0360-3016/92 $5.00 + .oO Copyright (C: 1992 Pergamon Press Ltd.
1111J Radimon Oncology Emi. Phys Vol. 24. pp. 819-823 Printed in the U.S.A. All rights reserved.
??Special Feature
EDUCATION
IN RADIATION ONCOLOGY IN EUROPE
J. W. H. LEER, M.D., J. DAVELAAR, ESTRO Secretariat, Department
PH.D.,
of Radiotherapy,
J. OVERGAARD,
M.D.
University Hospital, Capucijnenvoer
AND G. HEEREN* 35, Leuven, Belgium
The outcome of an inventory among 22 European countries with respect to the radiotherapy facilities and the training of new radiation oncologists in each country is described. The radiotherapeutic profession, which mostly prescribes also cytostatics or hormones, has become well-regulated in the last 20 years. Most radiation oncologists are also involved in the diagnostic work-up and follow-up of the cancer patient. The numbers of radiotherapists and other staff, treatment capacities, and patients are given. The training for radiation oncologists is mostly taken at the university centers, but the curricula are rather diverse. Radiation oncology, Radiotherapy,
Education.
of breast cancer can be the interest of gynecology in one country and of general surgery in another. In conclusion, there is no uniform European medical system nor an uniform training program for medicine and there is no such thing as European Specialty of Radiotherapy. The European Society for Therapeutic Radiology and Oncology (ESTRO) has recognized this along with the need for an exchange of ideas on this issue as a first step toward more uniform training programs, creating the possibility of a mutual acceptance among them. As a start, ESTRO has tried to map the situation in Europe. It was felt necessary not only to investigate training programs but also to investigate the organization of the specialty in the different countries, because this was supposed to have a relation with training requirements. To this aim two questionnaires were developed. The first pilot questionnaire was sent out in 1986 to individual members of the society we knew were interested in the subject. A corrected version was sent in 1989 to officially appoint representatives of the national radiation oncology societies in these countries. A second questionnaire aimed for more information about the theoretical training and was sent out in 1990. The analyses of these questionnaires were checked together with these representatives in meetings, which were made possible by a grant of the European Community.
INTRODUCTION
Bordersin Europe are rapidly disappearing, not only for trade but also for the mobility of students and scientists. The European Commission has initiated programs to facilitate the possibility for students to study at different universities in Europe (e.g., the Erasmus program) and for scientists to work in another European country. Nationality is no longer allowed to hamper a medical doctor to practice in a country other than his native country. However, the mobility of scientists, including medical specialists, can only become successful if their skills are more or less comparable and generally accepted throughout the different European countries. For that, we need a system of mutual accreditation of training programs, for instance as already exists in the United States. The situation in Europe is, however, quite different from the one in the United States and can hardly be compared. First of al! Europeans do not share a common language. In the 12 countries of the European Community nine completely different languages are already spoken. Also the educational systems in the European countries are varying widely, which is also true for the training programs in medicine. In addition, the legal regulations and requirements, with respect to the medical profession, differ. The organization of the medical specialties is not the same in the different countries. For instance, the treatment Reprint requests to J. W. H. Leer. * On behalf of the committee on education of ESTRO and the representatives of the national societies in this matter: S. Allman, D. Ash, M. Bamberg, G. Baris, N. Bilge, D. Chassagne. L. Cionini, J. M. Dubois, R. G. B. Evans, J. Evensen, J. GravenBattle, J. P. Gerard, G. Heeren, A. Hliniak, J. M. Hlfliger, H. P. Heilmann, J. C. Horiot, A. B. Jacobsen, M. Kinai, H. D. Kogelnik, J. Kuhelj, T. Landberg, J. W. H. Leer, B. Littbrand, A. Mayer, B. Mijnheer, 1. Monteiro-Grillo, M. Moriarty, J.
