Development of a gynecologic brachytherapy curriculum and simulation modules to improve radiation oncology trainees’ skills and confidence

Role of simulation-based training and assessment to improve brachytherapy competency among radiation oncology residents

Simulation is a technique used in healthcare to replicate clinical scenarios and improve patient safety, efficacy, and efficiency. Simulation-based medical education facilitates training and assessment in healthcare without increasing risk to patients, supported by ample evidence from surgical/procedural specialties. Simulation in radiation oncology has been leveraged to an extent, with successful examples of both screen-based and hands-on simulators that have improved confidence and performance in trainees. In the current era, evidence substantiates a significant deficit in brachytherapy procedure education, with radiation oncology residents reporting low confidence in this procedural skill, largely attributable to insufficient caseloads at some centers. Simulation-based medical education can facilitate structured training and competency-based assessment in brachytherapy skills. This review discusses existing advances and future directions in brachytherapy simulation, using examples from simulation in surgical specialties.

Can an in-person hands-on applicator-based teaching session improve trainee knowledge and comfort with complex gynecologic brachytherapy?

INTRODUCTION

With the emergence of imaged-based planning and hybrid applicators the complexity of gynecologic brachytherapy has dramatically increased. Despite the known advantages of brachytherapy, notable national declines in utilization of brachytherapy have been documented. Clearly improved education in the sphere of gynecologic brachytherapy is needed. We hypothesize that a hands-on applicator-based training session would improve trainee comfort with gynecologic brachytherapy.

METHODS AND MATERIALS

An in-person, applicator-based, hands-on training session was held with trainees from both radiation and gynecologic oncology programs. Trainees practiced assembling and handling applicators while receiving instruction on clinical scenarios in which various applicators are used in gynecologic cancer brachytherapy. Pre- and post-session, participants were administered an objective test of 10 pictorial-based case vignettes to quantify ability to select the correct applicator based on the interpretation of T2-weighted MR images. Participants additionally received a subjective survey to quantify comfort and experience with gynecologic brachytherapy using Likert-type question formatting.

RESULTS

A total of 14 trainees participated. Most common case volume experience was 0-10 intracavitary (57%), 0-10 hybrid (71%), and 0-10 interstitial (71%). Pre-session, the most common answer to comfort level was "not comfortable still learning" for all brachytherapy types, and most common answer to largest gap in knowledge was all facets of brachytherapy. Average case-based test score was 3.5/10 pre-session versus 5.3/10 post-session (p = 0.028). Post-session, all respondents reported improved comfort level with brachytherapy. Post-session, most common answer to largest gap in knowledge was applicator/patient selection, and applicator/patient selection was also the largest area of identified improvement. 100% of participants felt repeating the session in the future would be helpful.

CONCLUSIONS

Hands-on training with applicators improves both subjective and objective comfort with gynecologic brachytherapy. With 100% of participants requesting to implement this session into resident training, we suggest national opportunities might exist to expand educational processes and improve utilization of complex gynecologic brachytherapy in practice.

Improving the quality of care and patient safety in oncology, the contribution of simulation-based training: A scoping review

Objective

Simulation-based training (SBT) is an effective educational method widely used in many clinical settings, including oncology. This study aimed to undertake a scoping review of research related to SBT in oncology to provide a comprehensive understanding of the role of SBT in enhancing the skills of healthcare professionals and thereby improving the quality of care and patient safety in oncology.

Methods

We conducted a scoping review to map published studies in Medline, Scopus, and Web of Science databases. Peer-reviewed articles about data on the role of SBT in improving and enhancing the skills of healthcare professionals in oncology published in English and French from 2012 to 2022 were retrieved. Two researchers screened, extracted, and analyzed all identified studies independently.

Results

Of the 1,013 publications identified in the initial phase, 29 studies were included in the analysis. Twenty-five of these studies focused on non-technical skills, such as decision-making, communication, teamwork, and cognitive abilities. Thirteen studies focused on technical skills. The results of all included studies showed significant improvement in the skills of oncology healthcare professionals through SBT programs. Fourteen studies subjectively assessed the role of this educational tool, while nine objectively evaluated it. Six studies used a combined subjective and objective evaluation method.

Conclusions

SBT is a very effective tool for improving the skills of healthcare professionals in oncology. Supporting and promoting SBT is essential to providing high-quality care and ensuring patient safety in all areas of health care.

Survey on brachytherapy training among radiation oncology residents in the German-speaking regions of Europe

PURPOSE

This survey aimed to determine the perception of brachytherapy training among residents in the DACH region, consisting of Austria, Germany and Switzerland.

