#ResearchMatters

Getting published, starting a research project, navigating ethics approval, do you need a helping hand?

Research is important in healthcare; it should be at the heart of what we do. It is only through research and innovation that we can improve treatments, make the patient experience better and continue to develop interventions that work but don’t cost the earth. The Department of Health for England has research and innovation as a key priority(1). As a profession, radiography tends to lag behind other Allied Health Professions and nursing in terms of engagement with research; a recent research capacity audit highlighted this gap in our capability to bring in research funding, publish research outputs and produce a research ready workforce(2).

It’s not all doom and gloom though; there are pockets of excellence around the UK where research radiographers and Professors of Radiography are pushing forward this agenda. Dr Christina Malamateniou is leading a new mentoring programme for novice researchers in radiography. So if you have some research you want to publish, or an idea for a new research project or evaluation of a service, but you don’t know quite where to start why not join the scheme for the opportunity to be matched with an experienced radiography researcher to help realise your goals. Want to know more? Take a look below, join the radiography revolution show that research matters.

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 References

  1. Department of Health. Department of Health-priorities 2016 [Available from: https://www.gov.uk/government/organisations/department-of-health/about – our-priorities.
  2. Probst H, Harris R, McNair HA, Baker A, Miles EA, Beardmore C. Research from therapeutic radiographers: An audit of research capacity within the UK. Radiography. 2015;21(2):112-8.

Sometimes we just have to do better.

I’m very proud of my profession, I’m also proud of the great strides health workers of all professions have made over the years to improve treatments and care for patients diagnosed with cancer. However, there are some areas of cancer care where we simply need to do better. This month Dr Daniel Saunders presented at our Sheffield Hallam cancer research seminar series, the title of his talk “Understanding the needs of lesbian, gay and bisexual cancer patients, their partners and carers”. This thought provoking presentation is important for all of us working in cancer care, those working on the front line directly with patients and also researchers working in oncology.

I learnt a lot from Dan’s presentation, and found some of the statistics presented quite shocking. If you are a radiotherapy educator please share this presentation with your students; they are the future of healthcare delivery and we owe it to patients to make positive changes.  You can watch Dan’s full presentation here. We would love to hear your thoughts on this important topic, so leave a comment if you have time.

The next in our research seminar series will be a presentation by Professor Laura Serrant on her ‘screaming silences’ framework. Keep a look out on the blog for the link to her presentation coming in December.

Meet the Allied Health Professions Cancer Research Team at Sheffield Hallam.

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Welcome to the first in our new blog series from the Sheffield Hallam, Allied Health Professions (AHP) Cancer Research group. Our group of researchers have combined roles as educators and researchers, we combine teaching of under-graduate and post-graduate students with the running of research projects under the cancer (or oncology) theme. In this first blog I’d like to summarise the AHP cancer research group aims and vision, introduce you to the steering group, tell you about our current research projects and highlight what topics and discussions to expect in the coming months on the blog.

Cancer Statistics

Of those people born after 1960 in the UK one in two will be diagnosed with cancer in their lifetime, forty-two percent of cancer cases are preventable(1). In the 1970’s less than a quarter of all cancer patients survived their cancer. Today fifty percent of those diagnosed will survive(2). Of those diagnosed with cancer half will receive radiotherapy, sixty percent of these for curative intent. Radiotherapy is considered one of the most effective cures for cancer, with over 90,000 patients receiving radiotherapy in the UK each year(3).

Our vision

Dignified, evidence based, cancer care delivered by highly skilled AHP professionals.

Our Mission

To deliver high quality research to improve:

  • the accuracy and delivery of radiotherapy,
  • the patient experience,
  • patient engagement in treatment decision-making and self care and
  • public knowledge of how to reduce the risk of cancer development.

The Sheffield Hallam AHP Cancer Theme Steering Group

hp2

Professor Heidi Probst PhD, FCR, MA, BSc(Hons), DCR(T)

I am the research group lead my main research interests are in breast cancer and the oncology workforce. My research fits with the Allied Health Professions (AHP) cross cutting themes of innovation and technology in healthcare, and improving the patient experience.

