Patient Experience with Tattoo-Less Setup and Open-Face Masks

When we were first looking into SGRT, this was when I was working with US Oncology back in circa 2014. We were not exactly thinking about a patient experience. At the time, the evaluation committee was looking for a clinically useful solution that would enable faster workflow, faster setup, and motion management. We were focused on the clinical efficiency, not on patient experience. But as it turns out, that’s one of the biggest advantages of SGRT. So today I’m going to focus on patient experience, particularly for tattoo-less treatments for breast cancer patients and open face mask.

So here’s my agenda this morning. First, we’ll look at what patient surveys say about tattoos and skin marks in breast radiotherapy. And second, we’ll look at the data behind tattoo-less setup. And third, we’ll specifically look at the postural video feature. Then we’ll switch to the aspect regarding patient experience with open face mask and how SGRT complements its use. And lastly, just to wrap up by describing how we at Texas Oncology implement these workflows.

Okay. So most of us think of patient experience as maybe the soft touchy-feely aspect of radiotherapy. For example, how a woman feels about personal identity and body image because tattoos leave a psychological impact, or how a patient feels under a tight mask for immobilization. And Dr. Quan, I talked about loss of control for her breathing, but we think about the loss of control, distress, and anxiety, and then how patient feels when his or her body is exposed or immobilized. And the last aspect is just the treatment time, how long being on the couch matters. The point I want to make is that patient experience is not just soft, but it is clinical. A good patient experience translates into good clinical practice, meaning better treatment quality and treatment efficiency. And so in the next few slides, I will present evidence that shows how patient comfort affects motion compliance, gating events, setup accuracy, et cetera, and then how setup accuracies then correlate with decreasing repositioning rates and imaging frequency, and how all this translates into just better health economics to reduce work staff and increase throughput.

So from a survey of members of the Young Survival Coalition, which is an organization dedicated to issues unique to women diagnosed with breast cancer under the age of 40, they asked, “What are your overall feelings about receiving tattoos as a part of your cancer treatment?” Majority of young women scored negative or strongly negative. Similarly, follow-up question on, “What were your feelings about skin marks during your radiotherapy treatment?” And 70% of women scored negative or strongly negative. So, the conclusion from the author was that there was universal negative sentiment towards treatment-related tattoos and radiation skin marks.

In the same survey, 78% of women said that they would choose treatment to avoid tattoos, even if it means additional efforts such as additional costs, additional distance in miles traveled, or time for travel. So SGRT does allow us to remove the burden of tattoos and skin marks without sacrificing accuracy. And we’ll go into this in a little bit, but since 2023, in one of my practice sites, we transitioned to 100% tattoo-less for our breast cancer patients by using SGRT. The benefit for the patient is immediate and transparent, and there’s no more permanent skin marks, less anxiety attributed to the day-to-day marker care, no more worrying about losing their marks or humiliation that comes from the manual handling on the couch. And furthermore, patients feel more comfortable being coached, monitored in real time, getting feedback from therapists, especially when it comes to DIBH.

So what does the published data show and what we have seen in our own clinic is that tattoo-less positioning results in the same, or in some cases, even better setup accuracy compared to the traditional way of aligning in-room lasers to skin marks. So in a UK study comparing tattoo-less SGRT versus traditional tattoo-based setup, patients were further divided into free-breathing right breast and left breast DIBH. So they found that for the right breast free-breathing treatments, tattoo-less setup was similar in terms of mean shifts with traditional tattoo setups. And for left breast DIBH treatments, tattoo-less SGRT actually showed better setup accuracy with significantly smaller mean shifts compared to tattoos. And on the right side, in another pilot study from the Guy’s Hospital, the investigators used a step-wide implementation by first comparing tattoos plus SGRT versus the tattoo-only setup. And initially, tattoos plus SGRT showed a statistically significant improvements in lateral, vertical, and total translational displacements compared to tattoos only. So then subsequently, the center described how they moved towards implementing tattoo-free SGRT.

And just in a larger multi-institutional study, looking at 184 patients, investigators here compare the setup accuracy of tattoo-less versus traditional skin marks in specifically in hypofractionated whole breast irradiation. And again, the three graphs show that there was no statistically significant difference in these two groups in any direction, vertical, longitudinal, or lateral. One thing that this study looked at was time. So average time from initial positioning to the treatment beam completion for each of the 16 fractions of a typical course of hypofractionation. It shows that in the asterisks on the far right that the mean time across all fractions was reduced in tattoo-less SGRT compared to the traditional tattoos. And additionally, the most pronounced reduction in time was observed in the first treatment day.

So why is this reduction in setup time important? Because reduced setup time translates into improved clinical efficiency. And another way to look at it is from the AlignRT service data comparing time on couch for pre SGRT shown in the blue versus post SGRT AlignRT shown in the magenta. So here the post AlignRT group demonstrated clinically meaningful reductions in patients’ time on couch. That’s equal to time in position for both prostate and breast DIBH. And shorter time on couch translates into, for us, better patient experience.

