Simulation-based graduate medical education in MR-guided brachytherapy for cervical cancer

PurposeBrachytherapy is critical for the curative treatment of locally advanced cervical cancer. Although brachytherapy use is declining in the United States (U.S.), novel interstitial or intracavitary applicators and advances in image guidance for applicator placement and treatment planning have allowed for tumor dose escalation while reducing normal tissue toxicity. Recent survey data have suggested insufficient brachytherapy training for radiation oncology trainees in the United States. This study aimed to address these gaps by developing and piloting a simulation-based education (SBE) workshop for MR-guided cervical cancer brachytherapy.Methods and MaterialsAn SBE workshop was developed for graduate medical education (GME) trainees focusing on MR-guided brachytherapy for cervical cancer. Four hands-on stations, simulating aspects of the procedure, were led by a team of gynecological brachytherapy experts. The learners were radiation oncology residents and fellows in a U.S. GME training program. The primary outcome was feasibility, assessed by completion of the workshop within the time constraints of the curriculum. Learners completed preworkshop and postworkshop surveys to provide information on efficacy.ResultsThe workshop was successfully completed in a 1-h block of GME didactic time. Ten trainees completed all four stations, and all completed preworkshop and postworkshop surveys, which showed improvements in knowledge and technical proficiency. Feedback was positive, and trainees requested additional learning opportunities.ConclusionsThis study showed that GME-focused SBE in MR-guided cervical cancer brachytherapy was feasible. SBE provided a nonclinical environment in which to practice aspects of MR-guided brachytherapy. Ongoing work includes collaboration with other U.S. institutions. Future studies should focus on international adaptation.     

The American Brachytherapy Society prostate brachytherapy LDR/HDR simulation workshops: Hands-on,step-by-step training in the process of quality assurance

PurposeEducation and training on prostate brachytherapy for radiation oncology and medical physics residents in the United States is inadequate, resulting in fewer competent radiation oncology personnel to perform implants, and is a factor in the subsequent decline of an important, potentially curative cancer treatment modality for patients with cancer. The American Brachytherapy Society (ABS) leadership has recognized the need to establish a sustainable medical simulation low-dose-rate (LDR) and high-dose-rate (HDR) brachytherapy workshop program that includes physician–physicist teams to rapidly translate knowledge to establish high-quality brachytherapy programs.MethodsThe ABS, in partnership with industry and academia, has held three radiation oncology team–based LDR/HDR workshops composed of physician–physicist teams in Chicago in 2017, in Houston in 2018, and in Denver in 2019. The predefined key metric of success is the number of attendees who returned to their respective institutions and were actively performing brachytherapy within 6 months of the prostate brachytherapy workshop.ResultsOf the 111 physician/physicist teams participating in the Chicago, Houston, and Denver prostate brachytherapy workshops, 87 (78%) were actively performing prostate brachytherapy (51 [59%] HDR and 65 [75%] LDR).ConclusionsThe ABS prostate brachytherapy LDR/HDR simulation workshop has provided a successful education and training structure for medical simulation of the critical procedural steps in quality assurance to shorten the learning curve for delivering consistently high-quality brachytherapy implants for patients with prostate cancer. An ABS initiative, intended to bend the negative slope of the brachytherapy curve, is currently underway to train 300 new competent brachytherapy teams over the next 10 years.     

