Competency-Based Medical Education in Canadian Radiation Oncology Residency Training: an Institutional Implementation Pilot Study.

Canadian radiation oncology (RO) residency programs transitioned to a competency-based medical education (CBME) training model named Competence by Design (CBD) in July 2019. Prior to this, CBD was piloted in a single RO training program to characterize assessment completion and challenges of implementation. Six residents and seven staff participated in a mixed-methods study and were oriented to CBD. Four Entrustable Professional Activities were assessed over a 4-week-long block and documented using online assessment forms. Anonymized assessments were analyzed to characterize completion. Post-pilot surveys were completed by 4/6 residents and 5/7 staff. Semi-structured post-pilot focus groups were conducted with all residents. Assessments were requested and documented on a weekly basis. Narrative comments were found in 68.1% of assessments, of which 26.7% described specific examples of observed competence or recommendations for improvement. Three of five staff believed that assessments have a negative impact on clinical workflow. Three themes were identified: (1) direct observation is the most challenging aspect of CBD to implement; (2) feedback content can be improved; and (3) staff attitude, clinical workflow, and inaccessibility of assessment forms are the primary barriers to completing assessments. This study demonstrates that CBD assessments can be completed regularly in an outpatient radiation oncology setting and that implementation challenges include improving feedback quality, promoting direct observation, and continuing faculty development to improve perceptions of this assessment model. Further study is required to identify best practices and expectations for the discipline in the era of CBME.

Primary Breast Cancer Tumor and Patient Characteristics as Predictors of Adjuvant Radiation Therapy.

Adjuvant radiation therapy reduces the risk of local recurrence of breast cancer. Our study identifies patient and tumor characteristics that guide the use of adjuvant radiation therapy and evaluates our adherence to recommended guidelines. A retrospective review was undertaken of 1,667 stage I-III breast cancer patients treated at a regional cancer center from 2004 to 2007. Univariate analysis was used to select factors for entry into a multivariate stepwise logistic regression model. Descriptive statistics was used to compare use of radiation therapy of 382 stage I-III breast cancer patients diagnosed in 2013 to those from 2004 to 2007. The primary indicators for any radiation therapy (n = 935) were breast conserving surgery (OR 79.5, 95% CI [47.6-132.9]), four to nine positive lymph nodes (71.9, [17.0-304.7]), and greater than nine positive lymph nodes (60.5, [7.9-460.8]). In post-mastectomy patients (n = 408), the indicators for radiation therapy were four to nine positive lymph nodes (29.4, [12.9-67.4]) and greater than nine positive lymph nodes (108.3, [14.5-807.5]). In breast conserving surgery patients (n = 1,081) 96.1% were offered radiation therapy. Patients offered local-regional radiation therapy were more likely to have any positive nodes (ORs 4.3-91.0), have had a mastectomy (4.3, [2.2-8.4]), and had larger tumors (1.6, [1.3-2.0]). Local-regional radiation therapy was recommended less frequently in node positive patients in 2004-2007 (35.0%) compared to in 2013 (70.5%) [p < 0.001]. Patients who had a breast conserving surgery or had four or more positive lymph nodes were more likely to receive radiation therapy. Patients with any positive lymph nodes, larger tumors, or who had a mastectomy were more likely to receive local-regional radiation therapy. Our institution was more likely to offer local-regional radiation therapy in node positive breast cancer in 2013 compare to 2004-2007.

Effects of a regional guideline for completion axillary lymph node dissection in women with breast cancer to reduce variation in surgical practice: A qualitative study of physicians' views.

BACKGROUND: Recently the impact of completion axillary lymph node dissection (cALND) after positive sentinel lymph node biopsy on significant outcomes has been questioned, leading to variation in surgical practice. To address this variation, a multidisciplinary working group created a regional guideline for cALND. We explored the views and experiences of surgeons, medical oncologists (MOs), radiation oncologists (ROs) in a qualitative study that examined guideline implementation in practice. METHODS: The Pathman framework (awareness, agreement, adoption and adherence) informed the interview guide design and analysis. Semi-structured interviews were conducted with MOs, ROs and surgeons and transcribed. Transcripts were coded independently by 2 members of the study team and analyzed. Disagreements were resolved through consensus. RESULTS: Twenty-eight physicians (5 MO; 6RO; 17S) of 41 (68% of those approached) were interviewed. Ten of 11 (91%) hospital sites (54% community; 46% academic) and all 4 cancer clinics within the region were represented. Twenty-seven physicians (96%) were aware of the guideline, with all physicians reporting agreement and general adherence to the guideline. Most physicians indicated nodal factors, age and patient preference were key components of cALND decision-making. Physicians from all disciplines perceived that the guideline helped reduce variation in practice across the region. There were concerns that the guideline could be applied rigidly and not permit individual decision-making. CONCLUSIONS: Physicians identified breast cancer as an increasingly complex and multidisciplinary issue. Facilitators to guideline implementation included perceived flexibility and buy-in from all disciplines, while individual patient factors and controversial supporting evidence may hinder its implementation.

