Paediatric radiotherapy in the United Kingdom: an evolving subspecialty and a paradigm for integrated teamworking in oncology

Abstract

Many different malignancies occur in children, but overall, cancer in childhood is rare. Survival rates have improved appreciably and are higher compared with most adult tumour types. Treatment schedules evolve as a result of clinical trials and are typically complex and multi-modality, with radiotherapy an integral component of many. Risk stratification in paediatric oncology is increasingly refined, resulting in a more personalized use of radiation. Every available modality of radiation delivery: simple and advanced photon techniques, proton beam therapy, molecular radiotherapy, and brachytherapy, have their place in the treatment of children's cancers. Radiotherapy is rarely the sole treatment. As local therapy, it is often given before or after surgery, so the involvement of the surgeon is critically important, particularly when brachytherapy is used. Systemic treatment is the standard of care for most paediatric tumour types, concomitant administration of chemotherapy is typical, and immunotherapy has an increasing role. Delivery of radiotherapy is not done by clinical or radiation oncologists alone; play specialists and anaesthetists are required, together with mould room staff, to ensure compliance and immobilization. The support of clinical radiologists is needed to ensure the correct interpretation of imaging for target volume delineation. Physicists and dosimetrists ensure the optimal dose distribution, minimizing exposure of organs at risk. Paediatric oncology doctors, nurses, and a range of allied health professionals are needed for the holistic wrap-around care of the child and family. Radiographers are essential at every step of the way. With increasing complexity comes a need for greater centralization of services.

Keywords: brachytherapy; children’s cancer; complex photon techniques; multi-professional teamwork; paediatric radiotherapy; proton beam therapy.

Figure 1.

Commonly encountered long-term side effects following radiotherapy in children and young people.

Figure 2.

The health play specialist is involved in different ways throughout the child’s pathway through radiotherapy planning and treatment. Abbreviations: HPS = health play specialist; MDT = multidisciplinary team; RT = radiotherapy.

Figure 3.

The play room (A) is the epicentre of the health play specialists work, using models of equipment (B) to familiarize children with planned procedures, demonstrating the use of immobilization devices on toys (C) and making hand moulds (D) to let children experience the warmth and feel of thermoplastic before making a head shell, which can be decorated as the child chooses (E).

Figure 4.

The paediatric radiotherapy clinical nurse specialist is the child’s key worker and has many responsibilities. Abbreviations: CNS = clinical nurse specialist; CCNT = community children’s nursing team; PTC = principal treatment centre.