A framework for upskilling Canadian Radiation Therapists for online adaptive radiation therapy

Advancements in precision radiation therapy have enabled adaptive radiation therapy (ART), which involves modifying treatment plans based on anatomical changes observed during treatment. This study analyzes ART workflows and Radiation Therapist (RTT) roles to identify upskilling needs and inform recommendations for a national competency framework supporting advanced image-guided ART in Canada.

A multi-center, multi-phase mixed methods approach was used to explore RTT roles and training needs for ART across Canada. Phase 1 analyzed national survey data, focusing on RTT involvement and training in offline and online ART workflows. Phase 2 mapped online ART workflows for MR-guided and CT-guided linac systems and compared them to national and international competency frameworks. Phase 3 employed a Modified Delphi process with subject matter experts from five Canadian centers practicing online ART to reach consensus on tasks requiring upskilling beyond entry-level competencies.

Survey responses were received from 32 of 48 centers (67%), with 25 reporting offline ART and 5 reporting online ART. RTTs were involved in nearly all steps of both ART workflows, though their roles varied by modality. Offline ART tasks were primarily performed by dosimetry RTTs, while online ART tasks were concentrated among treatment unit RTTs. Training approaches differed significantly, with offline ART relying on in-house methods and online ART initially supported by vendor training. The Delphi process identified four key tasks requiring upskilling: structure propagation and contouring, target volume verification, plan modification, and dosimetric evaluation. These tasks, along with treatment decision-making, were also rated as highly important to the safety and efficacy of online ART.

Canadian RTTs are increasingly taking on expanded roles in the ART process. However, for those stepping into these roles, training has been inconsistent and often lacking beyond entry-level preparation. Tasks identified by expert consensus should serve as target training areas for centers aiming to upskill their RTTs and broaden the implementation of ART. An adaptive competency framework could equip RTTs with the necessary knowledge, skills and judgement to successfully work in this evolving ART environment and should standardize training nationally.