Exploring the Potential Psychological Benefits of Upright FLASH Radiotherapy

Radiotherapy techniques have constantly evolved since their earliest uses in the 1950s, gaining in precision and efficiency through the arrival of innovative new technology. The conditions in which radiotherapy treatments are delivered however, have changed very little in that time. It is still common practice for patients to lie on their backs, completely still for an extended time on consecutive days, for several weeks.

There has been a lot of focus on recognizing the impact that this can have on a person’s mental well-being and efforts have been made to improve methods of managing treatment-induced psychological disorders. Through the development of new treatment delivery methods and technological innovations, the norms of radiotherapy and the recognized triggers of patient anxiety, are being challenged.

Cancer treatment and psychological disorders

A recent study reported that around 21% of people with cancer show clinical levels of anxiety, which is over three times as much as the general public (Goerling et al, 2023).

Unfortunately, the psychological impact of a cancer diagnosis is not limited to anxiety alone. 68.8% of patients show depressive symptoms and 78.1% show signs of stress (Alagizy et al, 2020). Despite such a high number of patients experiencing these symptoms, only 15.5% report being on medications to manage their conditions and only 10% seek advice from a mental health professional (Cancer Research UK, 2018). Nixon et al (2018) found that 24% of patients being treated for head and neck cancer had their first radiation treatment session disrupted due to anxiety. The National Cancer Institute (2016) stresses that any delays or unplanned breaks in radiotherapy treatment can result in an increased risk of disease recurrence and contribute to inferior rates of survival without disease recurrence.

Person-centered care

Person-centered care is a model of care that focuses on the individual needs of a person, with the belief that by meeting these needs patients demonstrate better compliance and have improved treatment outcomes, reduced anxiety, and superior quality of life. The key areas in achieving this are planning, communication, respect and holistic care (Coulter and Oldham, 2016).

Upright radiotherapy allows for much better communication both verbal and non-verbal, between patient and their caregiver when compared to treatment in the supine orientation, simply because they remain face-to-face throughout the set-up process.

D’Agostino and Bylund (2014) found that non verbal communications such as eye contact, facial expressions and mutual gaze are a primary component in patient-centered communication variables and have been found to impact patient-centeredness, rapport, physician awareness of patients’ psychological distress, and both patient’s physical and cognitive functioning.

A person with experience of radiotherapy in the traditional supine position explains what greater eye contact would have meant for them: “Although I had an exemplary patient care team, eye contact ‘during’ my radiation was a ‘missing piece’ of human contact during a physically and emotionally stressful, challenging, frightening time of treatment.”

Keck, Hubner, and Buntzel (2023) make the very important point that, without face-to-face interactions between patients and their therapist, patients with a hearing impairment might not be able to give informed consent. In their study, only 28.3% of hearing-impaired patients understood all verbal instructions given to them and felt more uncomfortable asking for clarification. 76% of patients with a hearing impairment desired eye contact during conversations, treatment in an upright position would support this.

You in the driving seat

Patients often express a desire to have more control over their health and their treatments (Coulter and Oldham, 2016). An advantage of upright radiotherapy is the ease with which patients can set themselves up for treatment. Sophie Boisbouvier, a research radiographer with experience using the Leo Cancer Care’s upright patient positioning system shared these observations:

“In upright position, it’s difficult to say that radiation therapists (RTT) set up the patient. The patient can naturally set up him/herself on the chair and become an actor of his/her treatment. Obviously, RTT remains crucial to help them and verify the position but as it is a more natural position, it’s easier and quicker for a patient to set themselves up. During this setup time, patient and RTTs are physically close, at the same level and face to face, giving them an opportunity to discuss together and for the patient to be supported.“

By allowing a patient to set themselves up patients can feel some control over their treatment, and their own bodies and feel more empowered. Increased feelings of empowerment can reduce patient helplessness whilst simultaneously increasing self-advocacy, which in turn gives patients the confidence to ask questions and express their thoughts and feelings, thus increasing their satisfaction with their care and treatment (Salazar, L. 2018).

Boisbouvier’s research published in 2022 found that 94% of patients found it easy to get out of the upright patient positioning system compared to only 60% of patients saying the same about a supine treatment position. Increased difficulty getting out of a supine position requires more assistance from radiotherapy staff, therefore reducing patients’ feelings of empowerment. Data from this study showed patients had increased comfort, feelings of stability, and easier breathing in the upright position compared to supine and expressed a clear preference for this treatment position option.