MATERIAL & METHODS

An online questionnaire containing 22 questions related to trainee demographics (n = 5) and to brachytherapy training (n = 17) was sent in two iterations in 11/2019 and 02/2020. The following topics were evaluated: institutional support, barriers to training, extent of training, site-specific training (prostate, gynaecology, breast, gastrointestinal and skin), preferences for further training and outlook on overall development of brachytherapy. The responses were mostly based on a Likert scale of 1 to 5, thereby reflecting strength of opinion. Descriptive statistics were used to describe frequencies.

RESULTS

Among the 108 respondents, approximately 69% of residents considered the ability to perform brachytherapy independently to be important or somewhat important. However, only 31% of respondents reported to have a dedicated brachytherapy training during residency. The major limitation to achieve independence in performing brachytherapy was seen in a low case load in Austria, in the lack of training in Switzerland and in both of them in Germany.

CONCLUSION

The interest in brachytherapy training among residents in German-speaking countries was generally high, but there is a perceived lack of sufficient case volumes and partially also in formal training opportunities. Fellowships at departments with a high case load as part of a formalised curriculum and dedicated hands-on workshops at national or international conferences might help to overcome these issues.

Challenges in the Sustainability of Brachytherapy Service in Contemporary Radiotherapy

Brachytherapy has a long history of delivering a highly conformal radiation dose to the target volume with sparing of adjacent normal tissue and has an irreplaceable role in certain cancers, such as cervical and prostate cancers. There have been futile attempts to replace brachytherapy with other radiation techniques. Despite that there are multifaceted challenges in preserving this dying art, from establishment, to a trained workforce, to maintenance of the equipment and source replacement costs. Here we focus on the challenges to access brachytherapy, the availability and distribution of care across the globe and appropriate training leading to proper implementation of the procedure. Brachytherapy holds a significant place in the treatment armamentarium of most common cancers, such as cervical, prostate, head and neck and skin cancers. However, there is an uneven distribution of brachytherapy facilities, not only across the globe, but also at a national level, with a larger proportion of facilities concentrated in certain regions, more so in low and low-middle income countries. The regions with the highest incidence of cervical cancer have the least access to brachytherapy facilities. Attempts to bridge the gap are essential and should be focused on uniform distribution and access to care, improving training of the workforce through specialised training programmes, reducing the cost of care, planning to reduce the recurring cost, generating evidence and research guidelines, renewing interest in brachytherapy through rebranding, use of social media and building an attainable long-term roadmap.

Investigation of standardized training of radiation oncology residents for gynaecological tumours in China

BACKGROUND

Radiotherapy standardized training (ST) has been conducted for 7 years in China. This investigation evaluated the difficulties of and need for ST of radiation oncology residents (RORs) for gynaecological tumours (GYN) in China.

METHODS

An anonymous online survey was conducted on the "Questionnaire Star" platform. The questionnaire contained 30 questions, including the basic information of the students, their knowledge of radiotherapy theory, training on GYN, the difficulties and needs they faced, and possible solutions.

RESULTS

A total of 469 valid questionnaires were collected, resulting in a valid response rate of 85.3%. During the ST, only 58-60% of RORs received training in GYN, with a median clinical rotation time of 2-3 months. Among the RORs surveyed, 50.1% knew the physical characteristics of brachytherapy (BRT), and 49.2% could choose the appropriate BRT for patients. At the end of ST, 75.3% were able to complete the target delineation in GYN independently, and 56% were able to complete the BRT operation independently. The scarcity of GYN patients, insufficient teaching awareness of superior doctors, and lack of interest are the main reasons why ST cannot meet the standard.

CONCLUSION

In China, the ST of RORs in GYN should be strengthened, the teaching awareness of specialist trainers should be increased, and the curriculum should be optimized, especially the curriculum for specialist operation and a strict assessment system.

Implementing a simulation-based curriculum for hybrid intracavitary/interstitial brachytherapy using a new, commercially available, US/MR/CT-compatible gynecologic phantom

PURPOSE

To establish a simulation-based workshop for teaching hybrid intracavitary/interstitial (IC/IS) brachytherapy skills using a new, commercially available US/CT/MRI-compatible gynecologic phantom prototype.

METHODS AND MATERIALS

The VIOMERSE gynecological trainer phantom consisted of tissue-like colloid material and was US, CT, and MRI-compatible. We designed a hands-on workshop incorporating the phantom prototype to teach skills for hybrid IC/IS brachytherapy including pre-implant planning, procedural steps of implant placement, and post-implant evaluation. The workshop impact was evaluated with pre- and post-workshop surveys and responses were analyzed with Wilcoxon matched-pairs signed-rank test.

