Going the distance: Nicola Freeman on her life-changing research and running the Brighton Marathon

Working towards success

Nicola began her radiotherapy career in 2003 at the Leicester Royal Infirmary (LRI), where she has remained since. This followed three years of clinical placements at the hospital while she studied for her BSc with honours in radiotherapy and oncology. After earning her degree she worked in the radiotherapy department, becoming a senior radiographer after 18 months, and then moved up to become a team leader radiographer two years later.

In that role, Nicola took on a number of other responsibilities, such as becoming an undergraduate clinical placement facilitator for LRI placement students at Sheffield Hallam University. But it was her position as superintendent radiographer – which came eight years later – that gave her the opportunity to apply for a Macmillan-funded head and neck specialist radiographer role. “We applied for a funding bid with Macmillan Cancer Care to improve the pathway for complex tumour sites,” Nicola explains. “An opportunity arose, which was a 50/50 job share with another radiographer who was looking into the palliative radiotherapy pathway.”

After 18 months, the job became available as a full-time position. The role itself changed as Nicola gained more local in-house skills and completed her Masters in Advanced Clinical Practice Radiotherapy and Oncology at Sheffield Hallam University.

For the last two and a half years, Nicola has worked as a head and neck consultant radiographer at LRI. “Within [my masters] I completed independent prescribing and physical assessment and consultation skills,” Nicola says. “That allowed me to take on more of the role that traditionally would be undertaken by other medical professionals – the registrars and the consultants – to enable me then to provide efficient care for the patients as they’re on treatment.”

Nicola’s masters provided a defined pathway towards the advanced clinical practitioner pathway, then the consultant pathway. This then led to research opportunities within the consultant role, including introducing PBM therapy as a standard of care.

A large part of Nicola’s role nowadays requires her to manage patients’ acute toxicity. But this is more than monitoring dosages. At LRI, Nicola provides “practical, emotional and physical support for [patients] to make sure they get through treatment in the best condition they can”.

“We’ll try to optimise the physical, mental and practical aspects of their care,” she says. “And make sure that’s as efficient as we can get it. That ultimately means they can recover much more effectively.

Prioritising emotional wellbeing

Patient wellbeing is of great importance to Nicola. It’s why she takes every opportunity to shout about PBM therapy, which can significantly ease the side effects of radiotherapy for head and neck cancer patients. “Radiotherapy is a very difficult treatment, but for the head and neck it affects many aspects of the person’s life,” she says. “Not just their eating and their speech – it has a huge emotional toll.

“There’s a big burden not just on the patient, but also on the family. Meal times can be very difficult because they don’t produce enough saliva to be able to chew their food, their appetite is reduced and food has a nasty taste.”

Patients can also struggle with the textures and smells of food during treatment, causing them to withdraw from social occasions. “That focus on food, that becomes almost their nemesis, really,” Nicola explains. “Patients obviously get quite a high dose of radiation to their oral cavity, which then causes dryness and soreness, and a lot of pain can be associated with that.

“If we can minimise that in any way, and make that more comfortable for the patient, then it means they can eat for longer, they can potentially enjoy their food for longer and all of the emotional burden that comes with not being able to eat, drink, speak and communicate effectively is reduced. That has a huge impact on their emotional wellbeing as they’re going through the treatment.”

Assessing the impact

As part of her work at LRI, Nicola and her colleagues carried out an audit of one year’s worth of patients. They looked at 84 patients who had a variety of head and neck cancers and were being treated with radiotherapy, chemotherapy or surgery – and in some cases, all three. They assessed the patient’s toxicity scores and how their mucositis worsened throughout their treatment.

Nicola and Bilquis Musa, a senior radiographer at LRI, were responsible for data collection, while the department’s research radiographer, Alison Osborne, helped with data analysis and presentation. The patients used PBM in addition to caphosol mouthwash, which was the department’s standard treatment for mucositis.

The conclusion? With PBM, a patient’s strong opioid use could be reduced by close to 50 per cent. While less opioid use alone doesn’t significantly affect the NHS budget, patients could ultimately require less medication for other side effects in the future, meaning that the long-term effect is palpable. “The more medications patients require throughout the treatment, generally the more side effects from that medication they get,” Nicola explains.

Additionally, treating issues in the oral cavity means a patient can fuel themselves better. “If we can reduce that burden, make that more comfortable, then the patient has a better experience through the radiotherapy. But they will also have more calorie intake because they’re able to eat for longer, and it means that they will ultimately recover much more effectively. They’re not so tired for months and months.”

The PBM technology has been in the NHS for a number of years. It has been recommended by the National Institute for Health and Care Excellence since 2018 for the exact purpose Nicola treats patients for: oral mucositis. But not every treatment centre has the equipment needed to administer the therapy. The PBM machine used at LRI was purchased thanks to a charitable donation. It has been in use for two and a half years and has helped “hundreds and hundreds” of people so far, according to Nicola. Before it was introduced, she says LRI was prescribing a mouthwash for patients to help minimise oral mucositis. Now, with PBM in place, the hospital saves around £40,000 a year in mouthwash costs alone.