Clinical Oncology
Volume 22, Issue 8 , Pages 675-680, October 2010

Education and Training for Intensity-modulated Radiotherapy in the UK

  • D. Routsis

      Affiliations

    • Oncology Centre, Addenbrooke’s Hospital, Cambridge University Hospital NHS Trust, Cambridge, UK
    • Corresponding Author InformationAuthor for correspondence: D. Routsis, Oncology Centre Box 193, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK. Tel: +44-1223-586617.
    • ,
  • J. Staffurth

      Affiliations

    • Cardiff University, Research Department, Velindre Hospital, Cardiff, UK
    • ,
  • C. Beardmore

      Affiliations

    • Society and College of Radiographers, London, UK
    • ,
  • R. Mackay

      Affiliations

    • North Western Medical Physics, Christie Hospital, Manchester, UK
    • ,
  • on behalf of the Radiotherapy Development Board

Received 7 March 2010; accepted 15 June 2010. published online 23 July 2010.

Article Outline

Abstract 

A growing body of evidence as to the benefits of intensity-modulated radiotherapy (IMRT) has led to the recommendation for its adoption as a treatment option for cancer patients within the UK. Routine clinical implementation of this technology has been slow. One of the causal factors was identified as being the need to improve confidence by improving the understanding and technical skills for IMRT of clinical oncology staff. This report determines and describes the additional knowledge and skills required for IMRT practice for clinical oncologists, clinical scientists (radiotherapy physicists) and radiographers, derived from reviewing evidence from other nations’ IMRT practices and adapting them to UK needs. This knowledge and skills specification can be used to inform IMRT educational curricula. Novel educational methods to maintain the required understanding and skills are also described.

Key words: Education, intensity modulation, radiotherapy, skills, training

 

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Introduction 

This paper forms part of a series of analyses that examine the reasons for the slow adoption of intensity-modulated radiotherapy (IMRT) in the UK. A key causal factor has been identified as being concern in using the technology, stemming from insufficient understanding and skills in IMRT among the operative staff. The educational and training requirements to resolve this issue are identified and presented within this paper.

Background 

IMRT is a high precision form of radiotherapy for which there is a small, but growing, body of evidence for patient benefits in terms of reduced treatment-related toxicity [1] and as such recommendations were made for its widespread adoption in the UK [2]. However, a recent review of the general availability of this treatment highlighted the fact that a lower than expected number of centres were using IMRT [3], even though the equipment was available [3], [4]. A focus group meeting was held with stakeholders to identify the reasons behind this low rate of adoption [5]. A lack of confidence among oncology staff in their understanding and technical skills of IMRT was identified as a key underlying contributory factor.

This paper therefore seeks to determine the additional knowledge and skills required for IMRT practice for clinical oncologists, therapeutic radiographers, dosimetrists and clinical scientists and make recommendations for changes in educational curricula. Current developments in educational and training schemes are outlined, describing novel methods that could be used to incorporate the rapid changes in technology and technological understanding within IMRT.

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Methodology 

Other countries nationally implementing IMRT have already carried out work to establish the additional knowledge and skills needed for radiotherapy staff groups [6], [7], [8]. In the interest of efficiency, it was decided to collate and build on these works, rather than repeat them. The collated recommendations were assessed against the requirements for UK-specific radiotherapy IMRT processes and adapted accordingly.

To determine the specific UK requirement, the IMRT processes used in a few radiotherapy centres with IMRT experience within the National Health Service in UK were reviewed. The IMRT pathway was examined and each individual task involved in the process determined. The knowledge and skills required for these tasks were then derived. An additional assessment was made identifying the staff group or groups responsible for each task, to inform the development of educational curricula for the main oncology disciplines. Certain tasks can only be allocated to specific oncology professional groups, depending on their base qualifications, but others may be undertaken by various appropriately trained professional groups, according to local needs and competency assessments. It should be noted that the role ‘dosimetrist’ can be carried out by staff from either radiographer or medical technologist professions. The final collated results for IMRT knowledge and skills requirement and assignment were reviewed by representatives from the three main oncology professional bodies for consensus agreement.