RESULTS

Thirteen residents, divided into small groups, attended one of three separate 1-h workshop sessions held during the gynecologic education block. Workshop steps included IC applicator placement, tumor mapping and pre-planning desired location and depth of needles for hybrid IC/IS application, IS needle labelling and insertion, image review of needle placements, comparison of IC-alone versus IC/IS brachytherapy plans. Responses to questions ascertaining knowledge, confidence, and ability in planning and executing hybrid IC/IS procedures all demonstrated significant improvement from pre- to post-workshop. In response to whether the session was an effective learning experience, all residents rated the workshop with a score of 9 (n = 1) or 10 (n = 12) out of 10, with a score of 10 indicating "strongly agree."

CONCLUSIONS

Implementation of a hybrid IC/IS brachytherapy workshop utilizing a new, commercially-available phantom prototype was successful, with clear, subjective benefit for the residents in our program. This experience may inform continued efforts towards standardizing brachytherapy curricula across programs and increasing trainee exposure to interstitial procedures.

Implementation of online workshops on image-guided adaptive brachytherapy (interventional radiotherapy) in locally advanced cervical cancer: Experience of BrachyAcademy

PURPOSE

To provide educational support to brachytherapy users during the COVID-19 pandemic, online workshops were developed and implemented by BrachyAcademy, non-profit peer-to-peer educational initiative in Elekta.

METHODS AND MATERIALS

In 2021-2022 two online workshops were organized. Participating teams had to send a clinical case of locally advanced cervical cancer (LACC) including brachytherapy Digital Imaging and Communications in Medicine (DICOM) files and questions to the faculty. During the workshop, feedback was given to each clinical case by five faculty members (two Radiation Oncologists, one Radiologist, two Medical Physicists). Participants competed a post-workshop questionnaire which included combination of qualitative and quantitative questions via yes/no responses, Likert scale, and 1 to 10 scale.

RESULTS

Twenty-one teams from eight countries (Europe, Asia, Latin America) participated in two online workshops. The total number of participants was 49. The clinical cases represented LACC with The International Federation of Gynecology and Obstetrics (FIGO) stages from IB3 to IVA. During both, Workshop1 (W1) and Workshop 2 (W2) the following areas of improvement were identified: familiarity with the GEC ESTRO and The International Commission on Radiation Units & Measurements, Report 89 (ICRU 89) recommendations for contouring and planning based on clinical drawings and MRI sequencing choice; appropriate applicator selection; experience with interstitial needles; appropriate applicator reconstruction; dose optimization. The participants rated both workshops with overall scores 8,3 for W1, and 8,5 for W2. In 82% participants the training course fully met expectations for W1, and in 76% in W2.

CONCLUSIONS

We successfully implemented the online workshops on image-guided adaptive brachytherapy (IGABT) in LACC. Main performance issues and areas for improvement were identified based on multidisciplinary discussion of participant's clinical cases through all steps of the brachytherapy procedure. We encourage teams to consider online workshops in addition to hands-on training.

Brachytherapy training survey among radiation oncology residents in Europe

We aim to investigate the current state of brachytherapy (BT) training among the radiation oncology trainees in Europe.

MATERIAL AND METHODS

A 22-question online survey based on the one by the American Association of Radiation Oncology Residents (2017) with added queries pertinent to training in Europe was sent to 1450 residents in two iterations. These included site-specific training, volume of experience, barriers to training, institutional support, and preferences for further education. Responses to individual statements were given on a 1 to 5 Likert-type scale. The answers were reported by junior (≤3 years of training) and senior years of training (year of training 4/5/6 and junior staff). Descriptive statistics were used to describe frequencies.

RESULTS

Residents from 21 European countries participated, 445 (31%) responded. 205 (47%) were senior residents. 60% residents consider that performing BT independently at the end of residency is very or somewhat important. Confidence in joining a brachytherapy practice at the end of residency was high or somewhat high in 34% of senior residents. They reported as barriers to achieving independence in BT to be lack of appropriate didactic/procedural training from supervisors (47%) and decreased case load (31%). 68% reported their program lacks a formal BT curriculum and standardized training assessment.

CONCLUSIONS

Residents in Europe, feel independent BT practice is very or somewhat important, but do not feel confident they will achieve this goal. To address this gap, efforts are needed to develop and implement a formal and comprehensive BT curriculum with easy access to trained instructors.

