Geographical inequalities in cancer care, often termed the ‘postcode lottery’, have long affected patient access and outcomes across the UK. In Wales, radiotherapy services are concentrated within three specialist centres, meaning many patients must travel considerable distances for treatment, potentially extending the time between key steps in the pathway. This study examined whether distance from the South-West Wales Cancer Centre (SWWCC) influenced access to, or timing of, breast cancer radiotherapy and explored whether and how service developments have mitigated geographic inequity.

A retrospective cohort analysis was performed on 2,286 breast cancer patients treated at SWWCC between January 2018 and December 2023. Patients were grouped by travel time (≤60 min vs >60 min), transport type and treatment prescription. Statistical analyses, including Fisher’s exact and Kruskal-Wallis tests, assessed associations between travel distance, transport modality and treatment timing.

31% of patients lived more than 60 minutes away and were significantly more likely to require ambulance transport (16.8% vs 4.4%) or hostel accommodation (11.3% vs 0%) (p < .001). There was no statistically significant difference in time from booking to first treatment fraction (p = .676). Mean CT-to-plan-check intervals fell from 27 to <10 days, and the wait between booking and start of treatment fell from ∼60 to 25 days, reflecting efficiency gains linked to capacity release from adoption of hypofractionated regimens.

Treatment timeliness is equitable across South-West Wales. Five-fraction regimens have alleviated many postcode-related disparities, though differences in transport dependence and access to supportive services remain areas for improvement.

Radiotherapy (RT) and immune checkpoint inhibitors (ICIs) have each transformed the treatment of malignant solid tumors (STs). Beyond direct tumor killing, RT remodels the tumor microenvironment (TME), promotes antigen release, and enhances immune activation. ICIs targeting cytotoxic T-lymphocyte antigen 4 (CTLA-4), programmed cell death protein 1 (PD-1), and programmed cell death ligand 1 (PD-L1) restore antitumor immunity by reversing T cell exhaustion. Increasing evidence indicates that RT can synergize with ICIs through mechanisms such as the abscopal effect, immunogenic cell death (ICD), and activation of the cyclic guanosine monophosphate–adenosine monophosphate (cGMP–AMP) synthase–stimulator of interferon genes (cGAS–STING) pathway.

This review summarizes current radiobiological, immunological, and clinical evidence regarding the synergistic effects of RT and ICIs in malignant STs, with a focus on underlying mechanisms, recent clinical advances, and translational challenges.

RT can enhance tumor immunogenicity, promote immune priming, and reshape the TME to improve the efficacy of ICIs. Synergy between RT and ICIs is associated with ICD induction, cGAS‒STING activation, enhanced systemic antitumor immunity, and modulation of immune cell infiltration and checkpoint signaling. Clinical studies across multiple STs have shown encouraging efficacy and manageable safety, although outcomes vary according to tumor type, disease stage, radiation schedule, and patient selection.

RT combined with ICIs is a promising therapeutic strategy for malignant STs. Further optimization of treatment regimens and biomarker-guided patient selection will be essential to maximize clinical benefit and enable more precise combination therapies.

This study focuses on early recognition of carotid blowout syndrome type 1 (threatened artery) and the results of integrity restoration of the surrounding tissue by a pectoralis major myofascial flap.

This retrospective study included all patients in the period 2010–2020 with carotid blowout syndrome type 1 of the common or internal carotid artery, treated by pectoralis major myofascial flap.

Fifteen patients with carotid blowout syndrome type 1 were included, all but one after previous radiotherapy with a total dose up to 136 Gray (range 46–136). Median time from diagnosis till treatment was 1 day. None of the patients progressed to actual bleeding (type 2 or 3).

Carotid blowout syndrome type 1 should be early recognised and treated by insertion of a pectoralis major myofascial flap that protects the common or internal carotid artery and might prevent progression to a potentially fatal bleed. In our opinion, this policy should be part of the algorithmic approach of this complication.

High-risk cutaneous squamous cell carcinoma represents 3–5 per cent of all cutaneous squamous cell carcinomas but causes most disease-specific deaths. Head and neck tumours are often high risk. Recent phase-3 trials have challenged surgery plus or minus radiotherapy as standards of care. This review updates definitions and evidence on emerging treatments.

