Aubrie Rice

RST 3573
Compare/Contrast Paper
1. Johnson J, Nelson B, Hickman V, Kry SF. The cover up: skin dose increase during externalbeam therapy. Radiation Therapist. Fall 2009;18(2):97-100.
2. Fargerstrom JM, Hirata EY. Surface dose effects of linen coverings for breast and chest wall
patients. Radiation Therapist. Fall 2014; 23(2):119-124.
3. Hackworth, R. Treatment Considerations Presentation. [PowerPoint]. Columbus, OH: OSU
Radiation Therapy Program; 2014.
Skin sparing and patient comfort are both of great importance in radiation therapy.
Though each of these concepts is valued, there are times when they clash as well. For example,
draping a linen covering overtop of a patient increases the patients comfort but if this covering is
in the field in which they will be treated, it could increase the dose to the skin. It is important to
avoid such increased skin dose due to the fact it can cause patients to develop serious and painful
skin reactions such as erythema, dry desquamation, and eventually even moist desquamation.3
Studies have been done to examine whether linen coverings cause increased skin dose and while
some found that the increased dose created by such coverings was negligible, many including
both Johnson et al and Fargerstrom et al have preformed studies that yield different results.1,2
Johnson et al found in their study that there was a linear increase in surface dose which
corresponded to an increase in the thickness of the patient covering. They found these results by
using lithium fluoride thermoluminescent dosimeters (LiF TDLs) and the width of the coverings
tested were as follows: hospital gown (0.48 mm), blanket (1.55 mm), towel (2.10 mm), and all
three materials (4.13 mm). They used a 10 x 10 treatment field and arranged one TDL on the
central axis and distributed the other 4 throughout the field all on top of 10 cm of virtual water.
They did this for each of the four material thicknesses they tested. The entrance dose with no
covering was 26% of the Dmax of the 6MV beam. Johnson et al found that this increased to 31%

Aubrie Rice
RST 3573
Compare/Contrast Paper
with the gown, 37% with the towel, 40% with the blanket and 52% with all three coverings.1
Relative to no covering, this corresponded to a percent increase in surface dose of between 19%
with a gown to 100% with all 3 materials.1
Fargerstrom et al wanted to expand upon these findings by doing a similar research study.
Instead of Virtual Water like the Johnson study, the Fargerstrom study used an anthropomorphic
phantom.1,2 They took a CT scan of this phantom prior to their testing and created breast tangent
treatment plans for 6 and 16 MV photon energies as well as planning a boost treatment for 6, 9,
12, 15, and 18 MeV electron beams. For the photon set ups, two tangent beams were delivered,
moving one independent jaw to midline. For the electron set ups, a 7 cm circular block was
placed in 10 cm x 10 cm electron cone and the phantom was setup to 100 cm SSD to resemble an
actual boost treatment. Each energy was tested with the same materials used in the Johnson study
but they had slightly different thicknesses: a hospital gown (0.23 mm), a sheet (0.28 mm), a
towel (1.9 mm), and all three coverings (2.41 mm).2 The Fargerstrom study also had results that
supported the Johnson study. Fargerstrom et al found that there was a general increase in the
surface dose with an increase in thickness of the linen coverings. For the hospital gown, the
TDLs showed a 4.6 2.1% increase for the 6 MV and 6.9 2.7% increase for the 16 MV. For
the sheet, dose was increased -0.6 2.6% for the 6 MV and 7.0 1.1% for the 16 MV. The towel
resulted in an increase of 8.3 2.9% and 12.9 3.0% for 6 MV and 16 MV beams, respectively.2
Though the studies both showed results that supported the idea that linen coverings
increase dose, I feel that the Fargerstrom study probably had more realistic results do to the more
advanced technology that was used in taking the CT scan of the phantom and doing similar to
real life plans. I would be interested to see more studies done on this subject in the future as well.

Aubrie Rice
RST 3573
Compare/Contrast Paper
Both of these studies show how important it is as Radiation Therapists to make sure the
field being treated is not covered with a linen draping. We can work to make the patient
comfortable in other ways, such as offering them a warm blanket for areas above and below the
area they are being treated. In my own personal clinical experience, this is exactly what the
therapists have done. Many times when treating a patient with cancer of the pelvic area such as
the ovaries or prostate, if the patient would like a warm blanket and just covering their legs isnt
keeping them warm enough, we will cover them with another blanket up top but not let it
intersect with the treatment field. There have been a couple of times though (before I really knew
that it shouldnt be done) that a therapist has placed a pillowcase overtop of the treatment field to
maintain the modesty and comfort of the patient. I hope that more studies like these two are done
in the future and that more awareness is brought to this topic because I believe that is a very
important to our field.