Download Avenues for role expansion in image guided radiation therapy

Australian Institute of Radiography
Student paper: descriptive paper
The Radiographer 2009; 56 (3): 49–54
Avenues for role expansion in image guided radiation therapy: discussion
and recommendations for kilovoltage and megavoltage imaging
R Burow1, J Cavenagh1, C Simpson1, M West1, J Cox1 and K Szymura1,2
Discipline of Medical Radiation Sciences, University of Sydney, New South Wales 2006, Australia,
Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, New South Wales 2065, Australia.
Correspondence [email protected]
1
2
Abstract Recent advances in imaging modalities within radiation therapy departments have the capability to initiate
differing roles for radiation therapists. This has the potential to considerably improve the knowledge base and clinical
skills of radiation therapists, while also enhancing the relationship between the allied health and medical professions. In
addition, the quality of patient care may be improved while reducing the workload of oncologists. This article aims to
discuss possible links between role expansion and image guided radiation therapy (IGRT) and avenues where this may
be possible in modern radiotherapy departments. The work focuses on kilovoltage (kV) and megavoltage (MV) imaging modalities and their use in IGRT processes – primarily at treatment delivery. A literature review was conducted and
knowledge gathered based on clinical experience at a number of departments across New South Wales and Queensland,
Australia with the literature discussed framed by the authors’ clinical learning and experiences. It was found that
information is available supporting role expansion and IGRT separately; however, there is no direct correlation of
information between these two subject areas across the current Australian or international spectra. Role expansion for
radiation therapists must be accompanied by a clear definition of redeveloped roles and responsibilities in order to avoid
confusion between oncologists and therapists. The authors recommend funding as vital to ensure adequate education
and standardised training intra and inter departments. Ultimately, the development of radiation therapists into IGRT
specialists may involve exclusively in imaging planning and treatment aspects.
Introduction
Role expansion is currently occurring in the radiation
therapy setting across Australia and on an international
stage. This is precipitated by advances in technology, particularly medical imaging, and the drive for increased formal
recognition of professional responsibility undertaken. There
is a need for increasing research and literature to document
the evolving nature of the radiation oncology department;
specifically the role radiation therapists play in a continuously
changing technological1 environment. This article explores
current literature to elucidate the status of role expansion
within radiation therapy drawing on examples from similar, or
cognate allied health disciplines to identify opportunities for
role expansion within IGRT.
Role expansion
One aspect of role expansion allows a specialist from within an
area to utilise the skills and areas of practice that were previously
performed by another. The specialist role incorporates greater levels of accountability, responsibility and autonomy than the practitioner previously held.2 In Australia, interest has been expressed
in introducing role expansion into radiation therapy departments.3
This is a result of the effectiveness of role expansion within other
allied health disciplines, the development of new technology,
desire to gain new skills and to provide a higher level of patient
care.2 Extensive literature has been published on the effectiveness
of role expansion within cognate disciplines which also considers the benefits and possible hindrances to the development of an
advanced practitioner.2–11,13,14,17,18,22
History of role expansion
Role expansion has been implemented within a number of
health professions worldwide, particularly nursing and diagnostic radiography. The role of a clinical nurse specialist has been
established and implemented internationally, including in the UK
and the USA.4 The emergence of the advanced practitioner was
precipitated by staff shortages, skill shortages, a need for cost
reduction, government initiatives and health sector programmes.5,6
The UK piloted the development of the advanced practitioner
in nursing throughout the 1980s.5 In addition to developing new
roles, nurses have also extended their scope of practice performing tasks which were previously performed by a doctor; an
example being the prescription of medication.6
In the UK, role expansion has been implemented within
diagnostic radiography most significantly in the area of image
reporting,7,8,9 and also through the development of other specialist
roles such as a gastrointestinal radiographer10; instigated due to
the staff shortages of radiologists.10 Within Australia, advanced
practice for radiography has not been formally established despite
many radiographers indicating that they unofficially interpret
trauma x-rays for the radiologist.11
Radiation therapy advanced practice has not been formally recognised, yet the literature suggests it has been incorporated informally
into daily clinical practice. This is evident by the study performed by
Smith, et al.11 who found 40% of radiation therapists surveyed indicated a senior radiation therapist or chief radiation therapist approved
a final treatment plan rather than the radiation oncologist.11 It was
further indicated that radiation therapists interpret daily treatment
images for verification of treatment field location.