Overgaard, I. Petschen-Verdaguer, S. Pirhonen, W. Rhomberg, P. Scalliet, M. E. Silvestre, E. Siracka, G. G. Steel, H. Svensson, N. Throuvalas, W. van Daal, W. van den Bogaert, E. van der Schueren, H. von der Maase. Acknowledgement-The activities of the Committee on education were supported by the Erasmus program (Grants no. STV 88-B-O 193, STV 89-B-0209 and ICP 90-B-01 70). Accepted for publication 15 June 1992. 819
I. J. Radiation Oncology 0 Biology 0 Physics
820
The results of these questionnaires are described below and the present situation of the education in radiotherapy in Europe is discussed. METHODS
involved
in the two questionnaires First
Austria Belgium Czechoslovakia Denmark Finland France Germany Greece Hungary Ireland Israel Italy Norway Poland Portugal Rumania Spain Sweden Switzerland The Netherlands Turkey United Kingdom
Cumulative
number
of countries
20r
AND MATERIALS
Description of the questionnaires The first questionnaire comprised two parts: The first part contained questions about the specialty “radiotherapy,” the way it is organized in the different countries and its relation to other oncological specialties. The second part asked for information about the training of radiation oncologists. In part one we wanted to have an answer on the question whether the therapeutic use of x-rays was represented by a specialty itself (radiation oncology) or whether this was still a part of an other specialty (e.g., radiology together with diagnostic radiology or oncology together with medical oncology). We also asked whether radiation oncologists were prescribing other anticancer treatments (e.g., cytostatic drugs, hormones) and whether radiation oncologists were involved in the diagnostic work up and follow-up of their patients. Finally part one dealt with the position of other oncological specialties in relation to radiation oncology. In addition questions about population size, the numbers of radiotherapy machines, patients, and workers in the field of radiotherapy were meant to obtain a better insight in the infrastructure of the specialty in Europe. Through the answers to the questions in part two we wanted to obtain information about the duration of the training program, the way it was organized, and whether the program was a national one or differed from training
Table 1. Countries
Volume 24, Number 5, 1992
Second
X
X
X
X
X X
X
X X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X X
X
X
X
X X
X
X
X
X
X
0 1950
1960
Year of official
1970
recognition
1990
1960
of radiation
oncology
Fig. 1. Year of official recognition of radiation oncology as independent specialty in 22 European countries. The cumulative number of countries, in which the specialty was recognized is related to the year of recognition.
to institute. In the second questionnaire we looked in more detail at the requirements before the start of the training and the contents of the theoretical and practical training in radiation oncology.
institute
Results The questionnaire was sent to national representatives of the radiation oncology profession in the 22 countries. In a number of countries more persons responded, leading to 44 responders of the first questionnaire, representing these 22 countries (Table 1). The first questionnaire Part 1: information on the specialty. In all 22 countries the therapeutic use of x-rays is reserved to an independent medical specialty in itself, most commonly named “radiation oncology.” This specialty is officially recognized in 95% of the countries by government or law and occasionally only by professional bodies. In three countries radiation oncology is officially combined with medical oncology in a specialty named oncology which includes all non-surgical treatments of cancer. In two of these countries there is, in addition, an official separation between gynecological oncology and general oncology. In these countries the doctors are disease-oriented rather than treatment modality-orientated. The year of recognition of the specialty of radiation oncology is given in Figure 1. With the exception of one country the radiation oncologist also prescribes systemic anticancer treatments, mostly cytostatic drugs and endocrine treatment. In six countries radiation oncology is the only officially recognized oncological specialty. In most countries the other specialties dealing with oncology, although often not officially recognized as an independent oncological specialty, are: medical oncology (often as a part of internal medicine) in most countries, surgical oncology in two, haematology in five, and twice oncological gynaecology.
821
European radiation oncology education 0 J. W. H. LEER et al.
In all countries the radiation oncologist is involved in the diagnostic work-up and follow-up of new cancer patients and in 82% before the decision to treat with irradiation has been taken. The extent of this involvement is still unclear and supposed to differ widely. The number of newly registered cancer patients and new radiotherapy patients per year are summarized in Figures 2a and 2b as a percentage of the population. A “new” radiotherapy patient is defined as a patient treated with radiation for the first time in his life. Similarly, the number of radiation oncologists and physicists can be expressed per million inhabitants and an overview is given in the Figures 3a and 3b. To provide an insight in the radiotherapeutic treatment capacity in the various countries the number of new radiotherapy patients per year is shown in the Figures 4a, 4b and 4c, divided by the number of radiotherapists, physicists and high energy machines (Linacs and Co-60), respectively. Part 2: information on the training for radiation oncologists. In 19 out of 22 countries official national teaching program guidelines exist, which are the responsibility of the government (57%) and/or the national society and training institute (7 1%). There was no regulation on a national level in two countries. The actual programs are
Number of countries Radiation
o-2
New cancer
patients
averaged
. 0.34
% per year
1
0 - 0.1 %
-Radiation
a
0.2 - 0.3 %
Percentage I
0.3 - 0.4 %
0.4 - 0.5 %
of population
Cancer
patients
Number of countries 14
Radiotherapy
ca8e8
averaged
- 0.13 % per year
I
0 - 0.1 %
b
0.1 - 0.2 %
0.2 - 0.3 %
0.3 - 0.4 %
Percentage
of population
m
caae8
Radiotherapy
0.4 - 0.5 %
Fig. 2. (a) Number of new cancer patients per year in percentages of the population. The figure shows the spread of these percentages in 22 European countries. (b) Number of new radiotherapy cases per year in percentages of the population. The spread of these percentages in 22 European countries is shown as in Figure 2a.
