1. ROSALEEN CROUCH BSC (HONS), TEAM LEADER RADIOGRAPHER RADIOTHERAPY DEPARTMENT WESTON PARK HOSPITAL AMY TAYLOR BSC (HONS), MSC, PGCE, FHEA. SENIOR LECTURER SHEFFIELD HALLAM UNIVERSITY Time to Review: Evaluation of the timing of on treatment dietetic review after the introduction of Rapidarc for head and neck cancer patients.

2. BACKGROUND RapidArc™ (VMAT) for head and neck patients was introduced at WPH from November 2012, and replaced fixed field IMRT which had been in clinical use from 2003. RapidArc™ has shown great potential in reducing side effects, when compared to 3- dimensional conformal Radiotherapy; hence, an increase of the quality of life for patients receiving Radiotherapy, without compromising the probability of tumour control. (1,2,4,5 ) CBCT imaging was introduced alongside RapidArc™. This enabled us to monitor contour changes more closely than ever before. The decision was taken to increase the dietetic support offered to these patients in order to minimise weight loss and therefore contour changes. Was there evidence of severity of treatment toxicities that would also support this change in protocol?

3. AIMS AND OBJECTIVES Aim To assess whether the change in the timing and frequency of the on treatment dietetic reviews for head and neck patients was justified in light of toxicity data. Objectives To collect toxicity data for 50 patients receiving Rapidarc™ for head and neck cancer. To analyse the data to look for emerging trends. To assess whether the changes made to the timing and frequency of the dietetic support offered to these patients was justified in light of this evidence. To make recommendations for alteration/improvements/ areas for further study. To disseminate this information to peer group/multidisciplinary team.

4. METHOD 50 patients randomly selected. September 2013 and March 2014. Toxicities assessed by medical staff using a toxicity scoring sheet. These toxicities were graded using the CTCAE criteria. The data collected was analysed to look for any emerging trends. TOXICITYWEEK 3WEEK 5FINAL WEEK ORAL/ PHARYNGEAL MUCOSITIS PHARYNGEAL DYSPHAGIA LARYNGEAL INFLAMMATION XEROSTOMIA TRISMUS PROPORTION PEG FEEDING

5. RESULTS - WEEK THREE REVIEW

6. RESULTS- WEEK FIVE REVIEW

7. RESULTS - FINAL WEEK REVIEW

8. LIMITATIONS It was only possible to collect 39 data sets, not the 50 as originally intended. Of these 39, only 8 were complete data sets. The results show that the completion rates were better at the start of radiotherapy but these rates worsened significantly for the final week of treatment. Clinicians have identified that workload pressures made it increasingly difficult to have the time to complete the scoring sheet- the sheet could often get lost inside the patients treatment packet. Due to the lack of complete data sets it was necessary to review the data as a whole regardless of site and adjuvant treatments e.g. Chemotherapy/Cetuximab. Therefore there may be variation in the data because of this.

9. CONCLUSIONS AND RECOMMENDATIONS Conclusions This study has shown that patients are experiencing toxicities that will affect their ability to maintain an adequate oral intake from an early stage of their radiotherapy. Patients require early dietetic intervention to provide them with adequate advice and support to enable them to cope with the side effects of RapidArc for head and neck cancers. The increase in the frequency and the changes made to the timing of the dietetic review protocol for these patients is justified. Recommendations Increase awareness of the importance of the role of the dietician in the management of head and neck patients. Investigate methods of digital data collection to improve data collection success rates- Specialist Radiographer or Nurse role? Possible scope to roll out to other treatment sites.

10. ACKNOWLEDGEMENTS First and foremost, all the patients at WPH who took part. Bernadette Foran, Consultant Clinical Oncologist, Weston Park Hospital, Sheffield, UK. James Lester, Consultant Clinical Oncologist, Weston Park Hospital, Sheffield, UK. Nicola Moran, Senior Dietician, Weston Park Hospital, Sheffield, UK. Patrick Dawson, Student Radiographer, Sheffield Hallam University.

11. REFERENCES 1. Alongi, F., Bignardi, M., Garassino, I et al 2012, "Prospective phase II trial of cetuximab plus VMAT-SIB in locally advanced Head and Neck Squamous Cell Carcinoma”, Strahlentherapie Und Onkologie, vol.188,no.1, pp.49. 2. Smet, S., Lambrecht, M., Vanstraelen, B. & Nuyts, S. 2015, "Clinical and dosimetric evaluation of RapidArc versus standard sliding window IMRT in the treatment of head and neck cancer", Strahlentherapie und Onkologie, vol. 191, no. 1, pp. 43-50. 3. Scorsetti, M., Fogliata, A., Castiglioni, S et al. 2010, "Early clinical experience with volumetric modulated arc therapy in head and neck cancer patients", Radiation Oncology (London, England), vol. 5, no. 1, pp. 93-93. 4. Doornaert, P., Verbakel, W.F.A.R., Bieker, M et al. 2011, "RapidArc Planning and Delivery in Patients With Locally Advanced Head-and-Neck Cancer Undergoing Chemoradiotherapy", International Journal of Radiation Oncology, Biology, Physics, vol. 79, no. 2, pp. 429-435. 5. Matthiesen,C., De La Fuente Herman,T., Singh, H, et al 2014 “Dosimetric and radiobiologic comparison of 3D conformal, IMRT, VMAT and proton therapy for the treatment of early-stage glottic cancer”Journal of Medical Imaging and Radiation Oncology. Published online August 2014 6. Mazzola, R., Ricchetti, F., Fiorentino, A., Fersino, S., Giaj Levra, N., Naccarato, S., Sicignano, G., Albanese, S., Di Paola, G., Alterio, D., Ruggieri, R. & Alongi, F. 2014, "Dose-volume-related dysphagia after constrictor muscles definition in head and neck cancer intensity-modulated radiation treatment", The British Journal of Radiology, vol. 87, no. 1044.