Brachytherapy 14 (2015) 197e201
Current state of brachytherapy teaching in Canada: A national survey of radiation oncologists, residents, and fellows Marc Gaudet1,2,4,*, Jasbir Jaswal1,3,4, Mira Keyes1,4 1 Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada Departement de radio-oncologie, CSSS de Gatineau-H^opital de Gatineau, Gatineau, Quebec, Canada 3 Department of Radiation Oncology, London Regional Cancer Centre, London, Ontario, Canada 4 Canadian Brachytherapy Group
2
ABSTRACT
PURPOSE: The objective of the present study was to determine perceptions and barriers concerning brachytherapy (BT) teaching in Canada to guide the development of a BT credentialing process. METHODS AND MATERIALS: In May 2013, an electronic survey was sent to all radiation oncologists, program directors, residents, and fellows in Canada. Questions were asked regarding demographics, practice patterns, teaching methods and assessment, curriculum content, perceptions on resident education, and barriers to resident teaching. RESULTS: One hundred twenty-one staff radiation oncologists and 32 residents responded to the survey. Only 54% of respondents stated that their center had defined specific written objectives with respect to knowledge, skills, and attitudes required for a resident to be competent in BT. The main barriers to BT teaching were stated as being the lack of Royal College guidance (55%), heavy clinical workload (49%), lack of time (37%), and the fact that too much emphasis is placed on passing examinations (32%). Ninety-seven percent of respondents felt that it was important or very important that some elements of BT be included in the mainstream radiation oncology curriculum. Eighty percent of respondents were in agreement with the development of a formal credentialing process by the Royal College of Physicians and Surgeons of Canada, which would lead to separate certification in BT. CONCLUSIONS: The results of this study show the importance of developing specific BT curriculum and emphasize the need for a credentialing process. Crown Copyright Ó 2015 Published by Elsevier Inc. on behalf of American Brachytherapy Society. All rights reserved.
Keywords:
Brachytherapy; Teaching; Survey; Credential; Certification
Introduction The field of radiation oncology has undergone an extremely rapid evolution in its practice from a clinical and technological standpoint over the last 25 years (1). These technological advances and increasing complexity in imaging, treatment planning, and delivery seem to be progressing at an ever-increasing rate. In many areas of
Received 17 September 2014; received in revised form 28 October 2014; accepted 5 November 2014. Conflict of interest: All the authors do not have any financial disclosures or conflicts of interest to report. Meeting presentations: This work was presented in part at the 2013 annual scientific meeting of the Canadian Association of Radiation Oncology in Montreal, Quebec, Canada. * Corresponding author. Departement de radio-oncologie, CSSS de Gatineau-H^ opital de Gatineau, 909, boulevard La Verendrye Ouest, Gatineau, Quebec, Canada J8P 7H2. Tel.: þ1-819-966-6100; fax: þ1-819-9666284. E-mail address: [email protected] (M. Gaudet).
clinical radiation oncology, this has resulted in physicians evolving toward subspecialized practice, including brachytherapy (BT), stereotactic radiosurgery, and stereotactic body radiotherapy. Improved clinical outcomes for certain cancers have also been associated with specialized centers that have a higher caseload and physicians with subspecialized training (2, 3). BT is a field where it has been suggested that subspecialized training should be required because of not only an increased precision of treatment but also a significant risk of serious toxicity if treatment is not delivered appropriately (4, 5). Many have also shown the existence of a significant learning curve for junior radiation oncologists (ROs) starting a BT practice (6e10). Several recent surveys have highlighted the heterogeneity of training received by not only residents during their general radiation oncology training but also ROs currently practicing BT. In France, it was shown that 82% of residents felt that their training in BT was suboptimal (11). In Canada, a recent survey showed that only 43% of survey respondents practicing BT have completed a BT fellowship (12).
1538-4721/$ - see front matter Crown Copyright Ó 2015 Published by Elsevier Inc. on behalf of American Brachytherapy Society. All rights reserved. http://dx.doi.org/10.1016/j.brachy.2014.11.004
198
M. Gaudet et al. / Brachytherapy 14 (2015) 197e201
Other fields such as gastrointestinal endoscopy have implemented credentialing programs to ensure uniformity in training standards for credentialed endoscopists (13). The leadership of the American Brachytherapy Society has recently voiced its significant concern with the lack of uniform training requirements and credentialing for BT practitioners (14). Recently, the Royal College of Physicians and Surgeons of Canada’s (RCPSC) Specialty Committee in Radiation Oncology has undertaken steps to create a credentialing process that would lead to a certification in BT known as an Area of Focused Competence (Diploma) program that would follow general radiation oncology credentialing process and would require an extra year of training specifically in BT. For this reason, we undertook a national survey of ROs, radiation oncology fellows, and radiation oncology residents in Canada to better understand the current state of BT teaching in Canada and then to use this information to estimate the magnitude of support for such a process among Canadian ROs and to help guide the certification process that is currently being developed.
