Advance Radiation Therapy Practice:

Advance Radiation Therapy Practice: A view from 30000ft and the front lines Nicole Harnett, MRT(T), AC(T), BSc, MEd Grace Lee, MRT(T), BSc, CMD, MHSc. 2016 CAMRT Annual General Conference June 9 12, 2016, Halifax, NS 1

Disclosure None 2

Objectives Describe the development of advanced practice in radiation therapy Use the advanced practice development project as an example to identify opportunities to develop new ways of working Articulate the outcomes that signify the success of the new model of care 3

Advanced Practice: a view from 30,000 feet 4

Advanced Practice: a view from 30,000 feet 5

Why advanced practice? It works! For patients... Improved patient care Improved health outcomes Flexible services designed around patients needs Faster access to more focused services or specialized care Continuity of service provider For services... Improved patient outcomes Enhanced patient and family satisfaction with services Advent of innovative services (I.e. Brachytherapy, adaptive radiotherapy) Enhanced equitable access (I.e. OTN) Positive impact on recruitment and retention Enhanced continuity and coordination of care Better utilization of staff skills and expertise and, as a consequence, more targeted use of the skills of other professions Cost-effective method of delivering high-quality services Improved teamwork and multidisciplinary collaboration More appropriate skill mix within clinical teams Facilitates increased emphasis on prevention, education and health promotion For health professionals... Opportunity to improve patient care Opportunity to increase patient satisfaction Opportunities to increase knowledge, skills and competencies Increased job satisfaction Greater responsibility for services Leadership opportunities Expanded career pathway with increased job options 6

Why advanced practice? But only when its needed! There is NO USE in introducing an advanced practice role/position where there is no need. Unacceptable wait times related to increase demand New technologies Shortage of professionals 7

What is advanced practice? Depends who you ask! literature other jurisdictions other disciplines 8

What is advanced practice? The Literature is always right is always clear is always rigourous Nope. 9

What is advanced practice? The Literature conflicting terms used interchangeably needed to decide for ourselves what it meant 10

What is advanced practice? Model of developing expertise Dreyfus and Dreyfus (1980) Advanced Practice 11

What is advanced practice? Additional knowledge and skills including theoretical content Expert clinical and technical practice with increasing complexity in an area of specialization, causing a blurring of professional boundaries Integration of theory and use of evidence-based medicine Higher level of cognitive functioning, such as critical thinking and analysis with an ability to deconstruct assumptions and rebuild new ways of doing things Skills and aptitudes that transcend a particular niche and are transferable to a variety of settings and populations (i.e. can alter function from the individual patient to more system based thinking) Enhancement of other aspects of professional practice leadership, scholarship, research, teaching and consultancy Autonomy in some aspects of practice 12

What is advanced practice? 13

What is advanced practice? What will APRTs actually DO? Map out the workflow Identify where gaps/bottlenecks that can be alleviated with unique RTT skill sets Conduct a thematic analysis of all the elements being documented Build a competency profile! 14

What is advanced practice? CORE CLINICAL COMPETENCIES - Works as a member of the interdisciplinary care team to provide optimal patient care for radiotherapy patients CORE TECHNICAL COMPETENCIES - Uses advanced oncologic, radiobiological and dosimetric knowledge to optimize the use of available technology for the provision of tailored radiation therapy treatment to patients CORE PROFESSIONAL COMPETENCIES - Uses research and evidence-based practice principles to serve as a quality champion, role model, mentor and innovator in radiation therapy and especially in their area of specialization 15

What is advanced practice? Different than specialization At any point in the patient journey In a variety of settings (e.g. new patient, follow up, treatment review, at outreach clinic, etc.) In person or at a distance (remote consultation, phone, telehealth etc.). 16

Competency Profile CORE CLINICAL COMPETENCIES - Works as a member of the interdisciplinary care team to provide optimal patient care for radiotherapy patients 17

Competency Profile CORE CLINICAL COMPETENCIES - Works as a member of the interdisciplinary care team to provide optimal patient care for radiotherapy patients 18

Putting the Profile into Action! 1. Build a job description using the identified needs and the competency profile 2. Describe where the APRT will have impact outcomes 3. Identify how you will measure the impact (ie. what data sources do you have available to you to show changes?) evidence 19

Putting the Profile into Action! 1. Build a job description using the identified needs and the competency profile Example 1: Head and Neck patients are waiting too long to get on treatment after their radiation oncology consult. Example 2: Palliative inpatients at community hospitals are not being referred for palliative radiation therapy when they could be. 20

Putting the Profile into Action! 2. Describe where the APRT will have impact outcomes Example 1: Head and Neck patients are waiting too long to get on treatment after their radiation oncology consult. Example 2: Palliative inpatients at community hospitals are not being referred for palliative radiation therapy when they could be. 21

