New endeavours and exciting times
Over the past few months, it’s been all things new here on the MR-linac. Firstly, we have 2 new members of our clinical trials team – Philip Teles Amaro and David Roberts. Both will be valuable assets, helping to deliver treatment, conduct scans and further enhance the patient experience on our MR-linac.
We have also had some new equipment delivered. The Bayer-Medrad™ contrast injector now installed on our Unity MR-linac is believed to be a world first. The contrast injector will allow the radiotherapy team to administer contrast agent to further enhance our scans, and potentially future treatments. We have also had a gas panel installed to allow treatments under general anaesthetic, and our team are working on the development of oxygen-enhanced images for the MR-linac – this could change how we treat patients in the future.
We’re also starting to treat new groups of patients on our MR-linac. In January 2021, we started treating prostate patients under the PACE-C trial. This means we can now treat patients with intermediate to high-risk prostate cancer.
After much complex work in the background, we have also started treatment of our first patient with lung cancer. The potential benefits we could provide to this patient group with adaptive radiotherapy is very exciting for our whole multidisciplinary team.
As the indication list for our MR-linac grows, we’re able to treat patients with increasingly complex cancers in more difficult locations. We’ve started identifying our first patient with oropharyngeal cancer for treatment.
Our busy team have also helped expand the knowledge base of the MR-linac, with assistance in new research publications including Lee Whiteside “Development and results of a patient-reported treatment experience questionnaire on a 1.5T MR-linac” and Claire Nelder “Adaptive Radiotherapy in the Management of Cervical Cancer: Review of strategies and clinical implementation”.
Outside of work, our MR-linac team are currently competing in the “Miles for radiotherapy” challenge to help raise awareness of the cause and raise some money for charity.
Stay tuned for more exciting news from the world of the MR-linac over the next few weeks.
This month, we introduced adaptive fractionated cervical radiotherapy on the MR-linac. This made us the first site in the Elekta MR-linac consortium to do so!
To coincide with cervical cancer awareness week in the UK, the MR-linac team completed the MR simulation. We did this with a view to treating our first patient with cervical cancer fully on the MR-linac – this would be 25 fractions.
We have been preparing for this and searching for someone suitable to treat for quite some time. But now the day is here!
Our simulation scans took place on 18 January, followed by a day 0 mock treatment with the full team present to ensure everything would run smoothly on 29 January. After this, treatment began in earnest on Monday February 1.
How did we get there?
Lots of hard work goes on behind the scenes, in order to ensure new treatment sites are treated safely and accurately.
Let us walk you through the process…
To start with, we need to make sure the MRI scans from the MR-linac are fit for purpose. In this case, ‘fit for purpose’ means the scans define the areas to be treated or avoided. It also means we can use them to match each daily treatment to assess whether or not adaptation is required to account for anatomical or physiological changes.
Before we can do this for real treatments, our radiographers acquire MR images from volunteers taking part in the PRIMER and MOMENTUM studies. The radiographers and doctors then assess the scans to see if these images work for treatment with our team of physicists, testing new imaging sequences until they are treatment ready.
The PRIMER and MOMENTUM trials are data collection studies, investigating clinical and technical data of patients having treatment on the MR-linac. The data is used for service development, and consequently implementation of the best evidence based practice on the MR-linac.
We recently held a workshop so our radiographers, physicists and doctors could prepare for day 0, using the contouring tools on Monaco (our computer planning system).
For our cervix treatment, one of the doctors will contour the patient’s anatomy on a daily basis using the ‘adapt to shape’ (ATS) planning system.
As organs within the body move during the course of a radiotherapy treatment, the ATS software will allow us to adapt the plan to the patient’s anatomy daily. This means we can improve treatment accuracy and lower the dose to the surrounding healthy tissues.
Day 1 treatment
The focus and determination of our interdisciplinary team for the last few years has all been worth it. We successfully treated our first fraction of radiotherapy for a cervix patient, adding to the treatment sites commandeered by the MR-linac.
Stay tuned for our next blog to see what is next on the horizon.
It’s now December 2020 and a lot has happened since our last update!
Research radiographers Abbie and Jo have been leading on a local collaboration implementing daily COVID assessment for patients undergoing thoracic radiotherapy on CBCT guided treatment machines. CBCT stands for cone beam computed tomography – the tool we use to take a snapshot of an area to be treated to ensure patients are aligned properly for radiotherapy.
It is possible to sometimes see changes in the lung caused by COVID-19 on these images. Working with our research physicists and clinicians at the radiotherapy related research group, a tool was developed to flag CBCTs with such changes. These changes are then reviewed by Abbie, Jo and a doctor to determine if they require further interventions.
This will help develop a methodology so radiographers treating patients can successfully detect changes that might be caused by COVID-19. This benefits patients by getting COVID testing and treatment as early as possible and ensuring we take appropriate infection and precaution.