were from academic centers and 18% from community centers. Three percent were PDs, 68% were ROs with a BT practice, and 29% were ROs without a BT practice. There were respondents from all provinces except Prince Edward Island with Ontario (39%), British Columbia (21%), Quebec (21%), and Alberta (9%) being most represented. Other demographic characteristics of respondents are presented in Table 1. With regard to BT teaching and evaluation, teaching was mostly carried out by faculty ROs (100%), physicists (84%), residents (13%), fellows (14%), and outside experts (14%). The most common forms of BT teaching were informal lectures (49%) followed by didactic lectures (34%), problem-based approaches (28%), resident presentations (15%), and simulations (8%). Only 54% of respondents stated that their center had defined specific written objectives with respect to knowledge, skills, and attitudes required for a resident to be competent in BT. The main reasons given for not having such objectives were uncertainty as to what the Royal College objectives in BT should be (72%) and the feeling that BT was well covered by physics teachings (24%). Formal evaluations of practical skills
Methods and materials Two separate surveys, one for radiation oncology program directors (PDs) and ROs and a second for radiation oncology residents and fellows, were designed by the investigators and reviewed by members of the Canadian Brachytherapy Group (CBG) and the RCPSC’s Specialty Committee in Radiation Oncology. The RO and PD survey was composed of 35 questions (17 questions about demographics and practice patterns, seven questions about teaching methods and assessment, one question about curriculum content, six questions on perceptions on resident education, and four questions about barriers to resident teaching). The residents’ and fellows’ survey was composed of 25 questions (9 demographic questions and 16 questions on teaching methods and curriculum content). Surveys were simultaneously designed in French and English. Surveys were hosted by SurveyMonkey (www.surveymonkey.com). Members of the RCPSC Specialty Committee in Radiation Oncology reviewed surveys. Research and ethics board approval was obtained from the British Columbia Cancer Agency Research Ethics Board before distribution of surveys. Surveys were distributed to all members (424 ROs, 41 fellows, and 98 residents) of the Canadian Association of Radiation Oncology by e-mail on May 30, 2013 with a followup e-mail 2 weeks later. Final data analyses were done with all responses received by August 30, 2013.
Table 1 Demographic characteristics ROs and PDs
N
%
97/119 22/119
82 18
4/119 81/119 34/119
3 68 29
109/114 5/114
96 4
39/120 14/120 14/120 18/120 35/120
32 12 12 15 29
47/108 18/108 46/108 24/108 31/108 14/108 14/108 3/108 14/108 14/108 12/108 18/108 5/108 27/108
44 17 43 22 29 13 13 3 13 13 11 17 5 25
Radiation oncologists and program directors
Location of practice Academic Community Type of practice PD RO with BT practice RO without BT practice BT available at respondent’s center Yes No Years in practice 0e5 6e10 10e15 16e20 O20 BT procedures performed Gynecologic (intracavitary cervix) Gynecologic (interstitial) Gynecologic (vaginal vault) Prostate HDR Prostate LDR Skin HDR Skin mold Breast LDR Breast HDR Esophagus HN Lung (endobronchial) Sarcoma No BT practice
One hundred twenty-one responses were received from ROs or PDs (response rate, 28.5%). Eighty-two percent
ROs 5 radiation oncologists; PDs 5 program directors; BT 5 brachytherapy; HDR 5 high dose rate; LDR 5 low dose rate; HN 5 head and neck.
Results
M. Gaudet et al. / Brachytherapy 14 (2015) 197e201
199
were mostly carried out by means of direct observation (63%), oral examinations (44%), and written examinations (33%). Twenty-nine percent of respondents stated not having a formal evaluation method for practical skills. The main barriers to BT teaching were stated as being the lack of Royal College guidance (55%), clinical workload (49%), lack of time (37%), and the fact that too much emphasis is placed on passing examinations (32%). Ninety-seven percent of respondents felt it was important or very important that BT be included in the mainstream radiation oncology curriculum. Results concerning which BT techniques respondents believed should be part of the main radiation oncology curriculum are presented in Fig. 1. Residents’ and fellows’ survey Twenty-two residents (two postgraduate year 1 [PGY1], three PGY2, six PGY3, five PGY4, and six PGY5, response rate 22.4%) and 10 fellows (response rate, 24.4%) responded to the survey with all eight provinces with residency training programs represented. Sixty-three percent of residents expressed a desire to pursue a BT fellowship, and this number rose to 91% if a BT fellowship could help them get a staff position. Sixty-nine percent stated being extremely motivated or very motivated to learn about BT, 25% moderately motivated, 3% slightly motivated, and 3% not at all motivated. Residents and fellows felt that BT teaching should be carried out by faculty ROs (100%), physicists (84%), fellows (75%), residents (35%), and outside experts (28%). Figure 2 shows to what extent residents and fellows were satisfied with their learning concerning each BT technique. The residents and fellows were most satisfied with the teaching with regard to vaginal vault, intracavitary cervix, low dose rate (LDR) prostate BT with 80%, 70%, 68%,
Fig. 2. Residents’ and fellows’ satisfaction with teaching for each brachytherapy technique. HDR 5 high dose rate; LDR 5 low dose rate; Gyn 5 gynecologic.
