Brachytherapy Training Survey of Radiation Oncology Residents

Brachytherapy Training Survey of Radiation Oncology Residents

International Journal of Radiation Oncology biology physics www.redjournal.org Scientific Letter Brachytherapy Training Survey of Radiation Oncol...

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International Journal of

Radiation Oncology biology

physics

www.redjournal.org

Scientific Letter

Brachytherapy Training Survey of Radiation Oncology Residents Samuel R. Marcrom, MD,* Jenna M. Kahn, MD,y Lauren E. Colbert, MD,z Christopher M. Freese, MD,x Kaleigh N. Doke, MD,k Joanna C. Yang, MD,{ Catheryn M. Yashar, MD,# Michael Luu, MPH,** and Mitchell Kamrava, MD** *Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL; y Department of Radiation Oncology, Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia; zDepartment of Radiation Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas; xDepartment of Radiation Oncology, University of Cincinnati Barrett Cancer Center, Cincinnati, Ohio; kDepartment of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, Kansas; #Department of Radiation Oncology, University of California San Francisco, San Francisco, California; {Department of Radiation Oncology, University of California San Diego, San Diego, California; and **Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California Received Aug 29, 2018. Accepted for publication Oct 19, 2018.

Summary Brachytherapy use has declined, and the Association of Residents in Radiation Oncology performed an online survey of US residents to evaluate brachytherapy training. Comfort level with brachytherapy varies by modality and disease site. The major barrier as perceived by radiation oncology residents is caseload, and an increase in performed cases is correlated with increased

Purpose: As brachytherapy utilization rates decline, we sought to evaluate the state of brachytherapy training during radiation oncology residency. Methods and Materials: US radiation oncology residents in the Association of Residents in Radiation Oncology database were sent an online questionnaire regarding brachytherapy training. Survey questions addressed a wide array of topics, and responses were often given on a 1 to 5 Likert-type scale that reflected strength of opinion. Postgraduate year (PGY) 4/5 respondents’ answers were analyzed. Descriptive statistics were generated, and rank correlation analyses (Kendall’s s coefficient and Wilcoxon signed-rank test) were used for comparisons. Results: The survey was completed by 145 of 567 residents (62% being PGY4/5). Of PGY4/5 respondents, 96% (86 of 90) believed learning brachytherapy during residency was important, and 72% (65 of 90) felt their program valued brachytherapy training. Resident brachytherapy comfort varied by site, decreasing as follows: gynecologic, prostate, breast, skin. The current intracavitary 15-case minimum was believed adequate by most, but only a minority believed the 5-case interstitial

Reprint requests to: Samuel Marcrom, MD, Department of Radiation Oncology, University of Alabama at Birmingham, 1700 6th Ave S, 1240B Hazelrig Salter Radiation Oncology Building, Birmingham, AL 35249. Tel: (205) 934-1792; (205) 975-0222; E-mail: [email protected] Conflict of interest: D.K. has received an honorarium for speaking and proctoring cases. C.Y. is the past president of the American Brachytherapy Int J Radiation Oncol Biol Phys, Vol. 103, No. 3, pp. 552e555, 2019 0360-3016/$ - see front matter Ó 2018 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ijrobp.2018.10.023

Society. No conflicts of interest relevant to these data exist among the authors. Supplementary material for this article can be found at https:// dx.doi.org/10.1016/j.ijrobp.2018.10.023. AcknowledgmentdWe would like to thank all of the US residents who participated in the survey.

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confidence in brachytherapy practice. Respondents appear interested in augmenting their education with dedicated training experiences that are feasible to complete during residency.

