Oral Abstracts.

Yunfei Jia 1 1 Monash University, Melbourne, Australia Background: Lesbian, gay, bisexual, transgender and queer people (LGBTQ) have always existed in society, yet acceptance of their identity, both socially and legally, has only recently been recognised. Therefore, there is a knowledge gap about appropriately tailored patient care for this community. Aims: This study aims to understand the challenges that the LGBTQ community face in health care. In doing so, it creates a vision for providing better patient care for this community. Methods: A literature search was completed using the Monash University library search engine. Keywords such as LGBTQ, patient care, radiology, and allied health were utilised. The seven most relevant peer‐reviewed journal articles were chosen for inclusion in the review. Results: No studies were found relating to the Australian healthcare system. Only two articles were specific to a radiology setting with the rest relating to healthcare practitioners in general. Hormone therapy associated with transgender patients can have negative effects, some of which are of particular importance to medical radiation practitioners. These include reduced renal function and bone density, as well as increased risk of thromboembolism. Gender assumptions, gender identification and preferred name sections on forms contribute to miscommunication between patients and healthcare workers. Conclusion: Healthcare workers need to have a better understanding of the LGBTQ community to provide optimal holistic health care to this vulnerable group. There are also specific precautionary needs that medical radiation practitioners should be aware of. Education on LGBTQ groups should be implemented to better inform healthcare workers of specific needs of this community.

Carlie Nancarrow 1 1 Royal Darwin Hospital, Darwin, Australia The first post‐mortem computed tomography (CT) scan was reported in the 1970s. 1 Now forensic departments either have dedicated CT and/or MR scanners in their institutes or they establish relationships with local clinical centres. At Royal Darwin Hospital we are one of the lucky ones. Forensic radiology is a specialised area of medical imaging using radiological techniques to assist pathologists in determining cause of death and anthropologists to identifying remains. Our scans assist in documenting anatomy and pathology for forensic purposes, generate insight into the deceased’s mortal circumstances and allow for re‐evaluation of the evidence over the years to come. This presentation will open your eyes to the Royal Darwin Hospital post‐mortem CT procedure and explore the differences in seeing the scans of dead people compared to the scans of the living. Reference 1. Flach PM, Gascho D, Schweitzer W, et al. Imaging in forensic radiology: an illustrated guide for postmortem computed tomography technique and protocols. Forensic Sci Med Pathol 2014;10(4):583‐606.

Carolyn Mcgregor, 1 Andrew Diplugia, 1 Cameron Stanton, 1 Regina Bromley, 1 Gillian Lamoury, 1 Marita Morgia, 1 Susan Carroll 1 1 Northern Sydney Cancer Centre, St Leonards, Australia Objectives: Three‐dimensional printed bolus (3DPB) is becoming standard of care in radiotherapy due to improved clinical fit compared to materials such as superflab and wax. 1,2 This study evaluated the implementation of 2 mm thickness 3DPB to enable a single plan solution for chest wall radiotherapy (CWRT). 3 Methods: 3DPB using poly‐lactic acid (PLA) was created by exporting the planned bolus structure into 3D bolus software (Adaptiiv, Halifax, Nova Scotia, CA) to create the STL file required by our N2 Plus 3D printer (Raise3D, Irvine, CA). To remove user influence adversely affecting 3D print quality, semi‐automated post‐processing removed CT markers from the body structure. Based on a 10 patient trial, bolus print fidelity was assessed by CT‐scanning the prints and rigidly fusing them to the planning CT. Accuracy on treatment was evaluated using pre‐treatment imaging and in‐vivo film dosimetry. 4,5 Results: PLA bolus prints with an in‐fill density of 83% were found to be dosimetrically water‐equivalent. To enable 2 mm thickness bolus prints, CT scan resolution was increased to 1024 × 1024. Bolus prints showed no gross defects with sub‐millimetre print fidelity. Only one patient had an air gap >5 mm which was outside the target region. In‐vivo measurements showed surface doses under the bolus were within 2% ± 4% (k = 1) of that planned for all patients. Discussion/Conclusion: We have successfully produced 2 mm thickness 3DPB to facilitate a single plan solution for CWRT. Improvements in fit conformity and accuracy compared to superflab/wax, 1 and reduction in mould room burden, have also been achieved. References 1. Robar JL, Moran K, Allan J, et al. Intrapatient study comparing 3D printed bolus versus standard vinyl gel sheet bolus for postmastectomy chest wall radiation therapy. Pract Radiat Oncol 2018;8(4):221‐29. 2. Burleson S, Baker J, Ting Hsia A, et al. Use of 3D printers to create a patient‐specific 3D bolus for external beam therapy. J Appl Clin Med Phys 2015;16(3):166‐78. 3. Ordonez‐Sanz C, Bowles S, Hirst A, et al. A single plan solution to chest wall radiotherapy with bolus? Br J Radiol 2014;87(1037):20140035. 4. Butson MJ, Cheung T, Yu P, et al. Effects on skin dose from unwanted air gaps under bolus in photon beam radiotherapy. Radiation Measurements 2000;32(3):201‐4. 5. Khan Y, Villarreal‐Barajas JE, Udowicz M, et al. Clinical and dosimetric implications of air gaps between bolus and skin surface during radiation therapy. J Cancer Ther 2013;4:1251‐55.

Mathura Jeyandrabalan 1 1 The University of Sydney, Toongabbie, Australia Objectives: University clinical placements provide opportunity for radiography students to place theoretical knowledge into practice. 1 However, within healthcare environments emotional wellbeing is compromised when students are confronted with emotionally challenging situations. 2 Although various studies have identified clinical stressors and decreased emotional wellbeing in various health disciplines, little has been published within the scope of radiography clinical placements. Hence, this research study explores the lived emotional experiences of diagnostic radiography students on clinical placements and suggest improvements in practical interventions for enhancing emotional wellbeing. Methods: This study employed a qualitative study design. Three online focus groups were conducted. A total of 13 participants were recruited from an undergraduate university diagnostic radiography program. Focus group data were transcribed verbatim. Thematic analysis was utilised to analyse participants’ experiences. An inductive open coding approach was used, using NVivo 12. To improve rigour, interrater reliability was conducted, codes were discussed with three other project members until consensus was reached on themes. Results: Five themes were identified through the focus group data: clinical environment challenges and adaptations, relationship between clinical staff and students, students and professional identity, university teaching and clinical practice gap, and student support systems. Conclusion: The importance of emotional wellbeing throughout clinical placements was highlighted by the students through discussing the integral role of clinical staff relationships, professionalism and experiential learning. There is a need for closure of the theory practice gap as well as human interaction‐based intervention strategies to improve emotional wellbeing for positive clinical experience outcomes. References 1. Mason SL. Radiography student perceptions of clinical stressors. Radiologic Technology 2006;77(6):437‐50. 2. French HC. Occupational stresses and coping mechanisms of therapy radiographers a qualitative approach. J Radiother Pract 2004;4(1):13‐24.

Jenny Han 1 1 University of South Australia, Adelaide, Australia Background: Cryoablation therapy of renal cell carcinoma (RCC) is an emerging procedure that is seldom utilised in the Australian setting. 1 It is a minimally invasive technique that involves less recovery time, better quality of life and less complications for patients. 2 The procedure is heavily dependent on computed tomography (CT) imaging where the radiologist relies only on CT guidance to target the cryoablation probe. This means extensive involvement from the medical imaging team is required within the multidisciplinary team during the procedure. Objective: The purpose of this systematic review is to introduce cryoablation therapy to medical imaging professionals and students in Australia. The efficacy and limitation of this procedure will be discussed, as well as the medical imaging involvement in the multidisciplinary team involved with the procedure. Summary: In studies outside Australia, cryoablation therapy has shown to have comparable results to the gold standard procedure, partial nephrectomy, in treating renal mass while yielding a lower complication rate. 3 Cryoablation technique destroys tumour cells by freezing and thawing them. This causes apoptosis, leading to targeted destruction of tumour, providing pain relief for RCC patients. 2 The procedure utilises CT guidance to position the probes in strategic areas that targets tumour the most, and affects surrounding organs the least. 2 This is beneficial to both patients and hospitals, as it presents a fast recovery time while preserving patients’ quality of life. 4 However, the cost of probes can be problematic for short term healthcare, as seen in Australian Medical Services Advisory Committee report. 1 Conclusion: This review shows that cryoablation can contribute to better patient care. CT radiographers will be heavily involved in these procedures as part of a multidisciplinary team, and therefore it outlines the importance of imaging professionals understanding their role in this procedure. The initial finding shows the procedure will be beneficial to Australian healthcare as the reduced recovery time provides less pressure on hospital resources while providing better quality of life for patients. Studies with a longer follow up period should be utilised to show its efficacy within Australia and further research the long‐term effects of this procedure. References 1. Medical Services Advisory Committee. Cryotherapy for recurrent prostate cancer and renal cancer: part a – salvage cryotherapy for recurrent or persistent prostate cancer after radiotherapy part b – cryotherapy for renal cancer. Canberra: Government of Australia; 2009. 2. Maria T, Georgiades C. Percutaneous cryoablation for renal cell carcinoma. J Kidney Cancer VHL 2015;2(3):105‐113. 3. Breen DJ, King AJ, Patel N, Lockyer R, Hayes M. Image‐guided cryoablation for sporadic renal cell carcinoma: three‐ and 5‐year outcomes in 220 patients with biopsy‐proven renal cell carcinoma. Radiol 2018;289(2):2502. 4. Rodriguez R, Cizman, Z, Hong, K, Koliatsos, A, Georgiades, C. Prospective analysis of the safety and efficacy of percutaneous cryoablation for pt1nxmx biopsy‐proven renal cell carcinoma. Cardiovasc Intervent Radiol 2010;34(3):573‐578.

Louise Bulmer 1 1 Monash University, Clayton, Australia Background: Deep inspiration breath hold (DIBH) offers potential improvements to radiotherapy for lung cancer patients, however significant debate exists among the oncology community regarding the capacity of these patients to perform the necessary breath hold due to tumour‐related symptoms. 1,2 Methods: A search of the litwerature published prior to August 2019 was conducted via PubMed, using synonyms of the key terms ‘deep inspiration breath hold’, ‘lung cancer’ and ‘accuracy’. The search returned 110 results. An inclusion criterion was applied to the results and 10 papers were included in the final review. Results: A substantial proportion of patients in each study (65–100%) were able to perform DIBH. Intrafraction tumour position was not significantly changed (P ≥ 0.05), demonstrating good intrafraction reproducibility. Results were contradictory for interfraction motion, meaning that margin reduction cannot currently be recommended unless daily image guidance is also in use. The establishment of interfraction reproducibility would allow reduction of healthy tissue exposure and potential for dose escalation. All studies reporting lung‐dose volume parameters of V20 Gy and mean lung dose showed significant decreases with the introduction of DIBH (ranging from 6–6% and 13–32% decrease, respectively; P < 0.05), indicating reduced risk of pulmonary toxicities, especially radiation pneumonitis. Conclusions: A reduction in healthy lung tissue doses may allow for dose escalation without compromising quality of life due to toxicity. This may improve local control and disease‐free survival rates. DIBH should be implemented with current margins to reduce toxicity, and further research into reproducibility and margin reduction should be conducted. References 1. Kimura T, Hirokawa Y, Murakami Y, et al. Reproducibility of organ position using voluntary breath‐hold method with spirometer for extracranial stereotactic radiotherapy. Int J Radiat Oncol Biol Phys 2004;60:1307‐13. 2. Koshani R, Balter JM, Hayman JA, Henning GT, van Herk M. Short‐term and long‐term reproducibility of lung tumor position using active breathing control (ABC). Int J Radiat Oncol Biol Phys 2006;65:1553‐59.

Rachael Beldham‐Collins, 1,2 Georgia Halkett, 3 Kellie Knight, 2 Val Gebski, 1,4 Caroline Wright 2 1 Sydney West Radiation Oncology Network, Westmead, Australia 2 Monash University, Clayton, Australia 3 Curtin University, Perth, Australia 4 The University of Sydney, Camperdown, Australia Objectives: Determining the research capacity and culture of health professionals can ensure appropriate allocation of resources for those that wish to participate in research. This study aimed to measure radiation therapists’ perceptions of their research skills and develop metrics to quantify if existing employment influences an individual’s research capacity. Methods: Practising radiation therapists in Australia were invited to complete the Research Capacity Culture Tool (RCCT) 1 in October 2020. The 14 Likert scale questions (each 10 points) relating to individual skill level were classified into four groups reflecting different aspects of research activity. Within each classification, individual research activity was dichotomised to either medium/low (ML: <7) or high (H: ≥7). For each respondent, the number of ML activities over the four groups was obtained and associations between these scores and site location: metropolitan, rural/regional, public and private hospitals were investigated. Results: Of 122 RTs completing the RCCT, the need for substantial assistance within the different workplace institutions was: public 27/105 (25.71%); private 8/17 (47.06%); metropolitan 30/101 (29.70%); and rural/regional 5/21 (23.80%). Practitioners from all workplace institutions identified need for assistance in the following order: dissemination and promotion of research, tasks of initiating a project, performing a research project, and search and appraise the literature. Conclusion: This project has used a strategic approach to analyse data from the RCCT into a structure that has identified the research needs of employees at different workplace institutions and can inform future research capacity building initiatives. Reference 1. Holden L, Pager S, Golenko X, Ware RS. Validation of the research capacity and culture (RCC) tool: measuring RCC at individual, team and organisation levels. Aust J Prim Health 2012;18(1):62‐67.

Jia Hui Ng, 1 Noor Aqilah Abdul Rahhim, 1 Steven Hoon Chin Lim 1 1 Changi General Hospital, Singapore Objectives: The Radiographer Abnormality Detection Scheme has evolved from the red dot system to radiographer commenting, where radiographers provide a brief comment instead of a red dot on review of a radiograph. 1 Our hospital adopted the 'commenting model' and the system was implemented in 2012. A&E clinicians' satisfaction level, perception and feedback are crucial as a performance indicator and for improvement of the system. Methods: An online survey was distributed to the A&E clinicians. The survey was made up of 15 questions on a 4 or 5‐point Likert scale and one open‐ended field for additional comments. The survey contained six themes: awareness, frequency, quality, perceived clinical impact, satisfaction level and recommendation for implementation. Results: The overall response rate was 38% (32 out of 84 participants); 87% of the clinicians often or always used the system; 83% frequently used the system to confirm their own normal and abnormal findings; 77–100% rated good and excellent for the quality of the comments; 87% and 93% agreed or strongly agreed that the system has a positive clinical impact and reduces radiological misdiagnoses respectively; 100% are satisfied with the system; and 94% thought that the system should be implemented nationwide. The Figure shows an overview of quality of comments, perceived clinical impact and satisfaction level. Conclusion: The system has yielded mostly positive feedback and comments, and overall satisfaction level was high among the A&E clinicians, which reflected well on the effectiveness of the system. Reference 1. Murphy A, Ekpo E, Steffens T, Neep MJ. Radiographic image interpretation by Australian radiographers: a systematic review. J Med Radiat Sci 2019.

Kate Francis 1 1 Austin Health, Heidelberg, Australia Background: The introduction of MRI technology in radiation oncology departments brings a significant change in roles and competencies required for radiation therapists (RTs). MRI in radiotherapy planning is considered standard practice in many disease sites and RTs) have become competent in image fusion and delineation of many normal tissue volumes. Although the use of MRI in RT planning is established, scanning of patients and developing image protocols has always been carried out in the medical imaging department. Discussion: This presentation will discuss some of the differences between diagnostic scans and treatment planning scans as well as some of the competencies required by RTs in the MRI domain. Points to consider when implementing new MR roles for therapists include: access to education experience and time spent with competent radiographers mutual teaching of radiographers and RTs in radiotherapy MR simulation legislation and registration requirements for MR operators MR safety training for the wider interdisciplinary staff group. access to education experience and time spent with competent radiographers mutual teaching of radiographers and RTs in radiotherapy MR simulation legislation and registration requirements for MR operators MR safety training for the wider interdisciplinary staff group. Conclusion: While it is anticipated that RTs will develop skills required to operate the MRI scanner in context of radiation therapy, the support from an experienced MRI radiographer will ensure safe and effective implementation as well as an opportunity to collaborate in all aspects of imaging in the department. Investment in education of trained radiation oncology staff to bring them up to a competent and safe level for operating an MR scanner will need careful consideration.

Beverley Pearce, 1,2 Jo‐Anne Pinson, 1,2 Michal Schneider 2 1 Peninsula Health, Frankston, Australia 2 Monash University, Clayton, Australia Objectives: Patients presenting for imaging during orthopaedic review require prompt reporting of outcomes to provide optimal management; however, the radiologist reports are rarely available in a timely manner. The radiographer is uniquely placed to provide a preliminary clinical evaluation (PCE), but little is known about radiographer PCE accuracy in this setting. This study aims to evaluate the accuracy and potential clinical effect of radiographer PCE before and after receiving targeted education on traumatic appendicular orthopaedic injuries. Methods: Seven radiographers participated in a targeted education program describing radiographic appearances of appendicular skeletal trauma. This comprised of 24 week online non‐award image interpretation modules and a four‐hour face‐to‐face seminar given by a consultant orthopaedic specialist. X‐ray images of consecutive patients presenting in both the four weeks before and immediately following education delivery were retrospectively evaluated to compare radiographers PCE accuracy pre‐ and post‐education against the radiologist report (gold standard). Images were scored between 1 and 3 (1 = identical to radiologists’ reports; 2 = minor inaccurate PCE; 3 = inaccuracies, no effect on patient management) or 4 (inaccurate PCE, patient management affected). Results: Participation in targeted education significantly improved the accuracy of PCE. The proportion of scores of 1 increased significantly from 39.1 to 64.2% (P < 0.001). The proportion of scores of 4 (inaccurate PCE affecting patient management) decreased significantly from 12.8% to 4.8% (P < 0.001). Conclusion: Radiographers can provide accurate PCE for imaging of appendicular skeletal trauma following tailored education. This may improve workflow and reduce diagnostic errors when radiologists’ reports are not readily available.

Fiona Ramanauskas 1 1 Royal Children’s Hospital, Parkville, Australia When a request for a computed tomography angiogram (CTA) is considered and the patient is on extracorporeal membrane oxygenation (ECMO) a list of questions should be thought through before the patient even leaves the confines of their hospital room to ensure that the clinical question at hand can be answered and that the risk of moving such a precarious patient will be beneficial. Such questions include but are not limited to: the location of peripheral IV access if available; whether the flow rate of the ECMO circuit can be slowed or stopped during the CTA; what additional volume of blood has been added to the circuit which affects how dense the IV contrast will eventually be. This presentation will discuss the many facets of CTA ECMO cases. Some of the points for consideration include staff availability and skill mix to support the complex needs of such patients as they are moved from the ICU ward to CT; knowledge of the ECMO circuit and what aspects to discuss to tailor the situation to optimise the IV contrast timing; knowledge of congenital cardiac anomalies and the corrective surgical stages which affect many of these patients to help understand the expected blood flow and anatomy; how best to communicate with colleagues during these cases to mitigate risk to the patient.

Kim Faulkner, 1 Roland Yeghiaian‐Alvandi, 1 Mitchell Gibbons, 1 Liesl Daries, 1 Katie Sadler 1 1 Central Coast Cancer Centre Gosford Hospital, Gosford, Australia Objectives: In our department, stereotactic ablative radiotherapy (SABR) lung treatments require daily image verification by the radiation therapists (RT) using cone beam CT (CBCT) with the radiation oncologist (RO) reviewing the match at the treatment console on the first fraction. Consecutive treatment verifications are completed by the RT only. To assess consistency of image matching relative to tumour location in the lungs, we compared pre‐treatment day 1 CBCT image matches by the RT and RO, to the actual treated day 1 position. Methods: Day 1 pre‐treatment CBCT images for 40 lung SABR patients (N = 20 peripheral, N = 10 mediastinal and N = 10 inferior) were retrospectively matched using the current departmental SABR image matching guidelines. One RO and four RT (varying years of experience) completed the matches. Results were compared for inter‐user variability. Results: The median deviations for the RT and RO matches were 0.36 mm and 0.97 mm respectively. Splitting the data by location of the tumours we found that lowest variability of deviations between users was for inferior tumours (average st dev 0.46) followed by mediastinal tumours (0.58) and peripheral tumours (0.60). Conclusion: The data shows that RTs perform matches with a higher degree of consistency and accuracy than the RO when using deviation from the day 1 match as a measure, particularly when matching inferiorly positioned tumours. This opens the door for practice change concepts 1 to be discussed with the ROs regarding options for future management of day 1 image matching for SABR lung patients, particularly in areas of less movement and more certainty. Reference 1. White E, Kane G. Radiation medicine practice in the image‐guided radiation therapy era: new roles and new opportunities. Semin Radiat Oncol 2007;17:4:298‐305.

Tamara Ballerini 1 1 Monash University, Clayton, Australia Breast cancer is the most common cancer in women globally and the second leading cause of cancer death in Australian women. Breast screening was implemented to address this rising health concern through early detection but has since significantly increased the number of mammograms performed and reporting workload. Limitations such as radiologist interpretation variability and high false positive rates has generated an interest and high demand for alternative computational methods of diagnosis, including artificial intelligence (AI). A review of the literature was performed to assess the diagnostic performance and socioeconomic impact of AI compared to radiologists to determine if AI has reached the tipping point in stakeholder acceptance and is ready for clinical implementation in breast screening. Literature demonstrates that recent introduction of new deep learning algorithms in AI has significantly improved the diagnostic performance and accuracy of breast image interpretation, including sensitivity and cancer detection rates. Research suggests that the standalone performance of AI is significantly comparable to radiologists, and when used in combination as a second reader, is superior to radiologists alone. For clinical implementation, new technology must deliver comparable results more efficiently and cost effectively than the current standards in order to be accepted by the healthcare community. Literature has supported this positive socioeconomic impact in workflow including life years gained, suggesting it should be utilised in combination with radiologists, having reached a tipping point in stakeholder acceptance. However, future studies focusing on AI in breast imaging require prospective research within the clinical setting to confirm its readiness.

Nicole Zientara, 1,2 Eileen Giles, 1 Hien Le, 1,3 Michala Short 1 1 University of South Australia, Adelaide, Australia 2 Liverpool Hospital, Liverpool, Australia 3 Royal Adelaide Hospital, Adelaide, Australia Objectives: To conduct a scoping review exploring various clinical decision‐making tools and dose comparison methods used globally for proton therapy (PT) versus photon therapy patient selection. Methods: A literature search that followed defined scoping review methods was performed in Medline and Embase databases as well as grey literature sources for articles published from 1 January 2015 to 4 August 2020. Articles were eligible for inclusion if they clearly stated methods of patient selection and were in English. Results: 321 studies were identified; 49 studies met the study’s inclusion criteria, representing PT patient selection from 13 countries. Of these 13 countries, only nine of the 19 countries with PT clinically operational were represented. Six different clinical decision‐making tools and 14 dose comparison methods were identified, demonstrating variability within countries and internationally. PT was indicated for all paediatric patients except those with lymphoma and re‐irradiation where individualised model‐based selection was required. The most commonly reported patient selection tools included the Normal Tissue Complication Probability model, followed by cost‐effectiveness modelling and dosimetry comparison. Model‐based selection methods were most commonly applied for head and neck clinical indications in adult cohorts. Conclusion: While no gold standard currently exists for PT patient selection with variations evidenced globally, some of the patient selection methods identified in this review can be used to inform future practice in Australia. As literature was not identified from all countries where PT centres are available, further research is needed to evaluate patient selection methods in these jurisdictions for a comprehensive overview.