Other ongoing MR-linac and research projects have now wrapped up. This resulted in publications and presentations at the European Society for Radiation Oncology Scientific meeting for publications by Rosie, Lisa, Abbie and Lucy.
Publications included “Therapeutic Radiographers at the Helm: Moving Towards Radiographer-Led MR-Guided Radiotherapy” and “An unusual case of oedematous prostate volumetric changes observed over the course of radiotherapy on the MR linear accelerator”. ESTRO presentations included “visual grading analysis-based audit for MR simulation sequence development” and “Streamlining the image-guided radiotherapy process for proton beam therapy: a service evaluation”.
John and Rosie have now left the MR-linac team to pursue other avenues but we are happy to welcome Becky, Claire and Tee. To train everyone safely, we ran a simulation workshop. Simulation is where we image patients using the MR section of our MR-linac with Nemo (our anatomical phantom). This allowed our new staff to carry out end-to-end testing of the simulation process.
We also launched our Manchester CRUK RADNET doctoral academy for allied health professionals. We have now gained our first radiographer, Mairead, who will optimise motion monitoring strategies for abdominal tumours across multiple radiotherapy platforms (including MRL, CBCT systems and protons). And we look forward to welcoming Amreah in the New Year who will study the optimisation of adaptive cervical radiotherapy on the MRL.
Following much imaging and testing through 2020, we are excited to be working up treatments of others sites on the MRL in 2021. Lots of work is going on behind the scenes to enable us to do more – watch this space in 2021!
An early Christmas present to the radiographers was the installation of piped gases into the treatment room. This will allow us to start doing oxygen-enhanced imaging and begin to recruit patients to our research projects.
These projects are looking to determine potential imaging biomarkers and to validate any we find. This means that in the future, patients can undergo imaging of their tumour on any MRI scanner, and their doctors will be able to personalise their treatment depending on the biology of their tumour – exciting stuff.
An early Christmas present for the MR-linac machine was an extensive upgrade by engineers and physicists. Radiographers were busy writing papers and planning projects for the New Year, but not too busy to join colleagues in the proton beam therapy centre and take part in their Christmas quiz.
So with our next cohort of patients lined up, and new research projects opening for recruitment, we are raring to go into 2021, wishing all our readers a Merry Christmas and a Happy New Year.
One small step for Man(chester), one giant leap for our service!
18 August 2020
Over the last year, the MR-linac team has been making steady and incremental steps with the MR-linac machine. But today, the team took a large technological leap forwards to be able to target treatment more effectively.
The MR-linac team has now demonstrated the first clinical implementation of the machine’s ‘adapt to shape’ (ATS) capabilities. This lets the MR-linac deliver radiotherapy to a more targeted area of the body.
Conventional radiotherapy plans rely on rigid parameters derived from the planning CT scan to ensure the desired dose to target. This can be problematic as patients’ internal organs can move around from day to day.
ATS means the team can now deviate from this ‘one size fits all’ approach. It allows the flexibility to adapt the treatment plan to the patients’ anatomy presenting in each day’s treatment session.
This advancement comes hot on the heels of our first prostate stereotactic ablative body radiotherapy (SABR) patient treated on the MR-Linac in July. This dramatically shortened the time required to treat from 20 days to 5.
The ATS technology is the culmination of decades of research within the radiotherapy field and is undeniably the peak of what can currently be achieved. In theory, it means the MR-linac team can increase the radiotherapy to the cancer, whilst lowering it to the surrounding organs.
By doing so, it’s hoped that MR-linac patients will benefit from higher cancer cure rates and a lower toxicity profile as a result of treatment.
The new systems and learning requirements for such a feat are a result of hundreds of hours work by local physicists, oncologists and radiographers combined. This significant development builds upon the MR-linac team’s ever-increasing familiarity with the technology.
The versatility of the ATS feature means that it can be used for any site of disease as more areas for treatment are approved for the MR-linac. Most importantly, it’s hoped this development means the MR-linac service will be available for more patients.
It’s been a tough few months for everyone. With the restrictions imposed during lockdown, the research-only MR-linac at The Christie sadly shut its doors for a few months. We had to wait and see what happened while the ‘new normal’ evolved.
As excited as we were to re-open to treatment on 15 June, we were busy nonetheless. During this time, the team focused on:
- Honing some of our lesser-refined research skills managing to publish two manuscripts:
- Therapeutic Radiographers at the Helm: Moving Towards Radiographer-Led MR-Guided Radiotherapy. Hales RB, et al. J Med Imaging Radiat Sci. 2020 Jun 26:S1939-8654(20)30066-7. doi: 10.1016/j.jmir.2020.05.001. Online ahead of print
- Comparison of radiographer interobserver image registration variability using cone beam CT and MR for cervix radiotherapy. Rodgers J, et al. Br J Radiol. 2020 Aug;93(1112):20200169. doi: 10.1259/bjr.20200169. Epub 2020 Jun 16
- Analysing data collected, with the view to more publications this autumn
- Developing patient pathways and techniques to implement on re-opening and ramp-up including:
- Radiographer treatment planning for prostate
- Adapt-to-shape workflows
- Evaluation of the effect of gadolinium on dosimetry
- Evaluation of target motion in on-treatment MR images
- Prostate stereotactic ablative radiotherapy (SABR)
- Work in response to COVID-19 (development of a clinical service audit and collaborations with our colleagues in the radiotherapy-related research team to develop tools for a real-time review of patient images)
In the week starting 13 July, we were happy to do our part to help with the department’s response to delays in treatment caused by the lockdown by treating our first SABR prostate patient.