Gynecologic interstitial brachytherapy curriculum using a low-cost phantom with ultrasound workshop and a treatment planning workshop is effective

PURPOSE/OBJECTIVE(S)Standardized simulation training geared towards interstitial brachytherapy (IS BT) for gynecologic malignancies is lacking in radiation oncology resident education. We developed and implemented a curriculum for IS BT training with (1) lecture on equipment, workflow, and guidelines, (2) hands-on ultrasound-guided IS BT workshop, and (3) treatment planning workshop.METHODS AND MATERIALThe cost in materials of each phantom was approximately $66. After a lecture, two alternating workshops were performed. The first session consisted of a hands-on ultrasound-guided IS BT workshop with one resident imaging the phantom with a transabdominal ultrasound probe and the other resident implanting the phantom with needles. A second session consisted of a hands-on treatment planning workshop using BrachyVision and an l-Q spreadsheet with the following objectives: coverage goal, meeting D2cc constraints, and minimizing V200. The primary outcome was improvement in knowledge assessed with Likert-style questions and objective knowledge-based questions (KBQs).RESULTSFour of the seven medical residents that participated in this curriculum had prior IS BT experience. Residents reported significantly improved knowledge regarding gynecologic IS BT equipment and procedure, evaluating gynecologic anatomy using ultrasound, CT simulation, contouring, and plan review (overall median pre-session subjective score 2 (1) ^{? (}3) versus post-session score 4 (3) ^{? (}4, p < 0.01). Residents demonstrated improvement in answering KBQs correctly from 44% correct at baseline to 88% after completion of the curriculum (p < 0.01). All residents “Agree” and “Strongly Agree” the session was an effective learning experience.CONCLUSIONSResidents participating in phantom training with an ultrasound curriculum and a treatment planning session is effective for improving knowledge and skills in IS BT for radiation oncology residents.     

Development,implementation, and outcomes of a simulation-based medical education (SBME) prostate brachytherapy workshop for radiation oncology residents

PurposeDespite a preponderance of data demonstrating strong clinical outcomes and cost-effectiveness, prostate brachytherapy use and competency continue to decline. Enhanced resident education may help reverse this trend. We therefore developed and implemented a simulation-based medical education course for low-dose-rate prostate brachytherapy (LDR-PB).Materials and MethodsA 1-week LDR-PB course comprised four 1-h lectures on clinical outcomes, physics, radiobiology, and anatomy/contouring, followed by a 4.5-h simulation session on ultrasound-guided prostate phantom implantation, was developed for radiation oncology residents at an academic institution. A 10-statement Likert-scale survey and 20-question multiple-choice test were administered 1 week before and 4 weeks after the course.ResultsPrecourse and postcourse instruments were completed by 24 and 20 residents, respectively. The median number of prior LDR-PB cases after at least one genitourinary rotation was 10.5 (range 5–20). Overall mean test scores were significantly improved (55% before the course vs 68% after the course; p = 0.010). Mean Likert scores significantly increased on nine of 10 survey statements and were significantly increased overall (2.4 before the course vs 3.3 after the course, p < 0.001). When asked about interest in performing brachytherapy after residency, 37.5% of residents “agreed” or “strongly agreed” before the course vs 50% after the course (p = 0.41). Those with higher postresidency brachytherapy interest (scores of 4–5 vs 1–3) had significantly more LDR-PB cases (11.2 vs 5.3 cases; p = 0.005).ConclusionsA 1-week simulation-based medical education course for LDR-PB can improve didactic performance and self-reported technical competence/confidence, and may increase overall enthusiasm for brachytherapy. Future studies at our institution will incorporate evaluation of implant quality and assessment of procedural competence into this framework. Residency programs should dedicate resources to this essential component of radiation oncology.     

Establishing a simulation-based education program for radiation oncology learners in permanent seed implant brachytherapy: Building validation evidence

