Highlights
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Radiation Therapists often treat with reirradiation which impacts the full patient care pathway.
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Prior record access, standardized team workflows are critical for effective reirradiation.
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Radiation Therapists report competency gaps related to reirradiation physics and radiobiology.
Keywords: Reirradiation, Radiation therapist, Radiation therapy, Patterns of practice, Competency, Survey
Abstract
Purpose
Reirradiation for patients with new, recurrent or metastatic tumors is complex and requires intensive collaboration between Radiation Oncologists, Medical Physicists, and Radiation Therapists (RTT). Aside from dosimetry, little has been reported on the role of the RTT in reirradiation. The study characterized the reirradiation patterns-of-practice of RTTs to understand the knowledge and skills being applied in this increasingly important area of cancer care.
Materials and Methods
A cross-sectional, survey was conducted of all RTTs practicing in Canada over a 3-month period. The 48-item questionnaire asked RTTs the frequency of performing a range of reirradiation activities, to self-rate their competency levels, and to identify enablers and barriers to reirradiation practice. The survey was distributed by email and data were analyzed with descriptive statistics or thematic analysis for free-text responses.
Results
Responses from 214 RTTs revealed frequent and significant involvement in all steps of reirradiation pathway, ranging from pre-treatment imaging and positioning to patient supportive care. There was lower involvement in advanced reirradiation dosimetry techniques, which coincided lower competency self-ratings and knowledge gaps in this area. Access to prior patient records, standardized reirradiation workflows and multi-disciplinary communication were the most common elements reported as important for reirradiation practice.
Conclusions
RTT reported frequent and significant involvement in all steps of the reirradiation care pathway. Providing focused education and training for RTTs on reirradiation, coupled with team workflow optimization may enable more effective, safe and streamlined reirradiation care for patients.
Introduction
Reirradiation is being increasingly used to manage recurrent, metastatic, or new primary tumors and has been reported to now comprise an upwards of 25–30 % of cases in radiotherapy clinics [1,2]. The ESTRO-EORTC consensus defines reirradiation as a new course of radiotherapy overlapping a prior course, or when there is a heightened risk of toxicity from cumulative doses [3]. A large international survey of oncologists reported significant institutional variation in clinical application of reirradiation, highlighting the need to define optimal technical solutions and generate high-level evidence in prospective studies [4]. In the absence of best-practice guidelines, reirradiation workflows are often complex, resource intensive, and require strong inter-professional effort.
Given that normal tissues may have received prior doses near acceptable limits, optimal treatment planning for reirradiation may involve external record retrieval, image registration, and equi-effective dose summation prior to optimization [5]. As a result, research has focused on improving both the technical and workflow aspects of reirradiation treatment planning [2,5,6,7,8]. For example, dedicated medical physicist roles for reirradiation termed the ‘special medical physicist consult’ have been implemented at several institutions. These have enabled streamlined yet comprehensive dose evaluation to safely deliver reirradiation [6,7,9]. A survey of 13 North American institutions reported considerable variation in the level of involvement in different reirradiation tasks by oncologists, medical physicists, and dosimetrists, highlighting the need for effective teams [9]. A current lack of availability of advanced tools (e.g., deformable registration, radio-biologically corrected 3D doses) combined with low knowledge and skill in their safe application have also been noted as barriers to reirradiation planning [2,9]. In contrast to planning, far less attention has been paid to other steps in radiotherapy pathway that may be impacted in reirradiation cases including patient-facing RTT care.
RTT perform positioning, simulation, image-guided treatment delivery, and support patient care, all of which may have additional challenges for reirradiation cases. Understanding and enhancing RTT practices would enable consistent and high-quality reirradiation as has been demonstrated in other technologically complex scenarios such as online adaptive treatment [10,11,12]. RTTs in specialist or advanced-practice roles have also enabled expanded clinical capacity, streamlined care, and offered new services for patients [13]. There are no reports of the full scope of RTT practices applied in the evolving field of reirradiation.