The MR-linac team is glad to be back in action with renewed enthusiasm for the next innovations on this system!
24 December 2019
Merry Christmas from The Christie MR-linac team
2019 has been a great success for the MR-linac team at The Christie.
In January, the radiographers began end-to-end testing on the Elekta Unity. This helped us get used to the new technology and practice MR imaging. It’s a skill that we are continuing to refine – you can never learn enough about MR!
The following months saw us coordinate interdisciplinary learning with physicists, clinicians and other groups. This meant we could maximise the time available, write and test work instructions and procedures, and attend external courses to consolidate our learning.
At the end of April, our Elekta Unity MR-linac machine received CE marking, and in late May we began treating our first patient. Since then, we have continued to ramp up the service.
We have also opened two clinical research studies: PRIMER for optimising the imaging technology, and MOMENTUM to collect data from all patients imaged and treated on the MR-linac.
2019 also saw the team doing their utmost to spread the word about the MR-linac’s capabilities. We’ve had lots of radiotherapy centres ask to visit us, from as far away as Australia. We’ve already held tours for visitors and staff as part of The Christie advanced radiotherapy summer school 2019.
We have also been busy this year representing The Christie on the national and international stage. We presented a poster at the MR-linac consortium meeting in Copenhagen in April, and also spoke at the latest meeting in Amsterdam in November. We talked about our experiences at the North West Society of Radiographers meeting in October alongside our first patient, David, and Professor Choudhury.
Plans are already in place to present and educate other professional colleagues in the first few months of 2020. Beyond this, we are also working on our own MR-linac related research projects alongside clinical work and we are aiming to finalise these for publication soon.
Thank you for your interest and for following our progress this year. No doubt 2020 will be another very interesting and rewarding year for the Christie MR-linac team! We will keep you updated with our regular blog.
7 October 2019
New week, new job - Abigael Clough, MR-linac radiographer
It’s been strange to start a new job while doing the same walk to work and getting changed in the same changing room into the same uniform. A lot of things are the same as in my previous role but I also know that beyond this everything will be different – new colleagues, new patients, new equipment and a new way of working.
Even though I had previously worked with MRI and linear accelerators, the combination of both still made me feel apprehensive. My main feeling was excitement to start a new job and to help bring in new techniques to hopefully improve the treatment we are able to provide for our patients.
I am really enjoying having more time to interact with a smaller group of patients to build up a better rapport. It’s also been great working with such a lovely team.
Before I started, I attended the MR-linac study day organised by the Society of Radiographers North West Committee. The day covered the build and implementation of the machine at The Christie, how MR-guided radiotherapy offers the potential of adaptive radiotherapy as well as both the radiographer and the patient experiences.
This gave me a real insight into the applications of the machine and a rough idea of what daily workflow would entail. I couldn’t wait to be immersed into such an exciting development and to be with such a confident and aspiring workforce. I was delighted to see what a positive impact they had on patients – it made me feel proud be part of the team.
I have also been introduced to a new planning system, MONACO. This introduction has been enhanced through a specialist training course provided by MONACO itself which was such a good opportunity. I have also very much enjoyed the chance to understand more regarding research through the trials that are currently active on the MRL including MOMENTUM and PRIMER, an area I have been interested in but not previously had the opportunity to be more involved with.
Even though I have only just started, I am eager to build on my experiences. I want to expand my knowledge to help introduce more adaptive treatments with the end result of introducing oxygen enhanced treatment whilst working alongside such an enthusiastic team. I cannot wait to see what the future brings!
4 October 2019
Spreading the word about the Elekta Unity MR-linac
This weekend (5 October 2019), the core team of MR-linac radiographers at The Christie will be presenting alongside Professor Choudhury and our first patient, David, to a group of therapeutic radiographers. This will be at a study day organised by the Society of Radiographers North West Committee with a specific theme of the MR-linac.
We will be discussing the build and implementation of the machine here at the Christie, how MR-guided radiotherapy offers the potential of adaptive radiotherapy, and our first experiences. These talks will include insight from radiographers, physicists, clinicians and, of course, our patients.
For UK therapeutic radiographers who may not have had the chance to learn about this ground-breaking technology, this provides an opportunity to discover the applications of the machine, the chance to walk through a typical daily workflow, and discuss the potential benefits it can bring to a department.
We will particularly be focusing on radiographer role development and the unique prospects for this with the Elekta Unity MR-linac.
