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Head and Neck Neoplasms

Lay in treatment position for 20 minutes with surface monitoring technology activated

Mask-free headrest and couch for patient positioning for radiation therapy combined with a surface monitoring system

Mask-free surface monitoring

Paul Keall, Prof

Natalie Plant, MHSc

Suganthy Varadarajan

Tracy Pearl-Larsson

Purmina Sundaresan, Dr

A pilot-stage device feasibility study investigating a mask-free motion-monitoring patient immobilisation system for use during radiation therapy treatment of head and neck cancer (HNC). This mask-free system combines the standard radiation therapy (RT) head rest to help the patient remain still with a surface guidance detection system that uses sensors to detect and track patient movement.

Patients who will have RT treatment for head and neck cancer involving an immobilisation mask will be asked to lie on the treatment couch for the normal treatment fraction time while the surface monitoring system is activated. We will then assess:

i) The level of acceptance of the system by HNC patients currently being treated with RT using an immobilisation mask, and ii) The ability of the surface guidance system to monitor movement of the patients

Radiation therapy (RT) is a central treatment modality for 74% of head and neck cancer (HNC) patients where preservation of the form and function of localised organs and tissue is of prime importance. Radiation therapy offers the possibility of organ preservation by providing a non-surgical approach to curative treatment, while helping to limit the extent of surgery in cases where definitive surgery is unavoidable. Radiation therapy also has an important role in maintaining quality of life in the palliative management of incurable HNC, where it can prevent and alleviate pain, bleeding, tumour fungation and difficulty with swallowing, breathing and speech.

State-of-the-art RT for HNC delivers lethal radiation doses to the cancer while sparing vital organs situated just a few millimetres away. To achieve this level of accuracy, tight-fitting thermoplastic head and neck masks are used to immobilise the patient in the desired treatment position for the duration of each of their RT treatments. These thermoplastic immobilisation devices are accepted internationally as the necessary standard and included in published guidelines. Open masks are an emerging immobilisation measure and a first step to reduce patient discomfort and anxiety. An open mask has a smaller visual restriction and fewer restraint points.

Although, thermoplastic immobilisation masks are the accepted clinical standard for HNC RT, it is widely recognised and acknowledged that there are several limitations with their use. Changes to the mask's fit may be needed due to patient weight loss, tumour shrinkage, or treatment related oedema. Thus, radiation therapists are required to monitor the mask for fit throughout the treatment course, undertake imaging at regular intervals and make corrections as per published guidelines and local protocols. There is also risk of movement of the patient within the mask, which may lead to under dosing of the target and overdosing of organs at risk. Court et al. reported that patients in their study needed to be repositioned in the immobilisation mask before treatment for 14% of fractions; 30% of the repositioning was for shoulder shifts of 1 cm or greater. Neubauer et al. observed shoulder motion of 2-5 mm in each direction on average (20 mm max). These shifts resulted in coverage loss (dose to 99% of the clinical target volume decreased by up to 1Gy) or increased dose to organs at risk (e.g., dose to brachial plexus increased by 0.7Gy).

The ACRF Image X Institute at the University of Sydney has developed a novel surface guidance system that can be mounted to any RT imaging and treatment couch. This system is currently being used in a clinical trial (NCT02881203) to guide breast cancer patients into a reproducible breath hold: the patient's chest position is measured via surface imaging and the system delivers visual feedback to the patient via a screen for the patient to correct their breath hold level if necessary (i.e., surface guidance). This system uses off-the-shelf electronics, most importantly a sensor which includes an optical and a depth camera, delivering frames at a rate of 30Hz and allowing the patient and operator to see an augmented reality video feed, including the surface depth information.

Similar to this, we will apply optical and depth cameras for head and neck surface monitoring by integrating a second sensor and adapting it to the different location of treatment

Pilot-stage, single-arm study investigating the technical feasibility and patient acceptance of a non-interventional, non-invasive, mask-free surface detection system.

Towards the end of their scheduled radiation therapy treatments, people being treated for HNC with RT using a thermoplastic immobilisation mask will be asked to lie in a treatment position on a treatment couch using a standard radiation therapy headrest without the mask, for the normal amount of time taken for individual radiation therapy treatments (20 minutes). During this time, the mask-free surface detection system will detect and record their location and movement. Data collected by the surface detection system during this couch session will be analysed to determine the feasibility of using the equipment to detect location and movement over this period. Data collected directly from the participants immediately before, during and following the couch session will be used to determine their acceptance of the system in terms of comfort and anxiety when compared with wearing the mask, and any suggestions for improvement of the system. Data collected directly from the radiation therapists following the couch session will be used to investigate their thoughts on the abilities of the system, ease of use and suggestions they may have.

