Postgraduate teaching-learning pattern for radiation oncology students in India - A survey-based analysis.

CONTEXT: Teaching and training in Radiation Oncology is only at postgraduate level with 8-10 hours of theory sessions during undergraduate course. Uniform training during the post-graduation course across the country is a major challenge as many new concepts are introduced. AIM: This study is an effort to look into various aspects of training in terms of teaching-learning and assessment. In addition, we aim to look into innovative methods that can be implemented across the country. SETTINGS AND DESIGN: This is a survey-based analysis. METHODS AND MATERIALS: Postgraduate teaching institutes in Radiation Oncology were obtained from the National Medical Council and National Board of Examination websites. A questionnaire was created with Google form and sent to the heads of departments across the country. The data were entered on a spreadsheet and the responses were analyzed using Microsoft Excel sheet. RESULTS: Thirty-five out of 87 institutes responded out of which 40% were government institutes. Twenty-six (74%) offered MD seats with 14 (40%) having less than five teachers and 13 (37.14%) with 5-10 teachers. With uniform teaching learning method across the country, there was wide variation in formative assessment patterns. There was consensus regarding inadequate exposure in research methodology and statistics. CONCLUSION: There is uniformity in teaching learning methods with differing patterns of formative assessment. Innovative methods focusing on affective and skill domains with competency-based medical education will help in bringing out a competent radiation oncologist.

The tolerance to chemoradiation for cervical cancer patients: A comparative prospective study of rural versus urban population.

Context: Rural versus urban cervical cancer. Aims: This study aims to study the difference in toxicities and clinical outcome of chemoradiation in urban and rural cervical cancer patient. Settings and Design: This was a prospective study. Subjects and Methods: In a double-arm prospective study, cervical cancer patients were treated with chemoradiation followed by brachytherapy. Patients were monitored weekly for hematological, gastrointestinal toxicities, and electrolyte imbalance. Acute toxicities and long-term outcome were compared between the two groups. Statistical Analysis Used: Kaplan-Meier survival curves for analysis of disease free and overall survival and Pearson's Chi-square test and Fisher's exact tests for analysis of toxicities were used. Results: Fifty-seven patients from urban and 114 from rural region were studied. There were no difference between the two groups as far as the patient characteristics, overall treatment time (OTT), hematological, electrolyte imbalance, local control, and disease-free survival between the two groups. Associated comorbidities were significantly higher (53% vs. 17%) with P < 0.0001 in urban population. Grade II and III enteritis were significantly higher 15.78% versus 21.05% (P = 0.00001) and 12.28% versus 11.40% (P = 0.03) in urban patients, respectively. Conclusions: Tolerance to chemoradiation, disease-free survival, and overall survival are similar in both urban and rural patients of cervical cancer, with more enteritis in urban group. However, this did not increase OTT.

Dose to swallowing structures and dysphagia in head and neck Intensity Modulated Radiation Therapy - A long term prospective analysis.

AIM: To analyse the long term swallowing function in head and neck cancer patients and correlate with the dose to midline swallowing structures. BACKGROUND: The use of concurrent chemo radiation (CRT) as the present standard of care resulted in high rates of early and late toxicities. Dysphagia, aspiration, and xerostomia are early as well as late effects of radiation. Not many studies on the dysphagia scores during radiation and follow-up period have correlated dose to the swallowing structures, hence this study. MATERIALS AND METHODS: Histologically proven head and neck cancer patients treated with intensity modulated radiation therapy were accrued in this study. The pharyngeal constrictors, larynx and cervical oesophagus were contoured and labelled as midline swallowing structures. The volume of the midline swallowing structures which were outside the PTV was delineated separately and was given a mean dose constraint of 45 Gy. Dysphagia was assessed at baseline, weekly intervals during irradiation and follow-up at six years. The dose to the structures for swallowing was correlated with degree of dysphagia. RESULTS: There was a gradual increase in the dysphagia grade during the course of radiation. There was a significant recovery of late dysphagia compared to dysphagia during the completion of radiation therapy in patients who received <45 Gy to the swallowing structures (p < 0.0001). CONCLUSION: Giving a constraint to the swallowing structure and limiting it to <45 Gy resulted in earlier recovery of swallowing function resulted in good physical, mental and social well being of the patients when compared to those who received >45 Gy.

Optimal technique of radiotherapy for carcinoma cervix in developing countries: Dosimetric and logistic comparison.

PURPOSE: Carcinoma cervix is the most common malignancy affecting women in developing countries. Radical radiotherapy is the mainstay of treatment in more than 90% of patients. The present study is a dosimetric and logistic comparison of various techniques of radiotherapy, namely two-dimensional conventional radiotherapy (2DCRT), three-dimensional conformal radiotherapy (3DCRT), and intensity-modulated radiotherapy (IMRT). METHODS: All the patients underwent contrast-enhanced computed tomography (CT) scans for simulation. 2DCRT, 3DCRT, and IMRT plans were generated in 24 patients and dosimetrically compared. Radiotherapy treatment time involved in each technique was analyzed in 27 treated patients. RESULTS: The planning target volume (PTV) coverage was best in 3DCRT technique with a median coverage of 99.9% as compared to IMRT (99.3%) and 2DCRT (82.2%). There was progressive sparing of all the organs at risk in IMRT as compared to 3DCRT. The total planning time was longest in IMRT (332.1 min) and shortest in 2DCRT (11.7 min). The mean treatment time for the delivery of each fraction of 2DCRT, 3DCRT, and IMRT were 14.3, 13.6, and 24.7 min, respectively. CONCLUSION: 3DCRT technique is the most optimal technique for radical radiotherapy of cervical cancers with optimum PTV coverage, acceptable planning time, and minimal treatment time as compared to IMRT. 2DCRT technique should be limited to the setting where CT simulation is unavailable.