So next I want to highlight a feature of AlignRT, the postural video. So basically, it overlays the traced reference image onto a live video during the setup and also during treatment at the time of monitoring. So the therapist can make corrections in real time without pre postural video where you have to do multiple static captures. And for us, it’s been especially useful for regional nodal treatments when you’re looking at supraclavicular fields or high axillary, looking at movement of neck and shoulder rotations. So we refer to this as the patient comfort amplifier because it reduced time for patients in the uncomfortable position without compromising accuracy.

Okay. So again, the data behind this comes from a nice service data evaluation done at Christie NHS Foundation Trust. So they compared AlignRT with postural video versus just AlignRT without the postural video, looking at in respect to workflow efficiency and also setup accuracy. And workflow efficiency was measured as the time taken from when the patient got into the treatment couch to the time to delivery of the final treatment beam. So in other words, setup time plus delivery time. And they found that AlignRT with postural video resulted in mean reduction in time of 155 seconds or two minutes and 35 seconds per fraction. And another study from 2024 showed that AlignRT with postural video saved almost 28.8% in setup time, plus the 60-second wait time, and reduced repeat imaging rates also. So again, I want to stress the point from both the Christie study and this study is that less time in position during setup and beam means less re-imaging, and that equals to overall better patient experience.

So next, I just want to shift from breast cancer to head and neck cancer. We all know that closed face masks, especially the shoulder length IMRT masks, a lot of times are associated with a lot of discomfort, claustrophobic anxiety for patients. And some qualitative interviews with head and neck patients show that mask anxiety mainly comes from being clamped down and the subsequent feeling of not able to cope or loss of control with that being clamped down. And so open face mask may be a solution to reduce this anxiety. In fact, in a recent single-center, self-control randomized crossover trial, this was from the University Hospital in Zurich, Switzerland. So for this study, at simulation, two masks were made for each patient, one closed and one open face, and patients were initially randomized to start radiation with either a closed or open face mask. And then halfway through the treatment course, the masks were switched, and every patient served as his or her own control. And the primary endpoint was patient self-reported discomfort using this visual analog scale or VAS. And what they showed was that the VAS score, the discomfort score, and also the pain and anxiety score were much lower with open face mask compared to closed masks. The secondary endpoint was looking at intrafraction and interfraction setup variability also. One thing in the post-treatment survey, most of the patients reported that they much prefer the open face mask compared to the closed.

So in this study from St Luke’s Hospital in Dublin, investigators conducted a clinical trial called Optimizing Patient Experience in Head and Neck Radiotherapy or the Open Phase 3 Trial, and they randomized patient into one of three arms, which is one is closed face mask, two is a three-point open face mask, and then three is a five-point open face mask, and looked at intrafraction motion using both cone beam CT and SGRT. And they found the SGRT scored 95 percentile deviation across all patients. One thing they noted was SGRT detected transient max deviations not captured by cone beam CT, particularly in the yaw axis. So what does SGRT add to open face mask? Basically, the use of SGRT allowed for the detection of transient deviations and rotational differences that were not detected using cone beam CT. It supports a more safe adoption of open face masks. It gives the physician and the physicist more confidence in using a reduced immobilization. And these are for head and neck, and also there are reports in SRS, but I won’t go into that. I’m going to skip that.

So I’m just going to wrap up by talking about our experience. So at Texas Oncology, I would consider we were relatively early adopters of SGRT. Back in around 2014, 2015, we had around three to four sites, Memorial City, West Plano, Longview, Round Rock, that were among the first Texas Oncology sites to commission and use. Back then, it was Vision RT’s OSMS. Since then, those sites have all implemented different complex workflows. And our practice have grown. I was just talking to Jeff Limmer. We’re now more than 50 plus sites, and we have more than 80 LINACs in Texas Oncology. And as we grew, we were looking at different commercial SGRT products to achieve our goal of improving clinical efficiency, but also improving patient experience. And we evaluated AlignRT, Identify, BrainLab, C-Rad, and in the end Vision RT, we agree that Vision RT, because it was the first mover in the SGRT space, had a decade or more of jumpstart with the optical refinements and software integration. We decided that going forward, as we replace old LINACs, all new LINACs will have SGRT capabilities using Align RT.

At my own site, so in my own practice, we opened, in 2023, two years ago, a site on the Women’s Hospital of Texas in Houston, specializing in breast cancer. And we were able to successfully, within a few months, implement going tattoo-less for our breast cancer patients. And like any complex workflow, required a lot of training, competency, and SOPs, and QAs. And our physicists and therapists did all the heavy lifting, get all the credit. But we also relied a lot on the Vision RT staff for training and support. But we were able to pretty quickly, we did a stepwise implementation going from tattoos plus Align RT, and then going full Align RT with tattoo-less.

So in summary, tattoo-less setup removes a real psychological burden while maintaining setup accuracy, and the postural video feature is really helpful for our therapists, and that the proof is in the pudding. And then looking at head and neck cancer patients, open face masks improve patient experience, and SGRT definitely support the stability and allow us to be more confident in the reduced immobilization.

*This transcript has been AI-generated. Contact us at secretary@sgrt.org if there are any issues.