­50
The Radiographer
In a survey of 46 oncology facilities in Australia and New
Zealand, Rybovic, et al.12 showed the roles of image interpretation, and recommendations for subsequent treatment variations,
are most commonly shared between professional groups (radiation oncologists, radiation therapists). However, and importantly,
for a small number of centres it was seen that these duties have
become the sole responsibility of radiation therapists.
This demonstrates that current aspects of modern radiation
therapy practice associated with treatment planning, delivery and
verification can be utilised as avenues for possible role expansion.
Benefits and hindrances to role expansion
The literature suggests that the development of an advanced
practitioner role within the field of nursing has proved beneficial
to the profession.13 The use of an Advanced Nurse Practitioner
(ANP) in North American settings can manage 63% of a
physician’s workload at 38% of the cost; consequently this results
in substantial savings to the health care system.13 Within a radiation therapy context, the implementation of advanced practice
has a potential cost effectiveness as the radiation therapist may
perform some of the oncologist’s areas of practice. This may
result in a decreased need for hiring oncologists of whom there is
a shortage.14,15 Areas where radiation therapists may be able to role
expand in this context will be discussed shortly.
Eddy2 advocates that the development of an advanced practitioner role within radiation therapy has the potential to create
a higher level of patient care through incorporating additional
skills. Role expansion may also be advantageous to the radiation therapy profession through the improvement of professional
status and acclaim.11,16
Literature within cognate health disciplines17,18,19,20,21 also indicates, however, implications for the radiation therapy profession
regarding potential of hindrances for role expansion implementation. Such hindrances include medico-legal aspects, education
standards, medical dominance and the available frameworks and
policies for progression.
Medico-legal issues are heightened due to the increased level
of skills and responsibility associated with advanced practice.
This is evident within the field of diagnostic radiography where
the professional has skills that extend beyond the normal expectations. Subsequently, they are expected to provide a higher level
of care and are legally assessed in this manner.17 Advanced practitioner roles may also introduce greater levels of accountability,
responsibility and autonomy for radiation therapists.
Increased responsibility and accountability may introduce the
potential for litigation.17 In a study of radiography professionals,
Forsyth and Robertson18 showed 55% of respondents reported
feelings of anxiety related to role extension due to issues of
accountability. Forsyth and Robertson18 identify that mechanisms
of accountability, responsibility and clear medico-legal guidelines
must be established and documented for the successful expansion
of roles within diagnostic radiography. To overcome medicolegal hindrances – perceived and actual – similar mechanisms are
required for radiation therapy.
The educational standards and requirements for role expansion
are not formally stated in the Australian clinical environments
making standardisation between departments difficult.2 Eddy also
highlights potential challenges for traditional education methods
which need to be evaluated for effectiveness for successful implementation of advanced practice roles.2
In addition to required educational frameworks, the practical implementation of radiation therapy role expansion may be
R Burow, J Cavenagh, C Simpson, M West, J Cox and K Szymura
hindered if the time required to gain the necessary knowledge
and skills to participate in role expansion tasks is not available.
This is highlighted by a study performed by Spalding,19 who notes
that radiation therapists in the UK struggle to complete daily job
tasks without the additional pressure of “attending courses, gaining further qualifications and providing documentary evidence of
CPD activity”.
Medical dominance can provide a significant barrier to role
expansion which can upset the traditional balance of power
between the allied health professionals and medical professionals.20
Martino and Olde21 suggest that the push for professionalism can
lead to turf battles and inefficient use of personnel, which may ultimately affect patient outcomes. It is emphasised that a consensus
concerning scope of practice boundaries between practitioners is
necessary, requiring clearly defined responsibilities of each role.