Quantification of Dose-Volume and Dose-Length Parameters for Cervical Esophageal Stricture in Head and Neck Irradiation with the 3DCRT and IMRT Technique.

PURPOSE: To quantify and compare dose-volume and dose-length parameters of cervical esophagus between three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiation therapy (IMRT) and to correlate with incidence of cervical strictures in head and neck cancer irradiation with radical intent. MATERIALS AND METHODS: Forty consecutive head and neck cancer patients who received radical radiation therapy, either with 3DCRT (n = 20) or IMRT (n = 20), between December 2011 and August 2012 were retrospectively analyzed and followed up for at least 4 years post-treatment completion. RESULTS: The volumes of cervical esophagus receiving ≥54 Gy (V54) and ≥60 Gy (V60) and lengths receiving circumferential dose of ≥50 Gy (L50) and ≥54 Gy (L54) were significantly higher in patients treated with IMRT as compared to 3DCRT (P ≤ .05). At the end of minimum 4 years' post-treatment, nine patients had documented symptomatic strictures; three patients were treated with 3DCRT and six patients with IMRT technique. CONCLUSION: IMRT technique in entire-neck irradiation is associated with increased spillage dose to the cervical esophagus, and thereby increased risk for late sequelae. The cervical esophagus has to be considered as an organ at risk and constraints need to be given in IMRT planning, particularly for lower-neck irradiation.

Accelerated Radiation Therapy Using Weekend Boost with Concurrent Cisplatin in Head and Neck Squamous Cell Cancers: An Indian Institutional Experience.

PURPOSE: The purpose of the study was to evaluate the feasibility and efficacy of an accelerated radiotherapy schedule using weekend boost in terms of tumor response, compliance, and acute toxicities for head and neck squamous cell carcinoma, and to report long-term clinical outcomes. MATERIALS AND METHODS: Twenty-six patients with stages III-IV head and neck squamous cell carcinoma receiving radical chemoradiotherapy were accrued prospectively into the study. External beam radiation therapy to a total dose of 66-70 Gy in 33-35 fractions, 1.8-2.0 Gy per fraction along with concurrent weekly cisplatin was planned. Radiation regimen included delivery of six fractions per week, with boost field delivered as the sixth fraction on the weekend. The compliance, tumor response, and toxicities were recorded. Survival curves were estimated using the Kaplan-Meier method. RESULTS: Twenty-one of 26 patients (81%) completed treatment as planned and five patients died during the course of treatment. Sixteen patients (62%) completed treatment in less than 44 days and, at the end of 3 months' follow-up, 18 patients (69%) showed complete response and two patients (8%) showed partial response. The 2- and 5-year actuarial disease-free survival were 90% and 65%, respectively, and 2- and 5-year actuarial overall survival were 60% and 38%, respectively. CONCLUSION: Accelerated fractionation using weekend boost, along with concurrent weekly concurrent cisplatin, is an effective and promising approach with favorable impact on initial tumor response, comparable results, and acceptable toxicities.

A prospective dosimetric and clinical comparison of acute hematological toxicities in three-dimensional conformal radiation therapy and intensity modulated radiation therapy with concurrent chemotherapy in carcinoma cervix.

BACKGROUND AND OBJECTIVES: Acute hematological toxicities are an important cause of morbidity in patients receiving concurrent chemoradiation to pelvis in carcinoma cervix. The objective of this study was to evaluate the role of intensity-modulated radiotherapy (IMRT) in reducing the dose to the bone marrow as compared with three-dimensional conformal radiotherapy (3DCRT) and hence its impact on reducing the acute hematological toxicities. MATERIALS AND METHODS: Eleven consecutive patients treated with IMRT and 12 patients treated with 3DCRT to the whole pelvis along with concurrent chemotherapy were selected. Bone marrow was delineated. V10 Gy, V20 Gy, V95%, and Dmean of bone marrow were recorded. Weekly blood counts were recorded and graded as per Common Terminology Criteria version 4.0 for all the patients. RESULTS: The dose to the bone marrow V20 Gy was 206.78 ± 57.10 cc (75%) and 251.70 ± 40.45 cc (91%) for IMRT and 3DCRT, respectively (P = 0.04) and V95% was 23.30 ± 8.34% and 46.76 ± 6.71% for IMRT and 3DCRT, respectively (P = 0.001). The grade of toxicities during each week did not show the difference in either arm. However, the total count and Neutrophil counts during the 2nd week showed statistical significance between IMRT and 3DCRT. CONCLUSION: IMRT significantly reduces the dose to the bone marrow as compared to 3DCRT. The reduction of the dose did not translate into a decrease in acute hematological toxicities. Concurrent platinum-based chemotherapy is the probable cause for the hematological toxicities.