I am the chief investigator of the SuPPORT 4 All project; developing a support bra for women undergoing breast irradiation following a diagnosis of breast cancer. I have completed research investigating burnout and resilience in the cancer workforce and developed an intraprenurial pedagogy (through the 2INSPIRE project) to enhance the development of capabilities for service improvement. I am currently supervising 5 doctoral research students (3 projects are linked to breast cancer and two are workforce development studies).

Let me introduce you to the rest of the team:

keeley-rosbottom

Keeley Rosbottom MSc, BSc(Hons), PG(Cert)

Keeley is a Senior Lecturer in Radiotherapy and Oncology and undertaking a PhD, her areas of research interest include 3D Stereophotogrammetry as a tool for evaluating the accuracy and reproducibility of new radiotherapy immobilisation devices, and methods to evaluate patient comfort and dignity within radiotherapy.

cath-holborn

Cath Holborn MSc, BSc (Hons), PG (Cert).

Cath is a Senior Lecturer in Radiotherapy & Oncology and also Course Leader for the MSc Prostate Cancer Care, at Sheffield Hallam University. Cath’s primary area of interest is the management of prostate cancer and she has a particular interest in the lived experiences of those affected by the disease and the care they have received. Other areas of interest include the role of education, particularly in the post-registration and advanced/specialist practice setting, for individuals working in this field. Cath has recently undertaken a project on behalf of Prostate Cancer UK, exploring the impact of CPD (Continuing Professional Development) and CME (Continuous Medical Education) on patient care and patient reported outcomes.

laura-pattinson

Laura Pattinson MSc, BSc, PG(Cert)

Laura is a senior lecturer in Radiotherapy and Oncology and course leader for the BSc in Radiotherapy and Oncology at Sheffield Hallam. Laura’s areas of interest are in public health and the role of AHPs. Specifically Laura has had involvement in projects on the impact of lifestyle choices on chronic disease, the role of the Higher Education Institutions (HEI) in the delivery of public health messages, barriers and facilitators to the delivery of public health messages within radiotherapy and the future AHP workforce, smoking cessation strategies in radiotherapy practice and the impact on service users. A new area of interest Laura is developing (through her PhD) is the experience of service users with severe mental health conditions during diagnosis and treatment for cancer.

gemma-burke

Gemma Burke MSc, BSc(Hons), PG (Cert).

Gemma is a senior lecturer and the course leader for the PG Diploma (pre-registration) course in Radiotherapy and Oncology at Sheffield Hallam. Gemma’s research interests are Brachytherapy, specifically technical developments, patient care and the management of long-term side effects, and the management of radiotherapy skin reactions, click here for the Society and College of Radiographers guidelines on skin care during radiotherapy for health professionals (Gemma supported the development of these through a systematic review of the available evidence).

Coming next…

The next blog in this series will be available next month and is titled “Breast lymphoedema; why we need more research on this side effect of breast cancer treatment”. You can subscribe to our blog below to make sure you don’t miss out on any future posts. Watch out for our guest blog from Dr David Bottomley from the Leeds Cancer Centre on current developments in prostate cancer.

If you are a health professional or a healthcare student please also look out for our free research seminar series. If you are local to Sheffield feel free to join us in person, seminars run on the first Friday of every month (except where there are Bank Holidays) and take place in the Robert Winston Building at Sheffield Hallam University. We meet at 8.30am for coffee and cake with the seminars starting at 9am (sessions finish at 10am). Attendance is free but you must register to attend as places are limited, details of how to register can be found here. If you are remote to Sheffield look out for the recording of these seminars, the link will be posted here on the blog. Our first seminar in October will be delivered by Mark Collins and Amy Taylor who will present the rationale for their doctoral research and what it is like to be a doctoral student and the career opportunities it offers.

You can also join our free webinars, look out for these they will also be advertised here on the blog along with our ‘Hot Topics podcasts’ on cancer related research.

  1. UK CR. Cancer Survival Statistics 2015 [Available from: http://www.cancerresearchuk.org/cancer-info/cancerstats/survival/.
  2. UK CR. Beating Cancer Sooner Our Strategy Highlights. 2014.
  3. (NCRI). NCRI. CTRad: National leadership in radiotherapy research. . 2014.