To investigate the effect of changes in appearance due to weight loss over the course of HNC radiation therapy treatment, a 5-minute surface monitoring couch session conducted before the start of radiation therapy will record baseline surface-monitoring information only.

Data analysis will occur at the University of Sydney outside of participant sessions.

This is a hypothesis-producing feasibility study that does not involve power calculations. The number of participants (20) was chosen to enable confidence in the primary outcome calculation.

Surface Monitoring Technology to Remove The Mask - Stage 1

Non-identifiable individual participant data (IPD) may be shared with researchers for further scientific research. Facial images/photos identifying participants will not be shared.

Technical feasibility of surface-monitoring system in ≥90% of consumers - operates continuously throughout the session and provides information on the position and motion of the cranium, mandible and shoulders without obvious erroneous results or faults

Patients complete the session AND give a mean score of 4 or more for both comfort and acceptability on a Likert scale of 1-7, where 1 = 'Very Strongly Disagree' and 7 = 'Very Strongly Agree'

Qualitative semi-structured interview of patient experience of interacting with the surface monitoring system and how that compared with the experience of the immobilisation mask during their radiation therapy treatment.

Questionnaire of radiation therapist's experience scored according to a Likert scale of 1-5 where 1 = 'Strongly Disagree' and 5 = 'Strongly Agree'

Distance and direction of, and correlation between, motion of the cranial and upper torso anatomy relative to the fixed isocentre

Distance and direction of, and correlation between, motion of the cranial and upper torso anatomy relative to first image taken

Change in number of detection of points in the point cloud in response to residual motion of anatomical landmarks over 20 minutes of continuous data acquisition

A photograph taken by the system camera showing physical characteristics of face and hair (e.g. shape, tone, location, size)

The effect of change in weight (kg) from pre-RT to late RT on Outcome 5

The effect of change in weight (kg) from pre-RT to late RT on Outcome 6

Western Sydney Local Health District

University of Sydney

20 patients will be interviewed once, which will be approximately 60 minutes in duration. The interviews will be audio recorded.

Five patients who participated in stage 1 will take part in a cognitive interview, which will be approximately 60 minutes in duration.The interviews will be audio recorded.

not an intervention

Daisy Hopper

Jacqui Stringer, Dr

Jacqui Stringer

The study aims to explore the experience of patients with Head and Neck Cancer, who are preparing for and/or completed radiotherapy treatment.

This is a non-interventional study using interviews to explore head and neck cancer patients' experience of preparing for and completing radiotherapy utilising an immobilisation mask.

The study will be conducted in 2 stages:

The first stage is Item generation. Approximately 20 interviews will be conducted with head and neck cancer patients who have completed or partially completed radiotherapy. The interviews will capture their experiences and views pertaining to mould making, scans and radiotherapy, reported associated fear of restriction, suffocation, loss of control and fear of public embarrassment during treatment.

The data from the interviews will be used to develop potential items for a screening tool for identification of those patients likely to experience anxiety and claustrophobia before they start their treatment.

The second stage is cognitive interviews. Approximately 5 patients included in Stage I will be invited to take part in a further interview to review the themes and potential questionnaire items identified from interviews.

Qualitative Exploration of Head & Neck Cancer Patient Reported Experience of Radiotherapy

Qualitative Exploration of Head & Neck Cancer Patient Reported Experience of Radiotherapy With Focus on Restriction Anxiety & 'Claustrophobia

Interviews will be used to generate themes that capture the patients experience. These themes are the primary outcome.There are no units of measurement or data collection tools only an interview schedule.

interviews extracts will be used as potential item for the interview

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization	Link
Surface Monitoring Technology to Remove The Mask - Stage 1	NCT04266223	Head and Neck C... Radiation Thera... Anxiety	Mask-free surfa...	18 Years -	University of Sydney
Qualitative Exploration of Head & Neck Cancer Patient Reported Experience of Radiotherapy	NCT04543045	Oncology Head and Neck C... Anxiety	not an interven...	18 Years -	The Christie NHS Foundation Trust

Spots Global Cancer Trial Database for claustrophobia