Brachytherapy training survey

553

minimum was adequate. Most respondents (59%) believed that caseload was the greatest barrier to achieving independence in brachytherapy. Significant support exists for American Brachytherapy Society training courses and on-the-job education to enhance training, but enthusiasm about pursuing brachytherapy fellowship training was low. Most respondents expressed confidence in developing a brachytherapy practice (54%); however, this was significantly lower than the rate of those confident in developing a stereotactic body radiation therapy/stereotactic radiosurgery program (97%) (P < .001). Furthermore, there was an association between aggregate number of brachytherapy cases performed and resident confidence in starting a brachytherapy practice (s Z 0.37; P < .001). Conclusions: Brachytherapy is an important component of residency training that is valued by residents and programs. Because caseload was the greatest perceived barrier in brachytherapy training, with confidence correlated with case volume, attempts should be made to expand opportunities for training experiences that are feasible to complete during residency. Ó 2018 Elsevier Inc. All rights reserved.

Introduction

Results

The Association of Residents in Radiation Oncology advocates for improvements in radiation oncology resident training and education, particularly related to current topics within the field. One area that has attracted recent attention is brachytherapy use and brachytherapy education during residency training. Brachytherapy utilization rates have been declining across multiple disease sites, affecting both academic and community practices.1,2 Although many potential reasons exist, one possibility relates to resident training. The Accreditation Council for Graduate Medical Education requires that radiation oncology trainees perform 5 interstitial and 15 intracavitary brachytherapy procedures during residency. We sought to better characterize brachytherapy education among trainees via a brachytherapy training survey.

In total, 145 of 567 residents (26%) in the database completed the survey, with 62% (90 of 145) being PGY4/5 residents (Table 1). This resulted in a 24% (90 of 145) response rate among upper-level residents. Results did not significantly differ when analyzing answers from all respondents compared with upper-level residents only. Of PGY4/5 respondents, 96% (86 of 90) felt performing brachytherapy independently was “very important” or “somewhat important.” Additionally, 72% (65 of 90) of residents felt their ability to independently perform brachytherapy was valued by their residency program. Resident comfort with brachytherapy varied by site, decreasing as follows: gynecologic, prostate, breast, skin (Table 2). A total of 88% (79 of 90) considered the 15-case minimum for intracavitary brachytherapy adequate, whereas only 24% (21 of 89) believed the 5-case minimum for interstitial brachytherapy was adequate. Among PGY4/ 5 respondents, 31% (28 of 90) “strongly agree” or “agree” to having a formal brachytherapy curriculum, and 46% (41 of 90) reported formal evaluation of their brachytherapy ability. A total of 59% (53 of 90) believed low institutional caseload was the greatest barrier to achieving brachytherapy independence. Of 90 PGY4/5 respondents, 49 (54%) had “high” or “somewhat high” confidence in starting a brachytherapy practice after residency; however, this was significantly lower than the 97% (87 of 90) who expressed confidence in starting a stereotactic body radiation therapy/stereotactic radiosurgery (SBRT/SRS) practice (P < .001; Fig. 1).

Methods and Materials US radiation oncology residents in the Association of Residents in Radiation Oncology database during October 2017 were sent an online questionnaire regarding brachytherapy training. The survey was left open for 6 weeks with multiple participation requests. The survey addressed several brachytherapy topics, including site-specific training (prostate, gynecologic, breast, and skin), volume of experience, barriers to training, and institutional support. Responses to individual statements were often given on a 1 to 5 Likert-type scale, reflecting strength of opinion (Table E1; available online at https://dx.doi.org/10.1016/j.ijrobp. 2018.10.023). With a relatively low response rate, we limited statistical analyses to postgraduate year (PGY) 4/5 residents because their perspective was considered more likely to be representative. Descriptive statistics were used to describe frequencies. The Kendall’s rank correlation coefficient and the Wilcoxon signed-rank test were used for nonparametric rank analyses.

Table 1

Respondent level of training

PGY-2

PGY-3

PGY-4

PGY-5

Total

7% (n Z 10)

31% (n Z 45)

38% (n Z 55)

24% (n Z 35)

145

Abbreviation: PGY Z postgraduate year.

International Journal of Radiation Oncology  Biology  Physics

Marcrom et al.