Laura O'Connor 1 , K Skehan 1 1 Calvary Mater Hospital, Newcastle, Australia Radiation therapy has seen a rapid increase in the use of targeted treatment techniques. The highly conformal dose distributions, steeper dose gradients and the potential for dose escalation with these planning techniques mean that the detail and information required from imaging modalities is increasing. Due to this, magnetic resonance imaging (MRI) has played a greater role in radiation therapy planning than ever before, as it affords an improvement in tumour and soft tissue visibility and functional imaging abilities. MRI has been shown to increase the reproducibility and accuracy of tumour delineation in radiotherapy when compared to computed tomography and has the potential for further expansion on its use in radiation therapy. Commissioning an MRI scanner into a radiation oncology department brings with it a new set of safety risks, alongside training, education, staffing and equipment considerations. Having a dedicated MRI simulator allows for more tailored radiation therapy planning sequences. There are differing priorities between diagnostic imaging and radiation therapy planning, such as diagnosis, signal‐to‐noise ratio, spatial localisation and geometrical integrity; having a dedicated MRI simulator allows for a radiation therapy focussed approach to imaging. Given the added complexities and considerations around MRI, and to gain the greatest benefit from MRI in radiation therapy, a collaborative and multidisciplinary approach is required.

Kate Francis 1 1 Austin Health, Heidelberg, Australia Background: Magnetic resonance imaging (MRI) in radiotherapy offers superior soft tissue definition, functional information about the disease and the possibility of online adaptive radiotherapy however, there are challenges to overcome when introducing this technology into a radiation oncology department. Radiation safety within a radiotherapy department has always been a priority and is assessed with every change in technology. With the introduction of MRI equipment into the simulation and treatment environment, a new challenge of magnetic safety needs to be considered. Not only does the radiation equipment interact with the MR image, but the magnetic field interacts with the radiation treatment beam. The treating team are also not familiar with the MR environment, the usual positioning devices are not compatible, and the quality assurance procedures are significantly different. How do we plan for this new paradigm in radiotherapy? Discussion: The presentation will discuss themes to consider when designing a MR service within a radiotherapy department including: radiation/magnetic physics – implications for radiotherapy construction implications MR safety zones equipment considerations education roles within the team clinical considerations – referral pathways, patient selection, models of care. radiation/magnetic physics – implications for radiotherapy construction implications MR safety zones equipment considerations education roles within the team clinical considerations – referral pathways, patient selection, models of care. Conclusion: MRI offers exciting opportunities in the way we deliver radiotherapy treatment but also brings new and unique challenges. Radiotherapy departments can incorporate this new technology with careful planning and working in partnership with people who have experience and expertise in MRI.

Madeleine Whitting 1 1 University of South Australia, Adelaide, Australia An Indigenous liaison officer (ILO) is an employee who identifies as being Aboriginal or Torres Strait Islander and who provides support to staff, patients and their families. The employment of culturally appropriate services such as an ILO bridges barriers in Indigenous healthcare, however, ILOs are not widely known and their benefit within a radiation therapy (RT) department needs to be discussed. Indigenous cancer patients experience a poorer prognosis than non‐Indigenous patients for an equivalent stage of disease. 1 Reasons for this are multifactorial, however it is largely contributed to decreased screening participation, a mistrust in mainstream medicine, cultural beliefs about cancer and limited access to healthcare services. Literature states that culturally insensitive practice impacts whether Indigenous patients are willing to present for diagnosis and attend daily radiotherapy treatment sessions. Missed fractionations of treatment can be detrimental to the radiobiological effect of RT, whereby the number of double‐strand breaks in malignant DNA is reduced. Through patient advocacy and education at commencement of RT, the work of an ILO can improve treatment attendance and compliance. 2 Specifically, an ILO can assist in travel, accommodation and welfare needs as well as address tailored cultural needs to patients and their families. Radiation oncology departments are not strongly represented by people who identify as Indigenous, hindering the benefits the integration of this multidisciplinary team member can have regarding curative and palliative RT outcomes. The incorporation of an ILO needs to be recognised from the onset of RT treatment to maximise the benefits they can provide to Aboriginal and Torres Strait Islander patients. Moreover, a greater representation of Indigenous workers in radiation oncology departments is critically important to provide culturally appropriate services to maximise RT treatment attendance and compliance. Over time, the survival deficit experienced by Indigenous Australians compared to non‐Indigenous Australians for same‐staged cancers may be shortened by utilising an ILO. References 1. Le H, Penniment M, Carruthers S, et al. Radiation treatment compliance in the Indigenous population: the pilot Northern Territory experience and future directions. J Med Imaging Radiat Oncol 2013;57(2):218‐21. 2. Taylor E, Lyford M, Parsons L, et al. "We're very much part of the team here": a culture of respect for Indigenous health workforce transforms Indigenous health care. PloS One 2020;15(9).

Noel Cleaves 1 1 Department of Health and Human Services, Melbourne, Australia The idea is to start to ‘socialise’ the concept of a documented set of expectations of radiation regulators for the various regulatory obligation that are imposed on licence holders across the country. In this case, we are talking about the expectations in relation to the newly published Code for Radiation Protection in Medical Exposure. I’ll present some of the thinking that is going into these documents.

Belinda Arnold, 1,2 Afaf Girgis, 2 Haryana Dhillon, 3 Georgia Halkett 4 1 Illawarra Shoalhaven Local Health District, Wollongong, Australia 2 The University of New South Wales, Liverpool, Australia 3 The University of Sydney, Sydney, Australia 4 Curtin University, Perth, Australia Objectives: An online symptom and distress screening tool (PROMPT‐Care) 1 identifying patients’ physical and psychosocial concerns is administered by radiation therapists (RTs) at two radiation oncology departments in New South Wales. We explored the impact of a communication skills and emotional cues training program (RT Prepare CST) 2 on RTs’ perceptions of their role and barriers in providing patients with distress screening and psychosocial care. Methods: RT Prepare CST was delivered to all RTs employed at the two radiation oncology departments. Questionnaires were completed at three time points pre‐, post‐ and three months post‐training. Semi‐structured interviews were conducted with RTs six‐months post‐training. Results: 36 RTs completed questionnaires, and interviews were conducted with eight RTs who attended RT Prepare CST. Although there were no significant changes in RTs’ opinions of their role in patients’ psychosocial care following training, during interviews, RTs described the positive impact of training on patient interactions and skills to support a more active screening role. RTs also highlighted numerous barriers within the screening process that made it difficult to perform this role, including time pressures, the influence of managers and peers in providing psychosocial care, and the limited role of the RT when administering PROMPT‐Care. Conclusion: RT Prepare CST has enhanced the role of RTs by providing them with the skills and abilities to provide emotional care to patients, including symptom and distress screening. RTs feel patients’ psychosocial care is an important aspect of their role and want to be more active in reviewing and actioning screening results rather than only administering PROMPT‐Care. References 1. Girgis A, Durcinoska I, Levesque JV, et al. eHealth system for collecting and utilizing Patient Reported Outcome Measures for Personalized Treatment and Care (PROMPT‐Care) among cancer patients: mixed methods approach to evaluate feasibility and acceptability. J Med Internet Res 2017;19(10):e330. 2. Halkett G, O'Connor M, Aranda S, et al. Communication skills training for radiation therapists: preparing patients for radiation therapy. J Med Radiat Sci 2016;63(4):232‐41.

Min Ku, 1 Alan Malbon 1 1 ASMIRT, Melbourne, Australia Peer support is an important element for consideration in the quest for leadership. The medical radiation practitioner senior clinician who wishes to obtain clinical recognition while climbing the ladder towards a management position will experience many challenges. Sometimes these appointments are ‘accidental’, and the practitioner is not prepared or ready for the new vision of the department. One of the most significant identified challenges is the lack of support, guidance and mentorship to ensure success. 1 Being in management is tough, and loneliness is a recognised element of the equation that can lead to poor performance and affect the individual’s physical health and well‐being. 2 Leadership requires independence and vision and those wishing to move from a senior clinical practice role into management need to have solid foundations to support this career move. This case‐based presentation has been designed to provide some key strategies to assist those practitioners who are considering this type of career move and is the first step towards the vision of modern management. References 1. Zumaeta J. Lonely at the top: how do senior leaders navigate the need to belong? Journal of Leadership and Organisational Studies 2018;26(1)111‐35. 2. Erdil O, Ertosun OG. The relationship between social climate and loneliness in the workplace and effects on employee well‐being. Social and Behavioural Sciences 2011;24:505‐25.

Anne Collins 1 1 Peter MacCallum Cancer Centre, Box Hill, Australia In Australia in 2018, it is estimated that 3.5% of Australians (approximately 875,000 people) were primary carers for people because of disability or age. 1 Interestingly, over one‐third (37.4%) of primary carers have a disability themselves, in excess of twice the rate of non‐carers (15.4%). 1 A cancer diagnosis does not discriminate. So, when a primary caregiver requires cancer treatment, what additional support do they require? Jane* is a mother and primary caregiver of an autistic 9‐year‐old boy. Autism is defined as a ‘developmental disorder of variable severity that is characterised by difficulty in social interaction and communication and by restricted or repetitive patterns of thought and behaviour’. 2 When Jane attended her initial radiotherapy clinic appointment, she was visually anxious. Her concerns were not around her cancer treatment, but the impact her treatment would have on her family, and in particular, her autistic son. This posed a unique set of challenges for the radiotherapy team, tasked with balancing the best outcome for Jane while minimising the impact on her family. This presentation discusses the additional support, flexibility and understanding Jane required prior to and throughout her radiation therapy treatment. It also demonstrates how the relationships radiation therapists form with their patients every day helps provide the best quality care for each individual, tailored to the unique set of circumstances that each patient presents with. *Jane is a pseudonym used for the purpose of this presentation. References 1. Australian Bureau of Statistics. Survey of disability, ageing and carers, 2018. 2. Oxford University Press. 2019. Available at https://www.lexico.com/en/definition/autism

Elizabeth Brown, 1,2 Emma Thompson, 1 Thanh Bui, 1 Anne Bernard, 3 Tao Mai, 1 Jennifer Harvey 1 1 Princess Alexandra Hospital, Brisbane, Australia 2 Queensland University of Technology, Brisbane, Australia 3 University of Queensland, Brisbane, Australia Objectives: Anal canal cancer (ACC) is uncommon. The gold standard of care is chemoradiotherapy treatment. 1,2 However, this treatment is associated with considerable acute and late side effects. The aim of this pilot study was to prospectively collect and compare toxicity and patient reported outcomes (PRO) to determine if any potential relationships exist. Methods: 16 patients were recruited to this prospective longitudinal observational study from March 2015 to December 2017. All patients received volumetric modulated arc therapy (VMAT) in 30#. Toxicity data was graded by a radiation oncologist using the Common Terminology Criteria for Adverse Effects (CTCAE) version 4 at planning, weekly during treatment, 6 weeks and 3 months post‐treatment. PRO data was collected using the EORTC QLQ C30 and CR29 questionnaires completed by patients at planning, mid and end treatment and 3 months post‐treatment. Results: The majority of toxicity and PRO items peaked in severity at the end of treatment (week 6). Skin was the only item where >50% of patients had ≥ grade 2 toxicity at any point with 75% having ≥ grade 2 at week 6. Patient‐reported embarrassment significantly increased over time (P < 0.001). No significant relationships were found between PRO and CTCAE results. Conclusion: After reaching their maximum at the end of treatment, the majority of toxicity and PRO items approached baseline levels by 3 months post‐treatment. The results of this study suggest that PROs are an important complementary tool to CTCAE and provide greater vision of patient’s perception of treatment side effects. References 1. Vuong T, Devic S, Belliveau P, Muanza T, Hegyi G. Contribution of conformal therapy in the treatment of anal canal carcinoma with combined chemotherapy and radiotherapy: results of a Phase II study. Int J Radiat Oncol Biol Phys 2003;56(3):823‐31. 2. Milano MT, Jani AB, Farrey KJ, Rash C, Heimann R, Chmura SJ. Intensity modulated radiation therapy (IMRT) in the treatment of anal cancer: toxicity and clinical outcome. Int J Radiat Oncol Biol Phys 2005;63(2):354‐61.

Laura Baker 1 , Georgia Ross 1 , John Atyeo 2 , Andrew Le 2 1 University of Newcastle, Callaghan, Australia, 2 Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, Australia Objectives: Patients having radiotherapy for head and neck cancer experience weight loss or tumour shrinkage that can result in contour changes and positional errors during daily set up. 1,2 Adaptive radiation therapy (ART) can account for these variations and accurately deliver the radiation dose to the tumour. The aim of this study was to assess the impact ART might have on a patient’s treatment. Methods: 10 patients receiving radiotherapy for head and neck cancer were included in this study, with contour change data collected between fractions 11–20. For each patient, three plans were compared: the original plan, a dose evaluation plan (the original plan applied to patient’s daily cone beam computed tomography [CBCT]), and an adaptive offline plan produced from daily CBCT. Results: Across the patient cohort target volume doses increased, with slightly higher conformal dose across fractions 11–20 accounting for variation. Overall, coverage was improved using the adaptive offline plan, especially in the low dose target region. A comparison across all three plans indicated that following adjustment to compensate for dose coverage, little change in organs at risk dose was evident. Discussion: A dose evaluation of target volume and organs at risk doses indicated that daily CBCT matching and offline replanning can impact on a patient’s treatment. ART can account for variations such as weight loss or tumour shrinkage, delivering a more accurate radiation dose to tumour volumes, with little change in organs at risk dose. References 1. Barker JL, Garden AS, Ang KK, et al. Quantification of volumetric and geometric changes occurring during fractionated radiotherapy for head and neck cancer using an integrated CT/linear accelerator system. Int J Radiat Oncol Biol Phys 2004;59(4):960‐70. 2. Ottosson S, Zackrisson B, Kjellen E, Nilsson P, Laurell G. Weight loss in patients with head and neck cancer during and after conventional and accelerated radiotherapy. Acta Oncol 2013;52(4):711‐18.

Richard Mansfield 1 1 Deakin University, Geelong, Australia 2 Barwon Health, Geelong, Australia Objective: Temporal lobe epilepsy (TLE) is the most prevalent form of focal epilepsy, and the hippocampus is the vital linking structure between the temporal lobe and the deep brain. 1 Sclerosis of this structure can be a strong indication of underlying epileptic changes. Recent advancements of technologies and segmentation capabilities of structures allow a critical analysis of the hippocampus. 2 In this age of artificially enhanced segmentation, it is hypothesised that the data produced must be cross‐checked before being used with absolute confidence in the clinical setting. Method: Isotropic volumetric neurological magnetic resonance imaging datasets (N = 10) were analysed with Intellispace Discovery platform. Once the automated segmentation was complete, a series of manual measurements were completed and applied to a three‐dimensional mathematical model to give the manual representation of the structures. A control model of known values was evaluated as an ‘absolute truth’ value for direct comparison. Results: Initial results indicate that the automated volumetric and morphological analysis of the structure had a higher margin of error. Further results will hope to prove that the automated analysis is within reasonable limits to proceed with clinical use of this artificial segmentation technology. Discussion: The aim was to produce reliable metrics for both hippocampal and temporal lobe cortex analysis, which can give an early indication of TLE in the case of the first presentation of seizure‐like activity. The long‐term aim would be to employ these quality assured metrics in the development of predictive artificial intelligence to identify early changes to deep brain structures. References 1. Cook MJ, Fish DR, Shorvon SD, Stevens JM, Kuks JB. Hippocampal sclerosis in epilepsy and childhood febrile seizures. Lancet 1993;342(8884):1391‐94. 2. Fung Y, Ng K, Vogrin S, et al. Validating the utility of automated hippocampal measurement tools in clinical scans. Arch Clin Neurophys 2017;32(6):690‐90.

Kingsley Jones, 1 Peter Gorayski, 1 Rob Keys, 1 Emma Shierlaw, 1 Nicola Rowson, 1 Melanie Penfold, 1 Natasha Tunney, 1 Vivien Giamarelos, 1 Charlotte Sale 1 1 Royal Adelaide Hospital, Adelaide, Australia Traditionally, palliative cases have been required to undergo at least two or three visits to receive their radiation therapy treatment, consisting of an initial consultation, computed tomography (CT) simulation, dosimetry and treatment. The Rapid Access Palliative Radiotherapy Service (RAPRS) has been implemented at the Royal Adelaide Hospital to provide prompt management for patients suffering with advanced cancer. The RAPRS clinic is run weekly with an initial consultation, followed by CT planning and treatment performed in single departmental visits with a duration of less than 2 hours. The service aims to provide patient centred care, minimising the requirements for subsequent visits. The Royal Adelaide Hospital commenced the first CT planned RAPRS treatment in August 2019 and is continuing to develop and expand. The service has a vision to use linear accelerator‐based cone beam CT imaging for planning and treatment, generating a streamlined automated workflow for treatment delivery, further reducing the time that the patient is required in the department. To date, seven patients have received treatment via the RAPRS clinic, and the numbers continue to increase. This presentation is to share the experiences of implementing the RAPRS clinic at the Royal Adelaide Hospital and provide a roadmap for the deployment of the automated protocol.

Mikaela Hammond 1 , Mohamed Badawy 2 1 Monash University, Clayton, Australia, 2 Monash Health, Clayton, Australia In Australia, there are currently only diagnostic reference levels (DRLs) for the head, chest and abdomen‐pelvis computed tomography examinations for two paediatric age groups: 0 to 4 years and 5 to 14 years. As per the International Commission on Radiological Protection recommendations, age should only be used for head examinations, while weight is recommended for trunk examinations. 1 Additionally, the American Association of Physicists in Medicine suggest the use of size‐specific dose estimates (SSDE) for paediatric computed tomography, as this reflects a more accurate dose value. 2 This review synthesised the literature on DRLs for the paediatric head, chest and abdomen computed tomography in order to recommend national DRLs in Australia using SSDE. A systematic search of the literature was performed using the following databases: Medline, Embase, Emcare, Scopus, CINAHL, Cochrane and Web of Science. Articles were included if they measured DRLs based on less than 1 year, 1 to 5 years, 5 to 10 years and 10 to 15 years age brackets as these were the most common comparable age brackets. Of the articles included for the review, the SSDE adjusted DRL values ranged from 29.4 mGy to 37.7 mGy for the head, 4.6 mGy to 8.9 mGy for chest, and 8.5 mGy to 11.5 mGy for abdomen‐pelvis between age groups. The literature showed a considerable variation in the grouping of paediatric data, which resulted in a limited number of comparable articles. This highlights the need for international standardisation of dose reporting related to paediatric DRLs. Overall, the recommended DRLs from this review were lower than the current Australian Radiation Protection and Nuclear Safety Agency DRLs for the chest and abdomen‐pelvis, therefore emphasising the need for reviewing and updating Australian DRLs. References 1. Vañó E, Miller DL, Martin CJ, et al. ICRP Publication 135: diagnostic reference levels in medical imaging. Ann ICRP 2017;46(1):1‐144. 2. Boone JM, Strauss KJ, Cody DD, et al. Size‐specific dose estimates (SSDE) in pediatric and adult body CT examinations. College Park, MD, USA: American Association of Physicists in Medicine; 2011.

Andrew Pidgeon 1 1 Wagga Wagga Base Hospital, Wagga Wagga, Australia Introduction: In 2019 approximately 4 months apart, two patients presented to a large rural medical imaging department with similar pathologies. The diagnosis of the two patients were aortic dissections that extended from the thorax through to the abdomen, and one into the lower limbs. On initial viewing it appeared that there was only one course of action open to both patients, however the treatment and management were vastly different and resulted in very different outcomes for each patient. Case Study: 1) A 67‐year‐old man was referred for CT imaging which revealed an aortic dissection starting from the descending aorta, through the abdominal aorta and into the coeliac and superior mesenteric arteries. This was classified as type B aortic dissection. 2) A 49‐year‐old man was referred for CT imaging of his thorax. Subsequent imaging revealed an aortic dissection from the aortic root through the abdominal aorta and into the left common iliac artery. This was classified as a type A aortic dissection. Management: The management of both patients was different, with one undergoing medical management through antihypertensive therapies and the other undergoing complex surgical treatment. Outcome: One patient is still alive and being monitored for his stable aortic dissection, the other was not able to be saved. Discussion: Which patients should receive a medical treatment pathway, and which should receive a surgical treatment pathway all depends on the type of aortic dissection.

Michael Velec 1 1 Princess Margaret Cancer Centre, Toronto, Canada The increasing individualisation of cancer treatment and patients’ expectations for more seamless, personal care has put greater demands on radiotherapy practice. Radiation therapists often specialise in specific technical procedures for many patients, such as treatment planning or delivery, resulting in fragmented care provided by many staff over the patient’s journey. Reconfiguring this traditional model may improve patient experiences and facilitate more complex treatment strategies such as adaptive radiotherapy. Our institution is developing a new person‐centred model‐of‐care that partners patients with a primary radiation therapist who performs all the key technical procedures and supportive care for their patients. The primary therapist works within the clinical team to perform education, CT‐simulation, dosimetry, quality assurance procedures, treatment delivery as well ongoing supportive care for their assigned patients. Early experience has resulted in meaningful improvements for patients versus standard practice, including enhanced continuity‐of‐care and personal support, in additional to strengthening technical skills of staff and clinical processes. Multidisciplinary stakeholders have also perceived improvements in patient support, with resource needs and workflow impact as potential challenges that need to be addressed. Prospective clinical studies are underway to measure impact on patient outcomes as is staff training and deployment to implement this model routinely. This flexible model‐of‐care is independent of advance practice training or costly technologies, yet it will enable Therapists to seamlessly perform imaging, planning and delivery procedures for their patients within the existing scope of practice. Personalising patient experiences, coupled with improvements in treatment quality and supportive care, may improve clinical outcomes of radiotherapy.

Kristal Lee, 1 Marilyn Baird, 1 Sarah Lewis, 2 John McInerney, 1 Matthew Dimmock 1 1 Monash University, Clayton, Australia 2 University of Sydney, Cumberland, Australia Objectives: Computed tomography (CT) simulation offers educational opportunities outside traditional learning environments. Building on research presented at ASMIRT conference 2018, this study compared the academic outcomes of two high‐fidelity simulation environments: remote‐access (with peer‐assisted learning (PAL)) versus locally accessed (with facilitation) CT scanners for undergraduate radiography students and sought to understand the student’s perspective. Methods: Using a pragmatic approach with multiple methods, third year university radiography students (N = 62) were randomly assigned into two groups. Group ‘remote‐access’ (N = 31) completed workshop tasks in pairs using a remotely accessed CT scanner (NETRAD CT) for 1.5 hours (minimum) and were offered additional log on opportunities if so inclined. Group ‘local‐access’ (LA) (N = 31) completed the same tasks in a facilitated 1.5‐hour small group workshop at a locally accessed CT scanner with no additional logon opportunities. All students were assessed pre‐ and post‐clinical placement on core CT knowledge. Students were surveyed on their learning experiences. Results: Student test results demonstrated no significant difference in core CT knowledge between the groups (F(1,60) = 0.3, P = 0.6), however significant improvement was found in test scores across the pre to post‐clinical period for both student groups (F(1,60) = 37.4, P < 0.001). Four themes emerged: remote versus local‐access capabilities, facilitation versus PAL, use of a real scanner, and preparedness for the learning activity. Remote access students reported reduced confidence and enjoyment compared to local access students. Discussion/Conclusion: Both simulation environments provided equivalent academic outcomes, however the perceived confidence and satisfaction differences between the two groups can be used to help shape how emerging education technologies are best implemented.