PurposeThe purpose of this study was to establish a simulation-based education program for radiation oncology learners in permanent seed implant brachytherapy. The first step in formalizing any education program is a validation process that builds evidence-based verification that the learning environment is appropriate.Methods and MaterialsThe primary education task allowed practitioners to use an anthropomorphic breast phantom to simulate a permanent seed implant brachytherapy delivery. Validation evidence is built by generating data to assess learner and expert cohorts according to their proficiency. Each practitioner's performance during the simulation was evaluated by seed placement accuracy, procedural time-to-complete, and two qualitative evaluation tools—a global rating scale and procedural checklist.ResultsThe average seed placement accuracy (±SD) was 8.1 ± 3.5 mm compared to 6.1 ± 2.6 mm for the learner and expert cohort, respectively. The median (range) procedural time-to-complete was 64 (60–77) minutes and 43 (41–50) minutes for the learner and expert cohort, respectively. Seed placement accuracy (student t-test, p < 0.05) and procedural time-to-complete (Mann–Whitney U-test, p < 0.05) were statistically different between the cohorts. In both the global rating scale and procedural checklist, the expert cohort demonstrated improved proficiency compared to the learner cohort.ConclusionsThis validation evidence supports the utilization of this simulation environment toward appropriately capturing the delivery experience of practitioners. The results demonstrate that, in all areas of evaluation, expert cohort proficiency was superior to learner cohort proficiency. This methodology will be used to establish a simulation-based education program for radiation oncology learners in permanent seed implant brachytherapy.     

Feasibility of deploying a U.S. simulation-based gynecological brachytherapy educational workshop to an international setting

PurposeA decline in brachytherapy (BT) use for cervical cancer has negatively affected cure rates in the United States and abroad. To improve trainee exposure to BT, a simulation-based educational curriculum incorporating a pelvic mannequin was developed and implemented at several U.S. residency programs. We sought to describe an initial experience with deployment of this curriculum to an international setting.Methods and MaterialsThe setting was in Israel, a middle eastern country with cervical cancer incidence of 5–8 cases per 100,000 women. Israel was selected for this pilot because of its desire to increase exposure to trainees, lack of mandatory BT case requirements, and few residencies nationally. In determining the feasibility of deployment to this setting, a partnership was formed between a U.S. and Israeli brachytherapist to understand cultural context and institutional and logistical needs. Feasibility was defined as successful completion of the workshop. Trainee comfort and knowledge with BT was assessed with preworkshop and postworkshop surveys, with changes compared.ResultsThe curriculum was incorporated into a 1-day course on gynecologic malignancies, with adaptation to local setting and routine. Among 15 attendees, eight were residents, from four programs. All completed the workshop. All domains assessed by the surveys improved and all respondents found the program to be helpful.ConclusionsInternational deployment of the simulation-based educational BT curriculum was feasible and well-received. Further collaboration is needed to deploy and adapt the curriculum to countries of high cervical cancer incidence that could benefit from increased education.     

Resident-reported brachytherapy experience in ACGME-accredited radiation oncology training programs

PurposeTo describe resident-reported experience in brachytherapy in Accreditation Council of Graduate Medical Education–accredited radiation oncology training programs over the last 5 years.Methods and MaterialsArchived reports of Accreditation Council of Graduate Medical Education final resident case logs from the last 5 years were reviewed and summarized. Brachytherapy was categorized according to the dose rate (low dose rate vs. high dose rate), technique (interstitial vs. intracavitary), and primary tumor site. Linear regression was used to test for trends.ResultsThe mean number of total brachytherapy procedures performed per resident in the last 5 years has decreased from 80.8 in 2006–2007 to 71.0 in 2010–2011, but the trend is not statistically significant. The average number of intracavitary procedures has remained steady. The average resident experience with interstitial brachytherapy has decreased in a statistically significant manner. The average number of interstitial procedures has decreased by 25%.ConclusionsThe average number of interstitial procedures reported by residents has decreased by 25%. The community charged with training residents in interstitial brachytherapy should consider methods to ensure that residents obtain sufficient experience in the future.     