Challenges in the transition to independent radiation oncology practice and targeted interventions for improvement

Numerous radiation oncology residents and junior attendings have identified common weaknesses in residency training that hinder the transition from training to independent practice. Recurrent themes include not only general autonomy but also proficiency in technical skills, such as treatment plan review and image verification, and nontechnical skills, such as leadership, mentorship, and education. While multiple strategies to address these deficiencies have been investigated, many are not widely available or may be difficult to implement. We aim to summarize the frequently cited challenges in the transition to independent radiation oncology practice as well as the pertinent interventions that have been explored.

Treatment of cervical cancer: overcoming challenges in access to brachytherapy

INTRODUCTION

Brachytherapy is an essential component of the cervical cancer treatment paradigm as it contributes to improved clinical outcomes and overall survival. Yet brachytherapy remains globally underutilized, with disparities in access at both national and international levels.

AREAS COVERED

The review explores current brachytherapy utilization practices and efforts being undertaken to address barriers to implementation in low-, middle-, and high-income countries, and how these efforts are projected to impact future brachytherapy access. The content presented is based on a review of published literature and the authors' collective clinical experiences.

EXPERT OPINION

There exists a tremendous opportunity to expand access to essential brachytherapy services for women with cervical cancer. Many national and international brachytherapy efforts exist; yet it remains imperative that such focused efforts continue to grow and provide further access to this critical treatment modality for women in need worldwide.

Education in gynecological brachytherapy

Brachytherapy is an essential component in the curative treatment of many gynecological malignancies. In the past decade, advances in magnetic resonance imaging and the ability to adapt and customize treatment with hybrid interstitial applicators have led to improved clinical outcomes with decreased toxicity. Unfortunately, there has been a shift in clinical practice away from the use of brachytherapy in the United States. The decline in brachytherapy is multifactorial, but includes both a lack of exposure to clinical cases and an absence of standardized brachytherapy training for residents. In other medical specialties, a clear relationship has been established between clinical case volumes and patient outcomes, especially for procedural-based medicine. In surgical residencies, simulation-based medical education (SBME) is a required component of the program to allow for some autonomy before operating on a patient. Within radiation oncology, there is limited but growing experience with SBME for training residents and faculty in gynecological brachytherapy. This review includes single institutional, multi-institutional and national initiatives using creative strategies to teach the components of gynecological brachytherapy. These efforts have measured success in various forms; the majority serve to improve the confidence of the learners, and many have also demonstrated improved competence from the training as well. The American Brachytherapy Society launched the 300 in 10 initiative in 2020 with a plan of training 30 competent brachytherapists per year over a 10 year period and has made great strides with a formal mentorship program as well as externships available to senior residents interested in starting brachytherapy programs. Moving forward, these curricula could be expanded to provide standardized brachytherapy training for all residents. SBME could also play a role in initial certification and maintenance of certification. Given the burden of disease, it would be valuable to develop similar training for providers in low and middle income countries.

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 MATERIAL

The 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).

RESULTS

Four 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.

CONCLUSIONS

Residents 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.

Virtual reality-based simulation improves gynecologic brachytherapy proficiency, engagement, and trainee self-confidence

PURPOSE

Intracavitary brachytherapy is critical in treatment of cervical cancer with the highest rates of local control and survival. Only about 50% of graduating residents express confidence to develop a brachytherapy practice with caseload as the greatest barrier. We hypothesize that virtual reality (VR)-based intracavitary brachytherapy simulation will improve resident confidence, engagement, and proficiency.

METHODS

We created a VR training video of an intracavitary brachytherapy case performed by a board-certified gynecologic radiation oncologist and medical physicist. Residents performed a timed intracavitary procedure on a pelvic simulator before and after viewing the VR simulation module on a commercially available VR headset while five objective measures of implant quality were recorded. The residents completed a pre- and postsimulation questionnaire assessing self-confidence, procedural knowledge, and perceived usefulness of the session.

RESULTS

There were 14 residents, including five postgraduate year (PGY)-2, three PGY-3, four PGY-4, and two PGY-5, who participated in the VR curriculum. There were improvements in resident confidence (1.43-3.36), and subjective technical skill in assembly (1.57-3.50) and insertion (1.64-3.21) after the simulation. Average time of implant decreased from 5:51 to 3:34 (p = 0.0016). Median technical proficiencies increased from 4/5 to 5/5. Overall, the residents found VR to be a useful learning tool and indicated increased willingness to perform the procedure again.

CONCLUSIONS

VR intracavitary brachytherapy simulation improves residents' self-confidence, subjective and objective technical skills, and willingness to perform brachytherapy. Furthermore, VR is an immersive, engaging, time-efficient, inexpensive, and enjoyable tool that promotes residents interest in brachytherapy.