A Population-Based Study of the Effects of a Regional Guideline for Completion Axillary Lymph Node Dissection on Axillary Surgery in Patients with Breast Cancer.

INTRODUCTION: Evidence from the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial suggests completion axillary lymph node dissection (cALND) after positive sentinel lymph node biopsy (+SLNB) does not improve outcomes in select patients, leading to practice variation. A multidisciplinary group of surgeons, oncologists, and pathologists developed a regional guideline for cALND which was disseminated in August 2012. We assessed the impact of Z0011 and the regional guideline on cALND rates. METHODS: Consecutive invasive breast cancer cases undergoing SLNB were reviewed at 12 hospitals. Patient, tumor, and process measures were collected for three time periods: TP1, before publication of Z0011 (May 2009-August 2010); TP2, after publication of Z0011 (March 2011-June 2012); and TP3, after guideline dissemination (January 2013-April 2014). Cases were categorized by whether they met the guideline criteria for cALND (i.e. ≤50 years, mastectomy, T3 tumor, three or more positive sentinel lymph nodes [SLNs]) or not (e.g. age > 50 years, breast-conserving surgery, T1/T2 tumor, and one to two positive SLNs). RESULTS: The SLNB rate increased from 56 % (n = 620), to 70 % (n = 774), to 78 % (n = 844) in TP1, TP2, and TP3, respectively. Among cases not recommended for cALND using the guideline criteria, cALND rates decreased significantly over time (TP1, 71 %; TP2, 43 %; TP3, 17 %) [p < 0.001]. The cALND rate also decreased over time among cases recommended to have cALND using the guideline criteria (TP1, 92 %; TP2, 69 %; TP3, 58 %) [p < 0.001]. Based on multivariable analysis, age and nodal factors appeared to be significant factors for cALND decision making. CONCLUSION: Publication of ACOSOG Z0011 and regional guideline dissemination were associated with a marked decrease in cALND after +SLNB, even among several cases in which the guideline recommended cALND.

Management of patients with implantable cardioverter-defibrillators and pacemakers who require radiation therapy.

BACKGROUND: Radiation therapy (RT) may pose acute and long-term risks for patients with cardiac implantable electronic devices (CIEDs), including pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs). However, the frequency of these problems has not been accurately defined. OBJECTIVE: The purpose of this study was to determine the prevalence of CIEDs among patients requiring RT and report the common CIED-related problems when patients are managed according to a standard clinical care path. METHODS: In a single tertiary-care center, we prospectively screened all patients requiring RT and identified patients with ICDs or PMs. We collected clinical data about their cancer, RT treatment plan, and CIED. Radiation dose to the device was estimated in all patients, and any device malfunction during RT was documented. RESULTS: Of the 34,706 consecutive patients receiving RT, 261 patients (0.8%, mean age 77.9 ± 9.4 years) had an implantable cardiac device: 54 (20.7%) ICDs and 207 (79.3%) PMs. The site of RT was head and neck (27.4%), chest (30.0%), and abdomen/pelvis (32.6%). Using our care path, 63.2% of patients required continuous cardiac monitoring, 14.6% required device reprogramming, 18.8% required magnet application during RT, and 3.4% required device repositioning to the contralateral side before RT. Four patients (1.5%) had inappropriate device function during RT: 3 experienced hemodynamically tolerated ventricular pacing at the maximum sensor rate, and 1 experienced a device power-on-reset. No patient died or suffered permanent device failure. CONCLUSION: Nearly 1% of patients receiving RT in this series has a PM or ICD. However, with a systematic policy of risk assessment and patient management, significant device-related complications are rare.

Does the presence of an implant including expander with internal port alter radiation dose? An ex vivo model.