In addition, the existing education curricula for each oncology professional group were reviewed to determine the need for additional education in IMRT. The current educational programmes needed to address the imbalance were identified, together with possible novel educational methods.

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Results 

Knowledge and Skills Requirement for Intensity-modulated Radiotherapy 

When assessing IMRT processes, it was noted that establishing an IMRT service requires additional skills to maintaining an existing IMRT service [6], [9].

The recommendations for the knowledge and skills needed for IMRT are collated in Table 1, categorised by the stages in a typical IMRT pathway and the professional group usually undertaking this activity. The additional tasks required for service implementation and equipment commissioning are included. The table shows the considerable overlap in knowledge required between the professional groups, as also determined by other international reviews.

Table 1. Knowledge and skills requirements for all oncology professional staff for intensity-modulated radiotherapy (IMRT)
Knowledge or skill required for IMRTOncologistsRadiographersDosimetrists (radiographer or medical technologist)Physicists
EssentialDesirableEssentialDesirableEssentialDesirableEssentialDesirable
Service implementation
Developing patient selection protocols✓
Establishing patient pathways✓ ✓ ✓✓
Establishing local training and education methods ✓ ✓ ✓ ✓
Understanding of use and applicability of IMRT for disease sites✓ ✓ ✓ ✓
Understanding effect of IMRT on workload/efficiency✓ ✓ ✓ ✓
Developing patient review protocols✓ ✓

Acceptance testing and commissioning
Beam data acquisition ✓
Planning system models for IMRT ✓
Small field dosimetry ✓
Plan transfer to linac ✓
One-, two-, three-dimensional verification of dose ✓
Developing ongoing quality assurance systems ✓

Treatment planning
Patient preparation
Understand use and effect of immobilisation systems✓ ✓ ✓ ✓
Understand use and applicability of internal motion restrictors (bowel preparation, respiratory motion management)✓ ✓ ✓ ✓
Understanding variation with patient positioning✓ ✓ ✓ ✓
Understanding contraindications to use of IMRT for individual patients✓ ✓ ✓ ✓
Pre-treatment imaging
Physical characteristics of different modality imaging systems ✓
Effect of scan resolution on accuracy of dosimetric plan ✓ ✓ ✓✓
Effect of contrast use on dosimetric plan accuracy✓ ✓ ✓ ✓
Multimodality image fusion ✓ ✓ ✓✓
Sensitivity and specificity of different imaging modalities✓ ✓✓ ✓
Interpretation of multimodality fused images✓ ✓ ✓ ✓
Treatment dosimetric planning
Three-dimensional multimodality anatomical contouring✓ ✓✓ ✓
Biologically effective equivalent dose concepts✓ ✓✓ ✓
Specifying dose constraints for normal tissues and organs at risk✓ ✓ ✓ ✓
Defining objectives for the treatment plan in terms of dose prescription for the target volumes✓ ✓✓ ✓
Inverse planning systems✓ ✓✓ ✓
Mathematical principles of treatment planning and optimisation process ✓ ✓ ✓✓
Plan evaluation for clinically acceptability✓ ✓ ✓ ✓
Specification of target volumes with appropriate margin setting, following the International Commission on Radiation Units (ICRU) formalism✓ ✓ ✓ ✓
Understand dose distributions and dose-volume histograms✓ ✓ ✓ ✓
Concepts of dose-volume objectives and dose limits for critical structures and target tissues✓ ✓ ✓ ✓
Understanding of limitations of optimisation process✓ ✓ ✓ ✓
Understanding of achievability of dose plans and patient-specific quality assurance assessments✓ ✓ ✓ ✓
Effect of heterogeneity corrections and interfaces✓ ✓ ✓✓
Generation and documentation of the treatment plan✓ ✓ ✓ ✓

Treatment delivery
Capabilities and limitations of delivery equipment✓ ✓ ✓ ✓
Contingency planning✓ ✓ ✓ ✓
Understanding of avoiding gaps in radiotherapy✓ ✓ ✓ ✓
Effect of IMRT on workload/efficiency✓ ✓ ✓ ✓