6-8
6 - 10
. 6.2
B 10
Oncologlat
Number of countries 10 Phywzists 1
o-2
on average t
2-4
* 3.1
4-6
6-6
0 - 10
’ 10
Number per million inhabitants -Physicist
Fig. 3. (a) Number of radiation oncologists per million inhabitants and their spread in 22 European countries. (b) Number of physicists per million inhabitants and their spread in 22 European countries.
Id .__
0.1 - 0.2 %
4-6
on average
Number per million inhabitants
b umber of countries
2-4
Oncolog!st.9
usually organized by the national societies and/or the hospitals where the training is provided (86%) and the outcome is checked by the government in 32% and national societies in 73% of the cases. The overall impression is as follows: mostly the government or a national board endorsed by the government makes a rough outline prescribing the number of training years and the other aspects which should be dealt with such as the need for examinations. However, the extent to which official regulations are given is quite different. A more detailed program is consequently provided by the national societies and implemented at the level of the training hospitals. The freedom of the individual training hospitals to adapt the program to their own preferences is not known in detail yet, but it seems different for the various countries. The training programs show a diversity of subjects, which mostly but not solely encompass radiotherapy, physics, biology, chemotherapy and internal medicine. However, the curriculae we have received differed widely. The total duration of the programs ranges from 3 to 6 years, but is mostly 4 or 5 years. An average of 290 hrs are spent on pure theoretical training. The variation in hours however ranged from 195 to 700. Examinations are required in 73% of the countries, which is usually also the license qualification for the trainee. The training is largely paid by the government, training hospital or university,
a22
I. J. Radiation Oncology 0 Biology0 Physics
Number of countries 141
Patents per
Radiotherapist
on
average
Volume 24, Number 5, 1992
no radiation oncologists are unemployed time.
m 219
at the present
12 10
1
1
8642L
O0 - 100
100 - 200
200
- 400
400
- 600
600
- 800000
Number of new radiotherapy a
m
10
8
-1000
a 1000
patients
Radiotherapists
Number of countries
1/
Patients
per
Physicist
on average
- 540
1
0 - 200
200
-400
400
-800
600
-800
) 1000
800-1000
Number of new radiotherapy patients b
The second questionnaire The second questionnaire was answered by 17 countries (see Table 1) and the analysis turned out to be even more difficult than that of the first questionnaire. An additional training before the start of the pure radiotherapy-training is officially required in twelve countries: gynaecology in two (3 months); internal medicine in eight (3- 12 months); surgery in five (3-6 months) and radiodiagnostics in one (18 months). In some countries different combinations of training periods were possible in the above mentioned specialties. Occasionally paediatrics, haematology, primary health care, and psychiatry were mentioned as possibilities. Only one respondent indicated that the whole training program was based on a pure master-apprentice relation without any formally organised lectures or courses. In the other countries, preplanned teaching courses or lectures are given mostly in physics, biology, epidemiology, statistics, radiodiagnostics, pathology, radiation oncology, and medical oncology. However, the time spent on them differs widely from only a few hours a year to more than 100 hr a year. Only seven respondents indicated that preplanned theoretical training programs were more or less the same in all training institutes in their country.
Number of countries
10 3
Patient8 8A
on average
per
machine.
DISCUSSION
457
I
I
0-i
4 T\
0 - 200
ZOO-
400
400
- 600
600
- 800
800-1000
~1000
Number of new radiotherapy patients C
m
LINACSICO-60
Fig. 4. (a) Ratios between the number of new radiotherapy patients and the number of radiation oncologists and their spread in 22 European countries. (b) Ratios between the number of new radiotherapy patients and the number of physicists and their spread in 22 European countries. (c) Ratios between the number of new radiotherapy patients and the number of megavoltage machines and their spread in 22 European countries.
