Radiation Therapists Linked by TELESYNERGY^®

S. Hynds*, E. O’Shea**, D. Hollywood***

* MSc PGD DCRT, Superintendent Clinical Trials Radiation Therapist, Northern Ireland Cancer Clinical Trials Unit, Belfast City Hospital, incorporating Belvoir Park Hospital (Radiotherapy department), Belfast.
** B.Sc. (Ther.Rad), M.Sc, P.Grad.Dip in Stats, Clinical Research Radiation Therapist, Clinical Trials Unit, St. Luke’s Hospital, Dublin
*** MB MRCPI MSc FFRRCSI FRCR MD PhD

INTRODUCTION

Since the 1960’s telemedicine has been used throughout the world as a means of communication between health professionals and between health professionals and their patients. The necessary technology has become more accessible due to a decrease in costs and an increase in the capabilities of the hardware required to support the activities involved. The Centre for Information Technology (CIT) at the National Institutes of Health (NIH) in Bethesda, Maryland, USA, in collaboration with the Radiation Oncology Sciences Program (ROSP) of the National Cancer Institute (NCI) and the NIH Clinical Centre, have implemented a high speed asynchronous transfer mode (ATM) fibre optic network capable of supporting multimedia communication for medical research and education (1). Special purpose medical workstations were initially configured to support the radiotherapy treatment planning goals of the NCI ROSP (2). This TELESYNERGY^® Medical Consultation WorkStation and its technology promotes collaboration between cancer specialists, facilitates professional education and training, and permits consultation in cancer research protocols and patient care throughout the island of Ireland and at selected sites in the United States (3). Integrated Services Digital Network (ISDN) circuits are utilised to extend the ATM network to various medical centres in USA, Dublin and Belfast. The TELESYNERGY^® system represents a marked improvement over standard videoconferencing technologies through better imagery and elimination of delays in communication (4). It offers the added benefit of minimising travel costs and time for patients and care providers and facilitates education, training, and consultation in cancer research protocols and patient care. The technology also helps strengthen national and international expertise in cancer research and treatment by enhancing the adoption of uniform standards of care. TELESYNERGY^® has many potential collaborative and varied uses, including clinical case conferences, grand rounds, expert cas e review, multi-centre radiotherapy planning, and patient screening for clinical trials. The system can also be used to enhance distance learning and seminars, and allows for high-quality diagnostic radiology and pathology image transmission and for discussion and remote manipulation of biopsy specimens.

BACKGROUND

In October 1999, the Minister for Health and Social Services of Northern Ireland, the Minister for the Department of Health and Children of Ireland, and the director of the National Cancer Institute of the United States signed a Memorandum of Understanding establishing the Ireland-Northern Ireland-National Cancer Institute Cancer Consortium. The overall aim of the consortium is to reduce the incidence of cancer through clinical, academic and research collaborations in the three jurisdictions. The implementation of TELESYNERGY^® is part of a larger initiative of the Ireland-Northern Ireland-National Cancer Institute Cancer Consortium to enhance the island's informatics infrastructure as it relates to cancer clinical medicine and research (3). The TELESYNERGY^® equipment was installed and commissioned in St. Luke’s Hospital, Dublin (Figure 1) and at Belfast City Hospital in August 2002 and officially launched in November 2002.



TELESYNERGY^® USERS

TELESYNERGY^® has been installed in Belfast City Hospital in Northern Ireland, St. Luke’s Hospital in the Republic of Ireland, the National Cancer Institute in Washington, Wheeling Hospital in West Virginia and Holy Cross Hospital in Florida. Plans are underway to add the King Hussein Medical Centre, Jordan to this list and a total of 23 systems through the world have been earmarked for this project with the NCI providing mentorship to develop infrastructure for research and collaboration to all 23 centres.