5 August 2019
Moving to a clinician-lite model of care
With our first patient cohort now firmly under our belts, the knowledge and skills of the MR-linac (MRL) staff continue to grow. Not to exhaust any MOMENTUM (incidentally the title our next MRL trial!) on this experiential upward trajectory, the team is now intently focused on their ambitions for the immediate future. We have already started planning how the next iteration of our treatment processes can be evolved, but also how the new technology available may be best developed and utilised.
The most efficient way to integrate a new technology into an established department is to (as closely as possible) align its processes with established tried-and-tested ones. This provides substantial benefits to all involved, lessening learning curves for staff, speeding up the learning process and reducing overall patient treatment times.
Currently, certain steps in the MRL treatment process require the presence of the entire interdisciplinary team i.e. radiographers, oncologists and physicists. Our new streamlined workflow will allow the MRL team to operate in a manner much more in line with standard practices.
For example, our clinical oncologists will move from being ever present to a back-up role, allowing them to spend their time more efficiently on other vital projects. Because of the ‘real-time’ plan quality assurance required for the daily adapted plan, radiographers and physicists will continue to work together to deliver precise treatment.
All radiotherapy treatments begin with a ‘planning’ image. This is usually acquired on a CT scanner. The therapeutic radiographer then matches this CT picture with the images taken on the treatment machine. The closer the two pictures align, the more confidence we can have in the accuracy of the treatment.
The MR-linac works on exactly the same fundamental principles. The only difference is the imaging method employed is MRI, not CT.
On the surface, this may seem a relatively trivial divergence from our ‘norm’. However, the information it provides is poles apart. MRI is an extremely versatile imaging modality, capable of producing high resolution images with no extra radiation dose. This finer detail allows us to visualise anatomical variation in new and exciting ways not traditionally assessed during a radiotherapy treatment, including during the radiation beam itself!
The understanding of all of this information (and the radiographers' confidence in acquiring and acting upon it) is one crucial barometer enabling us to action our next steps.
3 July 2019
18 June 2019 – A momentous occasion
Well, we did it! After months of preparation, the tireless practice run-throughs and countless hours spent making sure procedures were finalised, our first patient successfully completed MR-linac radiotherapy treatment on 18 June.
It was a fitting testament to the dedication of the multi-professional MR-linac team that the whole experience went smoothly and exactly as we’d envisioned. However, now is not a time to rest on our laurels! In this dynamic department, the next patient is well on the path to treatment and our staff have been reflecting on their experiences and working on research activities.
Multiple members of the MR-linac implementation team, representing the different professions involved, have met to reflect on this positive experience, planning objectives for future treatments and discussing opportunities for further development of the service. Professor Ananya Choudhury, who has led this pioneering project, commented:
"I feel relieved and excited to see how smoothly treatment on the MR-linac has gone. The team worked together effortlessly and there were no hiccups at all. Best of all, the patient said that they had a wonderful experience and was very complimentary. Made it all worthwhile and can’t wait to treat the next patient!"
Therapeutic radiographers have vast experience in matching treatment images of a conventional linac (a low dose form of CT imaging often taken daily - CBCT) to a patient’s planning images (traditional CT). In the run-up to ‘go-live’, the therapeutic radiographers were keen to gain experience in comparing results of matching MR images to planning CT images using the new software of the MR-linac to ensure consistency in practice.
This project provided results that indicated that we were more than satisfied with our image-matching strategies using the MRL. It also provided us with great experience using the new software and confidence in our newfound skills.
A few members of our team successfully applied to present a poster of this work at the UK Imaging and Oncology Congress (UKIO) in Liverpool in June 2019, attended by professional groups within diagnostic imaging and radiation oncology. Our head of radiotherapy research and developments also fed back about MR-linac implementation and the knowledge gained from setting up this service.
UKIO was a great experience and a useful opportunity to represent the Christie and build connections with others involved in MR-guided radiotherapy. Members of the MRL team will continue to undertake research to improve the service and patient care, and present this work at future conferences.
Furthermore, we are now keen to raise awareness of the MR-linac both within the department and in the wider world of radiotherapy. We are currently preparing for the Advanced Radiotherapy Summer School held here at The Christie from 1 to 4 July. As part of this event, we are presenting about our experiences and conducting tours of the MR-linac.
23 May 2019
21 May – our first treatment delivered!
Many exciting and significant events have occurred in the last three weeks here on the Christie MR-linac. We received our official CE certification marking on the Elekta Unity and our research agreement with Philips was signed. And most exciting of all, our first patient has been planned and has now received their first treatment!
During the last few weeks, we have been focusing heavily on repeated end-to-end training – the old “failing to prepare is preparing to fail” mantra is always in our thoughts. The whole multidisciplinary team has been getting together for this training and working within the MR-linac environment as we would with a patient.
Constant repetition of end-to-end training helps to reinforce connections in the brain that are used to recall memories. Research has shown that if we repeat processes over and over again, our brain recognises that this particular skill is important and improves the pathways required for that skill. We have also been carrying out roleplay exercises – so it has been fantastic to finally go through the experience for real with our first patient.