Getting Started with Research: The Research Process.

If you are new to research I would always recommend undertaking some study in research methods first to gain insight into the stages of development of a research proposal and to understand the ethical, clinical and research governance regulations that exist to ensure the conduct of health research follows good practice and to ensure the safety of patients.

Most universities will run research methods training programmes as part of undergraduate or postgraduate courses that are a good starting point for learning the basics of research methods and research governance. You can search your local university web pages for research methods training programmes. Health Education England and the National Institute for Health Research also have research training opportunities for health professionals that are worth considering. There is also the e-learning for healthcare training programme for those working in the NHS and new to research. In addition, the UK Health Research Agency also runs training courses on ethics and governance processes for researchers, click here to find a relevant course for you.

As a novice researcher it is always worth referring to the research process when starting a new research project. Click here for a handy reminder of the research process, hover your cursor over the numbered bullets for each stage of the process for more detailed information on each stage of the process.

 

Research Webinar Series

If you work in healthcare you maybe interested in the Journal of Radiotherapy in Practice and Sheffield Hallam webinar series. This is a free webinar series offered through the Sheffield Hallam Radiotherapy and Oncology CPD Anywhere provision, all you need to do is register for the event to obtain the link to the webinar room and access to the journal article that accompanies the webinar.

The next webinar is on Wednesday 7th September at 18.00 (GMT, London, Lisbon) run by Neill Roberts from the St James’ Institute for Oncology (Leeds cancer Centre), title of the presentation is A development framework for the consultant radiographer in oncology: the Leeds experience. For more information and joining instructions please click on the link below.
http://www.slideshare.net/HeidiProbst/slideshelf

Let’s talk about tattoos

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When someone mentions tattoos what is the first thing that comes into your mind?

Do you think of a heavily tattooed man or woman? Your own tattoo perhaps? As a Therapeutic radiographer the word tattoo makes me think of radiation treatment positioning. During the planning for radiotherapy, Radiation Therapists/Therapeutic Radiographers will mark a patient’s skin to indicate a reference point for positioning the patient each day underneath the linear accelerator. More often than not these reference points are made into a permanent mark, a tattoo, using sterile Indian ink and a sterile needle. These permanent tattoos act as a reference point for each radiotherapy session helping to align the patient with the treatment machine with the aim of increasing treatment accuracy.

Radiotherapy tattoos are small; they are less than 2mm in diameter. Images available to view online at CRUK website and here on this personal blog show the actual size. So what’s the fuss? They’re tiny right? So why write a blog about them?

Well here is the problem. While they are small they are permanent, and act as a permanent reminder for many patients of an experience and a time in their life they may want to forget. This quote from a blog by Andrea Hut really exemplifies what many women I’ve come across over the years as a Therapy radiographer express:

The tattoos themselves are just tiny bluish dots. They’re barely visible, but they are permanent. Nobody told me that. It’s as though they think you wont care because of all the other stuff you’re going through. I’m sorry, but I care about any permanent mark that’s being made on my body. Especially the ones I didn’t choose. Scar or tiny black dot.

The critical reason for using permanent tattoos for positioning radiotherapy is the belief they provide an accurate guide to positioning of the radiotherapy beams on a daily basis.

So how accurate are they? Set-up accuracy for breast irradiation is dependent on a range of factors including the use of immobilization devices such as breast tilt boards, how the patient’s arms are positioned (one arm up versus two arms up) and support cushions, as well as patient factors (such as breast size). Using tattoos for positioning can enable accuracy of radiotherapy field placement in the region of 2-6mm(1). Where partial breast irradiation is employed accuracy between 3-7mm(2,3) have been reported. Accuracy using semi-permanent skin marks alone have been shown to be comparable to accuracy achievable using tattoos(4) where average systematic errors were 3mm for those patients with tattoos and 3.3mm for those with semi-permanent skin marks. The disadvantage of using semi-permanent marks is the need for the patient to take care when bathing to avoid the marks disappearing; this can cause patient anxiety, and could necessitate a re-planning of the radiotherapy, potentially delaying treatment.