Putting the Profile into Action! 3. Identify how you will measure the impact (ie. what data sources do you have available to you to show changes?) evidence Example 1: Head and Neck patients are waiting too long to get on treatment after their radiation oncology consult. Example 2: Palliative inpatients at community hospitals are not being referred for palliative radiation therapy when they could be. 22

Where to start? 1. Attend our workshop this afternoon 2. Become a change agent 3. Gather information About advanced practice About your unique clinical environment and its needs 4. Find a champion to work with 23

Where to start? If you can t attend the workshop, 1. Visit www.ontarioradiationtherapy.ca 2. Visit www.camrt.ca 3. Call Nicole @ 416-946-4501, ext 5756 4. Email Nicole @ nicole.harnett@utoronto.ca 5. @AdvPracticeRT 24

Acknowledgements Early champions Pam Catton Marcia Smoke Amanda Bolderston Donna Lewis Anthony Whitton Lynne Nagata Mary Gospodarowicz Partners CSRT Supervisors Departmental Managers The Project Oversight Cte CAMRT CMRTO The Core Team The CSRTs past, present and future Laura Zychla Elizabeth Lockhart Michelle Ang Carina Simniceanu Kate Bak Elizabeth Murray Eric Gutierrez Padraig Warde Funder Ministry of Health and Long Term Care 25

Advanced Practice: in the front lines 26

Princess Margaret Radiation Medicine Program 27

Princess Margaret Radiation Medicine Program Breast Site Multi-disciplinary team based Treat over 950 breast patients yearly Whole Breast RT (~60%) Breast + nodal regional RT (~30%) Others (~10%) Intensity-modulated RT (IMRT) Weekly tx reviews conducted for all radical patients 28

Breast CSRT Role: Patient Assessment and Symptom Management Responsibilities Assess patient & manage acute side-effects from RT Differentiate between radiation induced side-effects and other treatment/conditions Provide psychosocial support Refer patient to appropriate medical/social services

Decision to treat Planning imaging Target delineation Plan creation Follow up/ community Daily treatment Plan QA Plan approval Weekly review RO PHY RTT

Breast CSRT Role: Weekly Treatment Reviews Learning/Training Formal & Informal clinical teaching: one-on-one, shadowing, etc. Self study (text books, journal articles, etc) Structured education: pt assessment, history taking, documentation, breast imaging, etc.

Decision to treat Planning imaging Target delineation Plan creation Follow up/ community Daily treatment Plan QA Plan approval Weekly review RO PHY RTT

Breast CSRT Role: Weekly Treatment Reviews Study: Are the assessments made by the CSRT concordant with those of the RO? Prospective concordance analysis Women receiving breast RT & attending a weekly treatment review clinic Compared assessments of RO with the CSRT

Observer Concordance Event Toxicity Event Toxicity CSRT CSRT RO RO Hyperpigmentation Hyperpigmentation 22 22 29 29 0.76 0.76 Fatigue 25 29 0.86 Fatigue 25 29 0.86 Dermatitis 26 29 0.90 Dermatitis 26 29 0.90 Pruritus 27 29 0.93 Pruritus Mood alteration 27 27 29 29 0.93 0.93 Mood Breast alternation Pain 28 27 29 29 0.97 0.93 Breast Hot Pain flashes 29 28 29 29 1.000.97 Hot Hypopigmentation Flashes 29 29 29 29 1.00 1.00 Total Edema: limb 29 184 29 203 1.000.91 Infection 29 29 1.00 Sweating 29 29 1.00 Nausea 29 29 1.00 Dyspnea 29 29 1.00 Insomnia 29 29 1.00 Cough 29 29 1.00 Weight gain 29 29 1.00 Weight loss 29 29 1.00 Total 474 493 0.96

Breast CSRT Role: Weekly Treatment Reviews Agreement in Toxicity Between CSRT & RO Kappa statistics Hyperpigmentation Kappa = 0.37 (95%CI: 0.03-0.78) (76% concordance) (Fair agreement) Fatigue Kappa = 0.753 (95%CI: 0.53-0.98) (86% concordance) (Substantial agreement) Dermatitis Kappa = 0.85 (95%CI: 0.69-1.0) (90% concordance) (Almost perfect agreement)

Breast CSRT Role: Weekly Treatment Reviews Evidence High concordance and agreement between CSRT and RO patient assessment of RT related sequelae CSRT led patient assessment is possible with site specific advanced education and training

Breast CSRT Role: Weekly Treatment Reviews Impact Clinical: Decrease patient wait time in reviews Increase capacity for new patients Academic/Evidence-based practice:

Breast CSRT Role: New patient consults & Well follow-ups Responsibilities Perform history & physical for new patients Discuss treatment options & consent Communicate results of specific tests Provide technical and dosimetric consultation Impact Reduce referral to consult wait times Provide continuity of care Increase new patients/week