Before the first treatment day, our first patient David attended for a ‘dress rehearsal’ (or, as we call it in radiotherapy, Day Zero). On this day, we ran through the treatment delivery process from start to end, but without actually delivering the treatment. This presented an excellent opportunity to resolve any remaining queries – it was a chance for the multidisciplinary team to practice imaging, image registration and adaptive planning in real time with a patient on the bed. It was an exciting process and the concentration level was so high, you could have heard a pin drop!
On 21 May, David returned for his first treatment. Clinicians, radiographers, radiotherapy physicists and representatives from Philips and Elekta all gathered in the control room, working together to ensure that this fraction was delivered smoothly and to plan. David will return for four weeks in total and we hope to deliver an efficient treatment process like this every fraction.
We would like to take this opportunity to thank all involved in bringing this pioneering machine into the clinical service and we are excited to further explore its potential.
15 May 2019
Elekta MR-linac Consortium 2019 meeting
Copenhagen in springtime is a very special place. Waking up after a long winter, the city is full of life. The quaint, quirky coffee houses and cafes spill their customers onto the pavements. Flowers bloom everywhere, parks and squares throng with folk of all ages, enjoying warming sunlight and powder-blue skies. People greet you warmly with a smile and in perfect English.
It was a pleasure to visit such a delightful city for the Elekta MR-linac Consortium 2019 meeting.
The Consortium meeting is an bi-annual gathering hosted by Elekta attended by over 200 physicists, clinicians and radiographers from the seven founding MR-linac centres and an ever growing number of new sites, from far afield as China and Australia. At times, for a lowly and somewhat bewildered radiographer, it felt like a world record attempt at getting the highest number of world class radiotherapy researchers in one room.
During the first day’s plenary session, the centres already treating on the Unity machine updated on their clinical experience. While the Christie MR-linac team are well prepared, it is always valuable to gain the insights from others as we move closer to treating our first patient.
It is also interesting to see what directions different centres are moving in as they painted a panorama of possibilities already offered by the MR-linac. The manufacturers also provided glimpses of the work they are doing behind the scenes in response to user recommendations to ensure the MR-linac can work at its full potential in the future.
Picture used with kind permission of Marco Luzzaro, Elekta
An enthusiastic and energetic spirit of collaboration rested at the heart of the meeting. Networking was key, whether it was at breakfast, lunch, or the formal dinner held in the famous Tivoli gardens. Conversation was littered with the new MR-linac idioms and acronyms we are already becoming so familiar with.
In practical terms, the meeting allowed teams from each centre to cooperate together within technical and clinical working groups to establish consensus, develop robust research proposals (led, in part, by the Radiotherapy Related Research group from Manchester) and optimise the clinical effectiveness of this new technology.
From a radiographer perspective, it became clear that, whilst we are in an emerging phase of building new radiographer identities around new roles and competencies, there is already a focus on maximising radiographers’ scope of practice. Collaboration is already underway to establish training initiatives to support and move towards a radiographer led workflow, a natural evolution which will free up valuable physics and clinical resources whilst ensuring safe, effective and efficient treatment for patients.
The visit to Copenhagen was a great experience. Conferences and meetings can sometimes seem unrelated to day-to-day work, yet on this occasion the focus and intent from all participants was palpable. There is a clear sense that the MR-linac can become a game changer in radiotherapy and being present with the lead minds in radiotherapy at such an early stage was incredibly inspiring.
12 April 2019
Learning from those who have done it before
It is widely accepted that an excellent way to learn is to engage with a “subject matter expert”….or put more simply, someone who had been there before you, ironed out what works and what doesn’t, and is willing to share their experiences with you.
With this in mind, and an overflowing suitcase due to us Brits worrying far too much about the weather forecast, two of our team headed out to University Medical Centre (UMC) Utrecht to learn more about their experiences with the MR-linac (and about integrating MR into the radiotherapy planning and treatment process along the way too).
Heading to Utrecht
UMC Utrecht have a reputation for leading the way in their use of MR in the radiotherapy planning pathway. Being the testbed for the Elekta Unity, we had some fantastically inspirational presentations from the ‘godfathers’ of the MR-linac themselves, Professor Jan Lagendijk and Professor Bas Raaymakers discussing (amongst other things) how the MR-linac will ultimately change the radiotherapy landscape.
From the initial invention in 1999, to the first prototype in 2009 to the clinical Unity machine in 2018, it was impressive to see how an ambitious, in-house project developed into a commercially viable machine of which the impact and implications on the wider profession are yet to be realised.
The days were long, informative and interactive and we had many opportunities to ask questions of not only the speakers, but the staff on the coal face of the MR-linac. After an initial and much welcomed refresh of our MR physics knowledge, the days were broadly themed around disease orientated groups.