Narrative review.

High-risk cutaneous squamous cell carcinoma is defined by size greater than 2 cm, deep invasion, poor differentiation, perineural/lymphovascular invasion, nodal spread or immunosuppression. Surgery remains central, with adjuvant radiotherapy improving locoregional control. The KEYNOTE-630 trial of adjuvant pembrolizumab showed a non-significant recurrence-free survival gain (hazard ratio 0.76), with benefit in elderly and extracapsular extension subgroups. The C-POST trial established adjuvant cemiplimab as the first systemic therapy significantly improving disease-free survival (hazard ratio 0.32; 24-month disease-free survival 87 per cent vs 64 per cent). Emerging strategies include neoadjuvant programmed cell-death protein 1 blockade, circulating tumour DNA-guided monitoring and combinations.

Cemiplimab redefines the post-operative standard; pembrolizumab awaits confirmation. Future directions include earlier immunotherapy, biomarker validation and access expansion.

This study aims to compare the dosimetric accuracy between the enhanced leaf model (ELM) in Eclipse V18.0 and the traditional multileaf collimators (MLCs) modelling in Eclipse V16.1 for volumetric modulated arc therapy (VMAT) and stereotactic body radiotherapy (SBRT) treatments. The objective is to evaluate whether the ELM improves dose calculation accuracy and agreement with measurements in clinical practice.

A retrospective analysis of 30 patients was conducted, categorized into Head-and-Neck (H&N), pelvic and lung SBRT groups. Treatment plans were created using the Acuros XB algorithm in both Eclipse versions. Gamma index pass rates for 1%/1 mm, 2%/2 mm and 3%/3 mm criteria were calculated using portal dosimetry for patient-specific quality assurance. Validation of MLC modelling was performed using closed leaf fields, sweeping gap fields, and the Picket Fence (PF) test across 6MV, 10MV, 6FFF and 10FFF photon energies.

Eclipse V18.0 demonstrated statistically significant improvements (p < 0·05) in dosimetric accuracy and gamma index pass rates across all photon energies and test conditions. In fully blocked fields, dose discrepancies reduced from 1.1% in V16.1 to 0.49% in V18 for 6MV. For the 6 mm sweeping gap test, discrepancies reduced from 1.19% to 0.31% for 6MV. The 1%/1mm gamma pass rates improved from 70% to 91.8% for H&N cases and from 82.4% to 87.3% for SBRT cases.

The ELM in Eclipse V18.0 significantly improves dose calculation accuracy and treatment deliverability, supporting its adoption in clinical practice for VMAT and SBRT to achieve better treatment accuracy and outcome.

Verification of the coincidence between the radiation and mechanical isocentres is an essential quality assurance (QA) procedure for linear accelerators (linacs) in radiotherapy. Ensuring this alignment is critical for accurate beam targeting, especially in conformal and intensity-modulated radiotherapy techniques.

This study aimed to evaluate the feasibility and effectiveness of using computed radiography (CR) with a bare imaging plate (IP) to assess the coincidence between radiation and mechanical isocentres, as a practical QA method, especially applicable in resource-limited settings.

The study was conducted on a Precise linac installed at Bac Ninh General Hospital No2. A Fujifilm IP and an FCR Prima T2 reader were used. Mechanical isocentre marking was performed via 1 monitor unit (MU) open-field exposure. Radiation isocentre verification involved multiple exposures with narrow rectangular fields at various gantry, collimator and couch angles. The latent images were processed using FCR View software to analyse displacement diameters between mechanical and radiation centres.

The CR system demonstrated sufficient sensitivity to detect exposures as low as 1 MU. Deviations (diameters) were 0·44–1·04 mm with expanded uncertainty U up to 0·44 mm (k = 2). All measurements were within the ±2 mm tolerance recommended by American Association of Physicists in Medicine (AAPM) for non-stereotactic systems.

The use of a bare IP in CR offers a reliable and low-cost alternative for verifying the coincidence of radiation and mechanical isocentres. This method is suitable for routine QA procedures in clinical environments lacking access to radiochromic film or electronic portal imaging devices.

To characterize treatment trends and facial weakness outcomes in vestibular schwannoma management using real-world data from a large US patient cohort.