however for 19% it was stated that the trainee should pay himself. In 86% of the countries there are no legal requirements for continuous postgraduate training. The number of positions in a particular country is determined by the government (50%), or the hospital/university or national society (50%). The yearly production of trainees in radiation oncology is on the average 0.75 person per 1 million inhabitants with, however, a large range from 0.1 to 2.4. It could also be concluded that in Europe almost
Europe is slowly growing toward an economical unity, but also in other aspects borders are disappearing. Student mobility is stimulated by grants and the possibilities to work in other than the native country are created. This is also true for the medical profession and consequently also for the radiation oncologists. This new situation creates the need for mutual recognition of training programs and a system for accreditation and certification. Before this system can be created, it is necessary to get a better insight in the present state of the training programs-ESTRO tried, therefore, to create a platform for an exchange of information on training in radiotherapy, The national societies are supporting this enterprise enthusiastically and appointed national representatives. With the help of two inventories and two meetings granted by the European Community to correct the answers and analyses, we are now able to present a first outline of the European situation. Generally speaking, this is quite different from the situation in North America. Europe is not a federal state, which means that every country has its own language, its own education system, and its own organization of the medical profession. Radiation oncology is an independent specialty in all countries investigated and is officially part of a broader non-surgical oncological specialty in three. It is very important to realize this, because only lo-20
European radiation oncology education 0 J. W. H. LEER et (I/.
years ago (Fig. I), radiotherapy in most countries was a part of radiology, together with radiodiagnosticians and often outnumbered by the latter. In most European countries, radiation oncologists form the largest group officially (by law) recognized full time oncologists. Medical oncology, surgical oncology, etc. are mostly part of internal medicine or general surgery and no independent officially recognized specialties. European radiation oncologists should be aware of this and should promote themselves as such. It could help them to increase their influence on political decision making in medicine, especially in the field of oncology. Radiation oncologists are and should be involved in the diagnostic workup and follow-up of patients and their integral treatment, not seldomly also including the systemic treatment of cancer. To stress this point, the term radiotherapist is avoided in most countries and some even prefer oncologist or clinical oncologist instead of radiation oncologist. The degree of involvement in the diagnostic workup and the systemic treatment is quite different in various countries. Training programs should in any case provide the radiation oncologists with the knowledge and skills to remain generally accepted as oncologists and to enable them to follow the rapid developments in diagnostics, medical oncology, immunology, genetics, and supportive care. The number of cancer patients, new radiotherapy cases, radiation oncologists, and equipment presented here should be looked at with great reservation. Cancer registration is probably far from optimal in a large number of countries, which could also hamper manpower planning in radiotherapy. National societies should have a good insight in the epidemiology of cancer in their country to plan infrastructure and to estimate the expected need for radiation oncologists and trainees. Looking at the ratio between new cancer patients and new radiotherapy patients our figures indicate that there exists a substantial under consumption of radiotherapy in some countries. If this picture changes, and it should, this could also have an impact on manpower planning and the need for training facilities. The ratio between patients and radiation oncologists, physicians and machines should be interpreted with great care. They are influenced by regional differences in the incidence of certain cancer types, the
823
organization of the profession (e.g., only radiotherapy or non-surgical oncology) and the availability of other personnel (e.g., technical assistants, technicians, etc.). These figures tell very little about the workload in an individual country. However, in some countries there exists a real shortage and for those this information could be useful. The overall picture of the training program itself is that of great variety which is partly caused by differences in official regulations and requirements in the different countries. On the other hand some main elements could be recognized in all training programs. The issues dealt with in the theoretical training are very similar in most countries; however, the actual organization of the program varies enormously as well as the number of hours spent on these issues. The practical training seems to be mainly based on the master apprentice system in which the trainee learns directly from a more experienced radiation oncologist. There is mostly much freedom to create training programs (both practical and theoretical) on an institutional basis as long as these programs are within certain guidelines prescribed by the government, national bodies, or societies. The institute or teacher is regularly site-visited and accreditated for a couple of years in a number of countries. Examinations are not required at all in six countries, but are in the others however mostly not on a national basis. One has to be very careful to conclude that this overview would suggest that, because of this variety, the training in radiation oncology in Europe is bad and the level low. We are sure the opposite is true. This overview only illustrates that at present there is no uniform European training in radiotherapy (radiation oncology). However, if we want to follow the developments which take place in Europe we have to agree on a more or less uniform curriculum and we have to agree on an indication of the level of knowledge we want the trainee to acquire in each area of oncology. We also have to create a system of examinations as an objective check, which can serve as a basis for mutual recognition. The first step has been made by the acceptance of an European curriculum by 20 countries in March 199 1 (Radiotherapy and Oncology 22, 199 1). The next steps will follow, slowly but surely, and ESTRO hopes that it can remain the platform for the cooperation in education in radiation oncology in Europe.