The objective of this study was to characterize current reirradiation practices among RTTs in Canada. Specifically, it aimed to identify potential gaps in knowledge and competencies by comparing existing practices to the national competency frameworks and relevant international guidelines, with a focus on both the medical and technical considerations associated with reirradiation.
Methods
This pan-Canadian study used a prospective, cross-sectional survey of RTTs to characterize patterns of practice and self-rated competency levels in clinical cases of reirradiation. Eligible participants were RTTs certified to practice in Canada, including dosimetrists. Of note, Canadian RTTs are typically trained in dosimetry as part of entry-to-practice training without a requirement for dosimetry-specific certification. Participation was voluntary and anonymous with informed consent obtained electronically before questionnaire completion. The study was approved by the research ethics board at an academic cancer centre.
Questionnaire Design
A 48-item questionnaire was developed with four sections (Appendix A). The first part captured RTT demographics, the anatomic sites encountered for reirradiation and the frequency of cases. In the second section RTTs rated the frequency they participated in 19 reirradiation activities using a five-point frequency scale or selected either ‘Unsure’ or ‘N/A’. Items were initially derived from ESTRO-EORTC consensus recommendations and studies of reirradiation workflows [3,5,7,14]. In the third section RTTs self-rated their level of practice across 16 competencies in the setting of reirradiation using four-point rating scale or selected either ‘Unsure’ or ‘N/A’. Items were adapted from the Canadian Association of Medical Radiation Technologist (CAMRT) competency profile for entry-to-practice RTTs based on those competencies identified as being most relevant for reirradiation by the study team [15,16]. Finally, the last section captured perceptions of how reirradiation practice differs from other cases, interest in further training and open-ended questions on barriers and enablers regarding reirradiation practices were also included. An enabler was defined as a task or process that was positive or working well in clinical practice. A barrier was defined as something that was not working well.
The questionnaire was reviewed for face validity by the study team comprised of RTTs with reirradiation expertise and an early-career RTT, medical physicists, a radiation oncologist, and a patient partner. It was piloted for clarity with 5 volunteer RTTs taking approximately 20 min on average to complete. Machine translation was used to develop a French language version and reviewed by a bilingual RTT.
Survey administration and analysis
Informed consent, questionnaire administration and data management were done using a secure web-based application hosted locally (REDCap [17,18]). Potential participants were invited via an email that was primarily distributed by the national professional association (CAMRT) to its ∼ 1500 individual RTT members, followed by one reminder email. Managers of radiation therapy departments at each of the 48 cancer centres across Canada were also invited by email and encouraged to distribute the questionnaire to local RTTs.
Questionnaire response data were summarized using descriptive statistics. RTT responses indicating an item was not applicable (‘N/A’) to their practice were excluded from all results. Differential responses were explored across RTT demographics including geographic location, level of clinical experience, and area of professional practice (e.g., planning, treatment, etc.). Proportions were compared using Chi-squared tests with P < 0.05.
Free-text questions were thematically analysed as follows. Responses were grouped based on similarities observed into emerging themes by one researcher and reviewed by a second researcher. Discrepancies in theme assignment were discussed and resolved by consensus agreement.
Results
Over a three-month period (January–April 2025), 214 questionnaire responses were collected from RTTs across 9 Canadian provinces representing a 14 % response rate (estimated from CAMRT RTT membership). No responses from Quebec or the Territories were received. The majority 67 % (n = 144) had 11 years or more of experience and were working primary in treatment delivery 71 % (n = 152), CT-simulation 38 % (n = 82) and dosimetry 29 % (n = 61). Fifty-nine percent (n = 126) had university-level RTT education. Reirradiation-specific training was acquired during entry-to-practice education (47 %, n = 101) and/or by clinical experience (73 %, n = 156). Reirradiation cases were frequently encountered in clinic, with 57 % of RTTs reporting at least monthly, covering all anatomic tumor sites. Additional details of RTT experience and demographics can be referenced in Appendix B Supplementary Table 1.