Multimaterial three-dimensional printing in brachytherapy: Prototyping teaching tools for interstitial and intracavitary procedures in cervical cancers

PurposeAs the utilization of brachytherapy procedures continues to decline in clinics, a need for accessible training tools is required to help bridge the gap between resident comfort in brachytherapy training and clinical practice. To improve the quality of intracavitary and interstitial high-dose-rate brachytherapy education, a multimaterial, modular, three-dimensionally printed pelvic phantom prototype simulating normal and cervical pathological conditions has been developed.Methods and MaterialsPatient anatomy was derived from pelvic CT and MRI scans from 50 representative patients diagnosed with localized cervical cancer. Dimensions measured from patients’ uterine body and uterine canal sizes were used to construct a variety of uteri based off of the averages and standard deviations of the subjects in our study. Soft-tissue anatomy was three-dimensionally printed using Agilus blends (shore 30 and 70) and modular components using Vero (shore 85).ResultsThe kit consists of four uteri, a standard bladder, a standard rectum, two embedded gross tumor volumes, and four clip-on gross tumor volume attachments. The three anteverted uteri in the kit are based on the smallest, the average, and the largest dimensions from our patient set, whereas the retroverted uterus assumes average dimensions.ConclusionsThis educational high-dose-rate gynecological pelvic phantom is an accessible and cost-effective way to improve radiation oncology resident training in intracavitary/interstitial brachytherapy cases. Implementation of this phantom in resident education will allow for more thorough and comprehensive physician training through its ability to transform the patient scenario. It is expected that this tool will help improve confidence and efficiency when performing brachytherapy procedures in patients.     

Multi-Institutional Implementation and Evaluation of a Curriculum for the Medical Student Clerkship in Radiation Oncology

PurposeRadiation oncology curriculum development is challenging because of limited numbers of trainees at any single institution. The goal of this project is to implement and evaluate a standardized medical student clerkship curriculum following the multi-institutional cooperative group research model.MethodsDuring the 2013 academic year, a standardized curriculum was implemented at 11 academic medical centers consisting of three 1-hour lectures and a hands-on radiation treatment planning workshop. After the curriculum, students completed anonymous evaluations using Likert-type scales (1 = “not at all” to 5 = “extremely”) and free responses. Evaluations asked students to rate their comfort, before and after the curriculum, with radiation oncology as a specialty, knowledge of radiotherapy planning methods, and ability to function as a radiation oncology resident. Nonparametric statistical tests were used in the analysis.ResultsEighty-eight students at 11 academic medical centers completed the curriculum de novo, with a 72.7% (64 of 88) survey response rate. Fifty-seven students (89.1%) reported intent to pursue radiation oncology as their specialty. Median (interquartile range) student ratings of the importance of curricular content were as follows: overview, 4 (4-5); radiation biology/physics, 5 (4-5); practical aspects/emergencies, 5 (4-5); and planning workshop, 4 (4-5). Students reported that the curriculum helped them better understand radiation oncology as a specialty (5 [4-5]), increased specialty decision comfort (4 [3-5]), and would help the transition to radiation oncology residency (4 [4-5]). Students rated their specialty decision comfort significantly higher after completing the curriculum (4 [4-5] versus 5 [5-5]; P < .001).ConclusionsA national standardized curriculum was successfully implemented at 11 academic medical centers, providing proof of principle that curriculum development can follow the multi-institutional cooperative group research model.     

Still Coming Out of the Dark: Enduring Effects of Simulation-Based Communication Skills Training for Radiology Residents—Four-Year Follow-Up

PurposeTo evaluate the long-term efficacy of simulation-based communication skills training for radiology residents.Method and MaterialsThe simulation-based communication skills training curriculum was developed in 2014. The curriculum included a teaching module based on the essential elements of communication. Two sets of 6 communication scenarios encountered by radiologist were created. First and fourth year radiology residents reviewed the teaching module and completed the 6 simulated scenarios. They then underwent debriefing sessions, received faculty and staff evaluations. Four years later, the former first year residents (now fourth years) reviewed the teaching module again and repeated the simulation. They again underwent debriefing sessions after the simulation. This time the residents’ communication skills were evaluated by faculty and staff.ResultsA total of 5 residents participated in this simulation-based skills training. The resident performance 4 years after initial training show not only that residents maintained their improved scores, but also that their scores improved further as compared to after the initial training. The average overall score for all but 1 resident increased at the 4 year follow-up simulation. From 2014 to 2018, the average score of all the residents increased from 72.4% to 81.4%. Comparison of the average scores of each student across 6 stations from 2014 to 2018 showed a statistically significant difference between the scores after 4 years (P = 0.014).ConclusionsSimulation-based communication skills training is effective and long lasting.     

