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Before radiotherapy starts you have a planning appointment, usually a CT scan. You lie in the exact treatment position, sometimes with a mask, mould or cushion, and keep very still. Small skin marks (permanent dots or temporary ink) may be made to line you up each day. Depending on the area, you may need a full or empty bladder, a dye injection, or breath-hold practice.
The NCI booklet (2021) describes the planning session for patients: the radiation oncologist and therapist define the treatment area while the patient lies very still for scans; small permanent tattoos or ink dots are placed to line the patient up daily; a body mould or, for the head and neck, a mask may be made. The ESTRO ACROP head and neck guideline (2017) gives the radiographer's procedure: identification and consent checked before scanning; diagnosis, prescription and scan margins known in advance to keep imaging dose as low as reasonably achievable; contrast screened for, kidney function checked and the patient observed for at least 15 minutes after; nodes and scars marked and bolus placed before scanning; the couch set so all immobilisation is in the field of view; orientation entered correctly; slice thickness of 3 mm or less; dose-length product recorded; a photograph of the set-up taken if needed.
On skin marks, ESTRO-ACROP breast (2023) reports a randomised trial (176 against 166 patients) with no difference in set-up error between permanent tattoos and temporary marks on weekly portal imaging, notes that tattoos may affect wellbeing, and considers that surface guidance may allow marks to be omitted if validated locally. A randomised trial in 196 women found that a virtual-reality explanation before breast radiotherapy planning reduced anxiety immediately and improved knowledge of the procedure compared with the standard explanation. Site-specific preparation (bladder and bowel filling, breath-hold, 4D CT, masks) is in linked protocols.
Why: Knowing what will happen makes the appointment easier and helps people stay still.
“You will be asked to lie very still while x-rays or scans are taken.”
US National Cancer Institute 2021 · Patient information (ungraded)
Why: The planning scan is the first exposure in a course of treatment, and every later step depends on it being the right person.
“All departmental procedures in relation to patient informed consent and identification should be adhered to prior to commencing the CT scanning procedure.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: This keeps the radiation from the scan itself as low as possible.
“The patient diagnosis, prescription and required scanning margins should be known to the RTTs before commencing CT, so as to adhere to the ALARA principle.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: Contrast helps the team see the tumour, but reactions, though rare, need to be prepared for.
“If contrast is to be used, the RTTs must screen the patient for potential anaphylaxis as per departmental protocol, document this screening procedure and ensure that the emergency trolley is prepared and fully stocked.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: The plan is calculated on this scan, so anything present at treatment must be present now.
“If bolus is planned for the patient’s treatment, this should be in situ prior to CT scanning so as to account for the actual bolus to be used at treatment in the dose calculations.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: Devices must be in the scan to be accounted for in the dose, and a wrong orientation could flip the plan.
“The RTTs must ensure that both patient orientation and the orientation of the topogram or pilot scan are correctly entered at the CT console.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: Thin slices show small structures clearly, and recording the dose is a legal requirement for imaging.
“It is recommended to use axial slice thickness of 3 mm or less for head and neck cases.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: Marks help line you up each day; permanent tattoos are not the only option.
“Temporary skin marks may be an alternative to permanent tattoos with a lesser impact on patient well-being [70] .”
ESTRO-ACROP (Mast et al., Technical Innovations and Patient Support in Radiation Oncology) 2023 · Consideration (ESTRO-ACROP: practice the evidence could not support as a recommendation)
Why: The marks are used every day of treatment.
“Be careful not to remove them and tell the radiation therapist if they have faded or lost color.”
US National Cancer Institute 2021 · Patient information (ungraded)
Why: Every radiographer who treats the patient later must be able to reproduce the position exactly.
“If needed, a photograph of the patient position can be taken and added to the patient chart.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Prepare the patient (an explanation in advance; a staff-led preview such as a virtual-reality walkthrough reduced anxiety and improved understanding in one randomised trial), confirm identity, consent and pregnancy status, scan in the treatment position with all devices and bolus in place and the scan limits known in advance, screen for contrast and observe afterwards, use thin slices, record the scan dose, and document the set-up (ESTRO ACROP head and neck 2017; NCI 2021). Skin marks may be permanent or temporary (no difference in accuracy in one randomised trial reported by ESTRO-ACROP breast 2023), or omitted where surface guidance is validated. No single international guideline covers CT simulation across all sites; site-specific steps are in the linked protocols.