Patterns of RTT practices in reirradiation
RTTs rated how different their responsibilities and scope-of-practice for reirradiation cases versus conventional cases as 7 % very different, 23 % somewhat different, 33 % slightly different, 25 % similar or 13 % not different.
See Fig. 1 illustrates the frequency of RTTs performing reirradiation activities, ranging from pre-treatment to image-guided delivery. The most frequently performed tasks by RTTs (sum of ‘Sometimes, ‘Often’ and ‘Always’) were replicating previous positions at pre-treatment (94 %), image-guided reirradiation delivery (87 %), reproducing reirradiation setup for treatment (84 %), and designing optimal reirradiation plans (79 %). The least frequent performed by RTTs were completing radiobiological dose corrections (30 %), deformable image registration (36 %), delineating targets for reirradiation (44 %) and educating patients on reirradiation side effects (52 %). Over a quarter were also ‘unsure’ if RTTs performed deformable registration or radiobiological dose corrections.
Fig. 1.
Diverging stacked bar graphs of RTT frequency performing reirradiation procedures (%), sorted by the most common and with the ‘Rarely’/’Sometimes’ division as a reference point. Note that ‘Unsure’ responses are subjective and do not necessarily indicate lowest level. Note: re-RT = reirradiation.
Competency in reirradiation practice
The self-rated level of practice of RTTs regarding key competencies relevant to reirradiation is shown in Fig. 2. The highest proportions of competency (sum of ‘Competent’ plus ‘Proficient/expert’) were observed for treatment delivery (93 %), image-guidance (87 %), optimizing pre-treatment imaging/positioning (83 %), and applying knowledge of cross-sectional anatomy and physiology (72 %). The lower proportions of competency were for validating dose/fractionation (37 %), designing re-RT plans to limit organ-at-risk doses (50 %), and applying knowledge of reirradiation physics (49 %) and radiobiology (56 %). Table 1 reports the RTT interest in further education, with a majority selecting areas of radiobiology and clinical applications for reirradiation.
Fig. 2.
Diverging stacked bar graphs of RTT self-reported competency level for reirradiation cases (%), sorted by the most frequently reported as competent or higher, and with the ‘Advanced beginner’/’Competent’ division as a reference point. Note that ‘Unsure’ responses are subjective and do not necessarily indicate lowest level. Note: re-RT = reirradiation, RTT = Radiation Therapist.
Table 1.
RTT interest in reirradiation education and training (n = 214).
| Knowledge area | Responses |
|---|---|
| Radiobiology of reirradiation (bio-effective/equivalent dose scaling, organ-at-risk recovery) | 75 % |
| Clinical applications (indications, safety, toxicity, outcomes) | 67 % |
| Physics of reirradiation planning (deformable registration, dose warping and summation) | 48 % |
| Patient care (education, side-effect management and support, coordination of care) | 45 % |
| Planning workflows (reviewing plan records, dose constraints, composite dosimetry) | 40 % |
| Imaging and treatment considerations (positioning, motion management, image-guidance) | 30 % |
Enablers and barriers to reirradiation
Barriers and enablers to reirradiation processes identified during thematic analysis are shown in Table 2. The most common themes were accessing prior treatment records (dosimetry and setup instructions), followed by communication within the radiation team, and standardized processes across the entire workflow (scan, plan, and treatment delivery). A common gap in practice was timely access to previous radiation therapy records and sharing effective communication strategies in departments where input from RTTs is underutilized.
Table 2.