This retrospective cohort analysis utilized the TriNetX US Collaborative Network. The study included 72,496 patients diagnosed with vestibular schwannoma, managed with observation, stereotactic radiosurgery or surgical treatments. Main outcome measures were demographic profiles, treatment modality utilization, facial weakness incidence and historical (2022–2025) and predicted (2025–2026) treatment trends.

It showed a slight female predominance (54.35 per cent) and underrepresentation of Black and Asian patients. Observation was most common (87.6 per cent), followed by surgery (65.3 per cent) and stereotactic radiosurgery (34.7 per cent). Facial weakness rates: 4.7 per cent (observation), 9.1 per cent (stereotactic radiosurgery), 24.4 per cent (surgery). Combined treatments had higher facial weakness rates. Stereotactic radiosurgery use was stable; translabyrinthine surgery declined; posterior fossa approaches increased.

This comprehensive analysis highlights varying facial weakness risks across treatment modalities, disparities in the treatments and evolving treatment preferences.

The aim of this study was to identify potential risk factors for acute and late genitourinary toxicities and to determine, using a logistic regression model, which of these factors are also significant and robust predictors of these toxicities.

We conducted a retrospective study by analysing the patient records and their treatment plans from 2013 to 2021. In total, a cohort of 46 patients with clinically staged cT1c-T4N0-1M0 prostate adenocarcinoma was treated with three-dimensional conformal radiotherapy (3D-CRT) with doses ranging from 66 to 80 Gy. Post-radiotherapy genitourinary toxicities were classified and graded according to the Common Terminology Criteria for Adverse Events (CTCAE v4.0).

Median follow-up was 57·5 months (range: 39 – 88 months). In univariable analysis, patient age (p = 0·040), the prostate volume (p = 0·0423), the clinical prostate volume irradiated at the prescribed dose (p = 0·029) and the volume of the bladder receiving doses varying from 60 to 70 Gy were correlated with acute GU toxicities. Arterial hypertension (p = 0·022), some pre-existing urinary symptoms, a history of catheterisation (p = 0·044) and acute genitourinary toxicity (p = 0.009) were linked to late genitourinary toxicities. The logistic regression model found that the prostate volume (p = 0·0423) and the clinical prostate volume irradiated at the prescribed dose (p = 0·029) were predictive of acute GU toxicity. Hypertension (p = 0·039) and acute toxicities were predictive of late GU toxicity.

The results of our study showed that it is essential to identify patients at risk of toxicities from the start of radiotherapy and to offer more proactive monitoring and management.

For any patient’s cancer journey, effective communication and helpful information are key to staying informed and reducing anxiety; for radiotherapy, ideally before treatment commencement. This paper details the initial design and service evaluation of a virtual tour (VT) aimed at familiarising patients with the department before treatment starts.

Created by local digital science students, with input from hospital Patient Public Involvement groups, patients were recruited (after their initial planning visit) into non-VT and VT groups; the latter viewing the VT before their first treatment. Both groups completed identical online surveys with Likert-style questions and free-text entry to assess knowledge and understanding.

Twenty-three completed survey responses were received: 9 and 14 from the non-VT and VT groups, respectively.

• • 66.7% of the non-VT group felt anxious attending the department for the first time; compared with 28.6% in the VT group. Key comments included ‘not now that I’ve seen the video’

• • 92.9% of the VT group understood the queue calling and changing room systems compared with 55.6% in the non-VT group.

• • 85.7% of the VT group knew what to expect in the treatment room, compared to 33.3% in the non-VT group. Key comments included ‘the video helped’.

Other comments included ‘excellent idea’ and ‘alleviates the concerns about where to go and what to expect ahead of that first visit’.

The implementation of the VT has proved beneficial to patients, providing key information prior to treatment start, alleviating concerns and resulting in improved patient experience without the need for an extra visit.

Prolonged overall treatment time (OTT) in radiotherapy (RT) for head and neck cancer (HNC), particularly beyond 49 days, has been linked to poorer tumour control and survival, primarily due to accelerated tumour repopulation. Identifying modifiable factors contributing to treatment delays may help improve outcomes. This study aimed to evaluate the association between pre-treatment clinical, nutritional and inflammatory factors and prolonged OTT.