Treatment verification
Verification of patient-specific dosimetry ✓ ✓
Understanding geometric and dosimetric uncertainties and their consequences✓ ✓ ✓✓
Delivered treatment dosimetric verification techniques ✓✓ ✓
Delivered treatment geometric verification techniques ✓✓ ✓
Optimising imaging protocols✓ ✓ ✓
Capabilities and limitations of verification equipment✓ ✓ ✓
Implications of complex intensity patterns on treatment delivery accuracy and efficacy✓ ✓ ✓
Evaluation of systematic and random errors in treatment delivery✓ ✓ ✓
Understanding of doses from imaging✓ ✓ ✓
Evaluation of ongoing suitability of planned treatment✓ ✓ ✓ ✓

Patient review
Monitoring and evaluation of treatment outcomes (including early/late morbidity)✓ ✓

Review of Existing Educational and Training Provision 

Current education and training for radiographers 

The Society and College of Radiographers (SCoR) has a curriculum framework (Learning and Development Framework) that informs the development of all pre-registration programmes [10]; for most of those training this is a 3 year programme leading to a BSc(Hons) degree in radiotherapy. The framework is regularly updated and was last updated in 2007 to include underlying concepts of IMRT. Continuing professional development for radiographers is a requirement of the SCoR and Health Professions Council [11]. Competency to practice IMRT locally is managed by the individual radiotherapy centres according to their needs.

Current education and training for clinical scientists 

The most usual route for a clinical scientist is specialisation after the completion of a physics degree. A higher degree in medical physics, vocational training and a period of advanced training are all required before state registration. The higher degree will be an Institute of Physics and Engineering in Medicine (IPEM) approved MSc. IMRT is not explicitly mentioned as a requirement of the syllabus of an MSc or required as a competency [12]. The degree to which a trainee becomes trained in IMRT will depend on the work of the individual department, but it would be expected that IMRT would be included in some way in the training plan. Continuing professional development for clinical scientists is a requirement of the Health Professions Council.

Separate training schemes for dosimetrist training are currently being developed by IPEM and SCoR.

Current education and training for oncologists 

Clinical oncology training has undergone considerable changes after the UK-wide uptake of Modernising Medical Careers. The present system for new trainees requires medical doctors to be interested in pursuing a career in clinical oncology to enter a non-specialist medical training programme at the ST1 level. If they successfully achieve the required development in knowledge and skills, they will progress to the ST3 level, when they will be eligible to join a clinical oncology training programme at the ST3 level. They will need to pass the membership of the Royal College of Physicians examination and the fellowship of the Royal College of Radiologists. Training and education of clinical oncologists is the remit of the Warden of the Faculty of Clinical Oncology, RCR. The curriculum is defined in the RCR document Structured training curriculum for clinical oncology [13]. Intermediate training covers basic principles and common tumours. Advanced training covers broader and deeper knowledge of the management of common tumours, and the management of rare tumours. The basic principles of IMRT are included.

Additional Educational Requirements for Intensity-modulated Radiotherapy 

This overview of the educational curricula supported by the three main radiotherapy professional bodies shows that IMRT is being introduced at a trainee level. A deeper analysis is needed to assess the knowledge and skills currently being provided in each training programme against those determined in Table 1. Future staff should be equipped with the knowledge and skills necessary for IMRT. The necessity now is to ensure that these programmes evolve with the current rapid pace of change as the increased understanding of IMRT and its application is being generated from national and international studies. It would be preferable if the programmes could be developed collaboratively by the oncology professional groups. The knowledge and skills identified in Table 1 could be used as a basis for a national core curriculum for IMRT.

A fundamental problem is that although the training programmes for the oncology disciplines are well regulated and developed, there is relatively little educational provision for the trained workforce. We believe that this risks perpetuating the diversity in IMRT provision and standards as the trained staff are historically the group that train the trainees.

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Identify Resources Needed to Fill Gaps 

There are a few resources that can be used to fill the gap in IMRT understanding and skills after qualification training.

Educational Courses 

These courses teach the underlying principles behind IMRT and where its use is most applicable in clinical practice. These do not train staff on the use of specific equipment, but teach the concepts that are necessary for high-quality practice. Some cover all aspects of IMRT; others concentrate on a specific IMRT process, such as treatment planning.