Thematic analysis of qualitative RTT responses on enablers and barriers of high-quality reirradiation practice.
| Theme | Enablers | Barriers |
|---|---|---|
| Prior patient records, n = 89 |
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| Multidisciplinary communication, n = 79 |
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| Standardized practices, n = 67 |
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| Dosimetry, n = 52 |
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| Patient-centered care, n = 21 |
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| Experience, n = 18 |
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Exploratory subgroup analyses
There were significant differences (p < 0.05) between RTT with planning experience who self-rated at higher levels of practice across eight activities versus other roles, most of which were competencies directly related to dosimetry (Fig. 3). Other competencies were not different (p > 0.05) between the two groups. A similar pattern emerged comparing RTTs with > 10 years of experience who self-rated at higher levels versus with those with < 10 years, as more experience was associated with being in a dosimetry role (Appendix B Supplementary Table 2). Level of practice ratings across all competencies were comparable when examining responses from the provinces with the highest response rates: Ontario, Alberta, British Columbia (data not shown, P < 0.05).
Fig. 3.
Differences in self-rated level of practice between RTT in dosimetry roles versus all other roles combined, for select reirradiation competencies with significant differences (p < 0.05, Chi-square test). Competencies not listed were not significantly different.
Discussion
This study is the first to characterize RTT patterns of practice in reirradiation. The majority of RTTs (55 %) in Canada frequently provide care for re-RT patients impacting pre-treatment simulation, dosimetry, and image-guided treatment delivery. In addition, RTTs are regularly involved in replicating prior treatment positioning for simulation and performing image-guided delivery. This is to be expected as the highest frequencies of primary practice was CT simulation and treatment delivery. Fewer were involved in and expressed lower levels of competency in radiobiologic dose corrections and deformable image registration. These later activities appear to be more concentrated to RTTs engaged in treatment planning roles, suggesting an uneven distribution of expertise within the RTT team. Although treatment planning is particularly important for reirradiation, the results reveal that RTTs with CT-simulation and treatment delivery experience placed high value on accessing prior treatment records (e.g. to replicate prior position), effectively coordinating with all team members and standardized reirradiation workflows extending from pre-treatment to treatment delivery. This research identifies areas of focus for skill development, and furthers highlights the need to optimize the role of RTTs within the reirradiation care team and develop more streamline reirradiation practices in the increasingly complex area of radiation therapy.
Our findings align with existing literature reporting international variability in reirradiation workflows and roles across jurisdictions [4]. Compared to the work of Vaquez Osorio et al. which emphasizes formal planning team collaboration and structured planning processes[2], Canadian RTTs reported more fragmented participation. Murray et al. reported RTTs in the UK were rarely if ever involved in deformable image registration and dose accumulation[5], which is inconsistent with Canadian RTTs in the current study reporting moderate to occasional involvement in these areas. Notably, Canadian RTTs appear more engaged in patient-facing aspects of care such as patient setup, delivery, and side effect management. While RTTs play a significant role in delivering care, their knowledge around late effects and cumulative toxicity in reirradiation may be underdeveloped (Table 1), a finding echoed in previous studies noting gaps in radiation oncology teams’ preparedness for increasingly personalized and complex treatment plans [19,20].
From a clinical perspective, these gaps have meaningful implications for patient care as reirradiation becomes more common. RTTs play a critical role in patient education, psychosocial support, and safety checks during reirradiation [21]. Yet, our results suggest that RTTs may not be adequately trained to navigate the unique considerations of reirradiation, such as cumulative dose limits, uncertain toxicity profiles, and patient expectations around outcomes and risks. This reflects a broader issue in oncology, where patient education on reirradiation is often limited or inconsistent, and inter-professional communication may fall short [22]. Patients undergoing complex or palliative radiation treatment may need additional psychosocial and informational support, and RTTs are well suited to fill this role with additional structured education [23,24]. Moreover, since reirradiation treatments are highly personalized to the patient, it is challenging for RTTs to give patient-specific education when they are not involved in discussions with the Radiation Oncologist and patient regarding the complexities specific to their case. These findings highlight the need to incorporate reirradiation-specific education into both entry-to-practice and continuing professional development for RTTs. Doing so would not only enhance technical competency but also empower RTTs to provide high quality, informed, and compassionate care to patients undergoing reirradiation.