Andy Vuong, 1 John McInerney, 1 Carolyn Nguyen, 1 Daniel Nguyen, 1 Leanne Nguyen, 1 Grace Phouthasenh, 1 Raina Raju, 1 Carlos Santos, 1 Trinh Tran 1 1 Monash University, Clayton, Australia Background: Work integrated learning is an integral aspect of learning in undergraduate radiography curricula. The COVID‐19 pandemic challenged the way radiography students have received their clinical education and will continue to impact future placement experiences. This research investigates radiography students’ perspectives of clinical learning experiences during the pandemic. It will inform educators how to effectively support students in future clinical placements. Methods: Twelve radiography students ranging across second to fourth year were recruited using an online learning management system and Facebook. Semi‐structured focus groups were conducted via Zoom. Open‐ended questions were used as prompts for discussion. Anonymity was kept using pseudonyms. Focus groups were recorded and transcribed. Thematic analysis was carried out on the data. Results: Four main themes emerged from the analysis. These included infection control, interactions with patients, the impact on the individual student and workflow across varying clinical sites. Despite changes in learning opportunities available, students found that placements were an invaluable aspect for their learning during critical events. PPE training before entering placement was emphasised through frequent discussion of its usage and availability by participating students. Changes made to the traditional curriculum influenced by COVID‐19 were seen to have both beneficial and adverse outcomes on the student experience. This contrast allowed for stressors to be identified and analysed further. Conclusion: This study highlights the importance of infection control education prior to placement but juxtaposes the challenge of doing so in a remote learning environment. It also exposes student stresses associated with entering clinical placements during high‐risk periods of infection.

Laura O'Connor, 1 Jason Dowling, 2 Jarad Martin, 1 Helen Warren‐Forward, 3 Haylea Richardson, 1 Kate Skehan, 1 Swetha Sridharan, 1 Geetha Govindarajulu, 1 Anne Capp, 1 Mahesh Kumar, 1 Peter Greer 1,4 1 Calvary Mater Newcastle, Newcastle, Australia 2 CSIRO Australian eHeatlh Centre, Brisbane, Australia 3 School of Health Sciences, University of Newcastle, Newcastle, Australia 4 School of Mathematical and Physical Sciences, University of Newcastle, Newcastle, Australia Objectives: Previous studies have shown the viability of producing synthetic CT (sCT) scans from conventional magnetic resonance imaging (MRI) scans, for the purpose of MRI only radiation therapy treatment planning for prostate cancer. 1 This study aims to apply this same method for creating sCT scans, for the purpose of MRI only planning, for anal canal, rectum, endometrium and cervix sites. Given the volumes for these patients are comparatively larger than prostate treatments, the anatomy is more variable from day‐to‐day. Additionally, there is the requirement for gender specific sCT creation methods to cover both men and women with these tumour types. Methods: This is a single arm, single centre study. 20 male and 20 female patients with cancers of the anal canal, rectum, endometrium and cervix were recruited for the study. Participants underwent a CT and planning MRI in the treatment position. sCT scans were generated using a hybrid atlas‐voxel based generation method. The radiotherapy plan was generated on the simulation CT scan and then transferred to the sCT. Analysis will include 3D gamma dosimetric analysis and dose volume histogram analysis between the CT and sCT data sets. Results: Recruitment is closed. Preliminary analysis has begun, with encouraging results thus far. Full results will be ready by the time of the meeting. Conclusion: The outcomes of this study are technical in nature. The primary endpoint of this study is to demonstrate the dosimetric agreement between conventional CT and MRI‐generated sCT scans for radiotherapy planning for the greater pelvic region. Reference 1. Dowling JA, et al. Automatic substitute computed tomography generation and contouring for magnetic resonance imaging (MRI)‐alone external beam radiation therapy from standard MRI sequences. Int J Radiat Oncol Biol Phys 2015;93(5):1144‐53.

Yolanda Gomes, 1 Shayne Chau, 1 Jo Davies, 2 Helen Banwell, 1 Ryan Causby 1 1 University of South Australia, Adelaide, Australia 2 Flinders Medical Centre, Bedford Park, Australia Ankle and foot injuries are the most commonly presented musculoskeletal injuries in Australian emergency departments, 1 with 4667 such presentations in South Australia in 2017–2018. 2 The Ottawa Ankle Rules (OAR) are part of a clinical decision‐making tool to help clinicians accurately rule out ankle fractures and hence preclude the need for diagnostic X‐ray imaging of ankle trauma. 3 This instrument has a sensitivity of almost 100% across various studies. 3 The rules state that ankle X‐rays are only required if the patient experiences malleolar pain and bone tenderness of the posterior distal tibia/medial malleolus tip, the posterior distal fibula/lateral malleolus tip or an inability to weight bear for four steps both immediately and in the emergency department. 4 In this study, we undertook a retrospective clinical audit of 300 ankle imaging referrals to (i) assess the current usage of the OAR in ruling out ankle fractures in a major metropolitan emergency department in Australia; (ii) evaluate the current concordance rate of scoring with positive findings on radiography and (iii) report on referring trends between professions, including consultants, registrars, physiotherapists and nurse practitioners. Ethics review was not sought because the study met criteria for exemption from such review according to an institutional policy. The outcome measures are characteristics of the included patients, compliance rate with the OAR, overall prevalence of ankle fractures, referring trends and sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of the OAR in this study. Formal results are pending but will be available at time of presentation. References 1. Strudwick K, McPhee M, Bell A, Martin‐Khan M, Russell T. Best practice management of common ankle and foot injuries in the emergency department. Emerg Med Australas 2017;30(2):152‐80. 2. Australian Institute of Health and Welfare. Emergency department care 2017‐18. Canberra, ACT: AIHW; 2018. Available at https://www.aihw.gov.au/getmedia/9ca4c770‐3c3b‐42fe‐b071‐3d758711c23a/aihw‐hse‐216.pdf.aspx?inline=true [Accessed 6 November 2019]. 3. Bachmann LM, Kolb E, Koller MT, Steurer J, Riet GT. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid‐foot: systematic review. BMJ 2003;326(7386):417‐19. 4. Derksen RJ, Knijnenberg LM, Fransen G, et al. Diagnostic performance of the Bernese versus Ottawa ankle rules: results of a randomised controlled trial. J Emerg Med 2015;46(8):1645‐649.

Mikaela Dell'Oro, 1,2 Michala Short, 1 Puthenparampil Wilson, 2,3 Chia‐Ho Hua, 4 Melissa Gargone, 4 Thomas Merchant, 4 Eva Bezak 1,5 1 Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, Australia 2 Royal Adelaide Hospital, Adelaide, Australia 3 School of Engineering, University of South Australia, Adelaide, Australia 4 St. Jude Children's Research Hospital, Memphis, USA 5 University of Adelaide, Adelaide, Australia Objectives: Proton therapy has superior dose distribution compared to photon therapy, reducing normal tissue complication probability for organs at risk (OARs). Previously published 3D‐conformal comparative planning studies have been superseded by intensity modulated radiation therapy (IMRT). The aim of this study was to compare scanning beam proton therapy to IMRT with respect to target size and location for paediatric cranial tumours. Methods: Six gender‐matched paediatric cranial datasets (5, 9 and 12 years) were planned in Varian Eclipse treatment planning system (version 13.7). Up to 108 scanning beam proton plans and 108 IMRT plans were retrospectively optimised to treat supratentorial (ependymoma) and infratentorial (medulloblastoma) target volumes, including simulated variations in size (ranging from 1–3 cm in diameter) and position (central, 1 and 2 cm shifts). Dose and volume data were extracted for the comparative plans to assess the impact size and position of the target volume on OAR outlined by radiation oncologists. Results: 216 plans were created by a single planner with proton and photon planning training and experience. Planning objectives were achieved for all plan pairs as per clinical protocols. Preliminary results average mean dose to selected OARs are shown in the Table. Conclusion: The study compared latest clinically relevant proton and photon treatment techniques across a large range of simulated clinical scenarios demonstrating a dose reduction to normal tissues for proton plans across supratentorial and infratentorial tumour sites. These findings inform the next phase of research related to modelling intrinsic radiosensitivity of OARs.

John Ryan, 1 David Willis 2 1 RMIT University, Melbourne, Australia 2 Sunshine Coast University Hospital, Birtinya, Australia Objectives: Approximately 800 paediatrics will be diagnosed with cancer in Australia in 2019; 1 5‐year survival is 84%. 1 Paediatrics are 7–15 times more sensitive to radiation than adults. 2 Therefore, image‐guided radiation therapy (IGRT) should be optimised. The aim of this quality improvement project was to determine if, the accuracy of IGRT for paediatric patients can be maintained using reduced radiographic dose exposures instead of vendor pre‐sets. 3 Methods: A table of low‐dose radiographic exposure factors for paediatric IGRT was determined through a phantom study on a linear accelerator. This table was evaluated against the linear accelerator manufacturer pre‐sets, in terms of exposure dose and user accuracy when matching. Four anatomical sites, head and neck, pelvis, abdomen and thorax were included. Matching accuracy was assessed in a simulated clinical situation, where participants anonymously recorded their matched moves in an online survey. Results: 12 radiation therapists or radiation oncologists completed the image matching task and survey. The low‐dose exposure table reduced imaging dose by 20–94% compared to manufacturer pre‐sets (Table). No significant difference was observed in the accuracy of image matching (head and neck P = 0.82, thorax P = 0.15, abdomen P = 0.33, pelvis P = 0.59). Participant image exposure preference was largely equivocal. Conclusions: Optimising radiographic exposures in paediatric IGRT is feasible, logical and therefore reasonably achievable. Implementation of the low‐dose exposure table should be considered by paediatric radiotherapy departments wishing to image gently without compromising the potential to detect setup errors. References 1. Australian Government, Cancer Australia. Children's cancer statistics online. Based on data from the AIHW July 2019. Available at https://childrenscancer.canceraustralia.gov.au/about‐childrens‐cancer/statistics [Accessed November 2019]. 2. Hall EJ. Lessons we have learned from our children: cancer risks from diagnostic radiology. Pediatr Radiol 2002;32:700‐706. 3. Ryan J, Willis D. Paediatric image‐guided radiation therapy: determining and evaluating appropriate kilovoltage planar exposure factors for the Varian on‐board imager. J Med Radiat Sci 2020;67(1):16‐24.

Phillip Moloney, 1 Kenton Thompson, 2 Nigel Cristofaro, 3 Vanessa Panettieri, 4 Drew Smith 5 1 Andrew Love Cancer Centre, Geelong, Australia 2 Peter MacCallum Cancer Centre, Melbourne, Australia 3 Gippsland Radiation Oncology, Traralgon, Australia 4 Alfred Health Radiation Oncology, Melbourne, Australia 5 Olivia Newton‐John Cancer Wellness and Research Centre, Heidelberg, Australia Radiation oncology has undergone a rapid evolution over the last few decades. Complexity of patient treatments have increased, where once reserved for complex cases, it is now the standard of care. The continual development of radiation therapy technology and increased plan complexity makes the accurate sharing of a patient’s previous treatment information more important than ever. Current methods of sharing previous treatment information rely on sending a broad snapshot using a few 2D images of the radiation plan. This information is generally shared via email or fax. Faxing this information results in degradation of the images through imaging artefacts and conversion of coloured isodoses to grey scale. When using these methods of data sharing it is impossible to accurately model dosimetric overlap. The Leader of Planning Services at a Victorian public provider identified the need for a universal request and data sharing solution to enable sharing of DICOM plan data. They began a quest to build a sharing platform that would facilitate safe, accurate and appropriate radiation therapy re‐treatment decisions for all Victorian radiation therapy providers. This presentation will detail the steps undertaken to initiate a secure cloud‐based platform for sharing radiation treatment information. Steps included initial proposal, securing Department of Health and Human Services funding, consensus on system requirements, development sprints and acceptance testing. Key recommendations and lessons learnt will be shared, such that others can learn from our experience.

Shohani Douglas, 1 Nigel Anderson, 1 Kristie Matthews, 1 Elise Dunstan 2 1 Peter MacCallum Cancer Centre, Melbourne, Australia 2 Ourschool, North Melbourne, Australia During 2019, a shared undertaking between Peter MacCallum Cancer Centre (PMCC) and Ourschool – a not‐for profit program linking Victorian public high schools and alumni communities – was initiated to deliver a careers seminar to Year 10 students. The objective of the seminar was to enable students to hear from different professionals associated with PMCC, and the many pathways that had led them to the state‐of‐the‐art centre, with the intent to inspire future career decisions. The seminar provided the opportunity for students to develop a greater awareness of eight different professions available in a health service, including allied health, medical radiations and medical options. The aim of this presentation is to describe the vision, collaboration, and outcomes of the careers seminar, and future directions. Approximately 115 students from eight Ourschool partnered schools who were interested in pursuing health associated careers attended PMCC for the seminar. Students travelled from metropolitan and regional Victoria. An evaluation following the session indicated that students were more informed about the diverse health and medical pathways and were inspired to strive for the very best outcomes at school. It is believed that continuing to promote career pathways to students earlier in their learning will broaden awareness of the plethora of health professions, aid students’ decision making, lift aspirations, and inspire future cohorts into our professions. It is hoped that these inaugural and future attendees will continue to share their own journey with students once they too become alumni, developing an ongoing collaboration between the two organisations.

Yi‐chin (Andy) Huang 1 1 Royal Brisbane and Women's Hospital, Brisbane, Australia Background: The impact of cancer on adolescents and young adults’ (AYA) psychosocial health can be significantly detrimental, as young people often face a range of important life events and decisions that could potentially impact their health and wellbeing in the long term. However, this group of patients often fall in the gap between paediatric or adult strategy of care. Therefore, it is necessary to establish dedicated units for AYA and provide adaptive care strategies to bridge the gap. Objective: The purpose of this review is to explore the literature in order to identify the most effective and appropriate method to educate AYA patients before and during their radiotherapy simulation and treatments. The impact of establishing an effective and appropriate education method to AYA in a clinical setting will also be reviewed. Results: Results from the studies indicate that having a dedicated care team for AYA and delivering adaptive education strategies during their course of treatment can provide positive impacts for these patients. AYA said that they felt more connected with healthcare professionals when there is a special AYA team that look after them. Conclusion: There are many critical elements in providing effective and appropriate AYA support. Access to social events, fertility and sexuality counselling should be incorporated into standard care procedures. However, each patient is unique, so the AYA care team should always identify the specific needs of each patient and provide the most appropriate care based on these interventions.

Shivani Kumar, 1,2,3 Robba Rai, 1,2,3 Doaa Elwadia, 1 Lois Holloway 1,2,3,4,5 1 Liverpool Cancer Therapy Centre, Liverpool, Australia 2 University of New South Wales, Randwick, Australia 3 Ingham Institute of Applied Medical Research, Liverpool, Australia 4 University of Wollongong, Wollongong, Australia 5 Institute of Medical Physics, University of Sydney, Sydney, Australia Magnetic resonance imaging (MRI) is increasingly being integrated into radiation therapy (RT) planning owing to it superior soft tissue contrast compared to computed tomography. MRI has more degrees of flexibility, and by varying different parameters, MRI sequences can be tailored to visualise anatomical and functional aspects of organs and tumours. These benefits can help us develop a more personalised approach to care. Despite these advantages, the integration of MRI into the RT planning can be challenging, and careful considerations is required to ensure appropriate integration. Adapting MRI examinations to the RT treatment position may involve compromise in image quality, as a result of immobilisation devices, placement of coils to avoid external anatomy deformation, as well as clearance through MRI bore. System and patient related factors cause geometric distortion which is undesirable for RT planning and it is important to quantify and minimise these. In addition, safety and educational requirements for both patients and staff need to be incorporated into the integration process. In our department a dedicated MRI simulator has been utilised since 2013, for both research and clinical purposes. In this work we will be describing the department’s experience of integrating MRI into clinical workflows. This will include safety requirements, educational needs, development of site‐specific imaging protocols, and adaption of existing planning workflows to accommodate MRI integration. We will also discuss research utilisation, as well investigation of novel MRI sequences and potential application for RT planning.

Shivani Kumar, 1,2,3 Kylie Dundas, 1,2,3 Annamarie D'Souza, 4 Jessica Grundy, 5 Odette King, 1 Andrea Lee, 5 Lois Holloway 1,2,3,6,7 1 Liverpool Cancer Therapy Centre, Liverpool, Australia 2 University of New South Wales, Randwick, Australia 3 Ingham Institute of Applied Medical Research, Liverpool, Australia 4 South Western Sydney District Ethics and Research Governance, Liverpool, Australia 5 South Western Sydney Local Health District, Liverpool, Australia 6 University of Wollongong, Wollongong, Australia 7 Institute of Medical Physics, University of Sydney, Sydney, Australia Technology, techniques and patient processes are constantly evolving and becoming more complex. With the vision of improving patient outcomes, patient experiences and workflow efficiencies, Radiation therapists are increasingly undertaking research studies and quality improvement (QI) initiatives. Research and QI have subtle differences, which can make it challenging to clearly identify the appropriate pathway to investigate a clinical problem. Clarity regarding appropriate pathway is further clouded by ethical implications of both forms of investigations, and the frequent blurring of projects that may start as one type of project and evolve into the other over time. QI projects typically evaluate or audit implemented changes in patient care processes in a specific healthcare setting. 1 Research projects are typically investigations that test/compare different groups, and are often designed to develop or contribute to existing knowledge, or generate new understanding. 2 According to the National Health and Medical Research Council, irrespective of whether a project is classified as research or QI, staff involved in conducting the project must consider whether the participants involved (staff, patients, and community) will be exposed to any risks, burden, inconvenience or breach of their privacy and ensuring the activities are conducted in way that is ethical. 1 The aim of this work will be to review national guidelines and discuss in the context of typical radiation therapy projects and activities describing the appropriate oversight and or ethical review. We will also describe departmental initiatives on QI and research projects aimed to ensure appropriate ethical oversight and governance. References 1. National Health and Medical Research Council. Ethical considerations in quality assurance and evaluation activities. Canberra, ACT: Australian Government; 2014. 2. National Health and Medical Research Council. National statement on ethical conduct in human research. Canberra, ACT: Australian Government; 2007.

Rebecca Biles 1 1 Queensland University of Technology, Brisbane, Australia There are many examinations and procedures both past and present which are unfamiliar to students, emerging graduates and qualified radiographers alike. A university film library of historical radiographs submitted by former students was catalogued and analysed, which has provided an invaluable portal to the past 50 years of radiology practice. These resources have provided a unique opportunity to reflect on learnings from examinations which are now extinct, provoking thought about where the next 50 years of innovation may take the field of radiology. The historic examinations within the collection were directly compared with the current gold‐standard procedures, identifying similarities and differences, and highlighting the gaps in former practice that prompted subsequent changes and advancements. Some examples include procedures such as air encephalograms which have been replaced by computed tomography (CT) and magnetic resonance imaging (MRI) for neuroimaging, tomographic intravenous pyelograms which have been largely superseded by CT, and arthrography which has moved from being a fluoroscopic procedure to an MRI examination. By understanding this history, identification and awareness of current gaps in radiology practice may be facilitated, leading to a continued appreciation and drive towards innovation in technology and patient care. It is through reflection upon historical accomplishments that we can truly appreciate the vision of future improvements in our field.

Lorraine Reynolds, 1 Aiden Cook, 1 Gordon Mander 1 1 Queensland Health Darling Downs Health, Toowoomba, Australia Background: Clinical information errors in medical imaging can lead to a significant impact on a patient’s care. 1 The medical imaging department at Toowoomba Hospital has undergone a quality activity since 2015 collecting data around clinical information errors. The aim of this study was to identify factors that are associated with clinical errors in the medical imaging department. Method: Relevant factors such as study time, modality, error type and category of error were collected for all clinical information errors occurring between March 2015 and September 2019. Data was also collected from clinical staff on their impression of the importance of each error type, years of experience as well as fatigue factors. Binary logistic regression analysis was used to determine the probability of a particular factor being associated with an error occurring. An exemption from ethical review was granted by the institution’s Hospital Research Ethics Committee. Results: Over the study period, 2277 errors occurred. The preliminary analysis showed several factors were significantly associated with error occurrence: 39% of errors occurred when the radiographer was on an evening shift and 48.3% of errors occurred following a late or call shift. The percentage of errors that occurred from a radiographer with three or less years of experience was 24.6%. The most frequent error (26%) was incorrect paperwork on PACS. Conclusion: Clinical information errors in medical imaging are multifactorial. The study will assist management in understanding why errors occur and inform a program that will allow for a reduction in these occurrences. Reference 1. Zhou Y, Boyd L, Lawson C. Errors in medical imaging and radiography practice: a systematic review. J Med Imaging Radiat Sci 2015;46(4):435‐41.

Adam Steward, 1 Mia Holliday 1,2 1 Western Health, Footscray, Australia 2 Deakin University, Geelong, Australia Background: Pre‐operative templating using digital radiography is an effective method of planning for total hip arthroplasty and requires a generalised fixed magnification factor (MF) or external calibration markers (ECM). The effect on image magnification when changing source‐to‐image distance, object‐to‐image distance (OID) and different imaging conditions is not well‐described. Methods: A simple phantom study was performed. A 25 mm ECM was placed at eight different OID values along the anterior‐posterior phantom plane at three different SID values and imaging conditions, and X‐rays were obtained. On each radiograph, the ECM was measured using a line caliper tool by three radiographers and recorded. The MF was calculated and recorded. Results: The smallest observed image MF was 1.16, for an 8 cm OID, 120 cm SID with the ECM placed within the central ray and the X‐ray detector in bucky underneath the X‐ray table. The largest image MF was 1.40 for a 15 cm OID, 100 cm SID with the X‐ray detector placed underneath an emergency department imaging trolley. Conclusion: Digital pre‐operative templating for total hip arthroplasty relies on accurate radiographic positioning and is dependent of the patient body habitus, radiographic parameters and imaging conditions selected by the radiographer. Based on the findings of this study, we believe that the use of a generalised MF does not account for deviation of these factors, and hence can be inaccurate. The use of appropriately positioned ECMs – placed medially between the patient’s internally rotated legs at the level of the greater trochanter – lowers the potential for magnification inaccuracies.

David Crawford, 1 Michael Jameson, 1,2 Stacy Alvares, 1 Louise Hogan, 1 Conrad Loo, 1 Claire Pagulayan, 1 Urszula Jelen, 1 Tania Twentyman, 1 Zoe Moutrie, 1 Monique Henke, 1 Sandy Sampaio, 1 Jeremy de Leon 1 1 GenesisCare, Darlinghurst, Australia 2 The University of New South Wales, Kensington, Australia Background: MR linacs (MRLs) are being utilised more often within a radiation oncology setting. The use of this technology is changing clinical practice. Traditionally, SABR prostate treatments on a standard linac may require invasive procedures for placement of SpaceOAR and fiducials markers. Due to the enhanced soft tissue definition on MRI and daily replanning, the MRL can remove the need for these invasive procedures. We present the initial Australian experience of stereotactic prostate radiotherapy on the MRI linac using a fully adaptive workflow. Method: Prostate SBRT patients undergo a CT and MRI for target and organ at risk delineation. A prostate membrane specific antigen and SpaceOAR are optional. Fiducials are not required. Each fraction is delivered using an adapt to shape workflow, which involves recontouring and plan re‐optimisation. All patients underwent real‐time image guidance through the use of cine imaging. A treatment handover document is used to inform planning each day to improve consistency and efficiency Results: Since July 2020, eight patients have undergone treatment. Prescription was 36.25 Gy and 38–40 Gy to CTV delivered in five fractions on alternate days. Average treatment time was 45–55 minutes. Plan quality at each fraction was adequate. Conclusion: Stereotactic prostate radiotherapy treated with the adapt to shape workflow is well tolerated. Plan metrics were consistently met and treatments times where acceptable.