This also prevents any issues pertaining to the medical-legal aspects
of accountability, professional responsibility and liability.21
Eddy2 identifies that without a clear framework and policy,
which is constant across all centres relating to the achievement
of advanced practitioner status, formally recognised role expansion causes complications and confusion. It is difficult to achieve
role expansion to its full potential without a foundational basis
provided by protocols. Such protocols can provide frameworks
in which patients are managed, standardising medical care based
upon evidence based-research and ensuring a minimum of care.23
Image guided radiation therapy
Image guided radiation therapy (IGRT) is the process of localisation of the target volume or treatment position by using imaging
modalities in direct conjunction with the treatment; usually in the
treatment room.23 The goal of IGRT is to provide a framework
to manage both inter- and intra-fraction motion to improve the
accuracy of treatment delivery. It involves all steps in the radiotherapy treatment process, from patient immobilisation, CT
simulation, treatment planning, planning verification, patient setup
verification and correction, delivery, and quality assurance.24
IGRT modalities include trans-abdominal ultrasound, implanted markers with MV or kV imaging, optical surface tracking
systems, implantable electromagnetic markers, in room CT
such as the kVCT on rails system, kilovoltage or megavoltage
cone-beam CT (CBCT) and helical megavoltage CT.25 Due to the
variety of methods/techniques used in IGRT, we have limited our
discussion to kilovoltage (kV) and megavoltage (MV) imaging
modalities and their use in IGRT processes – primarily at treatment delivery. Literature, combined with the authors clinical
experience and anecdotal evidence suggests these two new imaging modalities are commonly being introduced or already applied
in Australian radiation therapy departments.
Within an oncology department, both kV and MV imaging can
be employed for many reasons including at treatment delivery,
where an online correction is used to improve setup accuracy,
for both kV and MV imaging.26 Pisani, et al.26 suggested that kV
image based corrections are more effective than MV based corrections; with some site dependence. Pisani, et al.26 also noted
that when using kV imaging, smaller variations in inter-observer
alignment variability and intra-observer variability are found
when evaluated against MV imaging. Better imaging quality
acquired with kV imaging and CBCT provided a highly effective
3D image data set with volume information23 perhaps explaining
these finding.
The ALARA principle (as low as reasonably achievable) which
recommends x-ray exposure should only occur when it produces
Avenues for role expansion in image guided radiation therapy: discussion and recommendations for
kilovoltage and megavoltage imaging
The Radiographer
­51
a net benefit to the patient and can be clinically justified,27 also
indicates kV imaging is justified over MV imaging. The use of
kV images in the radiation oncology department has been shown
to provide lower exposure doses when compared to portal imaging. For example, Walter, et al.23 found for pelvis that kV imaging
reduced patient surface and rectal doses by two orders of magnitude when compared to MV portal imaging techniques.
screening. All authors reviewed the resulting abstracts and articles. At the time of composing this article, all authors have undertaken at least 19 weeks of clinical placements, and the knowledge
acquired during such placements allowed for a comprehensive
analysis of the current status and use of IGRT within Australia.
Such knowledge was verified in consultation with article supervisors who have had extensive clinical experience in these settings.
Role of the radiation therapist
The radiation therapist is involved in the design and implementation of radiation treatment and issues of care and wellbeing
of people diagnosed with cancer and other conditions undergoing radiation therapy.28 The Australian Institute of Radiography
(AIR) defines the scope of practice for an accredited radiation
therapist.28
The current scope of practice indicates that a radiation therapist
is able to perform the following tasks:28
n Patient assessment including psychosocial issues
n Patient positioning and immobilisation
n Manufacture/construction of ancillary equipment
n Simulation, including tumour localisation, treatment planning
and dosimetry
n Treatment by superficial to megavoltage external beams and
verification
n Imaging for planning and treatment verification purposes
n Mentoring, clinical reasoning and research.
The scope of practice includes aspects of modern radiation
therapy relating to the use of image guidance for treatment planning and delivery – these include patient positioning, tumour
localisation and verification imaging.
It is reasonable to consider modern applications of image guidance through IGRT as an avenue for advanced practice within
radiation therapy.
Successful radiation therapy role expansion in IGRT must also
be informed by (i) an understanding of the technology and principles underpinning image guidance and (ii) the current role radiation therapists play in radiation oncology. Understanding these
two aspects will enable identification of contextually relevant
aspects of IGRT where role expansion as potential for success.
It was felt that an exploration of the literature to tie the concepts of role expansion, IGRT and the defined role for radiation
therapists was necessary.
