basal cell syndrome).

� Co-morbidity, e.g. connective tissue diseases, infectious diseases.

Table 1. Risk factors for radiation skin reactions

F E AT U R E

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to show that washing the skin with unper-fumed soap during treatment is quite safe,and indeed is more likely to reduce infec-tion. The majority of European cancer cen-tres allowpatients towash during treatment,but old traditions can persist, and nursesneed to challenge outdated practices wherethey exist. Although all patients should beadvised to wash, it is important that theytreat their skin gently. Avoiding friction andkeeping the skin clean and dry is important.A simple moisturising agent may enhancecomfort. However, despite a number of ran-domised trials, there is no clear evidence tosupport the use of any particular topical ororal agent to prevent radiation skin reactions.Current research studies appear to be focus-ing on the potential of corticosteroid cream(mometasone furoate) or Calendula cream toreduce the severity of erythema. Practical ad-vice for patients remains extremely impor-tant (see Table 2).

ASSESSMENT TOOLSAssessing the skin regularly during radio-therapy treatment is a cornerstone of goodnursing care. There are several assessmenttools available that give consistent informa-tion about the condition of a patient’s skinthroughout treatment. Clinical inspection ofthe skin is important and should be carriedout daily, as skin breakdown can occur rap-idly and needs to be picked up as soon aspossible. Observation of the skin should beaccompanied by assessment of any discom-fort, itching and/or other symptomor limita-tion imposed by the skin reaction, from thepatient’s point of view. It is important to re-member that the external skin reactionmim-ics the internal mucosal reaction within theradiation field, and that acute side-effectssuch as oral/pharyngeal mucositis (in pa-tients with head and neck cancer) and cysti-tis and/or proctitis (in patients undergoingpelvic treatment) may also cause consider-able discomfort, pain and loss of function —these problems need to be assessed and ad-dressed systematically. Supporting the pa-tient to achieve an optimal nutritional intakethroughout treatment is, of course, essentialto the process of tissue regeneration andwound healing.Most radiotherapy departments use the

Radiation Toxicity Oncology Group(RTOG) scale or the Common TerminologyCriteria for Adverse Effects (CTCAE) Ver-sion 3 scale to assess the severity of skin re-actions (see Table 3). Although these scalesare useful, they do not reveal anythingabout the symptoms experienced by pa-tients with skin reactions. Newer assess-ment tools include patient-reportedoutcomes such as pain, itching, burning, aswell as toxicity measures rated by thehealth care professional.2 European radio-therapy nurses are in an ideal position topromote the use of these measures and toencourage a more systematic approach toroutine skin assessment and recording.

PRINCIPLES OF SKIN CAREIf a skin reaction develops intomoist desqua-mation, the most important objectives are toensure comfort and avoid infection. There ismuch controversy in the literature as to themost suitable and effective dressing formoistdesquamation reactions, although it is gener-ally accepted that the principles of moistwoundhealing apply. There is consensus thatadherent dressings or tape should be avoidedas theymay damage the skin. Simple non-ad-herent dressings can be effective, and recentevidence suggests that soft silicone dressingsand moisture-vapour-permeable dressings,such asMepilix Lite® offer both comfort andprotection. Further randomised trials in thisarea are urgently required.3

The care of radiation skin reactions is acore component of oncology nursing. Until

there is more definitive evidence to supportthe management of this common and un-pleasant side-effect of radiotherapy, full at-tention must be focussed on the patientswho are most at risk of developing skin re-actions, and a constant effort made to pro-vide consistent and sensitive assessment,and educate patients about the principles ofskin care. Cleanliness, comfort, preventionof infection andprevention of trauma remainof fundamental importance.4

Details of the references cited in this article can

be accessed at www.cancernurse.eu/

communication/eons_newsletter.html

Wash gently with warm water and mild soap every day.Pat dry with a soft towel, do not rub.Do not expose the irradiated skin to direct sunlight.Wear soft, loose clothing over irradiated area to avoid friction.Do not shave the area using a wet razor.Do not apply perfumed creams or lotions to the area.If you are having radiotherapy under your arm, recent evidence suggests that amild deodorant can be used, but check with your radiotherapy department first.Before you apply anything new to your skin, check with the radiotherapy nurses.If you smoke, seek assistance and support from the radiotherapy nurses, ascontinuing to smoke may exacerbate your skin reaction.

Table 2: Skin care advice for patients undergoing radiotherapy

� Faint erythema or drydesquamation.

� Moderate to brisk erythema;patchy moist desquamation,mostly confined to skin folds andcreases; moderate oedema.

� Moist desquamation other thanskin folds or creases; bleedinginduced by minor trauma orabrasion.

� Skin necrosis or ulceration of fullthickness dermis; spontaneousbleeding from involved site.