Interspersed amongst the themed lectures were general physics and quality assurance talks and the programme quickly progressed on to how different MRI sequences could best be utilised for optimal visualisation of radiotherapy target volumes. What became strikingly clear was that many of the core tenets applied to traditional diagnostic MR imaging are inapt when applied within the sphere of radiotherapy – the two modalities, it seems, are very different beasts!
Valuable training opportunities
The final days in Utrecht saw peer to peer training take centre stage and the academic teaching of MR sequences climb a very steep gradient – if you’ll pardon the pun. The use of the interactive MR consoles to manipulate sequences was inspiring and thanks to Eveline @PhilipsHealth for her unending patience answering lots of questions! This peer to peer training was wrapped around visits to the MR-linac and further opportunities to ask specific questions from frontline therapeutic radiographers (RTTs).
Our Utrecht educational experience was not divided up into particular role related interest groups. All professionals were taught together, the kind of co-operative approach which very appropriately reflects the operational arrangement inherent to the MR-linac.
The workflow of the MR-linac is very much a microcosm of the conventional radiotherapy pathway, however with the input of all professions being condensed into a 40-60 minute treatment length, instead of being neatly separated out over a 2 week (site dependant) period. Working in such close proximity can cause its own challenges, however the strength of working in this fashion on the course was that it allowed people from disparate professions to see what other concerns and questions arose from previously unconsidered trajectories.
What we learned
The future has not yet been written for the MR-linac, its clinical implications too recent to evaluate. However, whatever its legacy, the impetus it will give our institutions to reassess and expand traditionally held professional roles will be a vital part of it.
All in all, we felt we learned lots, and returned to our department feeling reassured that many of our processes had striking similarities to the ones in use in the Netherlands. This gave us confidence that we are on the right track to deliver an exceptional service to our patients.
The Christie’s Advanced Radiotherapy Summer School has been an annual event running for the last four years and appeals to a wide range of professional groups. On the programme for 2019 are talks and workshops on adaptive radiotherapy, including demonstrations of the MR-linac workflow and tours of the build. The course takes place between Monday 1 and Thursday 4 July.
4 April 2019
Getting ready for take-off: clinician MR-linac boot camp
As the ‘go-live’ date for our MR-linac service draws ever closer, it is increasingly important for clinicians, physicists and radiographers to consolidate their knowledge. This means they can refine the workflows needed for treatment on the MR-linac.
Radiographers, along with representatives from @Philips and @Elekta, ran a two day boot camp to train clinicians in MR safety, essential MR physics and their role in the adaptive treatment workflows of the Elekta Unity machine.
The first day was aimed at providing grounding in MR safety and relevant MR physics, along with hands-on practice using the Philips terminal which allows us to manipulate parameters to provide increasingly better images. The second day built on this by providing an opportunity to practice contouring and plan review using the Monaco software, and to participate in full run-throughs of the online adaptive workflow with a phantom.
For some clinicians this was the first time they had seen the machine in operation providing an excellent chance to problem-solve and talk through potential scenarios that might occur during treatment.
Here is some feedback from the clinicians who attended the sessions:
“We were really excited to participate in the MR-linac boot camp and to see the machine in all its glory. We were really looking forward to spending some time on the machine and further understanding how we can make the most of this ground-breaking technology.
The boot camp was a very thorough and practical introduction. From an excellent programme, our highlights included:
- The important safety update from radiographer Lisa
- MR physics 101 by David from
- Using the software and simulating treatment”
From a radiographer’s perspective, the boot camp was an excellent opportunity to show the clinicians how the machine will be run from day to day. This is crucial as the technology involved differs greatly from conventional linear accelerators.
Hopefully this will mean the clinical oncologists now have a thorough understanding of the treatment and can better answer any questions that patients may have. In addition, it has provided a platform to ask and have answered any pressing questions, and enabled the MR-linac treatment team to get to know each other well.
At the first session of the boot camp, we had a surprise additional visitor.
Lottie visited The Christie Hospital from 11 to 15 March 2019 as part of Women’s Engineering Society’s 100th year anniversary. She was a guest from the Institute of Physics and Engineering in Medicine (IPEM).
Since her visit coincided with the boot camp, we invited her to the radiotherapy department to spend some time with radiographers and doctors, and to see the MR-linac.
Any visitor to the MR-linac has to complete an MRI safety check which included a questionnaire, and Lottie was no exception. Since Lottie was not really sure what she was made of, she also underwent a screening CT scan and a quick check with a strong magnet so we can be sure that she had no ferrous metals in her that would cause problems.
She sat in on several talks on day 1 of the MR-linac boot camp, learning about the principles of MRI and its role in image-guided radiotherapy.
Lottie does have a propensity for green buttons and had to be closely monitored during her visit.
29 March 2019
Documentation, documentation, documentation
We all know that creating and maintaining a safe environment not only reflects a compassion for patient welfare, it also encourages a confidence with staff groups. This will hopefully empower and motivate our staff, thus creating a positive feedback loop that will enhance the service we can deliver to our patient group.