We retrospectively analysed patients with non-metastatic HNC treated with definitive or postoperative RT (with or without chemotherapy) between 2020 and 2022. Pre-treatment factors included Eastern Cooperative Oncology Group (ECOG) performance status, tumour stage, treatment modality, body mass index (BMI), weight loss, sarcopenia (via C3 computed tomography imaging), neutrophil-to-lymphocyte ratio (NLR) and absolute lymphocyte count. Logistic regression was used to identify predictors of prolonged OTT (> 49 days).

Among 465 patients, 287 (61·7%) experienced prolonged OTT. Multivariable analysis identified ECOG status (OR 1·42, p = 0·004), significant weight loss > 5% (OR 1·26, p = 0·036), concurrent chemotherapy (OR 1·96, p = 0·005), NLR (OR 1·03, p = 0·041) and sarcopenia (OR 1·18, p = 0·042) as independent predictors. Patient-related delays accounted for 53·3% of OTT prolongation, while public holidays contributed to 42·5%.

Several modifiable pre-treatment factors—including poor performance status, pre-treatment weight loss, sarcopenia and systemic inflammation—were independently associated with OTT prolongation. These findings provide evidence to support early, patient-tailored interventions such as prehabilitation and intensive nutritional counselling before and during RT. In addition, system-level strategies, including staffing adjustments and compensatory scheduling during public holidays, may further reduce avoidable treatment delays and enhance care delivery.

Teaching volumetric modulated arc therapy (VMAT) treatment planning to therapeutic radiography students faces challenges, including time constraints and resource limitations. Gamification, an active learning strategy incorporating game-based elements, may enhance engagement and understanding of VMAT treatment planning.

A VMAT treatment planning session was implemented for 15 second-year undergraduate and postgraduate therapeutic radiography students using gamification. Participants were tasked with optimising a VMAT plan for a palliative prostate cancer patient using Eclipse treatment planning software. Students completed pre- and post-session questionnaires assessing perceived understanding and enjoyment. Plans were evaluated against clinical goals, and a leaderboard was used to rank top performers. Thematic analysis was applied to qualitative feedback.

About 86·7% of participants initially reported a limited understanding of VMAT planning structures. Post-session, all participants reported improved perceived understanding, with 93·3% finding the session beneficial and recommending its inclusion in the programme. While 66·6% enjoyed the gamified approach, technical issues limited individual optimisation time. Qualitative feedback highlighted increased confidence and engagement despite challenges.

Gamification enhanced student-reported understanding, enjoyment and engagement in VMAT planning. While technical issues affected session efficiency, feedback supports the integration of gamification in treatment planning sessions but should not be overused as its usefulness can wear off.

Squamous cell carcinoma of the external auditory canal is rare, with bilateral cases even rarer. We report the management of a patient with bilateral external auditory canal squamous cell carcinoma related to radiotherapy and immunosuppression.

A 47-year-old woman with a history of radiotherapy 14 years prior and renal transplantation 6 years prior presented with bilateral external auditory canal squamous cell carcinoma. Squamous cell carcinoma was excised with a purely surgical approach. The two operations included a tympanic membrane graft to preserve hearing on the left side. The patient remains disease-free six months post-op. She uses a bone-conduction hearing aid to good effect on the right side and has mild hearing loss on the left. The operative areas have healed well.

The patient’s previous radiotherapy and immunosuppression may have contributed to her bilateral external auditory canal squamous cell carcinoma. Preventative positron emission tomography scans have the potential to identify second malignancies early, allowing more conservative treatment plans.

Optimal radiotherapy technique selection for left-sided breast cancer remains challenging. This study compared volumetric-modulated arc therapy (VMAT), VMAT+IMRT (VMAT+IMRT) and IMRT+VMAT (IMRT+VMAT) using an innovative integrated scoring system and risk factor (RF) assessment.

Retrospectively analysed 41 patients with left-sided breast cancer. Treatment plans were evaluated using an integrated scoring system considering tumour coverage and organs at risk (OARs) sparing. RF analysis assessed potential adverse effects on the heart and lungs. Correlation analysis explored relationships between integrated scores and risk factors.