respectively, and being either very satisfied or satisfied with the teaching they had received thus far. The subsites for which they were least satisfied were sarcoma, head and neck (HN), and high dose rate (HDR) breast with 55%, 53%, and 51%, respectively, being dissatisfied or very dissatisfied with the teaching they had received thus far. The proportions of residents who felt that they were very competent or competent in performing BT procedures were the following for each subsite: cervix (86%), vaginal vault (83%), interstitial gynecologic BT (25%), HDR prostate (63%), LDR prostate (78%), LDR breast (6%), HDR breast (15%), esophagus (25%), HN (3%), lung (19%), and sarcoma (6%). Figure 3 shows residents’ perceived competency at performing each BT technique. Figure 4 also shows the proportion of residents and fellows who have observed BT procedures and the proportion of them who have actively participated in the procedures either with insertion/placement of applicators or planning and dosimetry. Because of small numbers we could not break these results down according to the training year, but the results were consistent in showing little exposure to less frequent sites even for senior residents, BT fellows, and those who described having a significant interest in BT. Credentialing process
Fig. 1. Brachytherapy techniques that ROs and residents/fellows agree or strongly agree should be included as part of the Royal College certification examinations. Gyn 5 gynecologic; LDR 5 low dose rate; HDR 5 high dose rate; RO 5 radiation oncologist; PD 5 program director.
The results of both residents, fellows, and ROs’ views on the possibility of a formal certification process in BT are shown in Fig. 5: 64% of ROs who responded either agreed or strongly agreed that BT should require a separate fellowship outside residency, whereas this was 76% for residents and fellows. Eighty percent of ROs and 81% of residents and fellows either agreed or strongly agreed that they would support formal postresidency certification process leading to RCPSC recognition of a diploma program in
200
M. Gaudet et al. / Brachytherapy 14 (2015) 197e201
Fig. 3. Residents’ and fellows’ perceived competency at performing each brachytherapy technique. HDR 5 high dose rate; LDR 5 low dose rate; Gyn 5 gynecologic.
BT. There were no clear demographic trends with regard to who was in favor of the certification process.
Discussion This survey has allowed us to gain valuable insight into the current state of BT teaching in Canada. Respondents were representative of all Canadian provinces but one and represented a diversity of community vs. academic ROs and those practicing BT and those not. We believe that this adds significant validity to our results. The relatively low response rate and heterogeneity of resident respondents can limit the interpretation of our data. However, of the 424 ROs surveyed, 81 of the 122 who responded practice BT. There are currently 86 members of the Canadian
Fig. 4. Proportion of residents and fellows who have observed brachytherapy procedures and the proportion of them who have actively participated in the procedures with either insertion/placement of applicators or planning and dosimetry. HDR 5 high dose rate; LDR 5 low dose rate; Gyn 5 gynecologic.
Fig. 5. Agreement with the fact that brachytherapy should require a separate fellowship outside radiation oncology training and the Royal College of Physicians and Surgeons of Canada’s intent to develop a certification process for brachytherapy. (a) Radiation oncologists and (b) residents and fellows.