1111J Radimon Oncology Emi. Phys Vol. 24. pp. 819-823 Printed in the U.S.A. All rights reserved.
??Special Feature
EDUCATION
IN RADIATION ONCOLOGY IN EUROPE
J. W. H. LEER, M.D., J. DAVELAAR, ESTRO Secretariat, Department
PH.D.,
of Radiotherapy,
J. OVERGAARD,
M.D.
University Hospital, Capucijnenvoer
AND G. HEEREN* 35, Leuven, Belgium
The outcome of an inventory among 22 European countries with respect to the radiotherapy facilities and the training of new radiation oncologists in each country is described. The radiotherapeutic profession, which mostly prescribes also cytostatics or hormones, has become well-regulated in the last 20 years. Most radiation oncologists are also involved in the diagnostic work-up and follow-up of the cancer patient. The numbers of radiotherapists and other staff, treatment capacities, and patients are given. The training for radiation oncologists is mostly taken at the university centers, but the curricula are rather diverse. Radiation oncology, Radiotherapy,
Education.
of breast cancer can be the interest of gynecology in one country and of general surgery in another. In conclusion, there is no uniform European medical system nor an uniform training program for medicine and there is no such thing as European Specialty of Radiotherapy. The European Society for Therapeutic Radiology and Oncology (ESTRO) has recognized this along with the need for an exchange of ideas on this issue as a first step toward more uniform training programs, creating the possibility of a mutual acceptance among them. As a start, ESTRO has tried to map the situation in Europe. It was felt necessary not only to investigate training programs but also to investigate the organization of the specialty in the different countries, because this was supposed to have a relation with training requirements. To this aim two questionnaires were developed. The first pilot questionnaire was sent out in 1986 to individual members of the society we knew were interested in the subject. A corrected version was sent in 1989 to officially appoint representatives of the national radiation oncology societies in these countries. A second questionnaire aimed for more information about the theoretical training and was sent out in 1990. The analyses of these questionnaires were checked together with these representatives in meetings, which were made possible by a grant of the European Community.
INTRODUCTION
Bordersin Europe are rapidly disappearing, not only for trade but also for the mobility of students and scientists. The European Commission has initiated programs to facilitate the possibility for students to study at different universities in Europe (e.g., the Erasmus program) and for scientists to work in another European country. Nationality is no longer allowed to hamper a medical doctor to practice in a country other than his native country. However, the mobility of scientists, including medical specialists, can only become successful if their skills are more or less comparable and generally accepted throughout the different European countries. For that, we need a system of mutual accreditation of training programs, for instance as already exists in the United States. The situation in Europe is, however, quite different from the one in the United States and can hardly be compared. First of al! Europeans do not share a common language. In the 12 countries of the European Community nine completely different languages are already spoken. Also the educational systems in the European countries are varying widely, which is also true for the training programs in medicine. In addition, the legal regulations and requirements, with respect to the medical profession, differ. The organization of the medical specialties is not the same in the different countries. For instance, the treatment Reprint requests to J. W. H. Leer. * On behalf of the committee on education of ESTRO and the representatives of the national societies in this matter: S. Allman, D. Ash, M. Bamberg, G. Baris, N. Bilge, D. Chassagne. L. Cionini, J. M. Dubois, R. G. B. Evans, J. Evensen, J. GravenBattle, J. P. Gerard, G. Heeren, A. Hliniak, J. M. Hlfliger, H. P. Heilmann, J. C. Horiot, A. B. Jacobsen, M. Kinai, H. D. Kogelnik, J. Kuhelj, T. Landberg, J. W. H. Leer, B. Littbrand, A. Mayer, B. Mijnheer, 1. Monteiro-Grillo, M. Moriarty, J.