VMAT showed the best overall integrated score (1·0931 ± 0·1707), followed by IMRT+VMAT (1·2011 ± 0·2440) and VMAT+IMRT (1·2264 ± 0·2499). VMAT had the highest percentage of Excellent OAR plans (14·6%), while VMAT+IMRT and IMRT+VMAT showed better PTV coverage (53·7% and 51·2% Excellent, respectively). RF analysis revealed: VMAT (heart RF: 0·341, lung RF: 0·671), VMAT+IMRT (heart RF: 0·294, lung RF: 0·750) and IMRT+VMAT (heart RF: 0·533, lung RF: 0·546). Correlation analysis showed strong positive correlations between integrated scores and lung RF for VMAT (r = 0·671) and VMAT+IMRT (r = 0·750), with IMRT+VMAT showing moderate correlations for lung (r = 0·546) and heart (r = 0·533) RFs.

VMAT demonstrated the best balance between PTV coverage and OAR sparing, hybrid techniques improved target coverage but increased risk to OAR. The RF analysis highlighted varying impacts on heart and lung across techniques. This analysis provides valuable insights for technique selection, potentially improving treatment outcomes and reducing complications in left-sided breast cancer radiotherapy.

The technological development of radiotherapy equipment enabled the changing of the dose rate over time during irradiation. Further, techniques, such as volumetric modulated arc therapy (VMAT), are becoming more widespread. This study aimed to assess the changes in radiation isocenter and beam alignment with different dose rates and investigate the dose error during VMAT plan delivery.

The Winston–Lutz (WL) test and three-dimensional water phantom profiles were measured at different dose rates using 4, 6 and 10 MV and flattening filter-free (FFF) at 6 and 10 MV of X-rays. Furthermore, the change in alignment with the dose rate was reproduced through beam parameter adjustments, and the change in dose difference (DD) in the VMAT plan was assessed.

The WL test revealed a 0·1–0·3 mm radiation isocenter displacement with dose rate. Further, the beam profile measurement results demonstrated a 0·3 mm beam centre position displacement in both the lateral and gun-target directions caused by the change in dose rate. VMAT plan delivery with a beam whose centre position changed by 0·3 mm caused a 0·2–3% decrease in the previous DD rate.

The radiation isocenter and beam alignment changed based on the dose rate. Evaluating the change in beam alignment at multiple dose rates is recommended when performing irradiation with different dose rates.

Radiotherapy is a critical component of head and neck cancer (HNC) management that requires reliable patient immobilization. Using thermoplastic masks helps to ensure reproducible patient positioning during radiotherapy, thus reducing the risk of a geographical miss. However, the use of these masks can also induce anxiety and distress, which can negatively impact treatment adherence and quality of life outcomes.

The research was a quantitative cross-sectional study that determined the prevalence and severity of thermoplastic mask-induced anxiety and assessed the scope of coping mechanisms used by HNC patients. Data were collected using a structured questionnaire from recruited participants and analysed with the Statistical Package for Social Sciences software, version 26·0. Relevant clinical and treatment-related data were retrieved from patients’ hospital-based medical records. Descriptive and inferential statistical analyses such as chi-square tests and likelihood ratios were conducted, with p-values < 0·05 considered statistically significant.

In all, there were 145 HNC patients with a male to female ratio of 1·9:1 and a median age of 52·8 years (IQR 20·7), ranging from 18 to 82 years. There was a high prevalence of thermoplastic mask-induced anxiety both during mask moulding (93·8%) and radiation therapy sessions (94·5%). Most participants (95·2%) adopted coping mechanisms including distraction (58%) and visualization techniques (46%).

Even though there was a high level of awareness and utilization of coping mechanisms, the high prevalence of thermoplastic mask-induced anxiety highlights a critical aspect of HNC patient care that may be overlooked in resource-limited settings.

Before COVID-19, breast cancer patients in the UK typically received 15 radiotherapy (RT) fractions over three weeks. During the pandemic, adoption of a 5-fraction treatment prescription and more advanced treatment techniques like surface-guided RT, meant a change in the duration and number of hospital visits for patients accessing treatment. This work sought to understand how breast cancer patients’ time in the RT department has changed, between 2018 and 2023.