Breast CSRT Role: Cavity Delineation In 2008, standardized procedures to contour seroma/cavity for all patients undergoing whole breast and/or boost radiotherapy Ensure accurate target coverage Clinical issues: High volume of patients requiring contours Limited resources; potential increase in patient wait-times

Retrospective contouring study: To determine whether the delineation of seroma volumes by the CSRT is clinically equivalent to the seroma contours generated by the physicians. Axial Sagittal Coronal

Cavity contouring: All RO observers + Consensus volume

Seroma volume agreement (Average ± SD) RO group (expert) CSRT (observer) Mean volume 26.56 ± 5.14 ml 28.25 ± 1.58 ml Concordance Index 0.61 ± 0.03 0.65 Overall kappa (range) 0.69* (0.50 0.90) 0.81* (0.67 0.92) Kappa statistics: almost perfect agreement Consensus volume (STAPLE) with CSRT

Breast CSRT Role: Cavity Delineation Evidence CSRT delineated seroma volumes comparable to those of the RO for breast radiotherapy treatment planning Support potential delegation of seroma delineation to CSRT in patients with visible seroma cavities

Breast CSRT Role: Cavity Delineation Impact Clinical: Decrease target contouring time for RO Increase patient throughput in planning Academic/Evidence-based practice:

Opportunity Automated Breast planning Breast CSRT Multidisciplinary Team QuickStart Rapid Breast RT Process CT sim, tx planning & delivery all in one day

Breast CSRT Role QuickStart Responsibilities Lead same-day simulation and treatment process Contour seroma target Monitor treatment planning process

Radiotherapy Pathway QuickStart Median (hr:min) Process Standard Median (hr:min) Net Time Savings Target Delineation 0:19 22:32 Planning/Publishing 0:48 67:59 Physics/ RO Approval 0:24 26:04 Quality Assurance 0:32 88:02 ~1 day ~2.5 days ~1 day ~3.5 days Total Plan Completion Time (range) 2:18 (1:33 3:24) 215:17 (97:05 597:01) ~9 days Total RT Wait time (range) 2:50 (1:52 4:04) 268:50 (147:55 601:11) 11 days

Breast CSRT Role QuickStart Evidence/Impact All patients treated within 14-day CCO wait target (median = 2 day) 31% pts experience delays prior to RT consult; treated with QuickStart in 2 days or less Cost savings = ~$142/pt [~Annually $29,500 ; 4 pts/week] Academic/Evidence-based practice

1. Cavity contouring CSRT Assess relevant patient info (diagnostic, path, operative note, etc.) Contour post-operative cavity Transfer contours for planning RO Dosimetrist RO review review/approve all CSRTdirected cavity contours in final plan assessment 1

2. Plan review (RO / CSRT) RO reviews final plan as per institutional policy CSRT independently reviews a copy of final plan RO & CSRT completes QA checklist (acceptability of plan) 1 2

Methods

Cavity Results Contours Non-Complex cases (CSRT-directed contours) Complex cases (CSRT preplanning consult with RO) Total patients (n= 30) 20 10 RO acceptance RO agree/no change 19 3 RO combined with CSRT -- 3 RO change 1 4 Conformity Index 0.93 0.88±0.12 Contouring time (mins) Median (range) 0:27mins (range: 0:14-1:29) 0:39mins (0:29-2:12)

Radiation Oncologist and CSRT Plan Review Agreement CSRT Final Plan Review RO Final Plan Review Approve Reject Approve 26 (86%) 2 (7%) Reject 2 (7%) 0 (0%) CSRT-rejected 2 cases: 1. Final plan did not display the required dose distribution 2. Cavity target under-coverage on treatment plan same case rejected in peer-review QA rounds and re-planned Both RO-rejected cases required re-planning to reduce cardiac dose CSRT approved both cases based on heart criteria but independently identified them for RO consultation

Conclusions CSRT delineated non-complex cavity contours appropriate for clinical planning and identified complex cases for RO review Academic/Evidence-based practice: Presented in CARO 2015 / RTi3 2016 Manuscript submitted for publishing

Decision to treat Planning imaging Target delineation Plan creation Follow up/ community Daily treatment Plan QA Plan approval Weekly review

Princess Margaret Radiation Medicine Program CSRT Role (Breast Site) Needs of the program Competency Profile Clinical Competencies: Perform patient assessment and manage RT side effects Technical Competencies: Planning target contouring Professional Competencies: Lead and participate in research studies Process enhancements and QA Teaching 57

Acknowledgements Clinical supervisors Dr. R Dinniwell Dr. P Catton Dr. A Fyles Dr. CA Koch CSRT project N Harnett L Zychla RMP J Wenz E Moyo S Foxcroft T Purdie Team 2 planners Team 2 physicists Team 2 treatment unit staff Team 2 PFCs