Overgaard, I. Petschen-Verdaguer, S. Pirhonen, W. Rhomberg, P. Scalliet, M. E. Silvestre, E. Siracka, G. G. Steel, H. Svensson, N. Throuvalas, W. van Daal, W. van den Bogaert, E. van der Schueren, H. von der Maase. Acknowledgement-The activities of the Committee on education were supported by the Erasmus program (Grants no. STV 88-B-O 193, STV 89-B-0209 and ICP 90-B-01 70). Accepted for publication 15 June 1992. 819
I. J. Radiation Oncology 0 Biology 0 Physics
820
The results of these questionnaires are described below and the present situation of the education in radiotherapy in Europe is discussed. METHODS
involved
in the two questionnaires First
Austria Belgium Czechoslovakia Denmark Finland France Germany Greece Hungary Ireland Israel Italy Norway Poland Portugal Rumania Spain Sweden Switzerland The Netherlands Turkey United Kingdom
Cumulative
number
of countries
20r
AND MATERIALS
Description of the questionnaires The first questionnaire comprised two parts: The first part contained questions about the specialty “radiotherapy,” the way it is organized in the different countries and its relation to other oncological specialties. The second part asked for information about the training of radiation oncologists. In part one we wanted to have an answer on the question whether the therapeutic use of x-rays was represented by a specialty itself (radiation oncology) or whether this was still a part of an other specialty (e.g., radiology together with diagnostic radiology or oncology together with medical oncology). We also asked whether radiation oncologists were prescribing other anticancer treatments (e.g., cytostatic drugs, hormones) and whether radiation oncologists were involved in the diagnostic work up and follow-up of their patients. Finally part one dealt with the position of other oncological specialties in relation to radiation oncology. In addition questions about population size, the numbers of radiotherapy machines, patients, and workers in the field of radiotherapy were meant to obtain a better insight in the infrastructure of the specialty in Europe. Through the answers to the questions in part two we wanted to obtain information about the duration of the training program, the way it was organized, and whether the program was a national one or differed from training
Table 1. Countries
Volume 24, Number 5, 1992
Second
X
X
X
X
X X
X
X X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X X
X
X
X
X X
X
X
X
X
X
0 1950
1960
Year of official
1970
recognition
1990
1960
of radiation
oncology
Fig. 1. Year of official recognition of radiation oncology as independent specialty in 22 European countries. The cumulative number of countries, in which the specialty was recognized is related to the year of recognition.
to institute. In the second questionnaire we looked in more detail at the requirements before the start of the training and the contents of the theoretical and practical training in radiation oncology.
institute
Results The questionnaire was sent to national representatives of the radiation oncology profession in the 22 countries. In a number of countries more persons responded, leading to 44 responders of the first questionnaire, representing these 22 countries (Table 1). The first questionnaire Part 1: information on the specialty. In all 22 countries the therapeutic use of x-rays is reserved to an independent medical specialty in itself, most commonly named “radiation oncology.” This specialty is officially recognized in 95% of the countries by government or law and occasionally only by professional bodies. In three countries radiation oncology is officially combined with medical oncology in a specialty named oncology which includes all non-surgical treatments of cancer. In two of these countries there is, in addition, an official separation between gynecological oncology and general oncology. In these countries the doctors are disease-oriented rather than treatment modality-orientated. The year of recognition of the specialty of radiation oncology is given in Figure 1. With the exception of one country the radiation oncologist also prescribes systemic anticancer treatments, mostly cytostatic drugs and endocrine treatment. In six countries radiation oncology is the only officially recognized oncological specialty. In most countries the other specialties dealing with oncology, although often not officially recognized as an independent oncological specialty, are: medical oncology (often as a part of internal medicine) in most countries, surgical oncology in two, haematology in five, and twice oncological gynaecology.
821
European radiation oncology education 0 J. W. H. LEER et al.
In all countries the radiation oncologist is involved in the diagnostic work-up and follow-up of new cancer patients and in 82% before the decision to treat with irradiation has been taken. The extent of this involvement is still unclear and supposed to differ widely. The number of newly registered cancer patients and new radiotherapy patients per year are summarized in Figures 2a and 2b as a percentage of the population. A “new” radiotherapy patient is defined as a patient treated with radiation for the first time in his life. Similarly, the number of radiation oncologists and physicists can be expressed per million inhabitants and an overview is given in the Figures 3a and 3b. To provide an insight in the radiotherapeutic treatment capacity in the various countries the number of new radiotherapy patients per year is shown in the Figures 4a, 4b and 4c, divided by the number of radiotherapists, physicists and high energy machines (Linacs and Co-60), respectively. Part 2: information on the training for radiation oncologists. In 19 out of 22 countries official national teaching program guidelines exist, which are the responsibility of the government (57%) and/or the national society and training institute (7 1%). There was no regulation on a national level in two countries. The actual programs are
Number of countries Radiation
o-2
New cancer
patients
averaged
. 0.34
% per year
1
0 - 0.1 %
-Radiation
a
0.2 - 0.3 %
Percentage I
0.3 - 0.4 %
0.4 - 0.5 %
of population
Cancer
patients
Number of countries 14
Radiotherapy
ca8e8
averaged
- 0.13 % per year
I
0 - 0.1 %
b
0.1 - 0.2 %
0.2 - 0.3 %
0.3 - 0.4 %
Percentage
of population
m
caae8
Radiotherapy
0.4 - 0.5 %
Fig. 2. (a) Number of new cancer patients per year in percentages of the population. The figure shows the spread of these percentages in 22 European countries. (b) Number of new radiotherapy cases per year in percentages of the population. The spread of these percentages in 22 European countries is shown as in Figure 2a.