It’s all about choice.

Body tattoos have been a part of human culture for a long time. Initially, tattoos represented a specific aspect of culture either identifying the bearer to a religion, strength or social status. In European culture in the 20th century body tattoos have been associated with groups such as sailors, and bikers and with the advent of the punk scene they became an expression of antithesis to mainstream culture. The 21st century has seen a rapid rise in body tattooing; with tattoos no longer seen as solely representing a tie to any specific sub-culture or group. Wohlrab, Stahl, and Kappeler(5) identify 9 different motivational reasons for obtaining a body tattoo:

  1. Beauty, art or fashion,
  2. Expression of individuality
  3. Personal narrative
  4. Physical endurance
  5. Group affiliations and commitment
  6. Resistance
  7. Spirituality and cultural tradition
  8. Addiction and
  9. Sexual motivation

Except when the individual obtains a tattoo while under the influence of alcohol or drugs, the majority of these motivations above represent a personal choice, a reasoned decision to gain a permanent embellishment to their body.

Take Eve for example, here is her tattoo and her motivation for getting it.

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“My tattoo is two magpies representing the old saying ‘one for sorrow, two for joy’. The saying is based on the fact that magpies mate for life so when you see two together you know they are happy and in love. Whenever you see one magpie you are meant to salute the bird so that you respect his loss as he no longer has a mate, and I have been doing this since I was little. By having the tattoo I will see them everyday and everyday ‘hopefully’ I will have joy in my life.” Eve

Eve tells us about her decision to get a tattoo:

How long were you thinking about getting a tattoo? 

Eve: “I thought about it for a couple of years as I had to wait until I was 18 years old before I could get it done.”

What made you want something so permanent?

Eve: “I have never been worried about it being permanent, as it reflects my personality and is something I believe in.”

Were you worried about what people would think? If not why not?

Eve: “ I have heard of people talking about people with tattoos as being wayward, however, I do not believe that. Most people now a days are not as judgmental, as more and more people are getting inked.”

Do you think you will ever regret it?

Eve: “No never, it will always reflect that period in my life.”

Eve’s motivation for getting a tattoo is clear, it represents something of meaning to her, something that she see’s will bring her joy and is a part of her personality. Eve’s is just one story, but most motivations for getting a body tattoo reflect a positive connection between the individual and the permanent image they choose. Patients that are tattooed during the radiotherapy planning process have less choice. The permanent dots, although small are unlikely to add or improve their appearance, and for many simply may act as a reminder of cancer treatment. For some cancer survivors they are an unwelcome reminder of a difficult time in their lives. These quotes below from our most recent research highlight the mixed emotions patients with breast cancer experience during the planning of radiotherapy and coming to terms with the notion of having permanent tattoos. (All the names have been changed to protect the individuals’ identity). Emotions and experiences are diverse and serve to highlight the need for healthcare practitioners to understand the individual patient journey:

Gill

“I’ve written a couple of things down there that kind of go back to something that Maryanne said about choice, you know the tattoos and not feeling like you have a choice.”

Sarah

“…when they put the tattoos on so it was all in the same incident, I did feel suddenly there that there was something permanent happening because you know they say these tattoos are permanent, up to then it felt like you know we’ll cut this out, I’ll get better, it’ll go away and then they went no you’re going to be permanently tattooed, I felt like you know you’re going to make me tattooed and marked ………. I did, I felt a real sense of loss at that point and I thought no this is not something I’m going to get through this is something that I’m stuck with and it’s silly really because it’s just tattoos and I’ve got used to the tattoos and I don’t notice them.”

Miranda

“some of these points to an outsider may sound small, like the tattoos, I wasn’t happy with those either, but because you’ve lost you know your sense of self and your confidence it just, you know every little thing even though it’s small like using different cream or something is a really big issue.”