In today’s society, we are all aware of the need for policies within our working practice which ensure we are safe. We used ‘the seven pillars of clinical governance’ as a guide for developing our policies. These are:
- Clinical effectiveness
- Risk management
- Patient experience and involvement
- Clinical audit
- Strategic effectiveness
- Staffing and staff management
- Education and training
We also developed cool process maps of what we anticipated our patient journey would be. This gave us a framework to build our policies around and made sure we didn’t forget anything! Where we could, we didn’t ‘reinvent the wheel’ and made sure that our documents were the same as other areas within the department.
This will give rotational staff familiarity with at least some of our working practices – this can help to reduce stress and encourage confidence. Where we couldn’t make our policies line up with others already in the department, we engaged with our colleagues and raised the question of whether updating their policies would allow us to issue joint ones, or whether we needed separate ones.
For some areas of the MR-linac pathway however, this was just impossible due to the difference in what this form of treatment can offer to patients. These documents needed to be developed from scratch!
But how do we know if we’ve done things correctly? Firstly, we based our practice on research evidence to start with and making a note of all those areas where the evidence base is lacking for future research project ideas of our own.
We did this because evidence-based practice means that using working practices that have been shown to be effective, in combination with experience and, most importantly, what patients prefer.
Secondly, we did lots of end-to-end training, using our new shiny workflow documents to ensure they are correct, and we haven’t made mistakes or forgotten anything.
Thirdly, peer review. Peer review is often used as a tool to demonstrate a level of quality assurance, but asking colleagues to peer review our documents allowed us to be confident that we hadn’t forgotten anything.
Because of the volume of documents that were being written or simply revised, we were keen to avoid oversight. Sometimes you really just don’t know what’s not there until someone tells you it’s not there.
Some of the team are off to Utrecht soon to attend training sessions on using magnetic resonance imaging for planning and guiding radiotherapy. We’ll let you know how we get on!
14 March 2019
MR safety in a radiotherapy environment
The field strength of the MR-linac magnet is 1.5 Tesla. To put this into context, the lifting magnets used in car scrapyards in the UK that can pick up cars and vans have a field strength of 1 Tesla.
The force required to not only lift the bed but suspend it in mid-air is huge. However, whilst the biggest risk to staff comes from the static magnetic field, the biggest risks to patients come from the additional magnetic fields that are created when scanning is taking place. According to the Health Education England (HEE) module on MR safety, 70% of reported injuries arise due to these fields and research shows that most incidents occur as a result of inadequate safety routines and lack of training.
Therapeutic radiographers and physicists are used to working in potentially hazardous radiation environments and recognise the need to work within safe practice guidelines (local rules). MR environments are no different in this respect. However, the main difference in the MR-linac environment is the constant presence of the static field. The field of the MR-linac’s superconducting magnet is never switched off.
Remembering THE MAGNET IS ALWAYS ON (yes, in capital letters!) is key to instilling into our staff the need for constant vigilance. Radiation local rules talk about a “controlled area” – this is usually one room. For the MR-linac, we needed to develop an entire controlled access area department. This would ensure we met the recommendations made by the Medicines and Healthcare products Regulatory Agency (MHRA).
To achieve this, our radiographers have been familiarising themselves with MR working practices by assisting in the radiology department with the positioning of patients on specific radiotherapy research studies. However, it is a huge leap to then becoming responsible for screening patients and visitors.
The first step was to ensure all our radiographers were MR authorised (as defined by the MHRA) and that they were up to speed with MR safety and safety screening competencies. This means staff working in the MR-linac have a good all-round knowledge of MR safety. This initial integration of MR into a radiotherapy environment has provided us with a very useful grounding on which to base some of our practice.
Safety screening is a significant responsibility within any MR pathway as it ensures that any individual is not only safe to enter the magnet room but also to undergo scanning. There is a risk to patient safety if this screening process is inadequate.
In lieu of screening actual patients (as our service wasn’t up and running at this point), a safety screening competency was developed. This included a review of 100 actual patient screening forms taken from radiology, which we then discussed as a group. It also included using strategies to investigate MR status of implanted devices and resulted in the creation of a local policy for investigating implanted devices.
The next step is to ensure all the clinical oncologists who will refer our patients understand MR safety as it will become their working environment too.
11 March 2019
‘R-E-S-P-E-C-T’ – the key to collaborative working
Lisa McDaid, principal radiographer
The MR-linac is a complex hybrid of two amazing technologies and the workforce needed to develop and deliver this service is very varied. Radiotherapy departments have relied heavily on their diagnostic colleagues to develop image guided radiotherapy working practices over the years, however, never has the partnership between MR radiology services and radiotherapy overlapped more than today.
The huge advantage that the MR-linac gives to the radiotherapy treatment is the ability to adapt the treatment daily so that as the morphology of the tumour changes, or internal anatomy shifts, so the treatment plan will change. This has never been done before at The Christie.
