Inside this issue: Radiation Therapy (a joint issue with ESTRO) and EONS at ECCO 2017

Virtual reality helps patient education in radiation therapy

Annette Boejen and Rikke L. Poulsen from Denmark explore the patient experience, looking at ways to inform and reassure those undergoing radiation therapy

Annette Boejen (left) and Rikke Poulsen (right)

Annette Boejen (left) and Rikke Poulsen (right)

Patients undergoing a complex process of radiation therapy (RT) experience fear, stress and anxiety related to the RT1, and most of the patients want as much information as possible about their disease, side-effects, treatment and rehabilitation. Patients’ collaboration for a correct positioning regarding the dose delivery is important. But RT is invisible and most of the patients don’t have knowledge about human anatomy, and radiation therapists (RTTs) are often confronted with issues related to the treatment such as “How does radiation therapy work” and “How to ensure a given treatment is correct”.

In 2007, a Learning Centre was established at the Department of Oncology, Aarhus University Hospital. A three dimensional (3D) imagine system VERT (Virtual Environment for Radiotherapy Training) (VERTUAL Ltd.) was established as part of the centre. A computer model of an accelerator and treatment room are integrated, and the system allows uploading of clinical patient cases2 (Fig. 1). Initially, the system was solely aimed at education of RTTs; today the facilities are used by all staff groups working with RT and by visitors.3 4

Fig. 1: VERT 3D imagine system (Credit Michal Harder, Aarhus University Hospital)

Fig. 1: VERT 3D imagine system

Increasing understanding, reducing anxiety

The positive experience with VERT for the education and training of staff inspired a test to see if use of the software could optimise information: Would patients and relatives gain additional knowledge if VERT was used as part of information in addition to oral and written information? Would VERT help patients to increase their understanding of how RT is delivered and consequently reduce anxiety? A pilot project with group sessions was scheduled and called ‘Open house’. The main programme was the planning and delivering of RT, and the teaching sessions were prepared with interaction between Power Point and VERT. All participants (n=89) in six sessions reported that VR was useful in the understanding of RT. A total of 97% replied they had found answers to questions they had been contemplating during the course of their treatment, but several patients expressed a wish to get their own treatment plan presented in 3D5

Receiving treatment (Credit Michal Harder, Aarhus University Hospital)

Receiving treatment

The preliminary experience was followed by the design of a study to test whether showing patients their own RT dose plan using VERT would increase their knowledge and confidence about RT treatment. Before the presentation, all patients were given standard oral and written information about their treatment. All patients (n=58) with cancer in the pelvic area starting curative RT at two accelerators during a period of 2½ months were offered a presentation of their own dose plan using VERT. Relatives were invited to participate. All the presentations were scheduled for half an hour and given by the project manager, who followed a template for the presentation:

  • Treatment room including accelerator, movement of gantry and equipment for image guided radiation therapy
  • Patient’s body contour – demonstration of own planning CT scan
  • Treatment area – defined, plotted and planned by physicians and physicists
  • Irradiation of organs at risk, and information of possible side effects
  • Dose distribution with emphasis on the importance of precision
  • Quality assurance using skin marks, laser, image verification and couch movement
  • Angles for beam entrance and protection of healthy tissue
  • Time for questions from patient or relatives along the way.

Important new knowledge

Before the VERT presentation, participants filled in a questionnaire including questions about confidence and knowledge about the target of RT, CT-scans and dose planning, positioning and dose delivery, possible side effects and causes of side effects. After the VERT presentation, the participants evaluated the topics again with a focus on level of confidence, amount of new knowledge and importance of the new knowledge; it was possible to supplement this with comments. The patient filled in the questionnaire in collaboration with the project manager.

Computer model

Computer model

Responses were obtained from 32 of 58 included patients (58%); the average age was 64 years (38-79), and the number of completed fractions at the time of the VERT session was nine on average (range 3-36). Relatives participated in almost half of the presentation sessions (n=15).