Less time in hospital, more time for you

Hospital anxiety is not unusual in healthcare, especially amongst those who require frequent hospital visits, are exposed to unfamiliar environments and procedures and are experiencing disease stress (Mirani et al, 2019) all of which are commonly seen in the radiotherapy setting.

Radiotherapy is typically delivered over a number of sessions referred to as fractions. This process of dividing the total radiation dose into multiple sessions has long been the standard approach, aiming to maximize tumor damage while minimizing harm to surrounding tissues. The number of radiotherapy sessions often ranges between 5 and 40 sessions and each typically lasts 15 to 30 minutes. This need for daily hospital visits can lead to concerns regarding travel and parking, work disruptions, and financial repercussions, all of which can contribute to the anxiety surrounding a patient’s treatment.

“FLASH” radiotherapy was first brought into the spotlight by Vincent Favaudon’s research in 2014 (Favaudon et al, 2014), and challenges the need for fractionated treatments. FLASH is able to deliver treatment at an ultra-high dose rate, within less than 100 milliseconds (Schuler et al, 2022) over one or two treatments.
Pre-clinical studies have shown that while both FLASH and conventional radiotherapy treatments administered at equal doses achieve equivalent levels of tumor control, data suggests FLASH causes significantly less toxicity to the surrounding healthy tissue. Whilst FLASH as a treatment modality is still in development, evidence already supports the use of shorter fractionations in terms of patient throughput, workflow and patient preference without compromising on clinical outcomes.

Tomastis et al (2023) identified that despite an increase in the number of patients requiring radiotherapy over the last 10 years, there has been a reduction in patient throughput due to the introduction of more complex treatment delivery methods. This has caused patient waiting times to increase and there has been a greater burden on radiotherapy departments in terms of staffing and the cost-effective management of long waiting lists.

Forner et al (2021) discussed the increased psychosocial distress witnessed in patients who experienced increased waiting times during the COVID-19 pandemic. Patients themselves identified that their high levels of stress were associated with alterations to daily life, uncertain treatment timelines and fear of cancer progression.
Tomastis (2023) observed that the introduction of hypofractionation regimes successfully reduced patient overcrowding in a radiotherapy department, and increased departmental workflow and patient access to services. With FLASH radiotherapy reducing fractionation further to a single treatment it could be hypothesized that this will result in greater machine availability which could reduce patient waiting times further.

When asked how their daily radiotherapy treatment over a number of weeks impacted them, this patient said:

“Daily radiotherapy sessions over weeks impacted my life: physically, emotionally, exhaustingly. I would welcome a single treatment plan: physically, emotionally, energized… feeling less like a patient and more like a person. Quality of life matters: in and out of treatment”

This patient’s own views are reflected in the research collected by Lee et al (2024) which found that patients in an ultra-hypofractionation group showed better quality-of-life scores when compared to patients in a longer fractionation plan. With the promise of reduced side effects as well as less time absent from work, traveling to consecutive radiotherapy treatments as well as the financial burden of this increased travel, it is easy to see how FLASH radiotherapy could improve on a patient’s quality of life in a number of different areas.

FLASH radiotherapy not only reduces the number of treatments a patient is required to receive, but the treatment itself is ultra quick with treatment being delivered in less than 100 milliseconds. In comparison with increasingly complex treatment plans in conventional radiotherapy treatment the delivery time is closer to 4.8 minutes for IMRT treatment and 2.2 minutes for RapidArc (Oliver, 2009) however the patient is expected to remain still from the start of patient set-up, during imaging and treatment delivery, meaning that the overall time is closer to 20 minutes and in more complex cases even longer.

Upright & FLASH: Transforming Patient Experience

The simultaneous application of two innovative approaches to cancer treatment, Leo Cancer Care’s upright patient positioning and THERYQ’s FLASH radiotherapy delivery system has created a partnership that forms the foundation of the FLASHDEEP project. This project will see patients receive ultra-fast treatment in a single session in the upright position.

This project will significantly improve all the aforementioned patient experience gaps during radiotherapy. The “Upright FLASH” approach to treatment will contribute to the empowerment of patients from beginning to end of the single required session and will allow their treatment to be more patient-focused.
The very first FLASHDEEP system is set to be installed at Gustave Roussy in Villejuif, near Paris, France once regulatory approval for both components has been acquired.