Table 2 “Highly Likely” or “Likely” to feel comfortable performing brachytherapy independently by the end of residency Modality

% (n of N)

Intracavitary endometrial (cylinder) Intracavitary cervix Cervix hybrid or interstitial Prostate (LDR or HDR) Breast single entry devices (SAVI/Contura/Mammosite) Breast multiple entry (interstitial tube and button) Skin (applicator such as Valencia/Leipzig/Xoft/Esteya)

97 83 66 46 38

(87 (75 (59 (41 (34

of of of of of

90) 90) 90) 90) 90)

8 (7 of 90) 15 (13 of 89)

Abbreviations: HDR Z high dose rate; LDR Z low dose rate; SAVI Z Strut-Adjusted Volume Implant.

Furthermore, confidence in starting a brachytherapy practice was positively correlated with aggregate brachytherapy cases performed (s Z 0.37; P < .001; Fig. 2). Most supported strengthening weak areas via American Brachytherapy Societyebased training courses and on-the-job education, but only a minority were interested in pursuing dedicated brachytherapy fellowship training (Table 3). Most believed the future role of brachytherapy would either increase or stay about the same across the evaluated disease sites (Table 4).

Discussion This brachytherapy training survey of U.S. radiation oncology residents identified caseload as the greatest perceived barrier to achieving independence in brachytherapy practice. The total number of performed cases was positively correlated with respondent confidence in starting a brachytherapy practice. Current residents seem to be interested in addressing weaknesses in brachytherapy training with educational experiences that can be completed during residency. High

Response

Somewhat High

Number of Brachytherapy Cases Performed

554

35 30 25 20 15 10 5 0 Low

Somewhat Low

Neutral

Somewhat High

High

Confidence in Starting Brachytherapy Practice

Fig. 2. Increased number of brachytherapy cases performed was associated with increased resident confidence in ability to start a brachytherapy practice using Kendall’s s correlation (s Z 0.37, P < .001). The greatest perceived barrier to achieving independence in brachytherapy was caseload, supported by the correlation between increased aggregate case number and increased confidence in performing brachytherapy. Low caseload may be due to patient demographics, attending physician comfort, utilization of alternate treatment modalities, reimbursement patterns,3,4 and/or expanding residency/fellowship positions.5-7 Because respondents supported ABS educational opportunities and on-the-job training, efforts to increase the availability of brachytherapy cases or simulation experiences would potentially be viewed favorably while contributing to increased confidence in brachytherapy practice, consistent with other promising reports of implementing prostate and gynecologic brachytherapy simulation courses.8,9 Residents and training programs appear to value brachytherapy training. Despite this perception, only a minority have a formal brachytherapy curriculum or have their brachytherapy skills formally evaluated. This is consistent with previous literature, wherein approximately half of respondents expressed adequate experience in formal brachytherapy didactics.10,11 Development of a

Neutral

P < .001

Somewhat Low Low Brachytherapy

SBRT/SRS

Confidence in Starting a Practice after Residency Completion

Fig. 1. Respondents were significantly more likely to be confident starting a stereotactic body radiation therapy/ stereotactic radiosurgery practice (97%) compared with starting a brachytherapy practice (54%) (P < .001).

Table 3 “Highly Likely” or “Likely” to pursue the following options if independence in brachytherapy is not otherwise achieved Educational/training option

% (n of N)

On-the-job training with another member of your group ABS brachytherapy school 1-2 week ABS observership Brachytherapy fellowship

90 (81 of 90) 57 (51 of 89) 49 (44 of 89) 2 (2 of 89)

Abbreviation: ABS Z American Brachytherapy Society.