BACKGROUND: There is a lack of literature examining the dosimetric implications of irradiating breast implants and expanders with internal ports inserted at the time of mastectomy. OBJECTIVE: To determine whether the presence of breast expanders with port in saline or silicone implants affect the dose uniformity across the breast when irradiated with various photon and electron energies. METHODS: One tissue-equivalent torso phantom with overlying tissue expanders in saline or silicone implants were irradiated using tangential fields with 6 MV and 18 MV photons and 9 MeV and 12 MeV electrons. All dose measurements were performed using thermoluminescent dosimeters (TLDs). The TLDs were arranged around the port and the perimeters of either the expander, or saline or silicone implant. Comparisons of measured radiation doses, and between the expected and measured doses of radiation from the TLDs on each prosthesis, were performed. Data were analyzed using two-tailed t tests. RESULTS: There were no differences in TLD measurements between the expander and the saline implant for all energy modalities, and for the expected versus actual measurements for the saline implant. Higher than anticipated measurements were recorded for a significant number of TLD positions around the silicone implants. CONCLUSIONS: Radiation doses around saline implants or expanders with internal port were unaltered, whereas dose recordings for silicone implants were higher than predicted in the present laboratory/ex vivo study.

HISTORIQUE: Peu de publications portent sur les conséquences dosimétriques de la radiation d'implants mammaires et d'expandeurs à port interne insérés au moment de la mastectomie. OBJECTIF: Déterminer si la présence d'expandeurs mammaires à port dans des implants remplis de solution saline ou de gel de silicone nuit à l'uniformité de la dose de diverses énergies de photons et d'électrons irradiée sur le sein. MÉTHODOLOGIE: Les chercheurs ont utilisé un fantôme thoracique équivalant au tissu pourvu d'implants remplis de solution saline ou de gel de silicone avec expandeur et l'ont irradié de champs tangentiels à photons de 6 MV et 18 MV et à électrons de 9 MeV et 12 MeV. Ils ont mesuré toutes les doses à l'aide de dosimètres thermoluminescents (DTL). Ces DTL étaient placés autour du port et des périmètres de l'expandeur ou de l'implant rempli de solution saline ou de gel de silicone. Ils ont comparé les doses de radiation mesurées, ainsi que les doses de radiation prévues par rapport aux doses mesurées à l'aide des DTL sur chaque prothèse. Ils ont analysé les données à l'aide de deux tests t bilatéraux. RÉSULTATS: Les chercheurs n'ont constaté aucune différence entre l'expandeur et l'implant rempli de solution saline et entre les mesures prévues et réelles de l'implant rempli de solution saline pour ce qui est des modalités d'énergie dans les mesures de DTL. Ils ont obtenu des mesures plus élevées que prévu à l'égard de nombreuses positions des DTL autour des implants remplis de gel de silicone. CONCLUSIONS: Les doses de radiation autour des implants remplis de solution saline ou des expandeurs à port interne ne changeaient pas, tandis que les doses enregistrées pour les implants remplis de gel de silicone étaient plus élevées que prévu dans la présente étude de laboratoire ex vivo.

Improving the consistency in cervical esophageal target volume definition by special training.

PURPOSE: Three-dimensional conformal radiation therapy requires the precise definition of the target volume. Its potential benefits could be offset by the inconsistency in target definition by radiation oncologists. In a previous survey of radiation oncologists, a large degree of variation in target volume definition of cervical esophageal cancer was noted for the boost phase of radiotherapy. The present study evaluated whether special training could improve the consistency in target volume definitions. METHODS AND MATERIALS: A pre-training survey was performed to establish baseline values. This was followed by a special one-on-one training session on treatment planning based on the RTOG 94-05 protocol to 12 radiation oncologists. Target volumes were redrawn immediately and at 1-2 months later. Post-training vs. pre-training target volumes were compared. RESULTS: There was less variability in the longitudinal positions of the target volumes post-training compared to pre-training (p < 0.05 in 5 of 6 comparisons). One case had more variability due to the lack of a visible gross tumor on CT scans. Transverse contours of target volumes did not show any significant difference pre- or post-training. CONCLUSION: For cervical esophageal cancer, this study suggests that special training on protocol guidelines may improve consistency in target volume definition. Explicit protocol directions are required for situations where the gross tumor is not easily visible on CT scans. This may be particularly important for multicenter clinical trials, to reduce the occurrences of protocol violations.