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · ESTRO-ACROP (Mast et al., Technical Innovations and Patient Support in Radiation Oncology) 2023 · US National Cancer Institute 2021 · International Journal of Radiation Oncology, Biology, Physics (Shin et al.) 2023
Where it differs: The patient sees the room, the machine and the sequence of the session in a headset (or on a visit) before the planning appointment, instead of a verbal or written explanation only.
Evidence: Randomised trial, 196 women before breast radiotherapy: immediate anxiety reductions of 26.0%, 16.1% and 55.8% on three scales against 8.1%, 8.5% and 13.7%, with only one scale showing a lasting difference; knowledge 81.9 against 76.8 out of 100 (P = .006).
International Journal of Radiation Oncology, Biology, Physics (Shin et al.) 2023
Where it differs: No permanent marks: the patient is aligned with a surface camera, or temporary marks are used.
Evidence: ESTRO-ACROP breast (2023) reports one randomised trial with no difference in set-up error between tattoos and temporary marks on weekly portal imaging, and considers that surface guidance may allow marks to be omitted after local validation.
ESTRO-ACROP (Mast et al., Technical Innovations and Patient Support in Radiation Oncology) 2023
A randomised trial of 196 women about to have breast radiotherapy found that explaining the treatment with a virtual-reality walkthrough lowered anxiety and improved understanding compared with the usual explanation. A review of 15 education studies found that leaflets and brief talks made little difference, and more intensive, staff-led preparation did.
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.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Virtual-reality explanation reduces anxiety at radiotherapy planning “Immersive VR applied to the current procedure reduces anxiety during RT planning for patients with breast cancer.” | Single randomised trial (196 patients) | International Journal of Radiation Oncology, Biology, Physics (Shin et al.) 2023 |
| Surface guidance may allow skin marks to be omitted “SGRT may improve setup accuracy and enable the omission of skin marks entirely, though this must be validated in the context of a department’s local workflow.” | Consideration (ESTRO-ACROP) | ESTRO-ACROP (Mast et al., Technical Innovations and Patient Support in Radiation Oncology) 2023 |
| Patient remains at least 15 minutes after contrast “As a minimum requirement, the patient must remain in the department for a further fifteen minutes.” | Guideline (ungraded) | ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 |
Shares Patient identification and pre-treatment time-out in radiotherapy, Immobilisation mask for head and neck and brain radiotherapy, including mask anxiety, Surface-guided radiotherapy (SGRT), Respiratory motion management (4D-CT, gating, breath-hold, tracking).
Shares Radiotherapy set-up without permanent ink tattoos, using surface guidance or invisible ink, Deep inspiration breath-hold for left-sided breast radiotherapy, Surface-guided radiotherapy (SGRT), Respiratory motion management (4D-CT, gating, breath-hold, tracking).
Shares Show people the radiotherapy room and the treatment before the planning appointment, using virtual reality or a guided visit, Deep inspiration breath-hold for left-sided breast radiotherapy, Respiratory motion management (4D-CT, gating, breath-hold, tracking), Breast cancer (all types).
Shares Radiotherapy set-up without permanent ink tattoos, using surface guidance or invisible ink, Immobilisation mask for head and neck and brain radiotherapy, including mask anxiety, Surface-guided radiotherapy (SGRT), Head and neck squamous cell carcinoma.
Shares Bladder filling and rectal preparation for prostate radiotherapy, Breast radiotherapy positioning, immobilisation and daily set-up verification, Deep inspiration breath-hold for left-sided breast radiotherapy, CT (computed tomography).
Shares Iodinated contrast for CT: kidney function checks, kidney protection and metformin, Iodinated and barium contrast for CT and X-ray, CT (computed tomography).
Shares Deep inspiration breath-hold for left-sided breast radiotherapy, Surface-guided radiotherapy (SGRT), Respiratory motion management (4D-CT, gating, breath-hold, tracking), Breast cancer (all types).
Shares Iodinated contrast for CT: kidney function checks, kidney protection and metformin, Iodinated and barium contrast for CT and X-ray, CT (computed tomography).