Brachytherapy Group (CBG); with this, we could extrapolate that most of those responsible for teaching BT in Canada (who would very likely be CBG members) responded to the survey. Resident teaching in Canada is currently mostly carried out with didactic methods with most centers not having specific learning objectives in BT, in large, because of the lack of guidance documents from the RCPSC. This illustrates the importance of having a prespecified curriculum for teaching BT with specific learning objectives. Since the survey, Speciality Committee in Radiation Oncology and CBG have developed comprehensive national objectives and competencies in resident training in BT. These have been recently distributed to residency training programs. The CBG has also discussed the possibility of having BT fellowships spread out over several institutions to allow fellows to be exposed to many different BT subsites in centers of excellence. The fact that many senior residents and fellows in our survey lack exposure to rare BT sites, such as sarcoma and HN, further accentuates the need for collaborative fellowships likely through collaboration with members of the CBG or by developing collaboration with international BT centers of excellence. Our survey results also show the same trends as a recent survey of American residents that shows that exposure to interstitial procedures is going down (15). This is also reflected in our survey results by the fact that residents’
M. Gaudet et al. / Brachytherapy 14 (2015) 197e201
satisfaction and perceived competency were both much lower for interstitial as compared with intracavitary procedures. The American Board of Radiology has also brought forth a Focused Practice Recognition Initiative in Brachytherapy that would be a voluntary component of its Maintenance of certification program and would recognize those with extra training and significant experience in BT procedures. Rose et al. (12) also showed that many practicing Canadian ROs are performing less of certain BT techniques per year than is recommended in certain guidelines such as those from the United Kingdom (12, 16). We believe that these facts combined with the significant level of agreement of staff, residents, and fellows concerning a certification process in BT justifies the RCPSC’s initiatives to pursue such a credentialing process to ensure that Canadian ROs wishing to practice BT are adequately trained to do so. Most ROs in Canada practicing BT already have significant subspecialized training and/or experience in BT, which should also facilitate the credentialing of those already in practice. The new credentialing process will ensure uniform standards of training and patient care across Canada. The first trainees are expected to enter this program in Summer 2015.
References [1] Thwaites DI, Malicki J. Physics and technology in ESTRO and in Radiotherapy and Oncology: Past, present and into the 4th dimension. Radiother Oncol 2011;100:327e332. [2] Lemmens VE, Bosscha K, van der Schelling G, et al. Improving outcome for patients with pancreatic cancer through centralization. Br J Surg 2011;98:1455e1462. [3] Woo YL, Kyrgiou M, Bryant A, et al. Centralisation of services for gynaecological cancer. Cochrane Database Syst Rev 2012;3: CD007945.
201
[4] Keyes M, Morris WJ, Spadinger I, et al. Radiation oncology and medical physicists quality assurance in British Columbia Cancer Agency Provincial Prostate Brachytherapy Program. Brachytherapy 2013;12:343e355. [5] Morton G, Walker-Dilks C, Baldassarre F, et al. Delivery of brachytherapy for cervical cancer: Organisational and technical advice to facilitate high-quality care. Clin Oncol (R Coll Radiol) 2010;22:605e614. [6] Chan EK, Keyes M, Pickles T, et al. Decline in acute urinary toxicity: A long-term study in 2011 patients with prostate brachytherapy within a provincial institution. Brachytherapy 2014;13:46e52. [7] Liu HW, Malkoske K, Sasaki D, et al. The dosimetric quality of brachytherapy implants in patients with small prostate volume depends on the experience of the brachytherapy team. Brachytherapy 2010;9:202e207. [8] Keyes M, Schellenberg D, Moravan V, et al. Decline in urinary retention incidence in 805 patients after prostate brachytherapy: The effect of learning curve? Int J Radiat Oncol Biol Phys 2006;64:825e834. [9] Lee WR, deGuzman AF, Bare RL, et al. Postimplant analysis of transperineal interstitial permanent prostate brachytherapy: Evidence for a learning curve in the first year at a single institution. Int J Radiat Oncol Biol Phys 2000;46:83e88. [10] Harper JL, Jenrette JM, Vanek KN, et al. Acute complications of MammoSite brachytherapy: A single institution’s initial clinical experience. Int J Radiat Oncol Biol Phys 2005;61:169e174. [11] Fumagalli I, Faivre J, Bibault J, et al. Evaluation de la formation a la curietherapie des jeunes oncologues radiotherapeutes franc¸ais. [Brachytherapy training: a survey of French radiation oncology residents]. Cancer radiotherapie: J de la Societe francaise de radiotherapie oncologique 2011;15:624. [12] Rose J, McLaughlin PY, Falkson CB. Brachytherapy practice across Canada: A survey of workforce and barriers. Brachytherapy 2013;12: 615e621. [13] Sedlack RE. Training to competency in colonoscopy: Assessing and defining competency standards. Gastrointest Endosc 2011;74: 355e366. e1-2. [14] Crook J. American Brachytherapy Society Newsletter. 2012. [15] Compton JJ, Gaspar LE, Shrieve DC, et al. Resident-reported brachytherapy experience in ACGME-accredited radiation oncology training programs. Brachytherapy 2013;12:622e627. [16] Royal College of Radiologists. The role and development of brachytherapy services in the United Kingdom. London, England: Royal College of Radiologists; 2012.