Paul Kane, 1 Ann Poulos, 2 Cherry Agustin 3 1 University of Otago Wellington, Wellington, New Zealand 2 University of Sydney, Sydney, Australia 3 Crown Princess Mary Cancer Centre Westmead, Sydney, Australia The Journal of Medical Radiation Sciences (JMRS) is co‐owned by the Australian Society of Medical Imaging and Radiation Therapy and the New Zealand Institute of Medical Radiation Technologists. As such, it is your professional journal. Since 2013, JMRS has been publishing peer reviewed scientific articles across a range of topics from the field medical radiation sciences. Discoverable in all the major scientific databases such as PubMed, Medline and Scopus and following the open access model, our reach extends to 150 different countries globally and we are experiencing an annual growth in readership of around 30%. The editorial team is a volunteer workforce drawn from all parts of Australia and New Zealand comprised of individuals working at all levels of clinical and academic practice. The editors are backed by a professional team of people working at Wiley (JMRS publishers). Our partners at Wiley provide the infrastructure and support needed to produce a top‐class international journal. Senior members of the editorial team wish to take the opportunity presented by this joint conference to report to delegates on the success your journal has been achieving in disseminating evidence around good practice in medical imaging and radiation therapy. We also wish to discuss how you can become involved and contribute to the future vision of JMRS.

Carly Wood, 1 Michael Tarollo 2 1 Austin Health, Melbourne, Australia 2 Western Health, Melbourne, Australia Objectives: As the COVID‐19 pandemic developed, many hospitals in Australia adapted their chest X‐ray (CXR) protocol when imaging suspected and confirmed COVID‐19 patients. Mobile CXRs became routine over conventional CXR to minimise transportation of COVID‐19 patients. In each examination, full PPE was required to be worn, and sometimes exams were performed at increased source to image distance (SIDs). Our aim was to assess any change in demand of mobile CXR imaging in 2020, to measure any additional time required for PPE, and to review the impacts of performing CXRs at increased SIDs. Methods: Mobile CXR data was retrospectively collected across four Melbourne hospital sites for the years 2018, 2019 and 2020. Data collected was total number of mobile CXRs per month at each site. Additionally, 50 mobile CXR examinations were evaluated, and data was collected regarding time required for the following factors: reaching ward, donning PPE, performing exam, doffing PPE and cleaning, returning to department and post‐processing. Results: When comparing 2018 and 2019 with 2020, an increase in total number of mobile CXRs was seen. The highest percentage increase in one month was 433%. Additional time was required for PPE, with an average increase in exam time of 31%. Conclusion: A significant increase was seen in number of mobile CXRs performed in 2020 compared to previous years, as well as an increase in time to perform these exams.

Glen Osbourne, 1 Karen McGoldrick, 1 Kenton Thompson, 1 Alan Turner, 1 Nicholas Hardcastle 1 1 Peter MacCallum Cancer Centre, Melbourne, Australia Objectives: Preliminary planning at our institution using HyperArc™ (Varian Medical Systems, Palo Alto, USA) identified the optimal beam energy of 10 MVFFF. Evidence suggests that single target plans do not require as many arcs as single isocentre, multiple target plans but there are trade‐offs. 1,2 The aim of this study was to determine the optimal arc selection from HyperArcs class solution beam geometries for post‐surgical cavities for stereotactic radiotherapy (SRT). Methods: For 16 retrospective solitary post‐surgical cavity cases, HyperArc plans comprising different arc geometries were generated. Prescribed dose for all plans was 24 Gy in 3 fractions with D99% ≥ utilising 10 MVFFF. Metrics analysed including indices: CI100 RTOG, CI50 RTOG, CI Paddick, GI Paddick, HI (ICRU 83) and plan complexity using modulation factor (MF) (MU/dose per fraction in cGy) comparing default arc selection versus varying arc selections. Results: The mean CI100 RTOG for default arc selection was 1.10 (1.03–1.25) compared to 1.11 (1.05–1.24) for the comparison plans. The mean CI50 RTOG for default arc selection was 3.24 (2.70–5.44) compared to 3.25 (2.79–4.46) for the comparison plans. The mean MF for default arc selection was 2.74 (2.40–3.40) compared to 2.76 (2.40–4.00) for the comparison plans. Results from the complete analysis to be presented with additional metrics. Discussion/Conclusion: Analysis highlighted minimal differences when comparing default arc selection to varying arc selection. Due to no clear benefit for either groups of plans, consideration in the decision making was given to both treatment time and isocentre verification at individual couch angles. Therefore, minimising arc angles for solitary intra‐cranial lesions was the preferred option. References 1. Yuan Y, Thomas EM, Clark GA, et al. Evaluation of multiple factors affecting normal brain dose in single isocenter multiple target radiosurgery. J Radiosurgery SBRT 2018;5:131‐44. 2. Clark GM, Popple RA, Prendergast BM, et al. Plan quality and treatment planning technique for single isocenter cranial radiosurgery with volumetric modulated arc therapy. PRO 2012;2:306‐13.

Christine Vanderley‐Reichner 1 1 Royal Hobart Hospital, Hobart, Australia As medical imaging specialists we want to provide our patients with the best safest examination we can give them. We need to ensure that they have all the information they need to understand and then consent to their imaging procedure. We can only do this if we put them at the centre of the process. Consent was in the past limited to larger or more complicated procedures. The changing expectations mean we need to change our processes. The conundrum for low‐risk procedures is how we do this in a busy X‐ray department without compromising the quality of the information and the safety of our patients.

Caroline Wright, 1 Sue Merchant 1 1 Monash University, Melbourne, Australia Objectives: Medical radiation practitioners (MRP) experience challenges raising concerns about their peers’ professionalism lapses. 1 The literature highlights barriers such as fear of adverse consequences as influencing healthcare students’ decisions whether or not to raise concerns about practitioner performance. 2,3 However, to date, this has not been investigated in MRP students. Aim: To investigate the challenges associated with students raising concerns about practitioners after experiencing professionalism dilemmas while on clinical placement. Methods: Ethics approval was granted and seventy students from six Australian universities were recruited to participate. Flyers, email and snowballing techniques were used for recruitment, through student, academic and administrative staff facilitation. Interviews were digitally recorded, transcribed and anonymised. Participants provided accounts of their experiences related to raising concerns about practitioner professionalism lapses. Team‐based framework analysis was used to code and theme the data. Team reflexivity was employed to add rigor to the study. Results: The following themes were identified: Fear of repercussions (alienation, burning bridges, assessment failure, tarnishing reputation), Inexperience, Confidence, Power/Hierarchy and Resolution ‘know how’. Discussion/Conclusion: Fear about the consequences of raising concerns/reporting and lack of ‘know how’ about the processes involved were commonly experienced. Curricula should be developed to ensure students are equipped with knowledge about the processes, confidence and skills to communicate concerns. Clinical organisations should provide a supportive, confidential environment to encourage and support students who wish to raise a concern. Non‐discipline related practitioner advocates could be identified to support this process. References 1. Wright CA, Schneider ME, Jolly B, Baird MA. An online survey investigating Australian radiation therapists' responses to hypothetical dilemmas concerning impaired fitness to practise. JMIRS 2015;46(3):287‐93. 2. DesRoches CM, Rao SR, Fromson JA, et al. Physicians perceptions, preparedness for reporting and experiences related to impaired and incompetent colleagues JAMA 2010;304:187‐93. 3. Milligan F, Wareing M, Preston‐Shoot M, et al. Supporting nursing, midwifery and allied health professional students to raise concerns with the quality of care: a review of the research literature. Nurse Educ Today 2017;57:29‐39.

Maddison Shaw, 1,2 Andrew Alves, 1 Jeremy Supple, 1 Cate Davey, 1 Rhonda Brown, 1 Andrew Cole, 1 Fayz Kadeer, 1 John Kenny, 3 Joerg Lehmann, 2,4 Moshi Geso, 2 Jessica Lye 1 1 Australian Clinical Dosimetry Service, ARPANSA, Melbourne, Australia 2 RMIT University, Melbourne, Australia 3 Health Stem Solutions, Melbourne, Australia 4 Calvary Mater Hospital, Newcastle, Australia Introduction: Stereotactic ablative radiotherapy (SABR) and stereotactic radiosurgery (SRS) techniques present an increased risk to patients due to the increased dose per fraction and high geometric precision. Specialised planning, treatment and quality assurance practices are needed to ensure patient safety. 1–3 Method: The ACDS offers end‐to‐end dosimetry audits of SABR and SRS techniques to radiotherapy facilities across Australia and New Zealand. The SABR audit utilises a thorax phantom to measure dose in lung, spine and soft tissue targets. The SRS audit utilises a cranial phantom to measure dose in multiple metastases, simple SRS targets and targets that are visible on MR imaging only. Gafchromic film is used to measure 2D delivery accuracy, along with point dose verification in centre of PTVs. Results: The SABR dosimetry audit has been performed in 42 radiotherapy facilities, with over 200 plans measured. The SRS audit has been performed in six radiotherapy facilities, with 18 plans measured. Plans that were assessed as out of tolerance in the audits will be discussed as case studies. The Figure shows the effect of linear accelerator isocentre misalignment in a SABR spine delivery. Other case studies to be presented include incorrect prediction of dose at the periphery of lung tumours, incorrect IGRT, limitations of Exactrac imaging in extra cranial targets, differences between single and multi‐isocentre treatments for multiple brain metastases and limitations of planning system calculation algorithms. Conclusion: The ACDS has developed a comprehensive audit for SABR and SRS treatments, highlighting areas for improvement in current clinical practice. References 1. Guidelines for safe practice of stereotactic body (ablative) radiation therapy. Faculty of Radiation Oncology, The Royal Australian and New Zealand College of Radiologists, 2015. 2. Solberg TD, Balter JM, Benedict SH, et al. Quality and safety considerations in stereotactic radiosurgery and stereotactic body radiation therapy. PRO 2011;2(1):2‐9. 3. Stereotactic ablative body radiation therapy (SABR): a resource. UK SABR Consortium. Version 4.0, 2013.

Magdalena Dolic 1 , Yaxuan (Lisa) Peng 1 , John Mclnerney 1 , Wendy MacLeod 1 , Ruth Druva 1 1 Monash University, Clayton, Australia Introduction: Commenting on radiographic abnormalities is an expectation in radiography and is an obligation for qualified radiographers.¹ Despite this, radiographers’ confidence articulating descriptions of radiographic pathology and anatomy varies.² The purpose of this research was to evaluate the influence of ePortfolios as a creative learning approach in enhancing students' confidence in commenting on normal and abnormal radiographic anatomy, both in the academic and clinical environment. Methods: A mixed methods survey comprised of both quantitative and qualitative questions was formed via a Monash installed platformed Qualtrics and then distributed to second year Monash radiography students who had used ePortfolios for anatomy study in year one. The survey was distributed to students at the beginning of a lecture via Moodle and data was obtained anonymously through Qualtrics. Results: Initial findings have been positive with 89% of respondents either agreeing or strongly agreeing that ePortfolio was useful in enhancing their confidence in commenting on radiographic pathology in the academic environment. The correlation was not as strong in the clinical environment where roughly 25% felt the ePortfolio was not as useful in helping them confidently identify and describe radiographic pathology respectively in their clinical placement. The clinical environment has unique challenges that affect the students’ confidence which was evident from the qualitative findings. Conclusion: Preliminary findings suggest that ePortfolios have assisted in improving confidence in the identification and description of abnormalities, particularly in an academic setting. A thematic analysis of the qualitative data will develop a deeper understanding of results. References 1. Medical Radiation Practice Board. Professional capabilities for medical radiation practice. Australia; 2013. Available at http://www.medicalradiationpracticeboard.gov.au/Registration/Professional‐Capabilities.aspx [Accessed 10 October 2019]. 2. Neep MJ, Steffens T, Owen R, McPhail SM. A survey of radiographers’ confidence and self‐perceived accuracy in frontline image interpretation and their continuing educational preferences. J Med Radiat Sci 2014;61(2):69‐77.

Stami Trakis, 1 Ritin Fernandez, 2 Dominique Parrish 3 1 St George Hospital Cancer Care Centre, Kogarah, Australia 2 St George Hospital Centre for Research, Kogarah, Australia 3 University of Wollongong, Wollongong, Australia Background: Rapid advancements in technology, prolonged treatment regimens, changes to the healthcare settings and increased patient care responsibilities has resulted in an increase of emotional struggle among radiation therapists (RTs). Therefore, a shared vision on developing the emotional intelligence (EI) among RTs is important for effective clinical practice, delivery of patient‐centred care and for the RTs’ mental‐social health performance. Objective: The objective of this study was to explore the demographic predictors of EI among RTs working in cancer care centres in New South Wales, Australia. Methods: A cross‐sectional self‐administered survey using the Trait Emotional Intelligence Questionnaire–Short version (TEIQue‐SF) 1 was used to measure EI. Multiple regression analysis was used to identify the demographic predictors of EI among RTs. Results: A total of 205 RTs participated in this study. The mean score for global EI was 5.16 (SD = 0.6) and the scores for the emotionality, self‐control, wellbeing and sociability dimensions were 5.3, 4.9, 5.7 and 4.7 respectively (maximum attainable score was 7). The predictors of global EI were younger age and higher levels of current employment. Higher levels of employment were also a significant predictor of the sociability dimension. Gender was a significant predictor of the emotionality dimension and higher levels of education was a significant predictor of the emotionality and sociability dimension. Conclusion: As level of education and level of employment are both amendable demographics factors, strategies to improve these EI predictors among RTs are required. Reference 1. Cooper A, Petrides KV. A psychometric analysis of the Trait Emotional Intelligence Questionnaire–Short Form (TEIQue–SF) Using Item Response Theory. J Pers Assess 2010;92:449‐57.

Shivani Verma, 1 Tumi Huynh, 1 Venus Ngau, 1 Hun Lee, 1 Phillip Lam, 1 Inshirah Naufan, 1 Alexander Mollaneda, 1 Christopher Nguyen, 1 Steven Truong, 1 Duy Vu 1 1 Monash University, Melbourne, Australia Introduction: COVID‐19 has affected the way radiography students learn in the absence of face‐to‐face classes. A rapid transition to online learning prompted teaching staff to plan and communicate cognisantly. Despite many challenges, COVID‐19 provided educational institutions the opportunity to re‐design learning and foster a safe online environment. This research aimed to highlight student learning during COVID‐19 and inform the future of radiography education in an increasingly online world. Methods: A qualitative study, which included second‐year Monash University radiography students, was conducted in three online semi‐structured focus groups using Zoom. Participants were recruited via Moodle and social media channels. An explanatory statement was provided to all potential participants. Participants used a pseudonym to preserve anonymity. Focus groups were recorded using the Zoom record facility and transcribed by the researchers. A thematic analysis was carried out on the data. Results: Participants had a mostly positive experience with online learning. However, some technological concerns impacted students’ confidence during assessments. Distractions, such as social media and family commitments, were the most predominant issues students struggled with when studying at home. Participation in classes was dependent on the scheduled class, subject and attendance of other students. Posture and eyesight were commonly affected due to the increased usage of technology. Conclusion: COVID‐19 presented many challenges for students in their academic learning, such as distractions associated with studying at home. However, students responded to the challenges and reported some tangible benefits to online learning with participants hopeful for a balanced integration of e‐learning alongside in‐person classes.

Aidan Leong, 1,2 Abbie Taylor 1 1 Bowen Icon Cancer Centre, Wellington, New Zealand 2 University of Otago, Wellington, New Zealand Objectives: Deep inspiration breath‐hold (DIBH) is an effective technique to reduce cardiac dose to patients undergoing radiation therapy (RT) for left‐sided breast cancer. 1 However, patients can find it challenging to accurately perform DIBH. 2 We implemented a wireless visual caching device (VCD) to guide patients during DIBH. This study analysed the accuracy and stability of VCD‐guided DIBH among an initial patient cohort. Methods: 20 consecutive left‐sided breast patients were treated with VCD‐guided DIBH. An infrared marker‐block was used to track DIBH depth during treatment. Marker‐block position data (captured every 0.015s) was analysed for agreement relative to each patient’s planned DIBH depth. Mean, systematic error (Σ), and random error (σ) were calculated for the cohort. MV images acquired during treatment delivery were similarly analysed to correlate intrafractional motion with marker‐block position. Results: 2934 seconds of DIBH data across 100 treatment fractions (five per patient) were analysed. Mean marker block deviation from planned position was –0.4 mm (Σ = 0.7 mm, σ = 0.9 mm). Pooled analysis of marker‐block data showed 91% and 56% of beam‐on time to be within ± 2 mm and ± 1 mm of the planned DIBH depth, respectively. High patient compliance was shown with 99.5% of fields delivered within a single breath‐hold. Mean intrafractional motion on MV imaging was <1 mm (Table). A limited correlation between VCD and MV imaging data was seen. Discussion/Conclusion: VCD‐guided DIBH treatments show a high level of accuracy, stability and compliance. This provides a baseline for on‐going development in improving the accuracy and ease of RT under DIBH. References 1. Smyth LM, Knight KA, Aarons YK, Wasiak J. The cardiac dose‐sparing benefits of deep inspiration breath‐hold in left breast irradiation: a systematic review. J Med Radiat Sci 2015;62(1):66‐73. 2. Mc Parland N, Nica L, Soo J, Menna T. Deep inspiration breath hold for left‐sided breast cancer: experience from the patient’s perspective. J Radiother Pract 2015;14(3):228‐35.

Andrew Wallis, 1 Ricky O'Brien, 2 Owen Dillon, 2 Armia George, 1 Sandie Smith, 1 Sarah Alnaghy, 2 Paul Keall, 2 Shalini Vinod, 1,3 Jan‐Jakob Sonke 4 1 South Western Sydney Local Health District, Liverpool, Australia 2 ACRF Image X Institute, University of Sydney, Sydney, Australia 3 University of New South Wales, Sydney, Australia 4 Netherlands Cancer Institute, The Netherlands Introduction: Four‐dimensional cone beam computed tomography (4DCBCT) is used for patient positioning for lung cancer. However, scan times are long (4 min), imaging doses are high with inconsistent image quality between patients. To enable time and dose efficient 4DCBCT scans, we have developed a system that adapts the gantry rotation speed and projection acquisition in response to the patient’s real‐time respiratory signal. In this study, we report on the initial experiences of this phase 1 pilot study utilising adaptive 4DCBCT. Methods: In this ethics‐approved study, an Elekta Versa linear accelerator was modified to acquire patient adaptive 4DCBCT images. In‐house circuitry was integrated to control the gantry rotation speed and suppress kV triggers to the kV generator during acquisition. A respiratory sensor was used to monitor the patient’s breathing in real‐time. Each patient is treated as per department protocol and then two ADAPT scans were acquired with 20 projections in 10 breathing phases across 20 breathing cycles were acquired. The projections were reconstructed with the motion compensated FDK algorithm available in the reconstruction toolkit. Comparisons were made with the conventional 4DCBCT reconstructed with the FDK algorithm. Results: Four patients have been scanned using the ADAPT protocol. A reduction in both imaging dose (85%) and acquisition times (75%) were achieved compared to the conventional scan. Image quality was acceptable for patient positioning (Figure). Conclusion: The initial experiences with adaptive 4DCBCT imaging protocol has been acquired showing large reductions in scan time and imaging dose.

Thomas Devereux, 1 Kenton Thompson, 1 Nick Hardcastle, 1 Shankar Siva, 1 Kaj Bayley, 1 Maria Portillo‐Coyne, 1 Shoaib Afzali, 1 Kevin Tu, 1 Latisha Walton 1 1 Peter MacCallum Cancer Centre, Melbourne, Australia Objectives: The SC‐24 trial reported improved pain outcomes for patients with spinal metastases when receiving stereotactic ablative radiotherapy (SABR). 1 Therefore, an effective and efficient method for planning SABR spine is required. The aim is to develop a consistent method for SABR spine planning that will assist in the development of a knowledge‐based planning model. Method: 20 patients were retrospectively re‐planned to test the impact on plan quality of different variables. Six plans (A, B, C, D, E, F) were generated: A: planning target volume (PTV) cropped from gross target volume (GTV) B: PTV cropped from GTV and spinal cord planning risk volume (PRV) C: PTV cropped from GTV and applying a generalised equivalent uniform dose (gEUD) constraint on spinal cord PRV D: Manually optimised using planner preference for settings E: PTV cropped from GTV and spinal cord PRV with an upper gEUD F: Ring structure added. A: planning target volume (PTV) cropped from gross target volume (GTV) B: PTV cropped from GTV and spinal cord planning risk volume (PRV) C: PTV cropped from GTV and applying a generalised equivalent uniform dose (gEUD) constraint on spinal cord PRV D: Manually optimised using planner preference for settings E: PTV cropped from GTV and spinal cord PRV with an upper gEUD F: Ring structure added. Metrics evaluated included D90% PTV (%), GTV min dose (Gy), D0.03cc (Gy) spinal cord PRV/cauda equina PRV, CI50 and modulation factor. Results: 10 patients were planned 20 Gy in 1 fraction and 10 patients were planned 24 Gy in 2 fractions. Reported means for PTV D90% were 99.58% (105.97–88.62), 99.61 % (106.03–86.81), 99.69% (105.84–79.67), 99.70% (106.29–73.1), 99.9% (106.11–64.48) and 99.81% (106.12–96.5) for A, B, C, D, E and F respectively. Conclusion: A systematic method can be used to ensure consistency with the aim of developing a standardised solution that can facilitate in the development of a knowledge‐based planning model for SABR spine. Reference 1. Sahgal A, Myrehaug SD, Siva S, et al. CCTG SC.24/TROG 17.06: a randomized phase II/III study comparing 24Gy in 2 stereotactic body radiotherapy (SBRT) fractions versus 20Gy in 5 conventional palliative radiotherapy (CRT) fractions for patients with painful spinal metastases Int J Radiat Oncol Biol Phys 2020;108:1397‐98.

Tracey McKernan 1 1 Curtin University, Bentley, Australia Objectives: Clinical reasoning (CR) is a complex skill considered essential for health practitioners. It is a skill that must be developed but is often not visible to novice practitioners, nor easily articulated by experienced practitioners. This research sought to investigate how radiation therapists (RTs) describe CR, how they make their thinking visible and the strategies they use to cultivate CR skills in RT students. Methods: Participants for this constructive descriptive study were recruited to complete an anonymous survey via a snowball method. The sample was purposefully selected to be RTs who currently supervise students on clinical placement. The survey consisted of open and closed questions. Closed questions provided demographic information. Thematic analysis was applied to the open questions to identify major themes within the data. Results: 24 RTs responded to the survey. Major themes identified from the responses were the tools for CR, supervisor attributes, skill development and the learning environment. Conclusion: The participating RTs use forward‐reasoning based on protocols to decide the course of a patient’s treatment but importantly incorporate experience and reflection to personalise the patient’s care. This study confirmed that communication is key to role‐modelling CR to students, and to assessing the development of their CR skills. The participants emphasised the need to establish an open environment where discussions and questions are welcome from all members of the team. Acknowledging uncertainty in decision making is encouraged to promote CR.