TELESYNERGY^® IN IRELAND

The new state-of-the-art technology enables scientists and clinicians in Ireland to interact in ’real time’ with each other and with cancer specialists at the world-renowned National Cancer Institute (NCI) (4). It places them in a ‘virtual’ room in Belfast or Dublin with all the information and images needed to allow the NCI experts to provide analysis and advice to our leading cancer experts. Without TELESYNERGY^® this sort of interaction would be impossible to achieve unless the NCI expert was physically standing in Belfast or Dublin. The TELESYNERGY^® system will greatly enhance the level of cancer patient care in Ireland and it is the first installation and use of its kind outside the United States.

On November 13th, 2002, a three-way TELESYNERGY^® conference was held between Cancer Centres in Dublin and Belfast, and the National Cancer Institute in Bethesda, MD. Scientists at NCI, along with their counterparts in Dublin and Belfast, used the TELESYNERGY^® technology to seamlessly transmit medical data and images simultaneously between these centres, allowing the participants to collaborate on three separate clinical case presentations.(5)

In addition to standard teleconferencing capability, TELESYNERGY^® allows for the transmission of high-quality diagnostic radiology and pathology images.(6)

RADIATION THERAPISTS AND TELESYNERGY^®

At present the TELESYNERGY^® users are Radiation Oncologists, Physicists, Radiation Therapists, Engineers and Nurses. The first Consortium Users meeting took place in Washington in January 2003, attended by representatives from Ireland, including a clinical trials radiation therapist from St Luke’s Hospital in Dublin (Figure 2). The newly formed Users Group shared their experiences with the system and explored potential applications. One of the initial areas of clinical investigation to utilize the technology within TELESYNERGY^® will be a joint US - Ireland study of the clinical, molecular and genetic factors that predetermine patient sensitivity to new forms of chemo-radiation treatment. Ultimately TELESYNERGY^® will enable the development of an 'international virtual campus' between the geographically separate hospitals and through this enhance all areas of oncology practice including professional training, clinical trial participation, translational research, and the management of patients with compl ex and rare cancers (3). The group shared their ideas about the use of the telemedicine system for educational and training purposes (including joint conferences) and for assessment of the system.



In February 2003, research radiation therapists from Dublin and the NCI had their first TELESYNERGY^® conference and discussed their respective roles, current research interests and outlined how they could use TELESYNERGY^® for sharing information andresearch ideas in the future. Research radiation therapists from St Luke’s Hospital in Dublin and the Belfast City Hospital held their first Telesynergy^® conference on May 7th 2003, with the support of the respective IT Systems Specialists. (Fig. 3 and 4) A number of Radiation Therapists from the Radiotherapy departments from both institutions also participated in this TELESYNERGY^® conference. This meeting was deemed to be a great success by all involved. TELESYNERGY^® proved to be an ideal medium for sharing experiences and ideas and for detailed discussions on topics that included;

• new and ongoing cancer clinical trials,
• radiotherapy feasibility studies,
• case study presentations,
• patient care issues including radiotherapy information, cancer fatigue and acute toxicity assessment,
• new radiotherapy equipment including discussion of lung, breast, head and neck and pelvic immobilisation devices,
• technical issues regarding multi-leaf collimators, electronic portal imaging, image fusion and record and verify systems.

During the TELESYNERGY^® meeting it was possible to transmit pictures of immobilisation devices and discuss the problems as well as benefits of such equipment. The facility of transmitting CT, MRI, PET/CT, or Radiotherapy planning images for discussion and teaching purposes was also explored. The radiation therapists outlined potential areas for their on-going use of Telesynergy^®, including:

• Converse with colleagues, share clinical and research experiences and new ideas that ultimately enhance patient care and radiotherapy services for patients.
• Develop clinical trial protocols and collaborative research.
• Develop the role of the Clinical Research Radiation Therapist by sharing research experiences and information and providing mutual support in this specialised field.
• Patient screening for clinical trials
• Clinical case conferences
• Multicentre radiotherapy planning and quality assurance.
• Continuous professional development and education for radiation therapists

On June 11^th 2003 Clinical trials radiation therapists from the three jurisdictions in the Consortium had their first three-way TELESYNERGY^® conference. They were able to discuss their roles, responsibilities and research interests in cancer clinical trials, accrual figures, information and support for patients and future research collaboration. The participants each took the conference podium to present their work and research interests. For example, research radiation therapist, Karen Ullman, NCI, Washington presented her patient information booklet for prostate patients undergoing MRI guided Brachytherapy, using a video visualiser that was transmitted to the television monitors at the participating centres. This meeting was a great success and has opened the door for future teleconferences allowing radiation therapists to present case studies, research projects and develop radiotherapy clinical trials.