Results
The review found a vast amount of information was readily
available on the features, description and use of IGRT in a clinical setting. Such information included techniques such as CBCT,
kV imaging, electronic portal imaging (EPI), temporal CT image
acquisition (4DCT), gating and tomotherapy, and the benefits of
implementation of these techniques within a radiotherapy department. Similarly, the incorporation of role expansion in a variety
of health sciences disciplines, particularly nursing, appeared to be
an eminent theme presented in the majority of literature searches
relating to role expansion. The authors found that research relating to role expansion and radiation therapy is minimally available
within the international spectrum. However, the literature review
resulted in limited specific information on the link between IGRT
and role expansion internationally. Most critically, the authors
found minimal research relating to the impact of role expansion
and IGRT within the Australian environment.
Method
A literature review was conducted using the internet databases OVID, ScienceDirect, Medline, CINAHL and Scirus from
January 1990 to November 2008. Initial broad searches were
conducted for abstracts and journal articles written in English
using the key words “radiation therapist or radiation therapy
and role expansion”; “radiation therapist OR radiation therapy
and advanced practice”; “radiation therapist and image guided
radiation therapy”; “cone beam computed tomography”; “kV
imaging”; “image guided radiation therapy and advanced practice”; and “radiation therapist and advanced practice and protocol
development”. Professional organisations were searched via the
internet for documents and reports directly relevant to IGRT and
role expansion; such bodies included The Royal Australian and
New Zealand College of Radiologists, The Australian Institute of
Radiography, The Royal College of Radiologists (UK) and The
Society of Radiographers (UK). The “view related articles” link
and online reference lists were used to find additional relevant
articles that were not previously captioned through electronic
Discussion
With new and groundbreaking technology comes the opportunity for radiation therapists to expand their clinical skills and take
on more responsibility within the departments operations.
In synthesising the literature with our professional experience
and opinion we have identified various avenues for role expansion
within the radiation oncology profession as a result of the technological advances of IGRT.
Such opportunities include:
n Extension into other working roles and decision making
n Creation of an ‘IGRT Specialist’ role with appropriate education and training
n Significant role in protocol development.
Implications of these expansions will include:
n Increasing the professional profile of radiation therapists
n Increased job satisfaction with an extended knowledge
base
n Improved efficiency, and hence quality of care, in radiation
oncology practice.
The role expansion opportunities proposed are inter-related by
the very nature of practice in radiation therapy departments.
Extension into other working roles and decision-making
There is a significant shortage of radiation oncologists in
Australia15 and as a result they are subject to an increasing
personal workload. It is apparent that there are opportunities for
radiation therapists to branch into other roles within the radiation
oncology department in order to lessen the workload, particularly
for radiation oncologists.
Some examples of the possibilities for extension within the
radiation therapists’ clinical skills are found within kV and MV
imaging.
Our clinical experience suggests traditional MV portal images
or orthogonal kV images are typically acquired and reviewed
at the time of treatment by two treating therapists with a joint
decision being made for any repositioning that occurs. Any anatomy that lies outside a normal setup tolerance, specific to each
­52
The Radiographer
department, is then referred to the radiation oncologist for review.
In their study of Australian and New Zealand departments,
Rybovic, et al.12 showed this occurs according to departmental
protocol in 92% of centres surveyed.
In the authors’ experience, review of verification images occur
post treatment, possibly after a number of days and occasions of
treatment. The current scope of practice for radiation therapists
making decisions regarding day to day treatments is a part of
departmental protocol. However, despite daily decisions being
made and acted upon, the overall responsibility for the treatment
delivery and prescription lies with the radiation oncologist. We
recommend expansion permitting radiation therapists greater
responsibility in some specific treatment delivery and review
processes (previously domain of radiation oncologist) be allowed
within oncology departments, increasing the level of responsibility of radiation therapists. This may in turn address such issues as
image review turn around times, improving efficiencies.
The authors recommend that radiation therapy professionals
will require training to perform this expanded role to an acceptable
standard. This training may happen intra-departmentally, between
related departments, on a national or tertiary education level.12, 31
Cone beam computed tomography (CBCT) is also in the early
stages of implementation in an effective manner within Australian
departments. The literature and clinical experience suggest this
is currently being utilised to observe bladder filling and rectum
emptying in the treatment of patients with prostate cancer.32,33
These soft tissue data sets are acquired and sent to the radiation
oncologist for review which can occur up to several days after the
information is required. This presents an opportunity for appropriately trained radiation therapists to enter into a role expanded duty
while also reducing oncologist workload and as a result, improve
efficiency in the review process. Higher order soft tissue image
interpretation is not currently addressed within radiation therapy
degree programs. Such knowledge is needed to accurately and
confidently interpret such images and to delineate and identify
anatomy and target volumes. In order to acquire these skills, further tertiary study or training is necessary in order for the therapist
to undertake this new role in a capable and competent manner.