Michael Fuller 1 1 Flinders Medical Centre, Bedford Park, South Australia This presentation considers various aspects of the newly established ASMIRT Preliminary Image Evaluation (PIE) exam. PIE refers to the practice of radiographers flagging abnormal findings on X‐ray images via a short descriptive comment which is seen by the referring doctor at the time of the examination. Radiographer X‐ray image interpretation shifted from an informal practice to a formalised practice in the mid 1980s at Northwick Park Hospital in London. Several Northwick Park Hospital radiologists conducted a trial in which radiographers marked X‐ray images with a red dot to flag the existence of an acute abnormality. After publishing their trial findings in the British Medical Journal , 1 the practice of ‘red dotting’ became commonplace in the United Kingdom. It soon became apparent that this practice (referred to as ‘the red dot system’) had significant flaws. A revised method of flagging abnormal acute findings by radiographers was developed and became known as radiographer ‘commenting’. This presentation considers the development of commenting (PIE) and the ASMIRT commenting exam in Australia. The presentation includes practical information focussed on preparing for and sitting the ASMIRT PIE exam. Reference 1. Berman L, de Lacey G, Twomey E, et al. Reducing errors in the accident department: a simple method using radiographers. BMJ (Clin Res Ed) 1985;290(6466):421‐22.

David Crawford, 1 Michael Jameson, 1,2 Stacy Alvares, 1 Louise Hogan, 1 Conrad Loo, 1 Clare Pagulayan, 1 Urszula Jelen, 1 Tania Twentyman, 1 Zoe Moutrie, 1 Monique Henke, 1 Sandy Sampaio, 1 Jeremy de Leon 1 1 GenesisCare, Darlinghurst, Australia 2 The University of New South Wales, Kensington, Australia Background: MR linacs are being utilised more often within a radiation oncology setting. The use of this technology is changing clinical practice. Isotoxic radiation therapy is a novel concept of adaptive personalised radiation therapy whereby the prescription a patient receives is determined based on the doses received by the surrounding critical organs at risk (OAR). This presentation will outline our experiences with simulation, planning and treatment of the first five isotoxic abdominal cases that were delivered on the MR linac utilising the full adapt to shape workflow and real time image guidance. Method: All five isotoxic abdominal patents who underwent treatment on the MR linac received a 4DCT and MRI for target and OAR delineation for planning purposes. The planning team optimised the plan to the highest possible dose to the target while not violating OAR tolerances. Online, the adapt to shape workflow is utilised whereby the anatomy of the day is recontoured and a new plan is created. Results: To date, a total of five patients have been treated with this isotoxic technique, the dose regimen varied from 30–35 Gy and from 3–5 fractions. Of the five cases, all were limited by OAR constraints. Conclusion: Adaptive isotoxic treatments realise the full capability of MR linacs and enable maximal dose to be delivered to the tumour while not violating OAR constraints and not causing RT toxicity.

Tooba Zaidi, 1 Franziska Jerjen, 1 Shannon Chan, 1 Ajay Sharma, 1 Reuel Mudliar, 1 Khadija Soomro, 1 Yobelli Jimenez, 1 Warren Reed 1 1 The University of Sydney, Camperdown, Australia Diverticular disease is one of the most common causes of outpatient visits and hospitalisations across Australia, North America and Europe. Approximately 33% of Australians over 45 years of age and 66% over 85 years of age have colonic diverticulosis. 1 Further inflammation of colonic diverticulosis can progress into acute colonic diverticulitis (ACD) and subsequent inflammatory attacks can lead to a 70–90% chance of additional complications and recurring infections throughout one's lifetime. Medical imaging is fundamental in the diagnosis, treatment and ongoing management of ACD and its complications, with computed tomography (CT) identified as the prevailing gold standard in the past few decades. 2 Cross‐database searching highlighted a large gap in the literature regarding the effectiveness of magnetic resonance imaging (MRI) as a non‐ionising radiation alternative imaging tool for ACD imaging after the mid‐2000s, despite ongoing technological advancements in this modality. This narrative review identified 13 key publications (11 primary prospective cohort studies, one systematic review and one meta‐analysis) that evaluate MRI for ACD imaging, of which five were published within the past decade. Several existing MRI protocols were deemed suitable for ACD imaging and it is recommended they be re‐evaluated in larger cohorts. Future studies should consider the rapidly growing technological improvements of MRI, its cost efficiency and its applicability in modern day healthcare settings when addressing ACD management. This is especially important considering the gradual rise in radiation dose among the Australian population attributable to increased CT referrals, alongside increased reporting of ACD cases in younger individuals. References 1. Information about diverticular disease [Internet]. 4th ed. Mulgrave, Victoria: Digestive Health Foundation. 2010. Available at https://www.gesa.org.au/resources/patients/diverticular‐disease/ [Accessed 10 May 2020]. 2. Galgano S, McNamara M, Peterson C, et al. ACR Appropriateness Criteria® left lower quadrant pain‐suspected diverticulitis. J Am Coll Radiol 2019;16(5):S141‐S149.

Nigel Anderson, 1 James Korte, 1 Arian Lasocki, 1 David Kok, 1 Neda Haghighi, 1 Nick Hardcastle, 1 Tomas Kron, 1 Claire Phillips 1 1 Peter MacCallum Cancer Centre, Melbourne, Australia Brain metastases (BM) are the most common malignancy of the central nervous system, occurring 2–5 times more often than primary malignant brain tumours. 1 Of patients with BM, 20–50% have a solitary BM, 20–30% have 2–3 BM, and more than 30% have more than three BM. 2 Stereotactic radiosurgery (SRS) plays an important role in BM management. Consequently, with longer median survival due to improved response rates to modern systemic therapies, the incidence of brain radio‐necrosis (RN) is increasing‐ typically presenting 3–6 months post‐SRS. 3 While commonly asymptomatic, symptoms vary, and are RN location dependent. Delayed‐contrast MRI (DCMRI) presents a new paradigm in neuro‐oncology, where the clearance of contrast agent has shown a clear tumour/non‐tumour tissue differentiation in both primary and secondary malignancies of the brain. 4 Furthermore, DCMRI possesses some notable patient and operational benefits compared to performing additional diagnostic imaging with the additional MRI scan (10 minute duration) taken on the same day as their routine follow up MRI (1 hour after), with no additional contrast administration required. However, further corroborating evidence supporting the usefulness of this technique is still lacking. The Peter MacCallum Cancer Centre, which delivers in excess of 100 SRS courses annually, recently undertook an ethics‐approved 10 patient post‐SRS pilot study to investigate the utility of the Brain Lab Contrast Clearance software solution. This presentation will outline initial clinical and operational experiences, and share preliminary clinical observations surrounding the utility of DCMRI in the differential diagnosis of tumour recurrence and RN. References 1. Nayak L, Lee EQ, Wen PY. Epidemiology of brain metastases. Curr Oncol Rep 2012;14(1):48‐54. 2. Saria MG, Piccioni D, Carter J, et al. Current perspectives in the management of brain metastases. Clin J Oncol Nurs 2015;19(4)475‐79. 3. Fink J, Born D, Chamberlain MC. Radiation necrosis: relevance with respect to treatment of primary and secondary brain tumors. Curr Neurol Neurosci Rep 2012;12(3):276‐85. 4. Zach L, Guez D, Last D, et al. Delayed contrast extravasation MRI: a new paradigm in neuro‐oncology. Neuro Oncol 2015;17(3):457‐65.

Georgia Parry 1 , Mohamed Badawy 1,2 1 Monash University, Clayton, Australia, 2 Monash Health, Clayton, Australia Concerns regarding radiation‐induced effects in operators of fluoroscopy equipment are currently on the rise. Radiobiological effects reported in the literature include cataracts and carcinogenesis of the brain in cardiologists and interventional radiologists. Operators are mainly exposed to scattered radiation emanating from the patient. It has been suggested that a significant portion of this exposure can be removed by patient shielding materials in interventional procedures. The aim of this review is to evaluate the efficacy of patient shielding through the examination of current literature. Recent advances in protective products have enabled the use of non‐lead heavy metals including bismuth, barium, antimony and tin. These products are shown to be effective in attenuating scattered photons, however, the reduction of occupational exposure may not be significant if standard radiation safety devices are used such as lead aprons, thyroid shields and ceiling or table‐mounted shields. In instances where it is not feasible to use radioprotective equipment to reduce the dose to the lens of the eye or extremities, patient shielding could be an effective method to reduce exposure to areas not covered by operator shielding alone. The use of patient shielding for the purpose of operator dose reduction has been shown to potentially increase the dose to the patient, however, further investigations are required.

Karen Dobeli 1 1 Royal Brisbane and Women's Hospital, Brisbane, Australia Optimal image quality in cardiac computed tomography often relies on pharmacological preparation of the patient to lower and/or stabilise the heart rate and dilate the coronary arteries. This presentation will provide an overview of four types of drugs commonly used for patient preparation in cardiac computed tomography: beta blockers, calcium channel blockers, ivabradine and glyceryl trinitrate. Each drug will be briefly discussed, including what they are used for, how they work and patient safety aspects for their administration.

Stephanie Price 1 1 Icon, Sunshine Coast, Australia Literature demonstrates positive psychology plays a role at an individual, unit and organisational level. This presentation discusses the potential impact positive psychology strategies can have on productivity, culture and diversity, along with mental and physical health. The emergence of COVID‐19 has meant organisations have had to be reactive and re‐visit their approach to sustain a productive and happy workforce amid the challenges managing COVID‐19. A review of an organisations current positive psychology initiatives was undertaken followed by investigation into the group’s response to COVID‐19 with regards to workforce planning, employee wellbeing and communication mechanisms. An employee survey was conducted to ascertain if additional strategies instigated during the onset of COVID‐19 were of value in maintaining positive psychology currency. Employees included both clinical and non‐clinical staff. Analysis was conducted on staff feeling supported to work remotely and ability to maintain a positive outlook during a time of instability. Data indicated there were differences in the uptake and value of initiatives implemented. There was notable variance in employee positivity in relation to working from home for extended periods. The desire for regular communication, leadership and teamwork was evident. Positive emotions can guide behaviour and signal emotional and physical wellbeing. This study demonstrated additional mechanisms instigated at short notice as a pandemic rapidly unfolded did support employees and allowed for re‐vision in work practices.

Nick Maddock 1 1 Epworth Medical Imaging, East Melbourne, Australia Continuing professional development (CPD) seminars within imaging departments are useful for staff to learn about new concepts, cover new policies and further advance their skills. But what happens when they are all cancelled? This presentation will outline how to create a department CPD website within 15 minutes and discuss the production of content using free online resources. To create a department CPD pseudo‐website, storage and accessibility options will be explained in order to create restricted‐viewing pages that can be accessed on personal mobile devices. These settings are important for the development and security of a department website. Developing a slideshow presentation with accompanying audio is a way of recreating a seminar session. This session will show how to produce video versions of a seminar session, and how to upload them in a private‐viewing‐only format, and how to publish these onto a CPD website. Engaged learners learn more. 1 By engaging learners during CPD education, educational outcomes can be improved. Online resources to promote more engaging educational activities on your website will be demonstrated, which will also assist in documenting participants of online activities. Creating a CPD website for staff to access on personal devices can be done quickly and with relative ease. Developing and uploading engaging educational content for your department’s use can help overcome issues arising from the age of social distancing, but the legacy and usefulness of creating a mobile resource for radiographers will be longer lasting. Reference 1. Goss P, Sonnemann J. 2017. Engaging students. Creating classrooms that improve learning. Available at https://grattan.edu.au/wp‐content/uploads/2017/02/Engaging‐students‐creating‐classrooms‐that‐improve‐learning.pdf [Accessed 10 November 2019].

Karly‐Rose McLaren, 1 Mary‐Ann Carmichael, 1 Craig Opie, 2 Pete Bridge 3 1 RMIT University, Bundoora, Australia 2 Royal North Shore Hospital, St Leonards, Australia 3 University of Liverpool, Liverpool, United Kingdom Background: This study is a cross‐sectional census aimed at the current radiation therapy treatment techniques, the number of patients treated and cancer tumour site categories across Australia. Radiation therapy is a fast‐paced technology driven profession with approximately 68,000 Australians accessing radiation therapy treatments with Medicare subsidised services costing $454,131,927 in 2017. 1 Findings of a national single‐day audit conducted on radiation therapy practice across Australia in 2020 will be presented. Methods: The study design is a census method using Qualtrics (an advanced web‐based application for online surveys) with all radiation therapy centres in Australia being invited to provide quantitative summary data relating to patient case mix and technology use on a randomly selected, but common date. Anonymous and demographic‐free data will be analysed using descriptive statistics. Ethical approval is currently underway for this data collection. This data will be compared with the research of Bridge et al, 2,3 and Batumalai et al. 4 Results: Results of this census are pending as the survey is not yet closed. Conclusion: Discussion of the findings will focus on treatment techniques, case mix and technologies available. References 1. Australian Institute of Health and Welfare 2019. Cancer in Australia: In brief, 2019. Cancer Series No. 122. Cat no. CAN 126. Canberra: AIHW. Available at https://www.aihw.gov.au/reports/cancer/cancer‐in‐australia‐2019‐in‐brief/contents/summary 2. Bridge P, Carmichael M, Brady C, Dry A. A snapshot of radiation therapy techniques and technology in Queensland: an aid to mapping undergraduate curriculum. J Med Radiat Sci 2013;60(1):25‐34. 3. Bridge P, Dempsey S, Giles E, et al. Practice patterns of radiation therapy technology in Australia: results of a national audit. J Med Radiat Sci 2015;62(4):253‐60. 4. Batumalai V, Holloway L, Kumar S, et al. Survey of image‐guided radiotherapy use in Australia. J Med Imaging Radiat Oncol 2017;61(3):394‐401.

Aidan Leong 1,2 1 Bowen Icon Cancer Centre, Wellington, New Zealand 2 University of Otago, Wellington, New Zealand Introduction: This case study describes our clinic's first use of the Varian Hyperarc platform to deliver automated stereotactic treatment of multiple brain metastases simultaneously. Case Presentation: A 40‐year‐old woman with a history of metastatic colorectal cancer presented for treatment of an intracranial surgical cavity and two de novo lesions. 24 Gy in three fractions and 27 Gy in three fractions was prescribed to the cavity and lesions, respectively. Permission was granted by the patient for details of her treatment to be presented. Management/Outcomes: Treating staff completed training material and conducted an end‐to‐end procedure and dry run prior to treatment delivery. Planning CT and MRI were acquired at 1 mm slices in the treatment position using a specialised stereotactic mask system. A single non‐co‐planar plan for all three targets was generated using the custom Hyperarc workflow and met clinical constraints. Automated treatment delivery was utilised with a maximum treatment duration of 14 min and maximum intrafractional motion of 0.2 mm and 0.1°. Only minor treatment‐related symptoms were experienced post‐treatment. Discussion: Our team successfully treated a first case of multiple intracranial lesions using the Hyperarc platform. The patient was happy with the procedure and voluntarily filmed her experience and shared this publicly to raise awareness of radiation therapy as a treatment modality.

Rebecca Brooks, 1 Virginia Drumm 1 1 Icon Cancer Care, Warrnambool, Australia Objectives: Access to reliable and advanced healthcare can be a challenge in regional and remote Australia. 1 A newly developed regional cancer centre provides state of the art radiotherapy treatment with the support of a local foundation. This combination has continued the advancement of cancer initiatives throughout the region. Bolus has been used in radiotherapy to increase dose delivered to the patients’ skin for many years, however, tradition bolus materials introduce uncertainty and inconsistency in dose modelling. 2 3D‐printed bolus is at the forefront of modern technology and is becoming more common in metropolitan radiotherapy centres. Methods: Radiation therapists secured a grant to implement cutting‐edge 3D‐printed bolus technology to benefit patients within the region. An Ultimaker 2 Extended+ printer which utilises polylactic‐acid filament was purchased. A streamlined process was developed to export bolus structures from Eclipse directly into the printer software. Verification was completed on the HU value and spatial accuracy of the 3D‐printed bolus, along with its conformity to patient surface. Results: When compared to traditional wax, thermoplastic, or gelatine‐based bolus, the 3D‐printed bolus more accurately reflected dose modelling in Eclipse. Results also showed that overall workflow was less labour intensive than traditional processes. Conclusion: 3D‐printers are becoming more common in radiotherapy, producing more consistent bolus when compared to traditional methods, thus increasing the reliability of dose modelling. The unique collaboration between the foundation and regional cancer centre has created a health service that emulates its metropolitan counterparts and continually strives to deliver the most advanced cancer treatment available. References 1. Underhill CR, Goldstein D, Grogan PB. Inequity in rural cancer survival in Australia is not an insurmountable problem. MJA 2006;185(9):479‐80. 2. Barrett A, Dobbs J, Morris S, Roques T. Practical radiotherapy planning. 4th edn. London, 2009.

Shimon Prasad, 1 Florence Ko, 1 Cameron Stanton, 1 Ben Zwan, 1,2 Tayla Strachan, 1 Kevin Connell, 1 Linda Bell, 1 Mark Stevens, 1 Marita Morgia 1 1 Northern Sydney Cancer Centre, St Leonards, Australia 2 University of Newcastle, Newcastle, Australia Background: Pelvic tilt and rotation (spinal curvature) are common immobilisation challenges encountered in patients undergoing gynaecological radiotherapy which includes lymph node irradiation. Our aim was to compare reproducibility of patient setup between two stabilisation devices. Methods: The complete archived image sets of 16 patients were retrospectively reviewed. Eight were stabilised using the BlueBAG BodyFIX (BF) system (BodyFIX ® , Elekta, Sweden) and eight using a dedicated couch‐mounted Butterfly Board (BB) (Bionix Radiation Therapy, USA), SofTouch™ knee wedge and foot block (QFix, USA). Pelvic tilt and rotation were measured offline by comparing the bony anatomy alignment in the planning computed tomography (CT) scan with daily kilovoltage and cone beam CT images taken during treatment. Inter‐fractional differences between the two immobilisation devices were analysed. 1 Results: 400 treatment fractions were analysed. Overall systematic error was the same for both cohorts (0.1°). The standard deviation (SD) of systematic error was 1.1° and 1.6° for the BF and BB cohorts respectively. The SD of the random error was similar with 0.3° and 0.5° respectively. The frequency and variation in pelvic tilt is displayed in the Figure. There was no significant difference in the average inter‐fraction tilt between patient setup in BF vs. BB (P = 0.2), however use of BF significantly reduced the variance (P < 0.0001). Conclusion: Variation in pelvic tilt between the planning CT and daily pre‐treatment imaging was decreased by using the BF setup. Reference 1. van Herk, M. Errors and margins in radiotherapy. Semin Radiat Oncol 2004;14(1):52‐64.

Ruth Pape, 1 Kelly Spuur 2 1 University of Papua New Guinea, Port Moresby, Papua New Guinea 2 Charles Sturt University, Wagga Wagga, Australia Background: Papua New Guinea (PNG), has experienced an increase in breast cancer incidence correlating to the westernisation of the country. 1 Increased breast density is known to increase breast cancer risk. 2 This study investigates for factors unique to the women of PNG that may impact breast density and breast cancer risk. Method: A survey was undertaken of 1161 women who had undergone mammographic imaging at the Pacific International Hospital. 3 Results were correlated with the five Tabár patterns (TP), previously reported for each women and breast cancer risk factors. Statistical analysis was undertaken using chi‐square test, Fisher’s exact test and odds ratio (OR). Ethics approval was granted through the School of Medicine and Health Sciences Research Ethics Committee. Results: Relationships were identified between TP and parity (P < 0.001), marital status (P < 0.001), smoking (P < 0.001), alcohol intake (P = 0.029) and HRT (P = 0.029). There was no evidence of a relationship between TP and geographical location (P = 0.290), breast size (P = 0.592), occupation (P = 0.724), menstruation (P = 0.866) or exercise (P = 0.290). Married women (OR = 0.4004, 95% CI 0.2873–0.5579) and those with higher parity (OR 0.5034, 95% CI 0.3693–0.6862) were half as likely to have increased breast density reducing risk. Conclusion: Factors associated with increased breast density in PNG included parity, marital status, smoking, alcohol, and HRT use were evidenced in this snapshot of PNG women. Breast cancer risk was shown to be reduced for married women and those with increased parity. References 1. Halder AJ, Morewya J, Watters DAK. Rising incidence of breast cancer in Papua New Guinea. Aust N Z J Surg 2001;71(10):590‐93. 2. McCormack VA, Dos Santos Silva I. Breast density and parenchymal patterns as markers of breast cancer risk: a meta‐analysis. Cancer Epidemiol Biomark Prev 2006;15(6):1159. 3. Pape R, Spuur K, Umo P. Mammographic parenchymal pattern and breast cancer risk profile of Papua New Guinean women – a baseline study of the screening population. Radiography 2017;23(4):93‐98.

Bettina Boo 1 1 Royal Melbourne Hospital, Melbourne, Australia Introduction: Breast cancer is a worldwide health burden with a high incident and fatality rate. In 2021, it is estimated that 20,825 Australians will be diagnosed with breast cancer and is the most common cancer diagnosed in women in Australia. Some women diagnosed with early‐stage breast cancer will develop metastatic cancer and may further develop a fungating tumour in the region of the breast. Case Presentation: ‘Hope’ discovered a lump in her breast in 2013 and was diagnosed with early‐stage breast cancer but declined treatment due to her beliefs on the harmful effects of conventional medicine. In 2018, she presented to a tertiary oncology hospital to receive treatment for a large fungating breast tumour. Management: ‘Hope’ participated in a clinical trial and received treatment targeting her fungating breast tumour. She underwent CT and PET scans to measure and monitor her condition through the trial. Outcome: ‘Hope’ was discharged after four months of treatment due to the decrease in her quality of life despite the positive response of the tumour to the treatment given. Discussion: Fungating breast tumours are a debilitating development and greatly affects patients, both physically and psychologically. There are very few treatment options for patients with most treatments focusing on controlling symptoms rather than curing the tumour. By bringing more awareness to health professionals and patients about fungating tumours, it may lead to more research into prevention and encourage patients to seek treatment for their breast symptoms sooner.

David Johnson, 1 Francesca Langenberg, 1 Skye Coote, 2,3 Henry Zhao, 2,3 Patricia Desmond, 1,3 Damien Easton, 2 Michael Stephenson, 4 Lindsay Bent, 4 Shane Foster, 4 Karen Smith, 4 Bernard Yan, 2,3 Bruce Campbell, 2,3 Mark Parsons, 2,3 Geoffrey Donnan, 2,3,5 Stephen Davis 2,3 1 Royal Melbourne Hospital, Melbourne, Australia 2 The Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia 3 University of Melbourne, Melbourne, Australia 4 Ambulance Victoria, Doncaster, Australia 5 The Florey Institute of Neuroscience and Mental Health, Parkville, Australia Stroke is a major cause of death and disability in Australia. 1 As such, prompt diagnosis and treatment of stroke is critical. It is, therefore, essential that the type of stroke is established accurately and quickly to allow correct treatment to be commenced and clinical decisions to be made. Australia’s first dedicated Mobile Stroke Unit (MSU) ambulance was introduced to the streets of Melbourne in November 2017 2 and provides direct, at‐scene triage, CT scanning and reperfusion therapy by a multidisciplinary team of health professionals. 3 The radiographer’s role within the MSU team, from dispatch to scan, will be introduced. In particular, the challenges and technical aspects of obtaining diagnostic cross‐sectional imaging in a timely manner and within an on‐road ambulance will be discussed. In addition, case studies will be reviewed to demonstrate the value of time‐critical CT scanning remote from the familiarity of the hospital environment. References 1. Stroke Foundation. No postcode untouched, stroke in Australia 2017. Australia: Stroke Foundation, 2017. 2. Stroke Foundation Australia has first stroke ambulance on the road, 2017. Available at https://strokefoundation.org.au/Media‐Releases/2017/11/12/23/35/Australia%20has%20first%20stroke%20ambulance%20on%20the%20road [Accessed 2 January 2020]. 3. Zhao H, Coote S, Langenberg F, et al. 011 Melbourne mobile stroke unit halves workflow for acute stroke reperfusion therapy. J Neurol Neurosurg Psychiatr 2019;90:A4‐A5.