Current state of brachytherapy teaching in Canada: A national survey of radiation oncologists, residents, and fellows Marc Gaudet1,2,4,*, Jasbir Jaswal1,3,4, Mira Keyes1,4 1 Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada Departement de radio-oncologie, CSSS de Gatineau-H^opital de Gatineau, Gatineau, Quebec, Canada 3 Department of Radiation Oncology, London Regional Cancer Centre, London, Ontario, Canada 4 Canadian Brachytherapy Group
2
ABSTRACT
PURPOSE: The objective of the present study was to determine perceptions and barriers concerning brachytherapy (BT) teaching in Canada to guide the development of a BT credentialing process. METHODS AND MATERIALS: In May 2013, an electronic survey was sent to all radiation oncologists, program directors, residents, and fellows in Canada. Questions were asked regarding demographics, practice patterns, teaching methods and assessment, curriculum content, perceptions on resident education, and barriers to resident teaching. RESULTS: One hundred twenty-one staff radiation oncologists and 32 residents responded to the survey. Only 54% of respondents stated that their center had defined specific written objectives with respect to knowledge, skills, and attitudes required for a resident to be competent in BT. The main barriers to BT teaching were stated as being the lack of Royal College guidance (55%), heavy clinical workload (49%), lack of time (37%), and the fact that too much emphasis is placed on passing examinations (32%). Ninety-seven percent of respondents felt that it was important or very important that some elements of BT be included in the mainstream radiation oncology curriculum. Eighty percent of respondents were in agreement with the development of a formal credentialing process by the Royal College of Physicians and Surgeons of Canada, which would lead to separate certification in BT. CONCLUSIONS: The results of this study show the importance of developing specific BT curriculum and emphasize the need for a credentialing process. Crown Copyright Ó 2015 Published by Elsevier Inc. on behalf of American Brachytherapy Society. All rights reserved.
Keywords:
Brachytherapy; Teaching; Survey; Credential; Certification
Introduction The field of radiation oncology has undergone an extremely rapid evolution in its practice from a clinical and technological standpoint over the last 25 years (1). These technological advances and increasing complexity in imaging, treatment planning, and delivery seem to be progressing at an ever-increasing rate. In many areas of
Received 17 September 2014; received in revised form 28 October 2014; accepted 5 November 2014. Conflict of interest: All the authors do not have any financial disclosures or conflicts of interest to report. Meeting presentations: This work was presented in part at the 2013 annual scientific meeting of the Canadian Association of Radiation Oncology in Montreal, Quebec, Canada. * Corresponding author. Departement de radio-oncologie, CSSS de Gatineau-H^ opital de Gatineau, 909, boulevard La Verendrye Ouest, Gatineau, Quebec, Canada J8P 7H2. Tel.: þ1-819-966-6100; fax: þ1-819-9666284. E-mail address: [email protected] (M. Gaudet).
clinical radiation oncology, this has resulted in physicians evolving toward subspecialized practice, including brachytherapy (BT), stereotactic radiosurgery, and stereotactic body radiotherapy. Improved clinical outcomes for certain cancers have also been associated with specialized centers that have a higher caseload and physicians with subspecialized training (2, 3). BT is a field where it has been suggested that subspecialized training should be required because of not only an increased precision of treatment but also a significant risk of serious toxicity if treatment is not delivered appropriately (4, 5). Many have also shown the existence of a significant learning curve for junior radiation oncologists (ROs) starting a BT practice (6e10). Several recent surveys have highlighted the heterogeneity of training received by not only residents during their general radiation oncology training but also ROs currently practicing BT. In France, it was shown that 82% of residents felt that their training in BT was suboptimal (11). In Canada, a recent survey showed that only 43% of survey respondents practicing BT have completed a BT fellowship (12).
1538-4721/$ - see front matter Crown Copyright Ó 2015 Published by Elsevier Inc. on behalf of American Brachytherapy Society. All rights reserved. http://dx.doi.org/10.1016/j.brachy.2014.11.004
198
M. Gaudet et al. / Brachytherapy 14 (2015) 197e201
Other fields such as gastrointestinal endoscopy have implemented credentialing programs to ensure uniformity in training standards for credentialed endoscopists (13). The leadership of the American Brachytherapy Society has recently voiced its significant concern with the lack of uniform training requirements and credentialing for BT practitioners (14). Recently, the Royal College of Physicians and Surgeons of Canada’s (RCPSC) Specialty Committee in Radiation Oncology has undertaken steps to create a credentialing process that would lead to a certification in BT known as an Area of Focused Competence (Diploma) program that would follow general radiation oncology credentialing process and would require an extra year of training specifically in BT. For this reason, we undertook a national survey of ROs, radiation oncology fellows, and radiation oncology residents in Canada to better understand the current state of BT teaching in Canada and then to use this information to estimate the magnitude of support for such a process among Canadian ROs and to help guide the certification process that is currently being developed.