Applications Training 

These courses teach the application of IMRT, using vendor-specific equipment. There is often an educational component where the principles behind IMRT are taught, but the emphasis is usually on the use of these products for IMRT. Applications training is an essential part of implementing IMRT [8]. We believe that there is a risk in solely relying upon the vendors to provide this essential educational tool. The preferred method for establishing IMRT services in a radiotherapy centre is to send a team with representatives from each of the radiotherapy disciplines to attend both educational and applications training [14].

Peer Review 

A lesser-used method is peer review. Evaluation of practice by another bench marked radiotherapy centre can be useful in assessing the quality of the IMRT service.

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Novel Methods for Intensity-modulated Radiotherapy Education and Training 

Novel educational approaches are currently being developed in the UK. The three current developments described use remote access systems to supply education and training. There may be advantages in terms of both accessibility and the ability to rapidly update as technological advancements within IMRT occur.

Department of Health e-learning for Advanced Radiotherapy 

This is a programme recently funded by the Department of Health as a joint development from IPEM, SCoR and the Faculty of Clinical Oncology of the RCR. The concept is to develop an e-learning programme to provide the knowledge base and practical skills training for advanced radiotherapy techniques, such as IMRT.

The benefit of an e-learning approach is that it enables distance learning, saving travelling costs, staff time and the cost of course attendance. One of the drawbacks of attending national educational courses is that very little practical hands-on training is given. Applications training locally is restricted by the need for the equipment to be used clinically. It has been shown that practice and reiteration is the most effective way of learning. By making the resource more available, more staff will be able to train, promoting greater use of skills mix. The system will also be designed to include a competency assessment programme so that competencies can be managed more easily.

VERT 

VERT is a virtual environment representing a radiotherapy treatment room. The system aims to create a life-size three-dimensional replica with linear accelerator equipment from different manufacturers. This allows students and staff the opportunity to develop practical physical skills, without taking up any valuable clinical resource time. The virtual environment has a variety of educational packages that can be used to teach different IMRT-related concepts, such as three-dimensional anatomy and the consequences of poor positioning techniques [15].

Cambridge Cancer Medicine Online 

Cambridge Cancer Medicine Online is the site of a web-based, e-learning programme for radiotherapy concepts currently in development. It will aim to provide resources to users in their own time and at their own pace. The programme is being designed to link in with the RCR oncology e-learning curriculum and to provide additional activities to enable distance learning, without taking up clinical time and equipment. The system runs a fully functional micro-planning system that can be safely used to practice IMRT treatment planning and to learn the effect and consequences of dose constraints, optimisation and plan evaluation. It also has an automatic scoring tool that evaluates accuracy of target volume contouring, against a gold standard and offers simulation tools for related IMRT activities, such as image-guided radiotherapy and the linac room environment.

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Conclusion 

The required increase in adoption of IMRT into radiotherapy centres in the UK requires oncology staff to acquire the IMRT knowledge and skills needed. These have been identified and could be used as a basis for a national core curriculum for IMRT. It is recommended that IMRT is specifically included in the training curricula for all oncology professional staff groups. Post-qualification educational programmes are needed to ensure that the existing, qualified workforce can gain the skills required to practice IMRT (and other advanced radiotherapy techniques); collaborative development of these programmes is recommended. It is important to ensure that these programmes evolve with the rapid pace of change of the technology and as the increased understanding of IMRT and its application is being generated.

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Acknowledgements 

This paper has been written with contribution from all members of the Radiotherapy Development Board: Chair Dr S. Davies, Professor A. Barrett, Dr J. Barrett, Mrs C. Beardmore, Mr T. Cooper, Mr S. Hood, Mrs S. James, Dr R. Mackay, Dr P. Mayles, Mr A. Poynter, Professor P. Price, Mrs D. Routsis, Dr S. Thomas and Dr M. Williams. Additional contributions were received from Dr C. Scrase, Dr R. Jena, Dr L.T. Tan and Dr A. Beavis.

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References 

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PII: S0936-6555(10)00209-8

doi:10.1016/j.clon.2010.06.012

Clinical Oncology
Volume 22, Issue 8 , Pages 675-680, October 2010

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