American Brachytherapy Society (ABS) consensus statement for soft-tissue sarcoma brachytherapy

PurposeGrowing data supports the role of radiation therapy in the treatment of soft tissue sarcoma (STS). Brachytherapy has been used for decades in the management of STS and can be utilized as monotherapy or as a boost to external beam radiation. We present updated guidelines from the American Brachytherapy Society regarding the utilization of brachytherapy in the management of STS.Methods and MaterialsMembers of the American Brachytherapy Society with expertise in STS and STS brachytherapy created an updated clinical practice guideline including step-by-step details for performing STS brachytherapy based on a literature review and clinical experience.ResultsBrachytherapy monotherapy should be considered for lower-recurrence risk patients or after a local recurrence following previous external beam radiation; a brachytherapy boost can be considered in higher-risk patents meeting implant criteria. Multiple dose/fractionation regimens are available, with determination based on tumor location and treatment intent. Techniques to limit wound complications are based on the type of wound closure; wound complication can be mitigated with a delay in the start of brachytherapy with immediate wound closure or by utilizing a staged reconstruction technique, which allows an earlier treatment start with a delayed wound closure.ConclusionsThese updated guidelines provide clinicians with data on indications for STS brachytherapy as well as guidelines on how to perform and deliver high quality STS brachytherapy safely with minimal toxicity.     

ACR–ABS–ASTRO practice parameter for the performance of radionuclide-based high-dose-rate brachytherapy

purposeThis practice parameter aims to detail the processes, qualifications of personnel, patient selection, equipment, patient and personnel safety, documentation, and quality control and improvement necessary for an HDR brachytherapy program.Methods and MaterialsThis practice parameter was revised collaboratively by the American College of Radiology (ACR), the American Brachytherapy Society (ABS), and the American Society for Radiation Oncology (ASTRO).ResultsBrachytherapy is a radiotherapeutic modality in which radionuclide or electronic sources are used to deliver a radiation dose at a distance of up to a few centimeters by surface, intracavitary, intraluminal, or interstitial application. Brachytherapy alone or combined with external beam radiotherapy plays an important role in the management and treatment of patients with cancer. High-dose-rate (HDR) brachytherapy uses radionuclides, such as iridium-192, at dose rates of ≥12 Gy/hr to a designated target point or volume, and it is an important treatment for a variety of malignant and benign conditions. Its use allows for application of high doses of radiation to defined target volumes with relative sparing of adjacent critical structures.ConclusionsHDR brachytherapy requires detailed attention to personnel, equipment, patient and personnel safety, and continuing staff education. Coordination between the radiation oncologist and treatment planning staff and effective quality assurance procedures are important components of successful HDR brachytherapy programs.     

American Brachytherapy Society radiation oncology alternative payment model task force: Quality measures and metrics for brachytherapy

PurposeBrachytherapy is an essential technique to deliver radiation therapy and is involved in the treatment of multiple disease sites as monotherapy or as an adjunct to external beam radiation therapy. With a growing focus on the cost and value of cancer treatments as well as new payment models, it is essential that standardized quality measures and metrics exist to allow for straightforward assessment of brachytherapy quality and for the development of clinically significant and relevant clinical data elements. We present the American Brachytherapy Society consensus statement on quality measures and metrics for brachytherapy as well as suggested clinical data elements.Methods and MaterialsMembers of the American Brachytherapy Society with expertise in disease site specific brachytherapy created a consensus statement based on a literature review and clinical experience.ResultsKey quality measures (ex. workup, clinical indications), dosimetric metrics, and clinical data elements for brachytherapy were evaluated for each modality including breast cancer, cervical cancer, endometrial cancer, prostate cancer, keratinocyte carcinoma, soft tissue sarcoma, and uveal melanoma.ConclusionsThis consensus statement provides standardized quality measures and dosimetric quality metrics as well as clinical data elements for each disease site to allow for standardized assessments of brachytherapy quality. Moving forward, a similar paradigm can be considered for external beam radiation therapy as well, providing comprehensive radiation therapy quality measures, metrics, and clinical data elements that can be incorporated into new payment models.     