were from academic centers and 18% from community centers. Three percent were PDs, 68% were ROs with a BT practice, and 29% were ROs without a BT practice. There were respondents from all provinces except Prince Edward Island with Ontario (39%), British Columbia (21%), Quebec (21%), and Alberta (9%) being most represented. Other demographic characteristics of respondents are presented in Table 1. With regard to BT teaching and evaluation, teaching was mostly carried out by faculty ROs (100%), physicists (84%), residents (13%), fellows (14%), and outside experts (14%). The most common forms of BT teaching were informal lectures (49%) followed by didactic lectures (34%), problem-based approaches (28%), resident presentations (15%), and simulations (8%). Only 54% of respondents stated that their center had defined specific written objectives with respect to knowledge, skills, and attitudes required for a resident to be competent in BT. The main reasons given for not having such objectives were uncertainty as to what the Royal College objectives in BT should be (72%) and the feeling that BT was well covered by physics teachings (24%). Formal evaluations of practical skills
Methods and materials Two separate surveys, one for radiation oncology program directors (PDs) and ROs and a second for radiation oncology residents and fellows, were designed by the investigators and reviewed by members of the Canadian Brachytherapy Group (CBG) and the RCPSC’s Specialty Committee in Radiation Oncology. The RO and PD survey was composed of 35 questions (17 questions about demographics and practice patterns, seven questions about teaching methods and assessment, one question about curriculum content, six questions on perceptions on resident education, and four questions about barriers to resident teaching). The residents’ and fellows’ survey was composed of 25 questions (9 demographic questions and 16 questions on teaching methods and curriculum content). Surveys were simultaneously designed in French and English. Surveys were hosted by SurveyMonkey (www.surveymonkey.com). Members of the RCPSC Specialty Committee in Radiation Oncology reviewed surveys. Research and ethics board approval was obtained from the British Columbia Cancer Agency Research Ethics Board before distribution of surveys. Surveys were distributed to all members (424 ROs, 41 fellows, and 98 residents) of the Canadian Association of Radiation Oncology by e-mail on May 30, 2013 with a followup e-mail 2 weeks later. Final data analyses were done with all responses received by August 30, 2013.
Table 1 Demographic characteristics ROs and PDs
N
%
97/119 22/119
82 18
4/119 81/119 34/119
3 68 29
109/114 5/114
96 4
39/120 14/120 14/120 18/120 35/120
32 12 12 15 29
47/108 18/108 46/108 24/108 31/108 14/108 14/108 3/108 14/108 14/108 12/108 18/108 5/108 27/108
44 17 43 22 29 13 13 3 13 13 11 17 5 25
Radiation oncologists and program directors
Location of practice Academic Community Type of practice PD RO with BT practice RO without BT practice BT available at respondent’s center Yes No Years in practice 0e5 6e10 10e15 16e20 O20 BT procedures performed Gynecologic (intracavitary cervix) Gynecologic (interstitial) Gynecologic (vaginal vault) Prostate HDR Prostate LDR Skin HDR Skin mold Breast LDR Breast HDR Esophagus HN Lung (endobronchial) Sarcoma No BT practice
One hundred twenty-one responses were received from ROs or PDs (response rate, 28.5%). Eighty-two percent
ROs 5 radiation oncologists; PDs 5 program directors; BT 5 brachytherapy; HDR 5 high dose rate; LDR 5 low dose rate; HN 5 head and neck.
Results
M. Gaudet et al. / Brachytherapy 14 (2015) 197e201
199
were mostly carried out by means of direct observation (63%), oral examinations (44%), and written examinations (33%). Twenty-nine percent of respondents stated not having a formal evaluation method for practical skills. The main barriers to BT teaching were stated as being the lack of Royal College guidance (55%), clinical workload (49%), lack of time (37%), and the fact that too much emphasis is placed on passing examinations (32%). Ninety-seven percent of respondents felt it was important or very important that BT be included in the mainstream radiation oncology curriculum. Results concerning which BT techniques respondents believed should be part of the main radiation oncology curriculum are presented in Fig. 1. Residents’ and fellows’ survey Twenty-two residents (two postgraduate year 1 [PGY1], three PGY2, six PGY3, five PGY4, and six PGY5, response rate 22.4%) and 10 fellows (response rate, 24.4%) responded to the survey with all eight provinces with residency training programs represented. Sixty-three percent of residents expressed a desire to pursue a BT fellowship, and this number rose to 91% if a BT fellowship could help them get a staff position. Sixty-nine percent stated being extremely motivated or very motivated to learn about BT, 25% moderately motivated, 3% slightly motivated, and 3% not at all motivated. Residents and fellows felt that BT teaching should be carried out by faculty ROs (100%), physicists (84%), fellows (75%), residents (35%), and outside experts (28%). Figure 2 shows to what extent residents and fellows were satisfied with their learning concerning each BT technique. The residents and fellows were most satisfied with the teaching with regard to vaginal vault, intracavitary cervix, low dose rate (LDR) prostate BT with 80%, 70%, 68%,
Fig. 2. Residents’ and fellows’ satisfaction with teaching for each brachytherapy technique. HDR 5 high dose rate; LDR 5 low dose rate; Gyn 5 gynecologic.