Prof. Eric Deutsch, Head of Radiotherapy Department shared his thoughts on the benefits for patients of Upright FLASH radiotherapy treatment:
“FLASH radiation therapy in an upright position offers patients significant advantages, both physically and emotionally: it reduces side effects, minimizes the need for multiple hospital visits, and alleviates anxiety by providing a more comfortable treatment experience, ultimately improving the patient’s overall well-being and quality of life during their cancer journey.”

Please note: The Leo Cancer Care and Theryq solution, FLASHDEEP, is not yet commercially available and used for research purposes only.

Reference

Alagizy, H.A., et al. Anxiety, depression and perceived stress among breast cancer patients: single institute experience. Middle East Current Psychiatry. (2020) 27:29.

Boisbouvier, S., et al. Upright patient positioning for pelvic radiotherapy treatments. Technical Innovations and Patient Support in Radiation Oncology. 24: 124-130.

Cancer ResearchUK (2018) https://news.cancerresearchuk.org/2018/08/22/the-realities-of-cancer-mental-health-issues-and-changes-to-energy-levels-top-concerns-among-cancer-1/#:~:text=The%20new%20data%20reveals%20that,from%20a%20mental%20health%20professional.

Coulter, A., Oldham, J. Person-centred care: what is it and how do we get there? Future Healthcare Journal. 2016, 3(2):114-116. Doi: 10.7861/futurehosp.3-2-114

Favaudon, V., et al. Ultra high dose-rate FLASH irradiation increases the differential response between normal and tumor tissue in mice. Science Translational Medicine. 2014, 6(245), 245ra93-245ra93

Forner, D., et al. Psychosocial Distress in Adult Patients Awaiting Cancer Surgery during the COVID-19 Pandemic. Current Oncology. 2021, 28(3): 1867-1878. Doi: 10.3390/curroncol28030173

Goerling, U., et al. Prevalence and severity of anxiety in cancer patients: results from a multi-center cohort study in Germany. Journal of Cancer Research and Clinical Oncology. 2023, 149: 6371-6379

Guedes de Pinho, L., et al. Patient-Centred Acre for Patients with Depression or Anxiety Disorder: An Integrative Review. J. Pers. Med. 2021, 11(8), 776. Doi: 10.3390/jpm11080776

Lee, S. F., et al Randomised controlled trials on radiation dose fractionation in breast cancer: systematic review and meta-analysis with emphasis on side effects and cosmesis. British Medical Journal. 2024; 386. Doi: https://doi.org/10.1136/bmj-2023-079089

Mirani, S., et al. Frequency of Depression and Anxiety Symptoms in Surgical Hospitalized Patients. Cureus. 2019, 26;11(2):e:4141. doi: 10.7759/cureus.4141

National Cancer Institute. Missed Radiation Therapy Sessions Increase Risk of Cancer Recurrence. 2016. Available at: https://www.cancer.gov/news-events/cancer-currents-blog/2016/missed-radiation-therapy

NHS. Signs of an anxiety disorder. 2022. Available at: https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/feelings-and-symptoms/anxiety-disorder-signs/

Oliver, M., Ansbacher, W., Beckham, W.A. Comparing planning time, delivery time and plan quality for IMRT, RapidArc and tomotherapy. Journal of Applied Clinical Medical Physics. 2009, 10(4): 117-131. Doi:10.1120/jacmp.v10i4.3068

Salazar, L. The Effect of Patient Self-Advocacy on Patient Satisfaction: Exploring Self-Compassion as a Mediator. Communication Studies. 00(00): 1-16

Schüler, E., et al. Ultra‐high dose rate electron beams and the FLASH effect: From preclinical evidence to a new radiotherapy paradigm. Medical Physics. 2022, 49, 2082-2095

Gazis, N., et al. Simulation Dosimetry Studies for FLASH Radiation Therapy (RT) with Ultra-High Dose Rate (UHDR) Electron Beam. Quantum Beam Science. 2024, 8(2), 13-13

Tomatis, S., et al. Twenty Years of Advancements in a Radiotherapy Facility: Clinical Protocols, Technology, and Management. Current Oncology. 2023, 30(7): 7031-7042. Doi:10.3390/curroncol30070510