Creation of an IGRT specialist role
The issues of time lag and efficiency of the department
within IGRT operations present an opportunity for the possibility of role expansion for radiation therapists. This leads
to the concept of the creation of a specific IGRT specialist
role. We envisage that one or more radiation therapists within
the department would be responsible for overseeing the IGRT
operations for planning and treatment, in addition to providing
the necessary training to improve the clinical skills of the staff.
The IGRT specialist would be required to undergo additional
education or tertiary study in the area of IGRT concepts that
will provide them with the specialist skills to oversee this
within the department. Minimum requirements may include a
Masters or PhD in research or coursework relevant to imaging
techniques alongside professional recognition and accreditation from bodies such as the AIR. Standard competency and
accreditation is required for these specialist roles, perhaps
using models similar to that of the Australasian College of
Physical Scientists and Engineers in Medicine (ACPSEM).29
This would enable more fluid movement between departments
and define a set of explicit criteria to which candidates must
demonstrate competency to achieve the award or accreditation.
Other avenues of education for therapists that may allow them
R Burow, J Cavenagh, C Simpson, M West, J Cox and K Szymura
to present their knowledge include seminars, participation in
working parties and committees which would allow for sharing
of new skills with the department providing benefit to others.
The creation of this role or something comparable will certainly increase the profile of the radiation therapist within the department and demonstrate the capabilities of the profession. This is
particularly important to move radiation therapy towards a more
defined and fulfilled profession. It is important to note, however,
that not all radiation therapists in the department will necessarily
make the transition to advanced practice roles, as they will require
a significant amount of personal motivation to undertake further
study and undertake the increased responsibility.
Other roles which may be inclusive of the IGRT specialist role could include more physics-based or oncology-based
studies which can give the specialist a more technical and indepth understanding of the technologies and machinery and a
better knowledge of disease processes. This may also lead into
a better technological understanding, as well as improved and
expanded capability to define treatment planning volumes and to
contour critical structures.
Protocol development
Protocol production and improvement, as part of multidisciplinary oncology teams, is currently within the role of some
experienced radiation therapists.
As modern image guidance techniques are being introduced,
there is an obvious need for protocols to be developed within the
department for simulation, planning and treatment. Examples
of this include modifications to existing CT scanning protocols,
positioning and mark up of the patient, daily treatment tolerances
and verification. An individual with a radiation therapy background in addition to extra IGRT training would be a necessary
member on a committee that is deliberating on protocols for this
new technology.
Further knowledge allows for a more informed articulation of
reasoning with an understanding of both technical and clinical
aspects. The scope for radiation therapist participation in protocol
and or guideline development should be expanded from not only
within the department to state, national and international scale.
As mentioned, the implications of successful expansion into
these areas will encourage an increased professional profile, job
satisfaction, efficiency and quality of care in radiation oncology
practice. The benefits in departmental recruitment and retention
experienced by cognate disciplines, such as nursing,6 are valuable
examples for role expansion in radiation therapy.
By increasing responsibility and autonomy within the workplace, IGRT opens the metaphorical door for both clinical and
technical extension within the department and such further specialist training would also allow this new and exciting technology
to be utilised to its full potential. On a big picture scale, radiation
therapists enriching their skills will consequently enhance communication and relationships between the health and medical
professions in addition to providing improved patient care.
Conclusion and recommendations
The concept of advanced practice will undoubtedly evolve
over time and is something that will inevitably require consistent evaluation and re-evaluation because of the changing
nature of technology. Some concepts that feed into advanced
practice within radiation therapy include the extension of the
current scope of practice, creation of new positions such as an
“IGRT specialist”, increasing job satisfaction and enhancing the
Avenues for role expansion in image guided radiation therapy: discussion and recommendations for
kilovoltage and megavoltage imaging
professional standing of radiation therapy. In our current clinical environment, there is a need to standardise and co-ordinate
role expansion for radiation therapists, as well as providing
clear frameworks that define the nature of role expansion. In the
future, the role expansion associated with responsibility of MV
and kV imaging (especially in CBCT) may become routine practice for radiation therapists if it is encompassed within training
and education in addition to the clinical setting environment.