Addressing the burden of cervical cancer through IAEA global brachytherapy initiatives

PurposeBrachytherapy (BT) is an essential component of definitive therapy for locally advanced cervical cancer. Despite the advantages of the dose distribution with BT in cervical cancer, there is paucity of specific skills required for good-quality BT applications. Furthermore, replacing BT with other modern external beam techniques as a boost can lead to suboptimal results in cervix cancer.Methods and MaterialsReview of available IAEA resources, research and cooperation programs available from the IAEA was completed. These opportunities can be used to address challenges in Brachytherapy.The International Atomic Energy Agency (IAEA) provides support for BT through various means that includes education and training, both long term, short term and continuing medical education of professionals, providing expert visits to support implementation, development of curricula for professionals, e-learning through the human health campus, contouring workshops, 2D to 3D BT training, and virtual tumor boards. In addition, the IAEA provides support for implementing quality assurance in radiotherapy to its member states and provides guidelines for comprehensive audits in radiation therapy (QUATRO), and produces safety standards and training in radiation safety. In addition, mapping BT resources, making the case for investment and support for setting up BT services and radiotherapy centers are also available. The IAEA Dosimetry Laboratory provides calibration services to Secondary Standards Dosimetry Laboratories for well chambers used to confirm the reference air kerma rate of Co60 and Ir192 high-dose-rate BT sources, as well as for Cs137 low-dose-rate sources.Furthermore, the IAEA supports research and development in radiotherapy (and BT) through coordinated research activities that include controlled randomized clinical trials, Patterns of Care studies among others. Partnerships with professional organizations and funding bodies, as well as through the United Nations Joint Global Programme on Cervical Cancer Prevention and Control support radiotherapy activities, including BT in countries worldwide.ConclusionThe IAEA supports brachytherapy implementation, training and research and provides resources to professionals in the area.     

Geographic access to brachytherapy services in the United States

PURPOSEDisparities in geographic access to medical care exist in nearly all fields of medicine including radiation oncology. We aim to update knowledge of the geographic distribution of radiation oncologists in the United States.METHODS AND MATERIALSWe used the Physician and Other Supplier Public Use File (PUF) from the Centers for Medicare & Medicaid Services (CMS) as well as the International Atomic Energy Agency (IAEA) Directory of Radiotherapy Centers (DIRAC) database to identify practices that either coded for or are marked as having access to brachytherapy services. Geographic analysis was performed on several levels including United States (US) Census region, Dartmouth Atlas Healthcare Referral Region, and the county level.RESULTSWe identified 327 providers that billed for a brachytherapy code during the calendar year 2018 and 564 facilities providing brachytherapy. Within the 306 HRRs in the US, 149 have access to brachytherapy. This represents 247.5 million people based on 2018 estimates of population from the US Census Bureau. This implies that 76.7% of people within the US live in an HRR with access to brachytherapy, and, conversely, that 75.3 million people (23.3%) do not. Numerically, counties in metropolitan areas were more likely to have access to brachytherapy than those outside of a metropolitan area.CONCLUSIONSGeographic disparities exist in access to brachytherapy; metropolitan counties are more likely to have access than non-metropolitan counties. We support continued development of databases of brachytherapy providers and programs that may support travel and lodging costs to minimize these disparities.