Invisible ink for radiation may improve patient quality of life
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A novel invisible ink tattoo technique may improve long-term quality of life and emotional well-being for people with cancer who undergo radiation therapy, according to study results.
Radiation setup typically involves marking treatment areas with permanent black or blue tattoo ink to ensure correct alignment of the radiation machine over the weeks-long duration of treatment.
Although visible ink tattoos are used for the duration of radiation treatment, the marks remain long after the completion of treatment. They can be a frequent, conspicuous, often upsetting reminder of a traumatic time in the patient’s life.
Findings published in Frontiers in Oncology showed patients preferred to receive invisible ink tattoos instead of visible ink tattoos for radiation treatment alignment. They also were willing to travel farther to avoid visible ink tattoos (P < .01).
“Ultimately, what we are hoping to see is an improvement in overall quality of life for our patients as they transition into survivorship,” senior author and trial principal investigator J. Isabelle Choi, MD, clinical director and director of research at the New York Proton Center and radiation oncology attending at Memorial Sloan Kettering Cancer Center, told Healio. “Outside of the usual surveillance that is required to ensure patients remain without evidence of disease recurrence or progression, we want them to be able to put their cancer diagnosis behind them.”
Healio spoke with Choi about traditional approaches to radiation delivery, how the invisible ink approach may improve survivor well-being, and the feasibility of this approach for widespread use.
Healio: What is the current protocol used for radiation setup?
Choi: Almost all external beam radiation therapy is still delivered using alignment with dark-ink, permanent tattoos. These are dark-black or blue ink tattoo dots that are placed on the skin in several places to allow the lasers to align each day precisely before radiation treatments. They appear as small circles placed throughout the treatment area — usually between four and eight tattoos, depending on the treatment site. These tattoos typically remain visible on the patient’s skin for the remainder of the patient’s life. Almost all radiation centers continue to use this paradigm.
Healio: Can you describe the rationale for conducting this study?
Choi: At the New York Proton Center, we treat patients with an ultra-precise form of radiation therapy called proton therapy. This radiation modality allows for enhanced normal tissue sparing and reduced exposure to unnecessary radiation dose. To maximize the benefits of proton therapy, it is of the utmost importance that we set patients up with millimeter precision prior to each treatment.
Initially, to cater to patient preference, we used tattoo-less setups — no tattoos of any kind. We relied on the use of semi-permanent markers. During the week and a half to 2 weeks between the planning session and the start of treatment, these marks tended to fade — especially if the patient was very active or bathed frequently. This would require re-marking patients prior to starting treatment. This issue raised the question of whether there might be a way to mark patients for accurate alignment using a more efficient approach using some type of more lasting marking tool.
Healio: What options did you consider?
Choi: We thought through several potential solutions, such as transient/temporary tattoos or henna. However, as we looked more closely at these alternative solutions, we identified important shortcomings of each approach. Temporary tattoos may disappear by the time of treatment initiation. Henna ink contains a substance to which some patients may have a very marked allergic reaction. At this point, we could have pivoted to visible ink tattoos, as this is the accepted standard of care. However, we persevered in our search, as we hoped to find a solution that preserved the patient’s quality of life and avoided leaving them with these permanent reminders of their cancer.
Finally, we came upon InkAlign tattoos, which are invisible ink tattoos that are only visible under UV light. Under normal fluorescent light, they are either not visible or may appear as a very faint pink mark. We wanted to see if this approach was feasible to implement and find out whether patients had a strong preference regarding the receipt of invisible ink versus visible ink tattoos.
Healio: How did you evaluate this?
Choi: We opened a prospective trial at the New York Proton Center for patients receiving proton therapy and evaluated the feasibility of implementing invisible ink tattoos for patient set up with the incorporation of new clinical workflows. We also provided a survey tool to patients before and after their treatment course that addressed their preferences regarding receipt of invisible ink versus visible ink tattoos. We also asked patients whether they would be willing to go a further distance or pay more money to avoid getting visible ink tattoos compared with invisible ink tattoos. In addition, we looked at treatment efficiency of using invisible ink tattoos versus a tattoo-less setup.
Healio: What did you find?
Choi: We enrolled 94 patients, and we found that 79.8% strongly preferred to receive invisible ink tattoos over visible, dark-ink tattoos. They also were willing to travel significant distances and pay more money to avoid receiving dark-ink tattoos. The primary reason they stated for wanting to avoid visible ink tattoos was for visibility and aesthetic purposes, and they also cited the emotional distress that came with visible ink tattoos. We found that the impact was greater among women than men in terms of willingness to travel farther and pay more. Almost all patients — 88.3% — said their cosmesis with invisible ink tattoos was good to excellent. We also found that by introducing the invisible ink tattoos, we improved treatment efficiency. Compared with our tattoo-less setup, the invisible ink tattoos shortened the average amount of time needed per treatment and the average amount of time needed for the initial setup of the patient on the treatment table.
Healio: Are there any potential drawbacks to this approach?
Choi: The invisible ink tattoos are nominally more expensive than the traditional dark-ink tattoos. However, the alternative approach of a tattoo-less solution often requires the availability of surface-guided radiation technology. This involves additional hardware and technology that is many orders of magnitude more costly and resource-intensive than invisible tattoos.
Our trial looked at adverse effects from invisible ink tattoos, such as allergic reactions, but we found that these adverse events did not occur. Any tattoo involves a small pinprick during administration, but these are generally tolerated well by the patients.
Invisible ink tattoos are now the standard practice at our center. Through the results of this trial, we believe we have demonstrated there is a need and that their use is feasible. This approach is already approved and can be adopted by other centers, and I would be very happy to share our protocols with any center interested in implementing invisible ink tattoos into their practice.
Healio: What are the potential long-term implications of these findings?
Choi: With advances in cancer treatment across disciplines, our patients are living longer, which means they have a greater likelihood to develop lasting impacts of their treatment. Much of my clinical and research interests are not only in what we can do in the short term to mitigate toxicities of treatment for our patients through advanced technologies like proton therapy, but what we can do to improve quality of life and mental and emotional well-being during survivorship. It is important to understand that survivorship encompasses a much longer period of time than the actual treatment. Along with the goal of more universal adoption of invisible ink tattoos across more radiation centers, we hope to continue to identify novel methods to improve quality of life in survivorship through our research.
Reference:
For more information:
J. Isabelle Choi, MD, can be reached at ichoi@nyproton.com.
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