CONCLUSION

Clinical Research Radiation Therapists have a major role as clinical trials co-ordinators undertaking duties of protocol review, ethical approval, patient eligibility screening, informed consent, patient support and information, co-ordination of radiation treatment and follow-up, data management, and play an influential part in the development of new radiotherapy services. They have unique roles, supporting the patient through both the radiation treatment experience and the clinical trial experience, from diagnosis to follow-up. Research radiation therapists benefit from regular TELESYNERGY^® meetings to discuss recruitment to open trials, radiotherapy quality assurance issues, design and completion of case report forms, implications of clinical trials on workload, role development for radiation therapists and collaboration in new trials. In addition, through their participation in TELESYNERGY^® and their subsequent collaboration with international radiotherapy centres,research radiation therapists have a leading role to play in the sharing of information with radiation therapists and ultimately enhanced patient care and improved radiotherapy services.

A major goal of the Consortium is to strengthen the capacity for cancer centres in Ireland and Northern Ireland to conduct cancer clinical trials, and thus improve patients' access to new therapies. Because of the relatively small population on the island—approximately 5.4 million people in Ireland and Northern Ireland combined—it is essential that the two countries collaborate with one another and internationally in order to create a sufficiently large pool of participants (7). Radiation therapists can participate in this collaboration to increase recruitment to trials because they are involved in all aspects of the clinical trial process and disseminate information to the multidisciplinary team. Facilitated by TELESYNERGY^®, Clinical trials radiation therapists from Dublin, Belfast and the NCI have already taken the first steps to begin this collaboration.

Future aspirations for radiation therapists include participating in collaborative cancer trials, injecting the radiation therapist’s perspective into new projects as part of the multidisciplinary team and proposing radiation therapist led trials to support evidence- based practice.

ACKNOWLEDGEMENTS:

The authors would like to thank Mr Kenneth Kempner, Prof. Patrick Johnston, Dr. Seamus McAleer, IT Systems Specialists: Mr John McGivney, Mr Vincent Smith, Mr Desmond O’Loan and Mr Philip Leighton, for enabling their use of TELESYNERGY^®.

For further information on the All-Ireland Cancer Consortium, the NCI or on TELESYNERGY^® see http://www.allirelandnci.org/

REFERENCES:

1. Kempner K.M. et al. Telemedicine Systems. Principles and Practice of Clinical Research, Academic Press; 2002; 22; 361-385.
2. Kempner K.M. et al. The development of an ATM-based Radiology Consultation Workstation for radiotherapy treatment planning. Society for Photo-Optical Instrumentation Engineers, Inc., Bellingham, WA, 1997; 3031:500-11.
3. Hollywood D. (November 2002) U.S Government Officials to participate in demonstration of multimedia medical imaging system to improve cancer research and care. Ireland-Northern Ireland – National Cancer Institute Cancer Consortium; www.allirelandnci.org
4. Cancer Consortium, Summer 2003, Vol. 3, Issue 3.
5. Irish Medical Journal. Pharmaceutical & Clinical News. Nov/Dec 2002 Volume 95, No. 10.
6. Graeff. A.S. Transatlantic demonstration of CIT technology signals huge leap in scientific collaboration. December 20, 2002 (number 225), Centre for Information Technology, National institutes of Health, USA.
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8. Clinical Trials. Ireland- Northern Ireland – National Cancer Institute Cancer Consortium; www.allirelandnci.org