respectively, and being either very satisfied or satisfied with the teaching they had received thus far. The subsites for which they were least satisfied were sarcoma, head and neck (HN), and high dose rate (HDR) breast with 55%, 53%, and 51%, respectively, being dissatisfied or very dissatisfied with the teaching they had received thus far. The proportions of residents who felt that they were very competent or competent in performing BT procedures were the following for each subsite: cervix (86%), vaginal vault (83%), interstitial gynecologic BT (25%), HDR prostate (63%), LDR prostate (78%), LDR breast (6%), HDR breast (15%), esophagus (25%), HN (3%), lung (19%), and sarcoma (6%). Figure 3 shows residents’ perceived competency at performing each BT technique. Figure 4 also shows the proportion of residents and fellows who have observed BT procedures and the proportion of them who have actively participated in the procedures either with insertion/placement of applicators or planning and dosimetry. Because of small numbers we could not break these results down according to the training year, but the results were consistent in showing little exposure to less frequent sites even for senior residents, BT fellows, and those who described having a significant interest in BT. Credentialing process
Fig. 1. Brachytherapy techniques that ROs and residents/fellows agree or strongly agree should be included as part of the Royal College certification examinations. Gyn 5 gynecologic; LDR 5 low dose rate; HDR 5 high dose rate; RO 5 radiation oncologist; PD 5 program director.
The results of both residents, fellows, and ROs’ views on the possibility of a formal certification process in BT are shown in Fig. 5: 64% of ROs who responded either agreed or strongly agreed that BT should require a separate fellowship outside residency, whereas this was 76% for residents and fellows. Eighty percent of ROs and 81% of residents and fellows either agreed or strongly agreed that they would support formal postresidency certification process leading to RCPSC recognition of a diploma program in
200
M. Gaudet et al. / Brachytherapy 14 (2015) 197e201
Fig. 3. Residents’ and fellows’ perceived competency at performing each brachytherapy technique. HDR 5 high dose rate; LDR 5 low dose rate; Gyn 5 gynecologic.
BT. There were no clear demographic trends with regard to who was in favor of the certification process.
Discussion This survey has allowed us to gain valuable insight into the current state of BT teaching in Canada. Respondents were representative of all Canadian provinces but one and represented a diversity of community vs. academic ROs and those practicing BT and those not. We believe that this adds significant validity to our results. The relatively low response rate and heterogeneity of resident respondents can limit the interpretation of our data. However, of the 424 ROs surveyed, 81 of the 122 who responded practice BT. There are currently 86 members of the Canadian
Fig. 4. Proportion of residents and fellows who have observed brachytherapy procedures and the proportion of them who have actively participated in the procedures with either insertion/placement of applicators or planning and dosimetry. HDR 5 high dose rate; LDR 5 low dose rate; Gyn 5 gynecologic.
Fig. 5. Agreement with the fact that brachytherapy should require a separate fellowship outside radiation oncology training and the Royal College of Physicians and Surgeons of Canada’s intent to develop a certification process for brachytherapy. (a) Radiation oncologists and (b) residents and fellows.