A total of 41% of the participants reported a higher level of confidence in the RT treatment after the presentation; none reported a lower level. A high number of patients reported they received important new knowledge about target definition, planning of treatment, positioning, possible side effects and causes of side effects and nearly all reported the new knowledge as important. Both patients and relatives evaluated the presentations as informative and relevant; statements included:

  • “It’s important to see my own dose plan, this clarifies organs being radiated and how healthy tissue can be spared”
  • “I’ve got a better understanding of what’s going on with my husband” and
  • “Looking at my own dose plan is important to imagine organs being irradiated and how healthy ones are protected. It’s much easier to understand”.

Increased confidence about RT

The results of this study showed that presentation of patients’ own dose plan in 3D virtual reality (VR) might give a visual understanding for most patients. The presentations also led to increased confidence about RT. The 3D VR technique makes it easier for patients and relatives to understand a high-technology treatment and can be used as a supplement to inform them about RT6.

Fig. 2: Patients confidence about receiving RT before and after the presentation on a scale from 1 to 10. 1=very low confidence, 10= very high confidence

Fig. 2: Patients confidence about receiving RT before and after the presentation on a scale from 1 to 10. 1=very low confidence, 10= very high confidence

A similar project has been done by Dr J. Sule-Sosu. One hundred and fifty patients with different types of cancer receiving radical RT were included in the study. Patients and relatives were shown using VERT on a one-to-one basis with an oncologist or a radiographer, a standard room where RT is given, a linear accelerator, and how RT is planned and delivered using their own planning CT Scans. Patients welcomed this information as it helped them to reduce their fears about RT. Relatives also felt more involved in the treatment of their loved one7.

  Knowledge about treatment
Age New knowledge n (%) Importance of the new knowledge n (%)
CT-scan and dose planning 30(94) 29(97)
Target of RT 26(81) 26(100)
Possible side effects 27(84) 26(96)
Causes of side effects 10(31) 10(100)
Target of RT 18(56) 17(94)

Fig. 3: New knowledge and importance of new knowledge according to patients.

Higher level of compliance

Modern RT has focused on reduction of long-term side effects for patients, and use of new technology in combination with patient involvement which might help to reduce these. Implementation of daily online image guided RT have resulted in documentation of soft tissue organs’ movements under the treatment and, depending on the diagnosis, adaptive strategies are developed and implemented in these years. A full bladder and empty rectum might, for example, help to eliminate the bowel volume around the cervix, for women treated in this area, and drinking protocols are presented for patients as part of the treatment. To motivate the patients and help them to understand the importance of daily treatments with the same bladder volume, a demonstration using a visual tool such as VERT may lead to a higher level of compliance.

Dr A. Steward-Lord has made a study where prostate cancer patients (n=38) attend a VERT patient information session four weeks prior to their planning CT scan, and follow-up with a questionnaire two weeks after the start of radiotherapy treatment. The results showed that the sessions enable patients to understand the potential impact of treatment volumes if the internal organ shape and location differed from that originally planned, enabling them to comply with radiotherapy treatment instructions. Additional key findings have demonstrated excellent levels of communication associated with the use of VERT8.

There is a wide range of opportunities for the use of VERT for patient education, e.g. drop-in sessions for general information9, systematic deployment for patient education regarding a correct position with reduced rotational errors10> and a demonstration of treatment facilities and the delivery of dose to parents whose child is going to be treated11

The first results from patient education using VERT point towards an increase in patients’ knowledge level about RT, less anxiety and a possibility reduction in rotational errors. VERT helps patients to understand the importance of following bowel and bladder treatment preparation instructions and it provides excellent levels of communication. However, more research and documentation of the effect is needed.

Annette Boejen, Head of the Learning Centre, RN, RTT and Rikke L. Poulsen, RN, RTT, project manager, Department of Oncology, Aarhus University Hospital, Aarhus C, Denmark