6-8
6 - 10
. 6.2
B 10
Oncologlat
Number of countries 10 Phywzists 1
o-2
on average t
2-4
* 3.1
4-6
6-6
0 - 10
’ 10
Number per million inhabitants -Physicist
Fig. 3. (a) Number of radiation oncologists per million inhabitants and their spread in 22 European countries. (b) Number of physicists per million inhabitants and their spread in 22 European countries.
Id .__
0.1 - 0.2 %
4-6
on average
Number per million inhabitants
b umber of countries
2-4
Oncolog!st.9
usually organized by the national societies and/or the hospitals where the training is provided (86%) and the outcome is checked by the government in 32% and national societies in 73% of the cases. The overall impression is as follows: mostly the government or a national board endorsed by the government makes a rough outline prescribing the number of training years and the other aspects which should be dealt with such as the need for examinations. However, the extent to which official regulations are given is quite different. A more detailed program is consequently provided by the national societies and implemented at the level of the training hospitals. The freedom of the individual training hospitals to adapt the program to their own preferences is not known in detail yet, but it seems different for the various countries. The training programs show a diversity of subjects, which mostly but not solely encompass radiotherapy, physics, biology, chemotherapy and internal medicine. However, the curriculae we have received differed widely. The total duration of the programs ranges from 3 to 6 years, but is mostly 4 or 5 years. An average of 290 hrs are spent on pure theoretical training. The variation in hours however ranged from 195 to 700. Examinations are required in 73% of the countries, which is usually also the license qualification for the trainee. The training is largely paid by the government, training hospital or university,
a22
I. J. Radiation Oncology 0 Biology0 Physics
Number of countries 141
Patents per
Radiotherapist
on
average
Volume 24, Number 5, 1992
no radiation oncologists are unemployed time.
m 219
at the present
12 10
1
1
8642L
O0 - 100
100 - 200
200
- 400
400
- 600
600
- 800000
Number of new radiotherapy a
m
10
8
-1000
a 1000
patients
Radiotherapists
Number of countries
1/
Patients
per
Physicist
on average
- 540
1
0 - 200
200
-400
400
-800
600
-800
) 1000
800-1000
Number of new radiotherapy patients b
The second questionnaire The second questionnaire was answered by 17 countries (see Table 1) and the analysis turned out to be even more difficult than that of the first questionnaire. An additional training before the start of the pure radiotherapy-training is officially required in twelve countries: gynaecology in two (3 months); internal medicine in eight (3- 12 months); surgery in five (3-6 months) and radiodiagnostics in one (18 months). In some countries different combinations of training periods were possible in the above mentioned specialties. Occasionally paediatrics, haematology, primary health care, and psychiatry were mentioned as possibilities. Only one respondent indicated that the whole training program was based on a pure master-apprentice relation without any formally organised lectures or courses. In the other countries, preplanned teaching courses or lectures are given mostly in physics, biology, epidemiology, statistics, radiodiagnostics, pathology, radiation oncology, and medical oncology. However, the time spent on them differs widely from only a few hours a year to more than 100 hr a year. Only seven respondents indicated that preplanned theoretical training programs were more or less the same in all training institutes in their country.
Number of countries
10 3
Patient8 8A
on average
per
machine.
DISCUSSION
457
I
I
0-i
4 T\
0 - 200
ZOO-
400
400
- 600
600
- 800
800-1000
~1000
Number of new radiotherapy patients C
m
LINACSICO-60
Fig. 4. (a) Ratios between the number of new radiotherapy patients and the number of radiation oncologists and their spread in 22 European countries. (b) Ratios between the number of new radiotherapy patients and the number of physicists and their spread in 22 European countries. (c) Ratios between the number of new radiotherapy patients and the number of megavoltage machines and their spread in 22 European countries.