Table 3. CTCAE v3 scale –Radiation dermatitis

Just over a decade ago an American book,To Err is Human: Building a Safer HealthSystem, opened a new and interesting debateabout medical errors and adverse events.1

According to the author, more than 50% ofthe errors can be prevented with effective

teamwork and better communication within andbetween professional groups in health care.More recently the Swedish National Board of Health

and Welfare have estimated the costs of medical errorsand adverse events to be as high as 20% of the entirenational health care budget.Several interventions to minimise the risk of errors have

been tested with positive results,2 but the vast majority ofthe studies undertaken involvedmulti-professionalemergency/trauma teams or operating theatres. Despitemany similarities between emergency/trauma care andmodern advanced radiotherapy (RT) and oncology(seriously ill patients, multi-professional teams, highlytechnical tasks, errors that may cause devastating damage,stress etc.) not much has been done to systematicallyimprove patient safety in oncology and RT settings, usingthese interventions.Two years ago, in an effort to address this pressing

issue, researchers led by Professor Carol Tishelman andclinical cancer nurses at Karolinska University Hospital,Department of Oncology and Karolinska Instituteconducted a series of focus group discussions to explorehow patients, nurses and other professions viewprofessional communication at the department. Theyfound that problems with communication had the

potential to seriously affect patient safety. While thefocus group discussions with patient representativesprovided useful advice on how to improve patient care,most of the problems raised clearly concernedcommunication among the staff. More problems thanexpected were found with hierarchical issues. For

Teamwork is widely recognised today as essential for high-quality cancer care, but does the

communication within and between professional groups affect patient safety? Researchers have

focussed on the cost of medical errors and how they can be prevented by communicating better.

Lena Sharp

30

Communicating Better to PreventErrors and Improve Patient Safety

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F E AT U R E

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instance, there were examples of RT nurses notfollowing the treatment protocols, to avoid disturbingphysicians on lunch breaks. There were also physicianswho felt things had been better in ‘the old days’ whenthe nurses had shorter education and were less qualified,which made them less likely to change jobs or advancein their careers.Subsequently the research team applied and received

funding for a project from the Swedish Cancer Society,as well as the hospital and the Institute, to develop andimplement a course in communication and patientsafety for all groups of staff — nurses in particular. Theproject, entitled “Communicate Better”, aims toimprove communication within and between differentprofessional groups at Karolinska University Hospital,and consequently develop a safer patient care

environment. A train-the-trainercourse was held for the projectgroup, incorporating materialfrom the focus group discussionsbased on transcripts and laterdeveloped for use in the coursefor the oncology staff.Crew Resource Management

(CRM) is a management conceptused in aviation to improveteamwork.2 It has been developedto be used in other complex,high-risk contexts, such asadvanced health care andinvolves a wide range ofknowledge, skills and attitudesincluding communication,situation awareness, problemsolving, decision making andteam work. CRM wasimplemented at the two RT unitsand the project is being extendedto the rest of the departmentcomprising four oncology wards,three outpatient clinics and threechemotherapy units. So far, 120nurses, 10 oncologists, 20physicists, eight nurse assistantsand seven medical engineershave taken part.

CLINICAL CONSEQUENCESNurses’ professional identity and roleIt was clear from these discussions that the attitude ofRT nurses to their profession changed as a result of thecourse. They stood up for themselves and took a moreactive role in the multi-professional teams. Some of theparticipants also initiated and developed a new jobdescription for RT nurses with a more active andprofessional role than before.

Briefing/debriefingIn daily briefing/debriefing sessions at the RT units andsome of the oncology wards,3 nurses who work togetherduring a shift met for a few minutes to plan their dailywork. Issues related to patient safety are written down todiscuss at these sessions. At the end of each shift, thedebriefing session takes place to evaluate the work.

ChecklistAnother result of the project is the implementation of anRT-specific checklist. Before each daily RT session, theteam spent less than one minute to examine together theitems on the checklist, such as ID, corect target area, setup and positioning, couch settings and imaging in orderto reduce the risk of errors.4 All of these areas have beeninvolved in earlier reported errors. This evaluation isongoing, but it became clear, after the first two-monthfollow-up, that the checklist helped avoid medical errorsfor 40 patients (5%) at two of the RT linac machines.

SBARTheSBAR (situation-background-assessment-recommendation)technique5 provides a non-hierarchical framework forcommunication about a patient's condition. The aim is toprevent miscommunication and promote patient safety.SBAR is used when making treatment decisions in criticalpatient situations, and everyone needs to be tuned into theplan and telephone consultations between professionalgroups. During the course, staff were trained in thistechnique and how to implement SBARwithin their teams.

Scientific evaluationAt baseline questionnaires were collected anonymouslyfrom all groups of staff (Teamwork and Safety ClimateSurvey from The University of Texas at Austin).6 This willbe repeated later in the year, to compare results. Inaddition, data from the diaries of nurses in the courseswere collected to help better understand their experiences.The qualitative data from the initial focus groupdiscussions have been analysed and will be published later.

Details of the references cited in this article can be accessed at

www.cancernurse.eu/ communication/eons_newsletter.html

There were examples of nurses not following

the treatment protocols to avoid disturbing

physicians on lunch breaks

What went well? What

could have been

done better? What

needs to be reported

to the next shift? The

experience of

briefing/debriefing

sessions has become

a crucial feature of

every workplace team.

Everyone has the same

information and the

same concept of the

job to be done, saving

time and improving

communications.

See you at the

16th ECCO - 36th ESMO Multidisciplinary Cancer Congress

StOCkhOlM, 23-27 SEPtEMBER 2011

www.ecco-org.eu

EC16ES36_210x270_cancerworld_Q_30_04_2010.indd 1 30-04-2010 12:30:18