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Brachytherapy training survey

Table 4 Percentage of respondents who believe that the role of brachytherapy will either increase or stay about the same over the next 10 years Prostate 78%

Cervix

Endometrial

Breast

Skin

93%

97%

66%

78%

readily implementable curriculum addressing brachytherapy educational concepts could add value to those currently lacking a brachytherapy curriculum. Graduate medical education is moving toward competency-based training, revolving around core competencies and milestone achievement, and this is an opportunity to reflect on current brachytherapy milestones. Because current intracavitary requirements make no distinction between tandem-based and nontandem brachytherapy, requirements can be met with vaginal cylinder brachytherapy without learning the more challenging tandem-based brachytherapy associated with improved survival in cervical cancer.2 Perhaps more controversial would be using competency-based time-variable training for brachytherapy with requirements based on a defined level of competency rather than a specific number of required cases (ie, appropriate high-risk clinical target volume identification or ability to independently place tandem and ovoids). Significantly more respondents felt confident in starting an SBRT/SRS practice than a brachytherapy practice, despite SBRT/SRS being a newer treatment technique. The survey did not inquire about SBRT/SRS case volume relative to brachytherapy, a potentially contributory factor, but the findings suggest that trainees are capable of learning new techniques. Brachytherapy differs from SBRT/SRS for multiple reasons, including its requirement for particular technical expertise and a skill set distinct from that of SBRT/SRS. With thoughtful consideration, we believe that trainees are capable of brachytherapy proficiency. This study has limitations, with responses being subject to recall bias, a known limitation of survey-based data. The low response rate (26%) means responses may not be widely generalizable; however, we analyzed only PGY4/5 residents, a cohort most likely to have an appropriate perspective on their training. Additionally, current trainees may not have the appropriate perspective to evaluate their readiness for independent brachytherapy practice; however,

555

these data provide valuable information regarding current brachytherapy training. Brachytherapy is an important component of radiation oncology practice. The major barrier to brachytherapy training as perceived by radiation oncology residents is caseload, and an increase in performed cases appears to be correlated with increased confidence in brachytherapy practice. To continue to widely offer this specialized radiation modality, efforts should be made to expand opportunities for training experiences that are feasible to complete during residency training.

References 1. Orio PF 3rd, Nguyen PL, Buzurovic I, et al. Prostate brachytherapy case volumes by academic and nonacademic practices: Implications for future residency training. Int J Radiat Oncol Biol Phys 2016;96: 624-628. 2. Gill BS, Lin JF, Krivak TC, et al. National cancer data base analysis of radiation therapy consolidation modality for cervical cancer: The impact of new technological advancements. Int J Radiat Oncol Biol Phys 2014;90:1083-1090. 3. Dutta SW, Bauer-Nilsen K, Sanders JC, et al. Time-driven activitybased cost comparison of prostate cancer brachytherapy and intensity-modulated radiation therapy. Brachytherapy 2018;17:556563. 4. Trifiletti DM, Grover S, Libby B, et al. Trends in cervical cancer brachytherapy volume suggest case volume is not the primary driver of poor compliance rates with brachytherapy delivery for locally advanced cervical cancer. Brachytherapy 2017;16:547-551. 5. Mohamad O, Meyer JJ. Recent trends in radiation oncology fellowship training in the United States. Int J Radiat Oncol Biol Phys 2017;99: 539-540. 6. Mohamad O, Doke K, Marcrom S, et al. A fellow’s fate: Employment outcomes of radiation oncology fellowship graduates. Int J Radiat Oncol Biol Phys 2018;102:16-17. 7. Royce TJ, Katz MS, Vapiwala N. Training the radiation oncology workforce of the future: Course correction to supply the demand. Int J Radiat Oncol Biol Phys 2017;97:881-883. 8. Thaker NG, Kudchadker RJ, Swanson DA, et al. Establishing highquality prostate brachytherapy using a phantom simulator training program. Int J Radiat Oncol Biol Phys 2014;90:579-586. 9. Zhao S, Francis L, Todor D, et al. Proficiency-based cervical cancer brachytherapy training. Brachytherapy 2018;17:653-659. 10. Nabavizadeh N, Burt LM, Mancini BR, et al. Results of the 2013-2015 association of residents in radiation oncology survey of chief residents in the United States. Int J Radiat Oncol Biol Phys 2016;94:228-234. 11. Gaudet M, Jaswal J, Keyes M. Current state of brachytherapy teaching in Canada: A national survey of radiation oncologists, residents, and fellows. Brachytherapy 2015;14:197-201.