Appointments for CT simulation, mould room, and RT, from January 2018 to December 2023, were extracted from the Mosaiq® Oncology Management System. Appointments lasting between 5 minutes and 5 hours were analysed. Total visit time was calculated from check-in to completion on the quality checklist.

In total, 29,523 attendances were analysed over 6 years. Average time spent in the department decreased during the pandemic but has since increased 12·4% above pre-COVID-19 levels. Early morning and late afternoon appointments resulted in the shortest visits, with early afternoon appointments leading to the longest visits. On average, patients spend the longest in the department on a Monday, and the least amount of time on a Friday. Friday was the least common day to start a 15-fraction treatment, whereas Tuesday and Friday were equally uncommon for the 5-fraction regime.

During the COVID-19 pandemic, the number of visits a patient makes for breast cancer RT and related services dropped, and remained lower post-COVID-19, due to fewer treatment fractions being prescribed. Average time spent in the department initially decreased but has since increased beyond pre-COVID-19 levels.

Accurate delivery of radiotherapy to head, neck and brain cancer relies on the use of sophisticated immobilisation devices, usually using a restrictive thermoplastic mask. These masks can cause anxiety and can make treatment difficult for many patients. Open-face or maskless techniques are alternatives which can improve the patient experience. This systematic review aimed to compare the effectiveness of open-face (OF) masks and maskless surface guided radiotherapy (SGRT) with conventional masks.

Primary research papers from the last 10 years were gathered from Scopus, PUBMED, Web of Science and OVID databases. Quantitative data reporting interfractional set-up errors and intrafractional patient motion were extracted from included studies and subjected to descriptive statistical analysis. Additional qualitative data relating to patient tolerance were also extracted to inform discussion.

Ten studies were identified for inclusion. The data identified that OF masks can reproduce patient set-up with an accuracy of <2 mm and <1° and can restrict movement to <1 mm and 0·4°, while maskless SGRT can achieve accuracy to within 0·05 mm and 0·1°.

This review indicates comparable reduction of intrafractional motion between conventional masks, Open-Face masks and maskless SGRT techniques. More research is needed into the impact of maskless SGRT techniques on translational and rotational motions compared to traditional masks.

Palatine tonsil squamous cell carcinoma can be diagnosed with either tonsillectomy or tonsil biopsies. Biopsies are quicker to perform, less invasive, and provide potentially quicker results. Tonsillectomy minimises risk of missed pathology, but with greater associated morbidity. We compared whether tonsillectomy or biopsy affected surgical margin status at subsequent resection.

Our Business Intelligence Team provided a list of all patients with a primary tonsil squamous cell carcinoma who underwent surgery as their primary treatment modality in the last five years at University Hospitals Bristol. Demographic and treatment details were collected along with margin status following surgical resection.

Of the 31 patients that met inclusion criteria, 16 had biopsies and 15 had diagnostic tonsillectomies. The group who underwent tonsillectomy had a reduced risk of close or involved margins (< 5 mm) at subsequent curative-intent surgery (p < 0.001).

Our results suggest that tonsillectomy is associated with reduced likelihood of close or involved margins at subsequent curative-intent surgery. We hope this work can prompt larger multicentre comparisons between these two groups to investigate this relationship in more detail.

The presence of nodal disease at presentation of a head and neck mucosal-based squamous cell carcinoma has a significant impact upon outcomes.

This is a retrospective, ethics-approved study in which patients with squamous cell carcinoma of the larynx, oropharynx, hypopharynx and oral cavity were reviewed and compared with respect to nodal disease (N0 vs N1–N2 vs N3). Patient, disease and treatment parameters were evaluated with ultimate local control, regional control, cancer-specific survival and overall survival investigated.

In the cohort of 1265 patients, 764 presented with nodal disease (N3 = 60). The majority of the N3 group had oropharynx squamous cell carcinoma (52%) and experienced worse ultimate local control (63%; p < 0.001), regional control (67%; p < 0.001) and both squamous cell carcinoma and overall survival (log rank p < 0.001).

Patients presenting with N3 nodal disease had poor regional control, a lower cancer-specific survival and a worse overall survival compared to patients with lesser to no nodal disease.