Brachytherapy Group (CBG); with this, we could extrapolate that most of those responsible for teaching BT in Canada (who would very likely be CBG members) responded to the survey. Resident teaching in Canada is currently mostly carried out with didactic methods with most centers not having specific learning objectives in BT, in large, because of the lack of guidance documents from the RCPSC. This illustrates the importance of having a prespecified curriculum for teaching BT with specific learning objectives. Since the survey, Speciality Committee in Radiation Oncology and CBG have developed comprehensive national objectives and competencies in resident training in BT. These have been recently distributed to residency training programs. The CBG has also discussed the possibility of having BT fellowships spread out over several institutions to allow fellows to be exposed to many different BT subsites in centers of excellence. The fact that many senior residents and fellows in our survey lack exposure to rare BT sites, such as sarcoma and HN, further accentuates the need for collaborative fellowships likely through collaboration with members of the CBG or by developing collaboration with international BT centers of excellence. Our survey results also show the same trends as a recent survey of American residents that shows that exposure to interstitial procedures is going down (15). This is also reflected in our survey results by the fact that residents’
M. Gaudet et al. / Brachytherapy 14 (2015) 197e201
satisfaction and perceived competency were both much lower for interstitial as compared with intracavitary procedures. The American Board of Radiology has also brought forth a Focused Practice Recognition Initiative in Brachytherapy that would be a voluntary component of its Maintenance of certification program and would recognize those with extra training and significant experience in BT procedures. Rose et al. (12) also showed that many practicing Canadian ROs are performing less of certain BT techniques per year than is recommended in certain guidelines such as those from the United Kingdom (12, 16). We believe that these facts combined with the significant level of agreement of staff, residents, and fellows concerning a certification process in BT justifies the RCPSC’s initiatives to pursue such a credentialing process to ensure that Canadian ROs wishing to practice BT are adequately trained to do so. Most ROs in Canada practicing BT already have significant subspecialized training and/or experience in BT, which should also facilitate the credentialing of those already in practice. The new credentialing process will ensure uniform standards of training and patient care across Canada. The first trainees are expected to enter this program in Summer 2015.
References [1] Thwaites DI, Malicki J. Physics and technology in ESTRO and in Radiotherapy and Oncology: Past, present and into the 4th dimension. Radiother Oncol 2011;100:327e332. [2] Lemmens VE, Bosscha K, van der Schelling G, et al. Improving outcome for patients with pancreatic cancer through centralization. Br J Surg 2011;98:1455e1462. [3] Woo YL, Kyrgiou M, Bryant A, et al. Centralisation of services for gynaecological cancer. Cochrane Database Syst Rev 2012;3: CD007945.
201
[4] Keyes M, Morris WJ, Spadinger I, et al. Radiation oncology and medical physicists quality assurance in British Columbia Cancer Agency Provincial Prostate Brachytherapy Program. Brachytherapy 2013;12:343e355. [5] Morton G, Walker-Dilks C, Baldassarre F, et al. Delivery of brachytherapy for cervical cancer: Organisational and technical advice to facilitate high-quality care. Clin Oncol (R Coll Radiol) 2010;22:605e614. [6] Chan EK, Keyes M, Pickles T, et al. Decline in acute urinary toxicity: A long-term study in 2011 patients with prostate brachytherapy within a provincial institution. Brachytherapy 2014;13:46e52. [7] Liu HW, Malkoske K, Sasaki D, et al. The dosimetric quality of brachytherapy implants in patients with small prostate volume depends on the experience of the brachytherapy team. Brachytherapy 2010;9:202e207. [8] Keyes M, Schellenberg D, Moravan V, et al. Decline in urinary retention incidence in 805 patients after prostate brachytherapy: The effect of learning curve? Int J Radiat Oncol Biol Phys 2006;64:825e834. [9] Lee WR, deGuzman AF, Bare RL, et al. Postimplant analysis of transperineal interstitial permanent prostate brachytherapy: Evidence for a learning curve in the first year at a single institution. Int J Radiat Oncol Biol Phys 2000;46:83e88. [10] Harper JL, Jenrette JM, Vanek KN, et al. Acute complications of MammoSite brachytherapy: A single institution’s initial clinical experience. Int J Radiat Oncol Biol Phys 2005;61:169e174. [11] Fumagalli I, Faivre J, Bibault J, et al. Evaluation de la formation a la curietherapie des jeunes oncologues radiotherapeutes franc¸ais. [Brachytherapy training: a survey of French radiation oncology residents]. Cancer radiotherapie: J de la Societe francaise de radiotherapie oncologique 2011;15:624. [12] Rose J, McLaughlin PY, Falkson CB. Brachytherapy practice across Canada: A survey of workforce and barriers. Brachytherapy 2013;12: 615e621. [13] Sedlack RE. Training to competency in colonoscopy: Assessing and defining competency standards. Gastrointest Endosc 2011;74: 355e366. e1-2. [14] Crook J. American Brachytherapy Society Newsletter. 2012. [15] Compton JJ, Gaspar LE, Shrieve DC, et al. Resident-reported brachytherapy experience in ACGME-accredited radiation oncology training programs. Brachytherapy 2013;12:622e627. [16] Royal College of Radiologists. The role and development of brachytherapy services in the United Kingdom. London, England: Royal College of Radiologists; 2012.