Giovanni Mandarano 1 1 Deakin University, Geelong, Australia Background: Intravascular contrast agents are commonly used in medical imaging. They travel throughout a patient’s body with the intent of improving imaging of pathology. These can be non‐specific; the same contrast agent can be used for imaging an oncology condition, infection or other disease processes. The question remains; have we seen all sites of pathology? Aptamers are oligonucleotide or peptide molecules 1 capable of binding with high specificity to a specific target molecule. 2 Aptamers are smaller than antibodies, can infiltrate tissues and cells, are non‐toxic and non‐immunogenic. 3 If aptamers can be chelated to an isotope, then aptamers can carry these isotopes to target sites for diagnostic (gallium‐68 gamma ray emitter) or theranostic (lutetium‐177 simultaneous gamma ray emitter and beta‐particle emitter for therapy) applications. Objectives: To propose a new approach to developing contrast material that can target specific disease processes for either diagnostic or theranostic (diagnostic and therapeutic) purposes. Method: High performance liquid chromatography (HPLC) was used to identify the aptamer used, with the chelating agent and the isotope. Results: Proof‐of‐principle data from HPLC analysis was able to measure each component (aptamer, chelator, isotope) when transmitted individually and also when combined (chemically bonded) as one complex (an aptamer chelated to an isotope). Discussion/Conclusion: This new chemical arrangement can realistically be translational and introduce a class of agents for imaging and theranostic applications for patients. If we can modify our training to prepare these in a hospital laboratory, we can forge a new path of advanced practice. References 1. Lakhin AV, Tarantul VZ, Gening L. Aptamers: problems, solutions and prospects. Acta Nature 2013;5(4):19. 2. Soontornworajit B, Wang Y. Anal Bioanal Chem 2011;399(4):1591‐99. 3. Keefe AD, Pai S, Ellington A. Aptamers as therapeutics. Nat Rev Drug Discov 2010;9(7):537.

Gabrielle Ramsay 1,2 , Amanda Perdomo 1 , Alethea Rea 3 , Chris Harris 1 , Stephen Lacey 1 1 The Royal Children's Hospital, Parkville, Australia, 2 Monash University, Clayton, Australia, 3 Murdoch University, Perth, Australia Objectives: Orthopaedic surgeons are increasingly relying on the use of C‐arm fluoroscopy in paediatric limb deformity correction. 1 There is little research regarding the radiation dose exposure to the surgeon in the paediatric setting. 2‐4 The aim of our study was to compare the radiation dose rate to orthopaedic surgeons with and without an external fixation frame. Methods: A simulated environment was created using a urethane and epoxy resin‐based lower limb phantom (PBU‐50, Kyoto Kagaku, Japan). Using a Philips Veradius C‐arm the dose rate was measured with a solid‐state survey sensor (X2 Survey Sensor, Unfors RaySafe, Sweden). Dose measurements were taken from where surgeons most commonly stand at 15 cm height increments. Results: Preliminary statistics have been performed with a linear model. Compared to no frame there is a 0.02 mSv/hr increase in dose rate for a single ring (P = 0.008), 0.016 mSv/hr increase in dose rate for a Taylor Spatial frame (P = 0.027) and 0.023 mSv/hr increase in dose rate for a double ring (P = 0.006). At the level of the operating table, the dose rate to the primary surgeon on the tube side is 0.112 mSv/hr more than the flat panel detector side (P < 0.001). Discussion/Conclusion: To our knowledge, this is the first study investigating the radiation dose rate to the orthopaedic surgeon when using external fixations. The surgeon receives a greater dose rate when using an external fixation frame compared to no frame. It is important to quantify doses orthopaedic surgeons receive to ensure optimal radiation practices. References 1. Gowda SR, Mitchell CJ, Abouel‐Enin S, Lewis C. Radiation risk amongst orthopaedic surgeons – do we know the risk? J Periop Pract 2019;29(5):115‐21. 2. Hsu R, Lareau C, Kim J, Koruprolu S, Born C, Schiller J. The effect of c‐arm position on radiation exposure during fixation of pediatric supracondylar fractures of the humerus. J Bone Joint Surg 2014;96(15):E129. 3. Maempel J, Stone O. Quantification of radiation exposure in the operating theatre during management of common fractures of the upper extremity in children. Ann Royal Coll Surg Engl 2016;98(7):483‐87. 4. Keenan WN, Woodward AF, Price D, et al. Manipulation under anaesthetic of children's fractures: use of the image intensifier reduces radiation exposure to patients and theatre personnel. J Pediatr Ortho 1996;6(2):183‐86.

Fliss Cox 1 1 Canterbury District Health Board, Christchurch, New Zealand What happened on 15 March 2019 in Christchurch was not a day any of us ever expected. In the radiation therapy department on that Friday afternoon myself and fellow radiation therapist colleagues were in lockdown; fairly oblivious to the extent of what was happening elsewhere. Meanwhile, staff in the emergency department, theatres, intensive care unit and radiology were inundated with 50 seriously injured patients. Saturday, however, was a different story. There were 51 victims who did not survive the terror attack, and sadly needed identifying and establishing a confirmation of cause of death. Our relationship with the radiology department meant an instant collaboration with the morgue, radiology, PACS, the New Zealand Army and the radiation therapy department. Post‐mortem imaging is a concept we are not usually exposed to as radiation therapists. This is a story of how we thought, initiated, improvised and worked together to help the families get their loved ones back as soon as possible. Helpful information we all hope we don’t need.

Gerard Wheeler 1 1 Ballarat Health Services, Ballarat, Australia This proposal introduces a simple, innovative, cost‐effective and error reducing solution to the ongoing problem of image mislabelling and its associated life threatening and medico‐legal consequences. 1 Published audits have shown that missing or incorrect side marker events can occur in nearly 6% of medical images acquired, and in some more acute scenarios may exceed 50%. 2 Most attempts to reduce these rates focus on further training and auditing, 2,3 but can realistically only hope to achieve incremental improvements while human fallibility remains a factor. The introduction of a digital photographic image acquired simultaneously and archived with the medical image could provide widespread benefits including unequivocal side and position identification, eliminating the risk of human error. This concept could be easily applied across all modalities where side specificity and patient orientation is of concern. Multiple additional advantages include time and dose saving benefits through reduction in retakes and improved follow‐up reproducibility of images. It could also become an invaluable education and teaching tool, leading to improved radiology reporting accuracy (with an increase in available clinical information and patient identifiers) plus improve accuracy in forensic applications. A literature search revealed prior implementation and application of the same basic concept, though primarily focussing on patient identification rather than the potential elimination of side and orientation marker errors. This indicates that further study is required regarding the potential benefits in error elimination. Discussion regarding the feasible implementation of this simple technology, and the case for its mandatory inclusion into all imaging equipment, is raised. References 1. Finnbogason T, Bremmer S, Ringertz H. Side markings of the neonatal chest X‐ray: two legal cases of pneumothorax side mix up. Eur Radiol 2002;12:938‐41. 2. Barry K, et al. A clinical audit of side marker use in a paediatric medical imaging department. J Med Radiat Sci 2016;63(3):148‐54. 3. Fuller M. Side marker creep – have radiographers changed their habits? J Med Radiat Sci 2016;63(3):143‐44.

Weronika Cyranka 1 , Maryla Kuczyńska 1 , Monika Zbroja 1 , Magdalena Grzegorczyk 1 , Małgorzata Nowakowska 1 , Monika Piekarska 1 , Karolina Siejka 1 , Agnieszka Brodzisz 1 , Magdalena Woźniak 1 , Anna Drelich‐Zbroja 1 1 Medical University, Lublin, Poland Objective: Crohn’s disease (CD) is one of chronic inflammatory bowel diseases.¹ Magnetic resonance enterography (MRE) can demonstrate mural and extramural inflammatory signs and complications which makes it a valuable diagnostic modality.² The aim of the study was to demonstrate the value of MRE in the assessment of possible intestinal complications in both paediatric and adult patients with Crohn's disease. Methods: The study included 76 adults and 36 children diagnosed with Crohn’s disease. Each patient underwent MRE with intravenous administration of a contrast agent. All the studies were performed using Siemens Aera 1.5T scanner according to a local study protocol. Whenever applicable, MR findings were verified with endoscopy. Results: 40 adults and 36 children had active phase of CD according to MRE criteria. In both groups a thickened edematous ileum wall was the most common manifestation of an active disease. 58% of adults (N = 23) and 89% (N = 32) of children presented with edematous swelling of Bauhin’s valve, whereas inflammatory infiltration of the mesenteric adipose tissue was observed in 34% (N = 9) adult and 64% (N = 23) paediatric patients. Penetrating complications of Crohn’s disease were particularly found in adult population (40%, N = 16); 18 fistulas (14 adults, four children) and six abscesses (two adults, four children) were detected. Conclusions: MRE is a non‐invasive and reliable method in the evaluation of Crohn’s disease activity.³ CD manifestations seem to be age‐dependent – focal edematous lesions are more often encountered among children,⁴ while there are more penetrating complications in adults.⁵ References 1. Bruining DH, Zimmermann EM, Loftus EV Jr, et al. Radiology 2018;286(3):776‐799. 2. Nyree Griffin, Grant LA, Anderson S, Irving P, Sanderson J. Small bowel MR enterography: problem solving in Crohn’s disease. Insights Imaging 2012;3:251‐263. 3. Biko DM, Mamula P, Chauvin NA, Anupindi SA. Colonic strictures in children and young adults with Crohn's disease: recognition on MR enterography. Clin Imaging 2018;48:122‐126. 4. Chu KF, Moran CJ, Wu K, et al. Performance of surveillance MR enterography (MRE) in asymptomatic children and adolescents with Crohn's disease. J Magn Reson Imaging 2019;50(6):1955‐1963. 5. Park SH, Ye BD, Lee TY, Fletcher JG. Computed tomography and magnetic resonance small bowel enterography: current status and future trends focusing on Crohn's disease. Gastroenterol Clin North Am 2018;47(3):475‐499.

Michael Velec 1 1 Princess Margaret Cancer Centre, Toronto, Canada Online cone‐beam computed tomography guided radiotherapy has demonstrated how patients dynamic actually are and revealed limitations of the current static, plan‐and‐treat paradigm. Radiation therapists have observed positioning variations, substantial organ motion and deformation, progressive weight loss, and changes in tumours which can respond or progress. These scenarios cannot be simply corrected online and impact treatment quality by introducing uncertainties in the doses actually delivered and how individual patients respond to treatment. Accurately monitoring and tracking these changes using deformable image registration techniques to accumulate dose can inform clinicians of relevant dosimetric changes and potentially the need for treatment adaptation with higher specificity than simple visual review of imaging. Research using records of accumulated‐delivered doses has also enabled the creation of more accurate dose‐response models of tumour response and normal‐tissue toxicities that differ significantly from current models based solely on planned doses. This has the potential to further tailor treatment strategies at the individual patient level. Rigours validation of these processes are required prior to implementation to ensure new sources of error are not introduced into clinical processes. Additionally, they will require radiation therapists to develop new technical skills and clinical judgement. Moving towards a more explicit dose‐driven radiotherapy process using deformable dose accumulation will allow for more appropriate evidence‐based decision‐making and precise cancer treatment that will improve outcomes for patients.

Gordon Mander, 1,2 Karen Dobeli, 3 Caitlin Steffensen, 4 Zachary Munn 2 1 Toowoomba Hospital, Toowoomba, Australia 2 Joanna Briggs Institute, University of Adelaide, North Adelaide, Australia 3 Royal Brisbane and Women's Hospital, Brisbane, Australia 4 Philips Australia and New Zealand, Brisbane, Australia Introduction: Patients with high heart rates (HR) are frequently referred for CT coronary angiography (CTCA). In this group, motion artefact can negatively impact image quality and resultant diagnostic accuracy. Several technological advancements in scan hardware and software have been implemented to mitigate difficulties in scanning patients with high HR. 1 2 However, no previous reviews have examined the diagnostic accuracy of CTCA using current generation scan technology. The aim of this systematic review was to investigate the diagnostic accuracy of CTCA in current clinical practice, for patients with high HR. Methods: A systematic search was performed of PubMed, CINAHL, Embase and Scopus, as well as unpublished database sources and reference lists. Titles and abstracts were screened by two independent reviewers. Full‐text screening was then performed by the reviewers for all studies that met the inclusion criteria at the title and abstract level. Studies that were included in the review underwent critical appraisal using the QUADAS‐2 tool. 3 Data extraction was undertaken by the lead reviewer and results were collated and analysed through narrative synthesis and meta‐analysis. Results: 12 studies were included in the systematic review, with 11 included in a meta‐analysis. Meta‐analysis produced pooled sensitivity 99% (95% CI 0.98–1.00) and pooled specificity of 0.79% (95% CI 0.72–0.85). Conclusion: Diagnostic sensitivity of CTCA remains high at higher HR, although specificity may be reduced. Therefore, where standard HR control is contraindicated or ineffective, CTCA is still recommended in current generation scanners, however positive results should be treated with increased scepticism. References 1. Andreini D, Lin FY, Rizvi A, et al. Diagnostic performance of a novel coronary ct angiography algorithm: prospective multicenter validation of an intracycle CT motion correction algorithm for diagnostic accuracy. American Journal of Roentgenology 2018;210(6):1208‐15. 2. Nerlekar N, Ko BS, Nasis A, et al. Impact of heart rate on diagnostic accuracy of second generation 320‐detector computed tomography coronary angiography. Cardiovasc Diagn Ther 2017;7(3):296‐304. 3. Whiting PF, Rutjes AW, Westwood ME, et al. QUADAS‐2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011;155(8):529‐36.

Hayley Wood 1 , Crispen Chamunyonga 1 , Katheryn Churcher 2 1 Queensland University of Technology, Brisbane, Australia, 2 Sunshine Coast University Hospital, Birtinya, Australia Background: Respiratory motion causes anatomical uncertainties in three‐dimensional computed tomography (3DCT) datasets traditionally used in radiation therapy planning (RTP) for lung cancer. 1 The use of four‐dimensional computed tomography (4DCT) in RTP improves planning target volume (PTV) delineation for increased treatment accuracy. 2 The Sunshine Coast University Hospital acquires both 3DCT and 4DCT datasets for RTP of radical lung cancer patients, which has limitations, including reducing department efficiency and increasing patient imaging dose. Objectives: The purpose of this study was to compare dose distributions between plans generated on 3DCT and 4DCT datasets to determine a single CT dataset suitable for lung cancer RTP at Sunshine Coast University Hospital. Methods: 20 lung cancer patients were retrospectively selected for this study. Plans generated on 4DCT datasets were copied to 3DCT datasets and recalculated. Clinically relevant dose parameters including global maximum dose, 95% isodose PTV coverage, minimum, mean and maximum doses and volume doses to PTVs and organs a risk were statistically compared using t‐tests, Wilcoxon tests and Bland Altman plots. Results: Clinically small but statistically significant differences were found for PTV maximum dose (P = 0.04), mean dose (P = 0.028), D98% (P = 0.035) and D50% (P = 0.017). Bland Altman plot shows good agreement among the two datasets for 95% PTV coverage. Combined lungs‐PTV showed statistically significant differences for V5 (P = 0.005), V20 (P = 0.006) and V30 (P = 0.011) however again, these were clinically insignificant. Conclusion: 3DCT and 4DCT (AIP) datasets resulted in similar dose distributions, suggesting that 4DCT datasets alone would be suitable for radical lung cancer RTP. References 1. Aznar MC, Warren S, Hoogeman M, Josipovic M. The impact of technology on the changing practice of lung SBRT. Physica Medica 2018;47:129‐38. 2. Korreman SS. Image‐guided radiotherapy and motion management in lung cancer. Br J Radiol 2015;88(1051):20150100.

Molly Mee, 1 Kate Stewart, 2 Marika Lathouras, 2 Helen Truong, 2 Catriona Hargrave 1,3 1 Queensland University of Technology, Brisbane, Australia 2 Royal Brisbane and Women’s Hospital, Herston, Australia 3 Princess Alexandra Hospital, Brisbane, Australia Objectives: A challenge in implementing deformable image registration (DIR) in radiation therapy planning is effectively communicating registration accuracy to the radiation oncologist. This study aimed to compare qualitative user ratings of DIR accuracy with quantitative metrics as well as inter‐observer reliability when using a new quality assurance (QA) rating tool. Methods: A retrospective DIR was performed on the diagnostic and planning CT images for 35 head and neck cancer patients. The QA tool was used to rate DIR accuracy as good, fair or bad. 30 deformed images were assessed by three operators and a further five deformed images were assessed by five operators. Ratings were compared with quantitative metrics calculated for anatomical regions on the deformed images. Inter‐operator reliability was assessed using Krippendorff’s alpha test. 1 Rating time and volume measures for each rating were also calculated. Results: Volume variation metrics and Jacobian determinants for most anatomical sub‐regions assessed reflected expected values for good, fair and bad registrations. Highest inter‐operator reliability was observed in the good ratings and within the left and right parotids, while inter‐operator reliability varied the most in regions of dental artefact. Average rating time was 33 minutes. Overall, good ratings were applied to the greatest volume of the image with fair ratings to the lowest volume. Conclusion: Results from qualitative and quantitative data, rater differences and rating time suggest that highlighting only bad regions of DIR accuracy and implementing clinical guidelines and RT training would be required for consistent and efficient use of the QA tool. Reference 1. Krippendorff K. Computing Krippendorff's alpha‐reliability, 2011. Available at https://repository.upenn.edu/asc_papers/43

Callie Choong, 1 Phil Vial, 1 Sankar Arumugam, 1 Annie Lau, 1 Andrew Wallis 1 1 South Western Sydney Local Health District, Liverpool and Macarthur Hospital, Australia Cone beam computed tomography (CBCT) is a common tool used in image guided radiotherapy (IGRT). Traditionally, breast verification imaging has been performed within our department using a combination of treatment field electronic portal images and/or orthogonal images. This presentation will describe the implementation of daily pre‐treatment 3D CBCT verification for all breast treatments. The impetus for CBCT verification for breast was the implementation of IMRT simultaneous integrated breast boosts, the increased use of DIBH, and the growing use of VMAT planning techniques within our department (Figure). A number of factors needed to be taken into consideration prior to implementation including: the formation of a multidisciplinary project team, the investigation and creation of new, low‐dose imaging pre‐sets specific for breast, and staff training and education. An assessment of CBCT dose versus current practice was also considered. Benefits seen post‐implementation include improved visualisation of patient setup, bolus placement and anatomy changes, consistency in imaging protocols across differing breast treatment techniques and efficiency gains. Challenges include perceived benefits versus contralateral breast imaging dose, limited evidence on the necessity of daily CBCT imaging and the impact of CBCT positioning corrections on a traditionally field‐based treatment technique. Future plans for evaluation include quantifying imaging shifts and assessing the number of replans instigated due to changes seen on CBCT.

Elizabeth Serwan, 1,2 Donna Matthews, 2 Jo Davies, 3 Shayne Chau 2 1 Riverland General Hospital, Berri, Australia 2 University of South Australia, Adelaide, Australia 3 Flinders Medical Centre, Adelaide, Australia Introduction: Although breast compression is required in routine mammographic practices, current subjective protocols enforcing ‘breast tautness’ have minimal clinical reproducibility. While objective target force (daN) guidelines do not consider breast volumes, new pressure (kPa) measures account for associated variations. The study aims to determine characteristic compressive forces applied at an Australian diagnostic breast clinic, thereby establishing performance success in achieving ideal pressures of 10 kPa. Methods: Parameters of 1972 mammograms were analysed retrospectively from a South Australian diagnostic breast clinic. Raw data were processed using VolparaDensity software; applied compression (force/pressure), breast thickness/volume/density and average glandular dose estimates were investigated based on breast/paddle contact areas. Results: Distributions of applied average forces is large, yet distributions of applied average pressures are larger; this is internationally comparable. Regarding force‐compressions, 98.6% are >5 daN, 16.6% are >10 daN and 0.0% are >15 daN. Regarding pressure‐compressions, 94.5% are >5 kPa, 36.0% are >10 kPa and 6.3% are >15 kPa. Measures of average breast thickness/volume/density show anatomically consistent trends, with average glandular dose values constant, albeit high. Conclusions: Applied compression forces varied significantly in relation to breast/paddle contact area; applied pressure varied to a greater extent. This is comparable with existing literature. Real‐time compression pressure standardisation may benefit examination consistency. Relationships between breast volume, contact area, compression force and resultant compression pressure may aid in developing objective clinical compression protocols. Practical guidelines may increase image acquisition reproducibility, optimise patient discomfort and minimise radiation dose. Patient compliance may increase in accordance with perceived advantages of mechanical standardisation, ultimately assisting early‐stage breast cancer detection.

Nigel Anderson, 1 Kenton Thompson, 1 Judy Andrews, 1 Brent Chesson, 1 Alison Cray, 1 Damien Phillips, 1 Michelle Ryan, 1 Sally Soteriou, 1 Glenn Trainor, 1 Nilgun Touma 1 1 Peter MacCallum Cancer Centre, Melbourne, Australia COVID‐19, and subsequent government guidelines and restrictions implemented to mitigate the risk of virus spread, have forced radiation therapy departments globally to promptly adjust their models of service delivery to enable best clinical care. The inherent nature of the tri‐partied radiation oncology professions relies heavily on multidisciplinary teamwork and patient‐clinician interactions. Teamwork and patient interaction are critical to the role of a radiation therapist. Peter MacCallum Cancer Centre radiation therapy services made a number of changes during the preliminary stages of the COVID‐19 pandemic to minimise risk to patients, staff and our clinical service. Four critical areas were identified in developing risk mitigation strategies across our service: (a) workforce planning, (b) workforce communication, (c) patient safety and wellbeing, and (d) staff safety and wellbeing. Each of these initiatives had a focus on continuum of clinical care while minimising risk of cross infection for our radiation therapy workforce and patients alike. The aim of this paper is to share our risk mitigation strategies established throughout the early stages of the pandemic, combined with the ongoing impact on our service during Melbourne’s second wave on COVID‐19 throughout the winter of 2020. The COVID‐19 pandemic has dictated change in conventional radiation therapy practice. Some of this will remain for the betterment of our profession and its professionals. It is hoped that by sharing our experiences, the radiation therapy profession will continue to learn, adapt and navigate this period together, to ensure optimal outcomes for ourselves and our patients.

Kenton Thompson, 1 Micah Barnes, 1 Nicholas Hardcastle, 1 Alan Turner 1 1 Peter MacCallum Cancer Centre, Melbourne, Australia Patient positioning verification for intracranial stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) treatments always begin with the initial setup of the patient prior to the beginning of treatment, however clinical utilisation of intrafraction position verification varies. Currently, in our centre, patient positioning is required to be within 0.7 mm, 0.7 deg for all axes. An analysis of positioning data from ExacTrac® (Brainlab AG, Munich, Germany) for 102 patients showed that 42.3% required an intrafraction translation of 0.7 mm or greater and 24.7% required an intrafraction rotation of 0.7 deg or greater. This analysis highlights the need for intrafraction image guidance. For intrafraction image guidance, kilovoltage cone beam CT (CBCT) cannot be used when large couch rotations are introduced. When utilising CBCT for initial setup, various intrafraction verification techniques exist including no intrafraction verification, 2D planar MV at all other couch positions, and orthogonal pairs where possible with 2D planar imaging where restricted. To compensate for patient movement, we are investigating on‐board imaging techniques that are available on a standard TrueBeam® (Varian Medical Systems, Palo Alto, USA) with advanced imaging. OBI utilising kV and MV planar imaging with box‐based 6D automatic registration is promising compared to other systems. 1 However, before implementing on‐board imaging verification for this patient cohort clinically, validation should not only include accuracy and precision tests, but also simulate treatment workflows. This will enable refinement and optimisation for quality and efficiency while minimising collision risk for SRS/SRT treatment delivery. Reference 1. Sarkar V, Paxton A, Szegedi MW, et al. An evaluation of the consistency of shifts reported by three different systems for non‐coplanar treatments. J Radiosurg SBRT 2018;5:323‐30.