The traditional role of radiation therapists within their respective profession is rapidly changing due to significant technological advancements in image verification. Numerous recommendations can therefore be made in order to take full advantage of the
benefits of role expansion within IGRT in an Australian context.
Indeed, specialist roles with regard to advanced practice
within IGRT may include the implementation of an IGRT specialist. An IGRT specialist could be a radiation therapist who
specialises in IGRT in both planning and treatment aspects, having the responsibility to take online action regarding repositioning, bladder filling and rectal emptying if this is significantly
affecting organ motion on treatment. When used effectively, the
IGRT Specialist would have the capacity to lessen the radiation
oncologist’s workload due to the current shortages present in
Australia.15 The IGRT specialist may be educated in soft tissue
imaging as well as being involved in the quality assurance and
physical aspects of IGRT in order to provide a comprehensive
role speciality.
A clear definition of specialist roles within the department
is fundamental for role expansion in CBCT and kV imaging. A
potential model for radiation therapists to advance into IGRT specialist roles through training and further education is suggested
in the AIR Professional Advancement Working Party Report
(PAWP).3
Eddy2 identifies that without policy providing consistent
requirements for advanced practice across all departments,
attempts at role expansion cause complication and confusion.
This idea is supported by Welgemoed30 who states, “There is a
need for a framework within the profession that clearly conveys
the progression of the therapy radiographer”.
We believe that a clearly defined promotional structure must
essentially encompass IGRT training, education and accreditation. In addition, standardised frameworks across departments will
enable advanced practice radiation therapists to move between
oncology departments with formal recognition of their skills.
Funding must be available for education and training purposes;
additional education and training will provide extensive knowledge
in areas such as soft tissue delineation and professional development activities. With the relevant appropriate training, it is considered that radiation therapists will be able to make accurate and
correct recommendations concerning kV imaging and CBCT.
We recommend designated time periods be set aside in order
for the radiation therapists to participate in suitable training
to achieve an advanced level of competency. Alternatively,
training modules – potentially for all modalities used in image
guidance techniques – could be implemented in radiotherapy
departments and in the current undergraduate or graduate entry
university courses.
Future work may include designing standardised frameworks
for training, creating role definitions for the specialist roles
described, as well as modelling resources (physical and monetary) required to develop and promote the recommendations
highlighted in this work.
The Radiographer
­53
Authorship statement
This article has been produced by Robyn Burow, Jill Cavenagh
and Christine Simpson in association with Mark West, Kathryn
Szymura and Jenny Cox at the Faculty of Health Sciences,
University of Sydney, Australia.
The authors
R Burow BAppSc, J Cavenagh BAppSc, C Simpson BAppSc,
M West MAppSc, J Cox PhD, K Szymura BAppSc.
References
1 Department of Health and Aging. Report of the radiation oncology inquiry.
A vision for radiotherapy. Commonwealth of Australia 2002 in Field N.
Continuing professional education: Do we need it? The Radiographer 2004;
51 (1): 5–9.
2 Eddy A. Advanced practice for therapy radiographers – a discussion paper.
Radiography 2006; 14: 24–31.
3 Australian Institute of Radiography Professional Advancement Working Party.
Victoria: Australian Institute of Radiography 2006: 19.
4 Gibson F. Advancing clinical practice roles within nursing. Orthop Nurs 1999;
3: 41–9.
5 Cowling C. A global overview of the changing roles of radiographers.
Radiography 2008; 14: e28–e32.
6 Latter S, Courtenay M. Effectiveness of nurse prescribing: a review of the
literature. J Clin Nurs 2004; 13: 26–32.
7 Smith T. Baird M. Radiographers’ role in radiological reporting: a model to
support future demand. MJA 2007;186 (12): 629–31.
8 Price RC, Le Masurier SB. Longitudinal changes in extended roles in radiography: a new perspective. Radiography 2007; 13: 18–29.
9 Brealey S, King DG, Crowe MT, Crawshaw I, Ford L, Warnock N, et al.
Accident and emergency and general practitioner plain radiograph reporting
by radiographers and radiologists: a quasi-randomised controlled trial. Br J
Radiol 2003; 76: 57–61.