however for 19% it was stated that the trainee should pay himself. In 86% of the countries there are no legal requirements for continuous postgraduate training. The number of positions in a particular country is determined by the government (50%), or the hospital/university or national society (50%). The yearly production of trainees in radiation oncology is on the average 0.75 person per 1 million inhabitants with, however, a large range from 0.1 to 2.4. It could also be concluded that in Europe almost
Europe is slowly growing toward an economical unity, but also in other aspects borders are disappearing. Student mobility is stimulated by grants and the possibilities to work in other than the native country are created. This is also true for the medical profession and consequently also for the radiation oncologists. This new situation creates the need for mutual recognition of training programs and a system for accreditation and certification. Before this system can be created, it is necessary to get a better insight in the present state of the training programs-ESTRO tried, therefore, to create a platform for an exchange of information on training in radiotherapy, The national societies are supporting this enterprise enthusiastically and appointed national representatives. With the help of two inventories and two meetings granted by the European Community to correct the answers and analyses, we are now able to present a first outline of the European situation. Generally speaking, this is quite different from the situation in North America. Europe is not a federal state, which means that every country has its own language, its own education system, and its own organization of the medical profession. Radiation oncology is an independent specialty in all countries investigated and is officially part of a broader non-surgical oncological specialty in three. It is very important to realize this, because only lo-20
European radiation oncology education 0 J. W. H. LEER et (I/.
years ago (Fig. I), radiotherapy in most countries was a part of radiology, together with radiodiagnosticians and often outnumbered by the latter. In most European countries, radiation oncologists form the largest group officially (by law) recognized full time oncologists. Medical oncology, surgical oncology, etc. are mostly part of internal medicine or general surgery and no independent officially recognized specialties. European radiation oncologists should be aware of this and should promote themselves as such. It could help them to increase their influence on political decision making in medicine, especially in the field of oncology. Radiation oncologists are and should be involved in the diagnostic workup and follow-up of patients and their integral treatment, not seldomly also including the systemic treatment of cancer. To stress this point, the term radiotherapist is avoided in most countries and some even prefer oncologist or clinical oncologist instead of radiation oncologist. The degree of involvement in the diagnostic workup and the systemic treatment is quite different in various countries. Training programs should in any case provide the radiation oncologists with the knowledge and skills to remain generally accepted as oncologists and to enable them to follow the rapid developments in diagnostics, medical oncology, immunology, genetics, and supportive care. The number of cancer patients, new radiotherapy cases, radiation oncologists, and equipment presented here should be looked at with great reservation. Cancer registration is probably far from optimal in a large number of countries, which could also hamper manpower planning in radiotherapy. National societies should have a good insight in the epidemiology of cancer in their country to plan infrastructure and to estimate the expected need for radiation oncologists and trainees. Looking at the ratio between new cancer patients and new radiotherapy patients our figures indicate that there exists a substantial under consumption of radiotherapy in some countries. If this picture changes, and it should, this could also have an impact on manpower planning and the need for training facilities. The ratio between patients and radiation oncologists, physicians and machines should be interpreted with great care. They are influenced by regional differences in the incidence of certain cancer types, the
823
organization of the profession (e.g., only radiotherapy or non-surgical oncology) and the availability of other personnel (e.g., technical assistants, technicians, etc.). These figures tell very little about the workload in an individual country. However, in some countries there exists a real shortage and for those this information could be useful. The overall picture of the training program itself is that of great variety which is partly caused by differences in official regulations and requirements in the different countries. On the other hand some main elements could be recognized in all training programs. The issues dealt with in the theoretical training are very similar in most countries; however, the actual organization of the program varies enormously as well as the number of hours spent on these issues. The practical training seems to be mainly based on the master apprentice system in which the trainee learns directly from a more experienced radiation oncologist. There is mostly much freedom to create training programs (both practical and theoretical) on an institutional basis as long as these programs are within certain guidelines prescribed by the government, national bodies, or societies. The institute or teacher is regularly site-visited and accreditated for a couple of years in a number of countries. Examinations are not required at all in six countries, but are in the others however mostly not on a national basis. One has to be very careful to conclude that this overview would suggest that, because of this variety, the training in radiation oncology in Europe is bad and the level low. We are sure the opposite is true. This overview only illustrates that at present there is no uniform European training in radiotherapy (radiation oncology). However, if we want to follow the developments which take place in Europe we have to agree on a more or less uniform curriculum and we have to agree on an indication of the level of knowledge we want the trainee to acquire in each area of oncology. We also have to create a system of examinations as an objective check, which can serve as a basis for mutual recognition. The first step has been made by the acceptance of an European curriculum by 20 countries in March 199 1 (Radiotherapy and Oncology 22, 199 1). The next steps will follow, slowly but surely, and ESTRO hopes that it can remain the platform for the cooperation in education in radiation oncology in Europe.