Linda Bell, 1 Stephanie Roderick, 1 Thomas Eade, 1,2 George Hruby, 1,2 Andrew Kneebone 1,2 1 Northern Sydney Cancer Centre, St Leonards, Australia 2 Northern Clinical School, University of Sydney, St Leonards, Australia Objectives: A recent systematic review supports stereotactic body radiotherapy (SBRT) as a standard treatment option for prostate cancer. 1 Increasing dose to ≥40 Gy has been shown to improve local control but can be at the expense of increased toxicity. 2 We wish to report the preliminary feasibility of delivering dose escalated SBRT, with and without fiducial markers. Methods: All 29 patients from the dose escalated SBRT arm of the OPTIMAL trial ( NCT03386045 ) comparing five versus 20 treatments were selected. 3 Radiation oncologists used prostate‐specific membrane antigen (PSMA) scans and magnetic resonance imaging (MRI) scans to delineate a dominant nodule gross tumour volume (GTV) boost which received a dose of 45 Gy/5Fx while the PTV received 36.25 Gy/5Fx. 4,5 Urethral sparing was mandated. Clinical trial constraints for target coverage and organs at risk were reviewed (Table). Planning challenges such as lack of hydrogel, the presence of prosthetic hips and no fiducial markers for intrafraction monitoring on treatment were reviewed. Results: The dose constraints were regularly met with the exception of gross tumour volume primary (GTV P) when close to the rectum or urethra, and urethra sparing which needed to be covered by 36.25 Gy (Table). An intrafraction motion monitoring technique was successfully implemented for patients without fiducial markers. Conclusion: Early analysis of SBRT prostate radiotherapy has demonstrated a high level of planning constraint compliance. PSMA scanning has allowed treatment doses to be boosted to 40–45 Gy in these patients. Patients without hydrogel, fiducial markers and with prosthetic hips have been successfully treated. References 1. Jackson WC, Silva J, Hartman HE, et al. Stereotactic body radiation therapy for localized prostate cancer: a systematic review and meta‐analysis of over 6,000 patients treated on prospective studies. Int J Radiat Oncol Biol Phys 2019;104(4):778‐89. 2. Zelefsky MJ, Kollmeier M, McBride S, et al. Five‐year outcomes of a phase 1 dose‐escalation study using stereotactic body radiosurgery for patients with low‐risk and intermediate‐risk prostate cancer. Int J Radiat Oncol Biol Phys 2019;104(1):42‐49. 3. U.S. National Library of Medicine ClinicalTrials.gov. The Optimal Prostate Study, 2017. Available at https://clinicaltrials.gov/ct2/show/NCT03386045 [Accessed 29 October 2019]. 4. Monninkhof EM, van Loon J, van Vulpen M, et al. Standard whole prostate gland radiotherapy with and without lesion boost in prostate cancer: toxicity in the FLAME randomized controlled trial. Radiother Oncol 2018;127(1):74‐80. 5. Zamboglou C, Thomann B, Koubar K, et al. Focal dose escalation for prostate cancer using 68Ga‐HBED‐CC PSMA PET/CT and MRI: a planning study based on histology reference. Radiat Oncol 2018;13(1):81.

Setara Nadiri 1 1 Monash University, Australia The principal method of treating breast cancer (with nodal disease) after surgery is adjuvant radiotherapy, which lengthens survival and decreases rates of recurrence. Irradiation of the left breast can lead to unintended radiation exposures of the left lung, heart and contralateral breast, and is associated with long‐term effects including increased rates of secondary malignancies and coronary and pulmonary complications. Tangential volumetric modulated arc therapy (T‐VMAT) for the irradiation of left breast cancers with nodal disease show significant advantages in achieving higher dose conformity and homogeneity. T‐VMAT has proven to reduce doses to organs at risk compared to former techniques such as intensity modulated radiation therapy (IMRT) and/or electronic compensation planning. The tangential partial arcs are applied at strategic angles to reduce cardiac doses, and when this is combined with the deep inspiration breath hold technique (DIBH), the doses to the heart and ipsilateral lung are further reduced. The efficacy of these techniques can be tested with its associated monitor units (MU), where T‐VMAT utilises far less MUs than IMRT techniques, resulting in shorter treatment times and lower associated scatter doses. This presentation will cover the rationale behind T‐VMAT, the planning process, treatment delivery method and the comparison of dosimetry between T‐VMAT and conventional left breast treatment techniques. The importance of T‐VMAT for the treatment of patients suffering from left breast cancer (with nodes) both now and into the future, the advantages, limitations and anecdotal T‐VMAT plans for left breast cancer will also be discussed.

Jordan Sims 1 , Jo Davies 2 , Shayne Chau 1 1 University of South Australia, Adelaide, Australia, 2 Flinders Medical Centre, Bedford Park, Australia Acute knee pain is a common complaint in emergency departments, for which plain radiography has long been implemented to diagnose. 1 However, despite the popularity of radiographs, studies show knee fractures occur in only 5.2% and 6% of patients. 2,3 To combat this overuse, Stiell and colleagues in Ottawa, Canada, derived specific decision rules to justify knee radiography, later entitled the ‘Ottawa Knee Rules’ (OKR). 2 The rules state that knee radiographs are indicated if at least one of five criteria is met, including age 55 years or more, isolated patella tenderness, tenderness at head of fibula, inability to flex knee to 90 degrees and inability to weight‐bear more than four steps. 2 Patients meeting at least one of the criteria are highly suspected of having clinically significant knee fracture, and the rules themselves have established over 99% sensitivity across various studies. 1 This presentation will reflect a clinical audit performed in December 2019. The audit will evaluate the appropriateness of referrals for knee radiography in acute knee injury with reference to the OKR. This retrospective audit aims to analyse 300 knee X‐ray referrals that presented to the medical imaging department at a major public hospital in South Australia. The authors anticipate an accuracy of up to 100% for OKR in detecting knee fractures. The overall prevalence of knee injuries, including sensitivity and specificity, and referring trends between professions will also be evaluated in this study. Results of the final analysis will be reported in the presentation. This abstract is taken from the published manuscript, which can be found in the Journal of Medical Radiation Sciences https://doi.org/10.1002/jmrs.411 . References 1. Beutel BG, Trehan SK, Shalvov RM, Mello MJ. The Ottawa knee rule: examining use in an academic emergency department. West J Emerg Med 2012;13(4):336‐72. 2. Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med 1995;26(4):405‐13. 3. Stiell IG, Wells GA, McDowell I, et al. Use of radiography in acute knee injuries: need for clinical decision rules. Ann Emerg Med 1995;2(11):966‐73.

Nicole Peacock, 1 Adam Steward 1 1 Western Health, Footscray, Australia Radiographic positioning has largely remained unchanged in description over time, rendering a myopic approach to methodology with little adaption. Positioning for planar radiography of a lateral wrist projection is often inappropriately described in textbooks and some literature. These describe a method of positioning that requires the rotation of the radius over the stationary ulna from the posterior‐anterior projection with little other stipulation. This presentation provides a review of the article published in the July/August edition of Radiologic Technologist by the authors. The article describes the criterion and specifications of radiographic images in the diagnosis and management of wrist pathology that referrers and radiologists require. This presentation will describe the principles directing patient positioning in wrist imaging, conventional lateral wrist positioning for plain radiography, and an alternative positioning approach for a true lateral radiograph of the wrist joint; and provides a clear and considered vision for patient positioning in general, and specifically for the lateral wrist.

Susan Merchant, 1 Caroline Wright 1 1 Monash University, Clayton, Australia Background: Qualitative research focuses on understanding people’s lived experiences. Although long recognised as important in our profession qualitative approaches are emerging albeit slowly. Qualitative researchers need to be transparent and recognise their own perspectives and biases and how these can influence study design, conduct, data collection, analysis and interpretation. Reflexivity increases the rigour of the research, 1,2 however its use is seldom reported in the methods of qualitative medical radiation practice studies. Methods: Using an exemplar study, this paper provides an evidence‐based discussion and synthesis of researcher experiences of integrating reflexivity into qualitative research design. The exemplar study investigated student experiences of professionalism dilemmas. Reflexivity was applied in different ways throughout: 1. team reflexivity prior to study 2. reflection during data collection 3. reflection during data analysis 4. post‐study reflexivity. Discussion: To reach a common understanding of the research problem and design, reflexivity allowed all team members to acknowledge any biases or lenses of their own context through which they were viewing the research question. Team diversity and the collaborative nature of project work can add to the richness and depth of data analyses promoting robust debate around theming and interpretation. This contributes to the rigour and truthfulness of the findings, with the integrity of the research resting on disclosure of differing perspectives of the researchers. Conclusion: Reflexivity is a valuable aspect of the qualitative research process, increasing rigour through openness of the researchers. It is applicable to qualitative medical radiation practice research and team‐based clinical practice, warranting further investigation. References 1. Engward H, Davis G. Being reflexive in qualitative grounded theory: discussion and application of a model of reflexivity. J Adv Nurs 2015;71(7):1530‐38. 2. Murphy FJ, Yielder J. Establishing rigour in qualitative radiography research. Radiography 2010;16(1):62‐67.

Lyndal Newmarch 1 1 Royal Adelaide Hospital, Adelaide, Australia Objective: To compare the dosimetry for nose surface mould high dose rate (HDR) brachytherapy with external beam radiotherapy (EBRT) volumetric‐modulated arc therapy (VMAT), to determine if EBRT VMAT is a feasible alternative to surface mould HDR brachytherapy for superficial nose lesions. Methods: Six previously treated HDR brachytherapy nose surface mould (N = 6, three basal cell carcinoma and three squamous cell carcinoma) treatment plans were retrospectively selected. One plan was generated for brachytherapy Iridium 192 HDR (Brachyvison 13.7, TG‐43) and one plan was generated for external beam therapy 6 MV photon VMAT (Pinnacle 9.10). Target volumes and organs at risk (OARs) were contoured on a simulation computed tomography (CT) scan. Bolus, build up and backscatter material were utilised as necessary for optimal treatment plan generation. VMAT plans were optimised using an additional 5 mm setup margin on the clinical target volume (CTV) of the contoured HDR plans. 1 Ethics approval has been submitted and will be obtained prior to the conference. Results: Once ethics approval has been granted, target volume dose, dose homogeneity and mean, minimum and maximum doses to OAR will be evaluated. Conclusions: This presentation will provide insight into treatment modality selection for extensive superficial lesions with complex surfaces, irregular contours and close proximity to OAR. 2 With an increase in skin cancer across Australia, along with the complexity that arises with superficial lesions located on the nose, ensuring we are offering the best treatment available moving forward with the advances in treatment techniques and modality options. References 1. Bomand EL, Paterson DB, Pearson S, Naidoo N, Johnson C. Dosimetric comparison of surface mould HDR brachytherapy with VMAT. J Med Radiat Sci 2018;65:311‐18. 2. Park S, Kamrava M, Kayode O, Lee S, MD, Steinberg M. Comparative dosimetry of an extensive scalp lesion: HDR brachytherapy, electronic brachytherapy, VMAT, and tomotherapy. Int J Radiat Oncol Biolol Phys 2012;84:S516‐S517.

Ruth Pape, 1,2 Kelly Spuur, 3 JM Wilkinson, 3 P Umo 1 1 Pacific International Hospital, Boroko, Papua New Guinea 2 University of Papua New Guinea, Boroko, Papua New Guinea 3 Charles Sturt University, Wagga Wagga, Australia Objective: Women with increased breast density are at increased risk of breast cancer. The aim of this research is to evidence for the first time the mammographic breast findings of Papua New Guinean (PNG) women and the relationship between Breast Imaging‐Reporting and Data System (BI‐RADS) assessment, mammographic parenchymal patterns (MPPs) and age. Methods: A retrospective analysis of 1357 mammograms of women imaged at the Pacific International Hospital from August 2006 to July 2010 was undertaken. Mammographic findings were categorised using the BI‐RADS Atlas ® 5th edition. MPPs were recorded for each woman using the Tabar Pattern I‐V classification system. Age was recorded in years. Statistical analysis was by descriptive analysis and Kruskal‐Wallis with Dunn’s post‐test and Spearman’s rho correlation for inferential analysis. Results: True pathological findings (benign and malignant); BI‐RADS 2–5 were noted in 111 women (8.2%); 1242 (91.5%) were negative. BI‐RADS categories for malignancy were reported in 16 (88.9%) of women aged 30–60 years. The lower risk Tabar type I, II and III MPPs were associated with 94.4% (n = 17) of malignancies. Linear correlations between variables were weak and not statistically significant: age and Tabar pattern r = 0.031, P = 0.0261; age and BI‐RADS r = 0.018, P = 0.517; Tabar pattern and BI‐RADS r = 0.020, P = 0.459 (n = 1357). Conclusion: There was no correlation demonstrated between BI‐RADS category, age and MPP. Importantly, there was no correlation demonstrated between BI‐RADS categories 4 and 5 for breast malignancy and high‐risk Tabar type IV and V MPPs. The results of this study again reflect that the incidence of breast cancer in PNG cannot be explained by breast density and suggest that any formalised screening program in PNG has a target age group aimed at women younger than that of Western screening programs.

Yaxuan Peng, 1 Magdalena Dolic, 1 John Mclnerney, 1 Ruth Druva, 1 Wendy Macleod 1 1 Monash University, Clayton, Australia Objectives: Identifying and communicating urgent radiographic findings is within the scope of practice for Australian radiographers. 1 Despite this, radiographers’ confidence in describing radiographic pathology and anatomy varies. 2 In 2018, Monash University implemented ePortfolios as an anatomy learning and assessment task. Students used digital media to demonstrate their understanding of pathology and anatomy. This research seeks to investigate whether ePortfolios enhance student confidence when articulating descriptions of urgent radiographic findings in academic and clinical settings. Methods: A Qualtrics survey was distributed to Monash University radiography students who were involved in the creation of anatomy ePortfolios in their first year of radiographic studies (2018). After being collected anonymously, quantitative data was analysed using mean values and Pearson coefficients; Braun and Clarke’s method was used to analyse qualitative data. Preliminary results: Initial findings have been positive with 89% of respondents either agreeing or strongly agreeing that ePortfolio was useful in enhancing their confidence in commenting on radiographic pathology in the academic environment. This trend was not as strong in the clinical setting. Roughly 25% felt the ePortfolio was not as useful in helping them confidently identify and describe radiographic pathology respectively in their clinical placement. The clinical environment has unique challenges which affect student confidence, as evident in the qualitative findings. Conclusion: Preliminary findings suggest that the ePortfolios have assisted in improving confidence in identification and description of abnormalities, particularly in an academic setting. A thematic analysis of the qualitative data will develop a deeper understanding of results. References 1. Medical Radiation Practice Board. Professional capabilities for medical radiation practice, 2020. Available at http://www.medicalradiationpracticeboard.gov.au/Registration/Professional‐Capabilities.aspx [Accessed March 2020]. 2. Neep MJ, Steffens T, Owen R, McPhail SM. A survey of radiographers’ confidence and self‐perceived accuracy in frontline image interpretation and their continuing educational preferences. J Med Radiat Sci 2014;61(2);69‐77.

Imelda Williams, 1 Marilyn Baird, 1 Michal Schneider 1 1 Monash University, Clayton, Australia Background: The National Medical Radiation Practice Board of Australia (MRPBA) 1 expect radiographers to recognise and convey significant findings in order to facilitate optimal patient care. Radiographers employed in remote locations such as Far North Queensland (FNQ) often perform both radiographic and sonographic imaging without onsite radiologists’ services. Most patients presenting to these sites are Indigenous. Radiographers can be faced with unique sets of challenges which to date have received little attention. Objective: This ethnographic 2 study aimed to observe radiographer interactions with patients and interprofessional staff during routine radiographic and sonographic examinations. Methods: Non‐participant observations 3 and semi‐structured interviews were held at two FNQ hospitals. Radiographer‐patient interactions observed were recorded on checklists. Interviews were held with the radiographer at each site. Each interview was audio recorded and transcribed for thematic analysis. Results: Across both sites 24 patients were observed with the majority of Aboriginal and Torres Strait Islander status (N = 17/24 (70.8%)). In total 27 examinations were observed. Acute radiographic and sonographic findings were conveyed verbally to referring practitioners. Semi‐structured interviews highlighted complex issues such as radiographer communication in local dialect with Indigenous patients, the need for interprofessional collaborations to overcome a lack of immediate radiologists’ support, and isolation with regard to professional development opportunities. Conclusions: The study confirmed that radiographers acquire unique radiographer skills, complementing them when dealing with complex issues including provision of radiographic and sonographic reports without availability of radiologists’ reports. This study provides evidence that culturally competent radiographers are capable of undertaking reporting roles to facilitate patient management. References 1. Medical Radiation Practice Board of Australia. Professional capabilities for medical radiation practice, 2013. Available at https://www.medicalradiationpracticeboard.gov.au/registration/professional‐capabilities.aspx [Accessed 11 March 2019]. 2. Hoffmann T, Bennett S, Del Mar C. Evidence‐based practice across the health professions. 2010, Churchill Livingstone Elsevier, Australia, pp 210‐11. 3. Williams JP. 2008 Nonparticipant observation. In: Sage Encyclopedia of Qualitative Research Methods. Sage, pp.561‐62.

Allie Tonks 1 , Siena Maurici 2 , Justin Varcoe ¹ Vision Xray Group, NSW, Australia ² Westmead Public Hospital, Westmead, Australia Currently mandated under National Law, as articulated by the Medical Radiation Practice Board of Australia, is the minimum capability for all registered radiographers to assess acquired images for trauma or disease and convey findings to clinical staff. Despite endorsement of a written commenting system by professional bodies in several countries including Australia, radiographer input remains inconsistent and often informal.¹ The purpose of this review was an assessment of current literature to determine if commenting would be of value to the Australian health system, particularly when a radiologist report is not available within a clinically relevant timeframe. A structured search of four health research databases produced 58 articles used to support conclusions drawn within the review, with 11 core articles of highest relevance assessed for bias and quality forming the basis of discussion. Studies have suggested there is a contextual need for commenting due to increased imaging service pressures, radiologist shortages, and subsequent reporting delays.² Radiographers appear well placed and willing to provide accurate and confident initial input with evidence this would be valued and appreciated within the multidisciplinary team. Commenting has also been shown to reduce diagnostic and communicative errors, with the potential to improve patient management.³ Finally, it was shown that role extension enhances recruitment, retention, and job satisfaction among radiographers.² Therefore, current literature supports implementation of radiographer commenting within the Australian health system. Future research into financial and legal aspects of initial commenting would also be of value. References 1. Hardy A, Poulos A, Emanuel N, Reed W. An investigation of advanced practice carried out by radiographers in New South Wales. Radiographer 2010;57(3):29‐33. 2. Baird M. Improving the delivery of health care to patients: radiographers and frontline image interpretation. J Med Radiat Sci 2018;65(1):2. 3. McConnell J, Devaney C, Gordon M. Queensland radiographer clinical descriptions of adult appendicular musculo‐skeletal trauma following a condensed education programme. Radiography 20131;19(1):48‐55.

Michele Monahan 1 1 Connolly Hospital, Dublin, Ireland The European Council Directive 2013/59/EURATOM – which relates to medical exposures to ionising radiation – was transposed into Irish law in 2018 by Statutory Instruments No. 256 of 2018 (with amendments S.I. No. 332 and S.I. No. 413 of 2019). It replaces S.I. No. 478 of 2002 and all its amendments including S.I. No. 303 of 2007. In S.I. No. 256 the term ‘prescriber’ changed to ‘referrer’. The Irish Institute of Radiographer and Radiation Therapy (IIRRT) began making representations in 2007 when nurses were given prescriber rights under S.I. No. 478 of 2002 and radiographers and radiation therapists were not. Once European Council Directive 2013/59/EURATOM was published, the IIRRT made written proposals and held face‐to‐face meetings with key stakeholders to look for referrer and practitioner status in new legislation. This was achieved in S.I. No. 256 of 2018. The SIPTU (Services Industrial Professional and Technical Union) also made representation on behalf of radiographers and radiation therapists. This was a long journey, but radiographers and radiation therapists – once registered with the Radiographers Registration Board of CORU – are now ‘referrers’ and ‘practitioners’ in the legislation.

Katrina Woodford, 1,2 Vanessa Panettieri, 1,3 Jeremy Ruben, 1,2 Sidney Davis, 1,2 Trieumy Tran Le, 1 Stephanie Miller, 1 Sashendra Senthi 1,2 1 Alfred Health Radiation Oncology, Melbourne, Australia 2 Central Clinical School, Monash University, Melbourne, Australia 3 Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia Objectives: To determine the optimal volume of barium required to maintain oesophageal visibility and minimise imaging artefacts on cone bean computed tomography (CBCT) for locally advanced non‐small cell lung cancer (NSCLC) and quantify interfraction motion of the oesophagus relative to the tumour. Methods: 20 patients were administered oral barium before every second weekly CBCT in one of four dose levels: 25 mL, 15 mL, 10 mL, 5 mL. Six observers contoured the oesophagus on each dataset and a consensus contour was generated and compared to each observer contour. Visibility was determined by how similar the observer’s contours were to the consensus contour using a kappa statistic, dice coefficient and Hausdorff distance. Image artefact was scored by each observer. CBCT consensus contours were compared to the planning CT based off a soft tissue image registration to calculate interfraction motion. Correlations between displacement, oesophageal segment and other clinical variables were analysed. Results: Barium significantly improved oesophageal visibility on CBCTs compared to CBCTs without barium. The poorer the visibility without contrast the greater the improvement barium provided. There was minimal difference between dose levels with only 10 mL producing a higher kappa and dice. Artefact occurred infrequently and had minimal impact on image guidance. The median interfraction Hausdorff distance was 4 mm, with 95% of oesophageal displacement within 15 mm. No trends in position variation were seen between clinical variables. Conclusion: 10 mL of barium significantly improves visualisation of the oesophagus on CBCT with minimal image artefact. The oesophagus moves substantially and unpredictably over a course of treatment, requiring close daily monitoring in the context of hypofractionation.

Michael Tarollo 1 1 Western Health, Melbourne, Australia Background: It is a commonly accepted principle of general radiography that the central ray should be directed to the region of interest in order to obtain optimal positional image quality. Non‐central rays will be subject to a phenomenon known as beam divergence, causing distortion in the image. The concept of beam divergence is somewhat vague, with many radiographers being aware of its existence but generally unsure of the magnitude of its effects. An example of this is a common protocol of performing a lateral forearm X‐ray centred midway between the elbow and wrist and then performing an additional lateral elbow X‐ray centred on the elbow joint, a common request from referrers. In light of the ALARA principle, how appropriate is such a protocol or request? Aims: The purpose of this study is to define and quantify beam divergence by examining how drastic its effects are, and its consequential clinical impact. Methods: Radiographic phantoms were imaged at different central ray points to measure beam divergence. Source‐image‐distance (SID) an object‐image‐distance were also varied to examine their effects on beam divergence. A ‘perfect’ image with maximum elbow joint space was used as a baseline. Results: At a SID of 100 cm, beam divergence is clinically inconsequential at central rays 3–4 cm off‐centre. This increases to approximately 7–8 cm for off‐centred positioning for larger SIDs. These results were made by comparing images to the perfect lateral elbow. The presentation will discuss the clinical impact of these findings. Conclusion: Beam divergence is insignificant at larger SIDs.

