{"entity":{"id":"idea-pu-tattoo-free-set-up","kind":"idea","name":"Radiotherapy set-up without permanent ink tattoos, using surface guidance or invisible ink","aka":[],"tldr":"Most people having breast radiotherapy are given small permanent ink dots to line them up on the couch. In a United Kingdom survey of 204 people afterwards, half rated the impact of those tattoos as negative, and surface cameras or ultraviolet ink line people up as accurately without leaving a visible mark.","summary":"The harm being removed. Radiotherapy alignment tattoos are permanent dots of Indian ink about 2 millimetres across. In a survey distributed by Breast Cancer Now to people who had had breast radiotherapy, all 204 respondents had them and 95 per cent could still see the midline dot. Twenty-seven per cent described them as a constant negative reminder, 14 per cent said they affected clothing choices and 11 per cent said they hated them; overall impact was scored negative for 51 per cent, neutral for 43 and positive for 6. The authors call for alternatives that are accessible for people of all skin colours.\n\nThe alternatives. A systematic review of 13 studies found that surface-guided set-up for free-breathing breast radiotherapy was at least as accurate and reproducible as tattoos and lasers, with consistently smaller residual errors and better efficiency, and could reduce the number of routine imaging exposures. Where surface guidance is not available, a randomised trial of 34 women found ultraviolet-ink tattoos, invisible in daylight, gave set-up errors no different from dark ink with almost no effect on set-up time.\n\nThe question is not whether tattoo-free set-up can be done, which the review answers, but whether departments that already have surface cameras for breath-hold have switched. No survey OnCo found measures that.","asOf":"2026-10-20","links":[{"label":"Wickers et al., Permanent Indian ink tattoos for breast cancer radiotherapy: a United Kingdom study of the emotional impact on patients following radiotherapy (Radiography 2024)","url":"https://doi.org/10.1016/j.radi.2024.08.004"},{"label":"Naidoo and Leech, Feasibility of surface guided radiotherapy for patient positioning in breast radiotherapy versus conventional tattoo-based setups: a systematic review (Technical Innovations and Patient Support in Radiation Oncology 2022)","url":"https://doi.org/10.1016/j.tipsro.2022.03.001"},{"label":"Lim et al., A prospective randomized controlled trial to compare the use of conventional dark-ink tattoo and ultraviolet-ink tattoo for patients undergoing breast radiation therapy (Practical Radiation Oncology 2021)","url":"https://doi.org/10.1016/j.prro.2021.08.001"}],"tags":["protocol-upgrade","upgrade:promising","evidence:moderate","precision","breast"],"related":["idea-pu-open-face-masks","idea-pu-breath-hold-left-breast-routine","idea-pu-washing-and-deodorant-during-radiotherapy"],"cancers":["breast-cancer"],"sections":["radiation"],"technologies":["surface-guided-radiotherapy","patient-positioning-surface-guidance-systems"],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":[],"trials":[],"people":[],"bottlenecks":["b-survivorship","b-patient-voice"],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"hypothesis":"In departments with surface guidance, stopping permanent dark-ink tattoos for breast radiotherapy does not increase set-up error or imaging dose and reduces the proportion of patients reporting a negative impact of their marks at one year from about half to under one in ten.","rationale":"The harm is measured in a UK patient survey, the accuracy of the alternative is supported by a systematic review and a small randomised trial, and the surface cameras are already installed in many departments for breath-hold.","test":"A stepped-wedge implementation across departments with surface guidance, measuring set-up error on verification imaging, imaging frequency and patient-reported impact of marks at one year before and after the switch.","maturity":"early-clinical","actor":"clinic","cost":"small","horizonYears":3},"route":"/ideas/idea-pu-tattoo-free-set-up/","neighbours":{"idea":[{"id":"idea-pu-breath-hold-left-breast-routine","kind":"idea","name":"Deep-breath-hold radiotherapy for every suitable person with left-sided breast cancer","route":"/ideas/idea-pu-breath-hold-left-breast-routine/"},{"id":"idea-pu-open-face-masks","kind":"idea","name":"Open-face immobilisation masks for brain and head and neck radiotherapy where surface guidance can check the position","route":"/ideas/idea-pu-open-face-masks/"},{"id":"idea-pu-washing-and-deodorant-during-radiotherapy","kind":"idea","name":"Tell people having radiotherapy that they can wash the treated skin and use deodorant","route":"/ideas/idea-pu-washing-and-deodorant-during-radiotherapy/"}],"cancer":[{"id":"breast-cancer","kind":"cancer","name":"Breast cancer (all types)","route":"/cancers/breast-cancer/"}],"section":[{"id":"radiation","kind":"section","name":"Radiation Therapy","route":"/fronts/radiation/"}],"technology":[{"id":"patient-positioning-surface-guidance-systems","kind":"technology","name":"Patient positioning and surface guidance systems (AlignRT, Catalyst, ExacTrac Dynamic)","route":"/technologies/patient-positioning-surface-guidance-systems/"},{"id":"surface-guided-radiotherapy","kind":"technology","name":"Surface-guided radiotherapy (SGRT)","route":"/technologies/surface-guided-radiotherapy/"}],"bottleneck":[{"id":"b-patient-voice","kind":"bottleneck","name":"Patients lack understanding, navigation and agency","route":"/bottlenecks/b-patient-voice/"},{"id":"b-survivorship","kind":"bottleneck","name":"Survivorship and late effects are neglected","route":"/bottlenecks/b-survivorship/"}]}}