One of the key indicators for success in collaborative working is respect. Working with different staff groups can be more complex than one group and success is dependent on developing good working relationships that encourage a mutual respect and trust.
Communication is also key. Routine information sharing is important as it helps us develop the workflows, governance documents and also ensures that we are avoiding duplication of work. We have been waiting a long time to get our hands on this wonderful machine and can’t wait to bring this service to our patient group. Everyone in the MR-linac team is aware of how we are working together, defining our roles and responsibilities to build on relationships and avoid misunderstandings that can damage teams.
In terms of the MR-linac workflow we, as the radiographers, needed to develop a pathway that can be used for all patients, irrespective of site of cancer. We have enjoyed regular skype chats with our colleagues from the Odette cancer centre in Toronto, Canada and look forward to our future collaborations, as well as continuing to engage with international colleagues through Elekta using the Yammer social network platform.
Process maps have been developed to demonstrate the inter-professional interactions which has led to greater efficiency in developing pathways and governance documents. This has been particularly useful in protecting against duplication of work and potential oversights.
We were also keen for our workflows to be lean and efficient. We did fit in time for tutorials in physics, contouring and adapting plans.
Alongside us, the physicists and dosimetrists are all keenly working on their workflow documents, and regular catch-up meetings allow us to ensure there is parity in what we are developing, and that this is achievable. The clinicians are aware of their responsibilities too in terms of how to determine which patient groups would benefit most from being treated on the MR-linac. Research staff are involved with studies which will be used to build up the evidence base for this new technology and help to guide practice in the future.
When all these pathways are developed, these are put into practice through continuous end-to-end training. Starting with the referral process, through to planning the treatment, then onto the preparation, organisation of the appointments to ensure the appropriate staff are in attendance, daily imaging and through to actual treatment including the adaptive planning (changing the treatment plan on the day whilst the patient is on the couch).
15 February 2019
So, what is the MR-linac and how does it work?
The MR-linac is a huge machine, but because of the clever engineering work and the consideration given to the ambience, it does not look scary. Instead, it looks very modern and almost welcoming, and it is very easy to keep clean.
Image credit: Elekta
We can change the colour of the lights in the room and dim them if that’s more calming for individual patients. But, enough with the room, let’s look behind the covers to see more of this amazing piece of technology.
The integrated linac and MR scanner technology has been 18 years in the making by MR-linac manufacturer Elekta, which gives an indication of how complex a machine it is.
Image credit: Elekta
A linear accelerator – or linac for short – uses electricity to create X-ray beams. These X-ray beams are focused toward the tumour being treated. They are shaped by a multileaf collimator and some very clever physics to avoid healthy tissue around the tumour.
This X-ray beam is called the treatment beam. This collimator shapes the treatment beam into the same shape as the tumour it is treating. This beam is created by the magnetron and waveguide.
Elekta has taken a linac and integrated an MR scanner into it. The scanner has a very strong magnet with a field strength of 1.5T to give us crystal clear imaging.
This means the MR-linac can not only take very good quality images immediately before treatment to ensure that our beam is targeted at the tumour, but can adapt the shape of the beam if there are changes to a tumour or internal anatomy.
If the tumour moves within the body as a result of the bladder filling up quickly, the bowel moving, or the lungs breathing, the treatment beam can adjust for this and continue to target the tumour.
It also means that it’s easier to avoid damage to healthy tissues as a result of any internal movements in the body. The internal organs of the body are well known for not keeping still!
The MR-linac isn’t suitable for all tumour-types though. A patient’s oncologist will be able to look at individual circumstances, and the available clinical evidence, to decide if the MR-linac is the best option for a particular patient.
29 January 2019
Introducing The Christie MR-linac radiographers
The Christie is always looking for new ways to treat cancer. We are part of the Elekta MR-linac consortium, making us one of the world’s first cancer centres to have acquired an Elekta unity magnetic resonance linear accelerator; MR-linac for short.
This amazing machine uses MR scanning technology combined with a linear accelerator to enable us to adapt radiotherapy treatment which can improve accuracy for certain cancer sites.
Meet some of the radiographic team involved in bringing this exciting and ground-breaking technology to the clinical service.
Developing the clinical service is coming on leaps and bounds now that the MR-linac has been handed over to clinical radiographers to begin development of the clinical service.
We are a mix of both therapeutic and diagnostic radiographers and ‘Nemo’ the phantom is awaiting his repeated imaging and treatment with bated breath.
Here are some of the radiographers involved with this section of the project. The remainder of the team (including other radiographers, physicists, dosimetrists and engineers) are all hard at work developing their clinical pathways and processes, all of which we will work on bringing together over the next few weeks.
What’s next for the MR-linac radiographers?
We will be running a blog and posting on social media so that you can follow our progress in the run up to the MR-linac treating patients.
Over the next few weeks, we will introduce the machine and explain how it works, talk about key concepts in MR-guided radiotherapy safety, the benefits of adaptive radiotherapy and how we have been working collaboratively in this exciting project.