Barriers to high-quality reirradiation practice were primarily systematic. Limited access to historical treatment records, suboptimal communication across professions, and a lack of standardized protocols were consistently identified. These organizational inefficiencies not only risk compromising care quality but also place undue stress on RTTs, particularly in high-acuity reirradiation cases. The thematic analysis reveals a clear opportunity to enhance access to electronic medical record systems and radiotherapy data standardization so that cancer centres can retrieve previous records in a timely manner. However, financial resources and institutional variability in data sharing practices plays a significant barrier for some institutions [25]. More importantly, privacy legislation further complicates data sharing as institutions face fragmented, region-specific variations. Solutions such as interoperable electronic medical records with tiered access permissions and patient-portal-mediated consent workflows could mitigate these barriers while maintaining compliance [26]. The thematic analysis also highlighted a need to strengthen communication amongst an interprofessional team and embed RTT voices into clinical decision-making processes. Schultz et al. proposed that clarifying roles in an interprofessional team could improve communication in the context of a multidisciplinary team while enhancing patient centric care [13,23]. When doing so, RTTs can be positioned as individuals who can receive specialized training to gain core competencies for advanced reirradiation tasks to streamline care [13].
The desire for continuing education was robust, with 74 % of RTTs identifying radiobiology and reirradiation clinical applications as priority learning areas, provides a foundation upon which professional bodies, academic programs, and healthcare institutions can build. Furthermore, this highlights the need to accelerate efforts to upskill RTTs so that they can play a more impactful role in decision making within an inter-professional team. Generally, RTT’s felt that roles and responsibilities for reirradiation were similar other clinical cases, and it is presently not clear if specialized or advanced practice roles focused on reirradiation are warranted. The results of this study overall suggest initiatives focused on up-skilling all RTT as part of standard practice may be beneficial given the frequency of reirradiation cases.
Limitations to this study include the low response rate, including an absence of responses from some provinces such as Quebec, and that it was limited to RTTs in Canada. However, the response rate is in line with other studies using similar recruitment methods of RTTs in Canada [28,29,30]. Another potential limitation is that RTTs with no reirradiation experience may have declined to participate, also contributing to the low response rate. However, given the high frequency of reirradiation cases reported in prior studies [1,2] and the ranges of experiences reported in the current study (Supplementary Table B.12), the study sample is likely to be representative of Canadian RTTs. Further study may be needed to validate reirradiation practices externally, given RTT roles and training may vary substantially internationally. As multi-disciplinary efforts mount to develop reirradiation care, including ESTRO-EORTC’s platform E2-RADIatE and the multi-society Reirradiation COllaborative Group (ReCOG) [4,27], RTTs will need to engage to help define best-practices.
Conclusion
This pan-Canadian study of RTT patterns of practice revealed frequent and significant involvement in all steps of reirradiation pathway spanning pre-treatment, planning, delivery and patient care. However, RTTs reported more limited application of advanced reirradiation dosimetry techniques, underpinned by limited knowledge of reirradiation clinical physics and radiobiology. Systemic barriers were also identified including access to prior patient records as well as ineffective communication within a multidisciplinary team. Addressing these gaps through education and training, coupled with team workflow optimization will allow RTTs to effectively provide safe and streamlined reirradiation care for patients.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
ACKNOWLEDGEMENTS
This study was funded by a Canadian Association of Medical Radiation Technologists (CAMRT) Research Fellowship Grant (M.Velec). The authors thank Tatiana Ritchie, Princess Margaret Cancer Centre, with French translation editing.
Footnotes
This article is part of a special issue entitled: ‘Reirradiation’ published in Technical Innovations & Patient Support in Radiation Oncology.
Supplementary data to this article can be found online at https://doi.org/10.1016/j.tipsro.2025.100329.
Appendix A. Supplementary data
The following are the Supplementary data to this article:
Data availability
Data will be made available on request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data will be made available on request.