10 Nightingale J, Hogg P. The gastrointestinal advanced practitioner: an emerging
role for the modern radiology service. Radiography 2003; 9: 151–60.
11 Smith T, Yielder J, Ajibulu O, Caruana E. Progress towards advanced practice
roles in Australia, New Zealand and the Western Pacific. Radiography 2008;
14: e20–e23.
12 Rybovic M, Banati RB, Cox J. Radiation therapy treatment verification imaging in Australia and New Zealand. JMIRO 2008; 52: 183–190.
13 Mirr M. Evaluating the effectiveness of advanced nursing practice. New York:
Springer Publishing Co; 1995.
14 Daly WM, Carnwell R. Nursing roles and levels of practice: a framework for
differentiating between elementary, specialist and advanced nursing practice. J
Clin Nurs 2003; 12: 158–67.
15 Howe P. A serious shortage of radiation oncologists in Australia. The Lancet
Oncology 2001; 9: 528.
16 White P, Lee S, Wong C, Lee A, Cheung D. Role development for therapeutic
radiographers in the public hospitals of Hong Kong. Journal of Radiotherapy
in Practice 2005; 4: 66–77.
17 White P, McKay JC. Guidelines and legal requirements which inform role
expansion in radiography. Radiography 2002; 8: 71–8.
18 Forsyth L, Robertson E. Radiologist perceptions of radiographer role development in Scotland. Radiography 2007; 13: 51–5.
19 Spalding M. Towards continuing education and professional development:
drivers for change in therapy radiography. J Radiother Pract 2003; 3: 131–8.
20 Bolderston A. Advanced practice perspectives in radiation therapy. J Radiother
Pract 2004; 4: 51–65.
21 Martino S, Odle T. Advanced practice in radiation therapy. Alburquerque:
American Society of Radiologic Technologists 2007. pp 21.
22 Nightingale J. Developing protocols for advanced and consultant practice.
Radiography 2008; 14: e55–e60.
23 Walter C, Boda-Heggemann J, Wertz H, Loeb I, Rahn A, Lohr F, et al.
Phantom and in-vivo measurements of dose exposure by image-guided radiotherapy (IGRT): MV portal images vs. kV portal images vs. cone-beam CT.
Radiother Oncol 2007;85: 418–23.
­54
The Radiographer
R Burow, J Cavenagh, C Simpson, M West, J Cox and K Szymura
24 Huntzinger C, Munro P, Johnson S, Miettinen M, Zankowski C, Ahlstrom G,
et al. Dynamic targeting image- guided radiotherapy. Med Dosim 2006; 31(2):
113–25.
30 Welgemoed C. Role development for therapy radiographers in breast planning:
a case study and discussion of influencing factors. Journal of Radiotherapy in
Practice 2008; 7: 47–57.
25 Sorcini B, Tilikidis A. Clinical application of image-guided radiotherapy
(IGRT). Cancer Radiother 2006; 10: 252-7.
31 Rybovic M, Halkett GK, Banati RB, Cox J. Radiation therapists’ perceptions
of the minimum level of experience required to perform portal image analysis
Radiography 2008; 14: 294–300.
26 Pisani LP, Lockman D, Jaffray D, Yan D, Martinez A, Wong J. Setup error in
radiotherapy: online correction using electronic kilovoltage and megavoltage
radiographs. Int J Radiat Oncol Biol Phys 2000; 47 (3): 825–39.
27 Harvey CJ. Principles of radiology. Surgery (Oxford) 2008; 26 (6): 235–8.
28 Australian Institute of Radiography, Competency Based Standards for the
Accredited Practitioner. Australian Institute of Radiography 2005.
29 Australasian College of Physical Scientists and Engineers in Medicine,
Radiation Oncology Medical Physicist’s Training Program: Training, education and accreditation program. Mascot: ACPSEM, 2004.
32 Morin O, Gillis A, Chen J, Aubin M, Bucci MK, Roach M, et al. Megavoltage
cone-beam CT: System description and clinical applications. Med Dosim 2006;
31 (1): 51–61.
33 Polat B, Guenther I, Wilbert J, Goebel J, Sweeney R, Flentje M, et al. Intrafractional uncertainties in image-guided intensity-modulated radiotherapy
(IMRT) of prostate cancer. Strahlenhter Onkol 2008; 184 (12): 668–73.