Laura Adamson, 1,2 David Thwaites, 1,2 Jonathan Sykes, 1,2 Rachael Beldham‐Collins 1 1 Sydney West Radiation Oncology Network, Sydney, Australia 2 Institute of Medical Physics, School of Physics, University of Sydney, Sydney, Australia Background: Practice standards stipulate a safety and quality management (SQM) strategy within radiation oncology, ensuring quality improvement (QI), risk management, incident reporting, staff training and appropriate resources reducing risks proactively. 1 Implementation of a new radiation oncology‐specific incident learning system (ILS) began in 2019. ILS should include reporting, analysing and developing QI interventions with appropriate feedback loops. 2 Before implementation, baseline measurements around safety culture (SC) and ILS occurred. This presentation examines baseline investigations that were found. Methods: A 28‐question e‐survey was distributed to medical radiation oncology staff within one local health district between September and October 2018. The survey was based on similar surveys used to measure the SC and ILS. 3–5 Results: The survey was completed by 70 staff, an overall response rate of 64%, demonstrating varied levels of understanding and utilisation of ILS. 24% of respondents could identify all incident reporting systems in use, a distinct difference between the three professional groups around knowledge and use of reporting was revealed. 67% of respondents identified barriers to reporting an incident and 61% of respondents perceiving a no‐blame culture. Overall, results influenced an appropriate, relevant and robust ILS within our department. Conclusion: Results identified areas for SC improvements, and suggested staff should be receptive of the new ILS. It was imperative to quantify the baseline culture and understanding before implementation to measure the QI success and areas for continued QI within our SQM. References 1. The Royal Australian and New Zealand College of Radiologists. New revised radiation oncology practice standards; 2018. Available at https://www.ranzcr.com/whatson/news‐media/240‐new‐revised‐radiation‐oncology‐practice‐standards [Accessed 8 July 2018]. 2. Williams M. Improving patient safety in radiotherapy by learning from near misses, incidents and errors. Br J Radiol 2007;80(953):297‐301. 3. Bolderston A, Di Prospero L, French J, Church J, Adams R. A culture of safety? An international comparison of radiation therapists' error reporting. J Med Imag Radiat Sci 2015;46(1):16‐22. 4. Milosevic M, Angers C, Liszewski B, et al. The Canadian national system for incident reporting in radiation treatment (NSIR‐RT) taxonomy. Pract Radiat Oncol 2016;6(5):334‐41. 5. Montgomery L, Fava P, Freeman CR, et al. Development and implementation of a radiation therapy incident learning system compatible with local workflow and a national taxonomy. J Appl Clin Med Phys 2018;19(1):259‐70.

Hayley Fairless 1 1 Alan Walker Cancer Care Centre, Tiwi, Australia The aim of this presentation is to discuss and highlight how the barriers in communication that present in radiation therapy affect Indigenous Australian patients. Throughout this paper, differences in health ideals between Indigenous and non‐Indigenous Australians will be discussed, how these values, beliefs, cultural needs and variations in health history create the need for modifications to care pathways and in communication approaches in order to achieve optimal health outcomes for Aboriginal and Torres Strait Islander peoples. The role of language, culture, shame, men and women’s business, access to healthcare and the additional subcomponents that apply will be examined, and what is being currently done to improve the discrepancies that are present. This presentation is aimed at improving the knowledge of students across the multidisciplinary board of the clear health gaps that are present and how these complex issues can be improved by the acknowledgement and cohesion of health services.

Isabelle Fent, 1 Adam Briggs, 1 Alex Quinn, 1 Leigh Ambrose, 1 Shelley Wong, 1 Alexandra Turk, 1 Brian Porter, 1 John Ateyo, 1 Regina Bromley, 1 Jeremy Booth, 1,2 Andrew Kneebone, 1,3 George Hruby 1,3 1 Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia 2 School of Physics, University of Sydney, Australia 3 Sydney Medical School, University of Sydney, Australia Online adaptive radiation therapy (oART) is a novel solution to account for inter‐fraction anatomical variation. oART enables the reduction of margins required for day‐to‐day anatomical variation, resulting in reduced treatment volumes. Our department has completed significant preliminary work to implement oART using the first artificial intelligence driven CBCT based radiation therapy system, Varian’s Ethos™. Following collaboration with and contribution to the international Adaptive Intelligence Consortium (AIC), we first treated with oART in March 2020. In September 2020 the department was the first in the southern hemisphere to treat rectal oART. Three neo‐adjuvant long course rectal patients have completed treatment with oART. The introduction of a new planning system required multidisciplinary collaboration to develop auto‐plan templates which generate plans that match or exceed current departmental plan quality. Sixty automatic treatment plans were generated for recently treated rectal patients and over 100 fractions were treated in the test environment. Throughout implementation, technical challenges were encountered that included the impact of inter and intra‐fraction anatomical changes on imaging, structure propagation and plan generation, as well as practice changes due to software differences and limitations. Subsequently, numerous quality control processes were revised and developed to ensure safe and efficient treatment. The departments’ initial experience demonstrates that rectal oART is feasible and may be delivered safely and accurately.

Raewa Long 1 1 Central Queensland University, Australia Introduction: The Transflux contrast delivery system is a multi‐dose, multi‐patient intravenous injection apparatus ultilsed during computed tomography (CT) contrast examinations. It is designed to produce improved cost, waste and time efficiencies between patients when compared to conventional, single‐use systems.¹ This study was conducted to calculate the total volume and monetary savings of the Transflux implementation at the Logan Hospital Emergency Department (ED) and compare the findings to a previous study performed by the hospital’s main outpatient department. Furthermore, the study also attempted to ascertain the most cost‐efficient 12‐hour timeframe to utilise the Transflux. Methods: Four weeks of data from emergency CT contrast examinations were collected over a 4‐month period. Recorded parameters included the time of the scan, the amount of contrast injected and the size of the single‐use syringe that was used for any pre‐filled injections. Karisma RIS was used to collect the studies and Google Sheets was employed to record the data. The Transflux data was then compared to existing, single‐use injection parameters to compare efficiency in addition to outpatient department data. Results: The ED Transflux demonstrates a cost saving and contrast volume saving of $1812 and 8239 mL compared to the outpatient department savings of $739 and 3353.5 mL over the 4 weeks of data collection. The most cost‐efficient timeframe to implement the Transflux system in the ED is between the hours of 12:00 and 00:00. Discussion/Conclusion: The data has shown the ED Transflux has significantly improved cost savings than the outpatient department with the comparable data. The existing, implemented timeframe the Transflux being used is justified as the most cost efficient and clinically appropriate given the increased patient volume and staffing presence.

Casey Allison 1,2 1 SA Medical Imaging, Adelaide, Australia, 2 Murray Bridge Soldiers Memorial Hospital, Murray Bridge, Australia Autism spectrum disorder (ASD) in paediatric patients is a disorder with a prevalence of about 1% in Australia. ASD often results in difficulty interpreting verbal and non‐verbal cues and can create anxiety and impede effective communication.¹ Children with ASD frequently react to sensory stimuli in an atypical manner and this is evident in radiology departments during examinations.¹ This could include over‐reaction to sound stimuli and under‐reaction to pain stimuli. Healthcare visits can be anxiety‐inducing and overstimulating for the child, yet few radiology departments have guidelines in place for examining patients with ASD.² Imaging of autistic children can be eased by following a set of guidelines and customising these to form an individualised approach. This involves communicating with the parents/guardians of the patient to obtain information regarding the child’s needs.² Environmental features are another factor to consider.² Minimising external sensory stimuli, such as utilising dimmable light, closing doors and minimising sounds, can reduce the sensory overload and promote a calm environment.³ The most crucial focus in interacting with a child with ASD is communication and this should be customised to the patient.¹ Slow, simple and low toned language should be used, while observing all signs of recognition of communication, not only verbal responses.³ Repeated information or varied messages can be used to ensure patient understanding and, most importantly, the radiographer must maintain a calm and patient demeanour. A customised approach to examining a paediatric patient with ASD is vital in providing an optimal experience for the patient, guardian and radiographer. References 1. Berglund I, Björkman B, Enskär K, Faresjö M, Huus K. Management of children with autism spectrum disorder in the anesthesia and radiographic context. J Dev Behav Pediatr 2017;38(3):187‐96. 2. Björkman B, Gimbler Berglund I, Enskär K, Faresjö M, Huus K. Peri‐radiographic guidelines for children with autism spectrum disorder: a nationwide survey in Sweden. Child Care Health Dev 2016;43(1):31‐36. 3. Brown, AB, Elder, JH. Communication in autism spectrum disorder: a guide for pediatric nurses. Pediatr Nurs 2014;40(5):219.

Myxuan Huynh 1 , Ivan Kempson 2 , Wendy Phillips 3 , Eva Bezak 1 1 University of South Australia, Adelaide, Australia 2 University of South Australia, Adelaide, Australia 3 Royal Adelaide Hospital Cancer Centre, Adelaide, Australia Objectives: Head and neck cancers are characterised by hypoxia and radioresistance, cumulating in negative radiotherapy (RT) outcomes. 1 Standard‐of‐care involves concurrent chemoradiation, a treatment method associated with high acute grade toxicities. Gold nanoparticle (AuNP) radiosensitisers permit RT dose reduction through the promotion of localised dose deposition and sensitisation of cells to damage, offering a new approach to treatment delivery. 2,3 Methods: This project aimed to maximise the therapeutic benefits of AuNPs through the optimisation of RT doses, fractionation schedules and nanoparticle injection regimens. The HYP‐RT model, 4 capable of growing in‐silico tumours and simulating fractionated RT was utilised. This project involved the incorporation of probabilistic nanoparticle sensitisation factors into the model through the implementation of nanoparticle uptake distributions and dose enhancement ratio variables. HYP‐RT was used to predict total doses required for 100% tumour control probability with/without AuNPs during fractionated RT. Results: Minimal decreases in total doses for local tumour control were found with single AuNP injections. For hypoxic tumours with accelerated repopulation and reoxygenation applied, undergoing 2 Gy per fraction RT, weekly and bi‐weekly AuNP injections decreased required doses from 89.76 Gy to 62.24 Gy and 53.38 Gy, respectively. All total dose outcomes significantly reduced with the addition of AuNPs, with the most decrease associated with bi‐weekly AuNP injections. Discussion: For most simulations in which no AuNPs resulted in above standard clinical prescriptions, the addition of reoccurring AuNP injections enabled reductions below these doses. AuNPs allowed for the reduction in total tumour control doses and facilitates a method for effectively treating hypoxic (radioresistant) tumours. References 1. Awada A, de Castro GJ. Head and neck cancer emerging strategies: advances and new challenges. Curr Opin Oncol 2009;21(3):191‐93. 2. Turnbull T, Douglass M, Williamson NH, et al. Cross‐correlative single‐cell analysis reveals biological mechanisms of nanoparticle radiosensitization. ACS Nano 2019;13(5):5077‐90. 3. Her S, Jaffray DA, Allen C. Gold nanoparticles for applications in cancer radiotherapy: mechanisms and recent advancements. Adv Drug Deliv Rev 2017;109:84‐101. 4. Harriss‐Phillips WM, Bezak E, Yeoh E. Altered fractionation outcomes for hypoxic head and neck cancer using the HYP‐RT Monte Carlo model. Br J Radiol 2013;86(1024):20120443.

Paul Kane 1 1 University of Otago Wellington, Wellington, New Zealand The well‐designed education of radiation therapy practitioners is required to support growing demand on oncology services. In New Zealand, a range of stakeholders lay claim to a say in curriculum design for student radiation therapists. Universities expect graduates to display certain attributes; educators hold views on an appropriate learning environment; clinical leaders need good employees to deliver services and adapt to ever changing clinical practice; professional bodies seek to advance the profession and its members; a regulatory body must protect the public by ensuring those who use protected professional titles are quantifiably competent to do so; and students expect their learning experience to be engaging and prepare them for practice in their chosen field. This scenario could be applied equally well across other healthcare disciplines. Arguably those voices will have competing if not conflicting interests. All are valid and their expectations must be met at some level. Although current education provision successfully produces competent practitioners, no formal collation of the various perspectives has occurred nor has any theoretical underpinning been documented in the New Zealand context. A qualitative project, following a constructivist grounded theory design, is currently underway which aims to do just that. The study should generate a set of guiding principles to guide radiation therapy curriculum development now and in the future to meet changing needs. Initial results will be reported in this presentation, indicating the perspectives of a range of the stakeholders around the past, present and future state of radiation therapy education in New Zealand.

Michaela Beavan, 1,2,3 Kylie Dundas, 1,3,4 Felicity Hudson, 1,4 Yolanda Surjan, 2 Annie Lau, 1 Shrikant Deshpande, 1,4 Karen Lim, 1,4 Viet Do 1,4 1 Liverpool and Macarthur Cancer Therapy Centre, Sydney, Australia 2 The University of Newcastle, Newcastle, Australia 3 Ingham Institute of Applied Medical Research, Liverpool, Australia 4 South Western Sydney Clinical School, University of New South Wales, Sydney, Australia Objectives: The myelosuppressive effects associated with concurrent chemoradiotherapy (CRT) for locally advanced cervical and vaginal cancer can lead to treatment interruptions. The aim of this study was to investigate whether an emerging technique, known as bone marrow sparing (BMS) volumetric modulated arc therapy (VMAT), can effectively reduce dose to active bone marrow (ABM) while maintaining acceptable clinical objectives for targets and organs at risk (OAR). Methods: Ethics approval was obtained. Twenty gynaecological cancer patients treated with definitive CRT from our department between 2015 and 2020 were retrospectively included. ABM was delineated based on fluorodeoxyglucose‐positron‐emission‐tomography (FDG‐PET) imaging. Weekly blood tests and ABM dose parameters at the V10 Gy, V20 Gy, V30 Gy, V40 Gy, and Dmean were assessed on original plans for any potential correlation with grade 2+ HT. BMS plans were all replanned with VMAT, and various dose parameters were compared with the original plan to assess for any significant differences. Results: ABM doses were significantly reduced (P < 0.001 for all parameters) in BMS‐VMAT plans, and significant improvements in target and OAR coverage was found compared to the combined original plans. Compared to VMAT‐only, target and OARs were comparable. No significant correlations between HT and ABM dose were found. Conclusion/Discussion: BMS‐VMAT can significantly reduce dose to the ABM while maintaining acceptable target and OAR doses. A future prospective trial is planned to investigate the clinical impacts of BMS‐VMAT on HT.

Grace Seo 1 1 University of Sydney, Sydney, Australia Introduction: The incidence of obesity has been steadily rising over the past few decades and is having a significant impact on the health system. In radiography, a particular challenge of imaging obese patients is implementing the ‘as low as reasonably achievable’ (ALARA) principle when determining radiation dose and little research has been conducted into the technical and patient‐care adaptations that can be employed. This study aims to better understand the decision‐making strategies of expert radiographers in determining imaging and exposure factor selection, in the context of obese patients. Methods: The study employs a ‘think‐aloud’ methodology – a qualitative technique used for investigating the cognitive processes of an individual. 1 Eight diagnostic radiographers, working in clinical education, were recruited to perform routine AP abdominal X‐ray projections on an anthropomorphic phantom. They were simultaneously asked to verbalise emerging thoughts as they considered positioning, exposure selection and image evaluation. This process was repeated with three different phantom sizes, each representing an increased body mass index from ‘healthy’ to ‘morbidly obese’. Audio files were transcribed verbatim and interpreted via Bowman’s theory of radiographic judgement and decision‐making which identifies three stages: segmental, holistic and environmental. 2 Results/Conclusion: Preliminary analysis has demonstrated differences in radiographic concepts that are considered when imaging patients of different sizes. A general shift from segmental factors (e.g. positioning) to more environmental factors (e.g. patient comfort) with increasing patient size was observed. The findings will help inform future research, practice guidelines and learning resources to provide optimal imaging and care for obese patients. References 1. Hevey D. Think‐aloud methods. In: Salkind N (editors). Encyclopedia of Research Design. California: SAGE Publications Inc.; 2010. 2. Bowman S. Technical evaluation of radiographs: a case study in radiographic judgement and decision‐making. In: Paterson A, Price R (editors). Current Topics in Radiography. London: W. B. Saunders Company Ltd.; 1997. p 69‐86.

Shannen Brach, 1 Rachael Raynes, 1 Michelle Braybrook, 1 Marcia Costa 1 1 Ballarat Austin Radiation Oncology Centre, Ballarat, Australia At the beginning of radiation therapy, patients are often given a considerable amount of information regarding their treatment from many members of the multidisciplinary team. This may lead to difficulty with information retention, possibly resulting in a negative impact upon treatment experience. This project was designed to gain a better understanding of the patient’s perspective and priorities while undergoing radiation therapy, in terms of information provision. Critically, this project was consumer led with the aim of implementing changes to current practice. Patients (N = 17) were recruited at the beginning of their radiation treatment. The patients’ satisfaction and recall of information was measured by means of a consumer‐reviewed written survey, followed by an interview. Overall, patients were satisfied with the information given at the radiation therapists’ (RTs) first day chat. However, participants noted they were overwhelmed and had little to recall other than to stay still. These results correlated with the experiences of the consumers. From these results the RTs have adapted the way the first day chat for both planning and treatment are delivered. Only essential radiation therapy information is now provided during the first day chats. After commencement of treatment, RTs provide an optional appointment for patients to receive additional non‐essential information. The effectiveness of these changes to practice are currently under evaluation.

Aidan Leong, 1,2 Erika Burgess, 1 Ryan Caravana 1 1 Bowen Icon Cancer Centre, Wellington, New Zealand 2 University of Otago, Wellington, New Zealand Objectives: The individuality of each cancer patient’s experience presents a continual challenge in identifying, and responding to, physical and psychosocial care needs. Patient‐reported outcome measures (PROMs) capture subjective patient perceptions of their health. 1 This study describes the implementation and preliminary evaluation of PROMs for patients undergoing breast radiation therapy (RT). Methods: The Radiation‐Induced Skin Reaction Assessment Scale (RISRAS) and Distress Thermometer (DT) tools were selected as validated PROMs to implement. RISRAS includes four patient‐ and four nurse‐reported domains (scored 0–3, total = 24). The DT is scored by the patient (0–10) and identifies specific factors contributing to distress. PROMs were completed at baseline (planning CT), weekly (RISRAS) or bi‐weekly (DT) during RT, then 1‐week post‐treatment. Cohort assessment scores were analysed across the reported time‐points. Results: Interim analysis included 13 consecutive patients (71 RISRAS and 48 DT assessments). Mean (±SD) combined RISRAS score was 2.9 ± 3.1. RISRAS scores increased over time (Figure 1a), with good correlation bet2 two weeks of RT, and then progressively decreased (Figure 1b). Considerable interpatient variation was seen in both RISRAS and DT scores as evidenced by large standard deviations. Fatigue was the most frequently reported factor contributing to distress (48% of assessments) followed by skin (33%). Discussion/Conclusion: PROMs has enabled us to benchmark patient wellbeing throughout RT and compare perspectives from patients and staff. Reassuringly, overall distress levels were low, and decreased throughout RT. Several opportunities have been identified for ongoing practice development. Reference 1. Basch E, Abernethy AP, Mullins CD, et al. Recommendations for incorporating patient‐reported outcomes into clinical comparative effectiveness research in adult oncology. J Clin Oncol 20121;30(34):4249‐55.

Gabriella La Macchia 1 1 Sir Charles Gardiner Hospital, Nedlands, Australia In 2019, an era of change saw the implementation of the Eclipse™ planning system and Varian TrueBeam ® linear accelerators within the department. The changes meant that the conventional total body irradiation (TBI) technique protocol in place, requiring 18 MV energy and extended distances, was no longer viable. Research and implementation of a modernised technique was required. A practical review of available literature was undertaken late in 2019 to determine the clinical picture of TBI worldwide that would be feasible within the new infrastructure and systems within the department. Requirements included viability in smaller treatment rooms, use of 6/10 MV energy, minimal extra custom equipment and feasible for paediatric treatment under general anaesthetic. The resulting depiction in the literature of TBI is of variable methodology with no evidence based best practice or standardisation since conventional techniques were originally introduced. Several studies have shown the heterogeneity and inconsistencies of the technique between departments. 1,2 Protocols and techniques are department based; dependant on availability of equipment, software systems and resources. Several multidisciplinary discussions were required to formulate a new suitable technique considering the available literature and the structure, requirements and limitations of our department. The technique deemed most suitable for our department was a multi‐isocentric volumetric modulated arc therapy technique with a custom‐made turntable. 3 2020 saw significant effort in protocol development, end‐to‐end testing and rigorous quality assurance processes to allow for clinical implementation in January 2021. The newly implemented technique will modernise and align TBI with the current landscape of advance radiotherapy planning and treatment. References 1. Giebel S, Miszczyk L, Slosarek K, et al. Extreme heterogeneity of myeloablative total body irradiation techniques in clinical practice: a survey of the Acute Leukemia Working Party of the European Group for Blood and Marrow Transplantation. Cancer 2014;120. 2. Studinski R, Fraser D, Samant R, MacPherson M. Current practice in total‐body irradiation: results of a Canada‐wide survey. Current Oncology 2017;24(3):181. 3. Ouyang L, Folkerts M, Zhang Y, et al. Volumetric modulated arc therapy based total body irradiation: workflow and clinical experience with an indexed rotational immobilization system. Phys Imaging Radiat Oncol 2017;4:22‐25.

Sarina Wan, 1 Seyedamir Tavakoli Taba, 1 Sarah Lewis, 1 Timur Gureyev, 2 Patrick Brennan 1 1 The University of Sydney, Sydney, Australia 2 The University of Melbourne, Melbourne, Australia Objective: Breast cancer mortalities compose of 15% of women’s cancer deaths. 1 Current breast imaging modalities use absorption information that do not produce enough contrast for an efficient diagnosis. Propagation‐based computed tomography (PB‐CT) is a developing vision that exploits a more contrast‐sensitive property of X‐rays: phase‐shifts, in addition to absorption. 2 Current research is being undertaken to optimise PB‐CT for clinical implementation. A significant factor of PB‐CT is the X‐ray energy required to produce high‐quality images. This study aims to explore the relationship between X‐ray energy and radiological image quality in PB‐CT imaging. Methods: 39 samples were scanned at various energies of 26 keV, 28 keV, 30 keV, 32 keV, 34 keV and 60 keV, accumulating a total of 132 image sets. A visual grading characteristics (VGC) study was used to determine the highest quality radiographic image. Seven observers rated the radiological image quality of PB‐CT images against a reference absorption‐based (AB‐CT) image on a 5‐point scale. Results: PB‐CT images scanned at 28 keV, 30 keV, 32 keV and 34 keV displayed superior image quality than AB‐CT reference images. PB‐CT images scanned at 30 keV provided the most optimum images with the largest area under the curve of 0.754 (P = 0.009). Discussion/Conclusion: Within an optimum energy range (30 keV), PB‐CT technique may allow for advanced image quality at a dose comparable to conventional techniques. This vision enhances the justification of PB‐CT and can potentially increase diagnostic efficiency. Thus, PB‐CT may lead to a reduction in breast cancer mortalities and contributes to a higher standard of healthcare. References 1. World Health Organization. Breast Cancer [Internet]. 2019. Available at https://www.who.int/cancer/prevention/diagnosis‐screening/breast‐cancer/en/ [Accessed 5 December 2019]. 2. Tavakoli Taba S, Baran P, Lewis S, et al. Toward improving breast cancer imaging: radiological assessment of propagation‐based phase‐contrast CT technology. Academic Radiology 2019;26(6):e79‐e89.