 

The picture is clearly mixed, while there are negative experiences associated with patients having tattoos like those above. The complete picture includes many positive attitudes towards radiotherapy tattoos:

“small, discreet, only a few in number, quite freckley skin anyway, don’t mind needles, nothing to worry about compared to chemo, needed to keep me alive so what’s the problem?”

Some women even choose to change their radiotherapy tattoos into works of art on completion of treatment as this Guardian article highlights. It’s clearly all about choice.

So what are the choices?

Well let’s not throw the baby out with the bath water just yet. Permanent tattoos have been used for many years to mark the placement of radiotherapy beams for a range of cancer sites. For those women that don’t mind having tattoos they remain, at the moment, possibly the best alternative and an option patients can choose. It might be worth Therapy Radiographers/Radiation Therapists considering where they position the tattoos and the number used. Where possible, if tattoos can be positioned where they are less likely to be visible when the woman is dressed in her normal clothes, it may make them more acceptable to some women. In addition, for standard whole breast radiotherapy (where only the breast or chest wall is treated and not the lymph nodes in the neck) what is the optimum number of positioning tattoos that are needed to retain accuracy? There is no research evidence for us to use, and nothing to indicate that five tattoos are better than three for example; so will three suffice to improve the cosmetic outcome?

For those women that don’t want to have a tattoo the use of semi-permanent pen marks is often used with special dressings (that act as a clear skin) to avoid the marks rubbing off onto clothes and to maintain longevity. Semi-permanent marks come with restrictions on washing but can be as accurate as permanent tattoos if application is maintained carefully(4). Some centres have access to 3D surface imaging that can complement patient alignment and enhance accuracy of set-up; unfortunately not all radiotherapy centres have such a facility.

A recent trial has tested the viability of using ultra-violet (UV) ink for permanent tattoos. This option means that the tattoos are not visible in normal daylight conditions and only visible under UV lights that are applied in the treatment room. The use of UV tattoos still requires a needle prick to get the ultra violet ink underneath the skin. However, it may offer a solution in the future, and we await the published results of this recent trial to see the full benefit in terms of accuracy for treatment and acceptability to patients. The use of UV ink for tattooing is a fairly new development and we currently don’t know if there are any long-term risks associated with using UV ink for tattoos. It does also mean that while the radiotherapy tattoos would remain invisible during normal lighting conditions under any ultra violet lighting such as those sometimes used in clubs and restaurants the tattoos maybe visible.

Another future solution that could provide patients with an alternative to permanent tattoos (either indian ink or UV tattoos) is the use of a well fitting immobilisation device where the set up marks are incorporated within the device. This approach is used for radiotherapy application to areas of the head and neck where an immobilisation mask is fitted to the patient and marks placed on the mask rather than on the patient. We are currently developing a support bra for women undergoing breast radiotherapy that may allow for marks to be incorporated within the bra, avoiding the need for skin marks or tattoos on the patient; details of the SuPPORT 4 All study can be found here.

Is there sufficient choice for patients? What’s your view?

References

  1. Probst Heidi, Bragg, Christopher; Dodwell, David; Green, David; Hart, John. A systematic review of methods to immobilise breast tissue during adjuvant breast irradiation. Radiography. 2014;20(1):70-81.
  2. Gierga DP, Riboldi M, Turcotte JC, Sharp GC, Jiang SB, Taghian AG, et al. Comparison of Target Registration Errors for Multiple Image-Guided Techniques in Accelerated Partial Breast Irradiation. International Journal of Radiation Oncology*Biology*Physics. 2008;70(4):1239-46.
  3. Yue NJ, Goyal S, Zhou J, Khan AJ, Haffty BG. Intrafractional Target Motions and Uncertainties of Treatment Setup Reference Systems in Accelerated Partial Breast Irradiation. International Journal of Radiation Oncology*Biology*Physics. 2011;79(5):1549-56.
  4. Probst H, Dodwell, D, Gray, J.C, Holmes, M. An evaluation of the accuracy of semi-permanent skin marks for breast cancer irradiation. Radiography. 2006;12(3):186-8.
  5. Wohlrab S, Stahl J, Kappeler PM. Modifying the body: Motivations for getting tattooed and pierced. Body Image. 2007;4(1):87-95.