The role of intermittent androgen deprivation therapy in the management of biochemically recurrent or metastatic prostate cancer.

Androgen deprivation therapy (ADT) is a well-established treatment for locally advanced, biochemically recurrent and metastatic prostate cancer. However, it is associated with significant side effects including hot flashes, loss of libido and erectile function, muscular atrophy, metabolic abnormalities, and osteoporosis. In attempt to mitigate the side effects of ADT while retaining the oncological benefits, an approach of intermittent ADT (IAD) has been investigated. IAD involves alternating periods of treatment with intervals off treatment to allow hormone recovery. PSA thresholds are triggers for withdrawing and reinitiating therapy. Potential advantages of IAD include improved quality of life with fewer side effects and reduced cost. Delays in the development of hormone resistance have not been demonstrated clinically. The appropriate use of IAD requires patient selection and close monitoring of quality of life and disease status. This review presents the most recent evidence on the role of IAD in the management of prostate cancer.

Evaluating the impact of an integrated multidisciplinary head & neck competency-based anatomy & radiology teaching approach in radiation oncology: a prospective cohort study.

BACKGROUND: Modern radiation oncology demands a thorough understanding of gross and cross-sectional anatomy for diagnostic and therapeutic applications. Complex anatomic sites present challenges for learners and are not well-addressed in traditional postgraduate curricula. A multidisciplinary team (MDT) based head-and-neck gross and radiologic anatomy program for radiation oncology trainees was developed, piloted, and empirically assessed for efficacy and learning outcomes. METHODS: Four site-specific MDT head-and-neck seminars were implemented, each involving a MDT delivering didactic and case-based instruction, supplemented by cadaveric presentations. There was no dedicated contouring instruction. Pre- and post-testing were performed to assess knowledge, and ability to apply knowledge to the clinical setting as defined by accuracy of contouring. Paired analyses of knowledge pretests and posttests were performed by Wilcoxon matched-pair signed-rank test. RESULTS: Fifteen post-graduate trainees participated. A statistically significant (p < 0.001) mean absolute improvement of 4.6 points (17.03%) was observed between knowledge pretest and posttest scores. Contouring accuracy was analyzed quantitatively by comparing spatial overlap of participants' pretest and posttest contours with a gold standard through the dice similarity coefficient. A statistically significant improvement in contouring accuracy was observed for 3 out of 20 anatomical structures. Qualitative and quantitative feedback revealed that participants were more confident at contouring and were enthusiastic towards the seminars. CONCLUSIONS: MDT seminars were associated with improved knowledge scores and resident satisfaction; however, increased gross and cross-sectional anatomic knowledge did not translate into improvements in contouring accuracy. Further research should evaluate the impact of hands-on contouring sessions in addition to dedicated instructional sessions to develop competencies.

Evaluation of a 3-Dimensional-Printed Head Simulation Technique for Teaching Flexible Nasopharyngoscopy to Radiation Oncology Residents.

PURPOSE: Simulation-based medical education is an effective tool for medical teaching, but simulation-based medical education deployment in radiation oncology (RO) is limited. Flexible nasopharyngoscopy (FNP), an essential skill for RO residents, requires practice that typically occurs on volunteer patients, introducing the potential for stress and discomfort. We sought to develop a high-fidelity simulator and intervention that provides RO residents the opportunity to develop FNP skills in a low-pressure environment. METHODS AND MATERIALS: Computed tomography images were used to create an anatomically accurate 3-dimensional-printed model of the head and neck region. An intervention incorporating didactic instruction, multimedia content, and FNP practice on the model was designed and administered to RO residents attending the Anatomy and Radiology Contouring Bootcamp. Participants completed pre- and postintervention evaluations of the training session and model fidelity, and self-assessments of FNP skill and confidence performing FNP. Participants were video recorded performing FNP pre- and postintervention. Videos were scored by a blinded observer on a predefined rubric. Changes in scores were evaluated using the Wilcoxon signed-rank test. RESULTS: Twenty-four participants from 17 institutions and 4 countries completed the intervention, 50% were women, and most were senior residents. Postintervention, FNP confidence and FNP performance improved significantly (mean ± standard deviation on a 10-point scale: 1.8 ± 1.8, P < .001; 2.2 ± 2.0, P < .001, respectively). Participants felt the model was helpful (mean ± standard deviation on a 5-point scale: 4.2 ± 0.6), anatomically correct (4.1 ± 0.9), and aided in spatial comprehension (4.3 ± 0.8). Overall satisfaction for the intervention was high (4.3 ± 0.8). Participants strongly agreed the intervention should be integrated into RO training programs (4.3 ± 0.8). CONCLUSIONS: A 3-dimensional-printed model and associated intervention were effective at improving FNP performance and the teaching method was rated highly by participants. RO residents may benefit from broader dissemination of this technique to improve trainee performance.

Current state of brachytherapy teaching in Canada: a national survey of radiation oncologists, residents, and fellows.

PURPOSE: The objective of the present study was to determine perceptions and barriers concerning brachytherapy (BT) teaching in Canada to guide the development of a BT credentialing process. METHODS AND MATERIALS: In May 2013, an electronic survey was sent to all radiation oncologists, program directors, residents, and fellows in Canada. Questions were asked regarding demographics, practice patterns, teaching methods and assessment, curriculum content, perceptions on resident education, and barriers to resident teaching. RESULTS: One hundred twenty-one staff radiation oncologists and 32 residents responded to the survey. Only 54% of respondents stated that their center had defined specific written objectives with respect to knowledge, skills, and attitudes required for a resident to be competent in BT. The main barriers to BT teaching were stated as being the lack of Royal College guidance (55%), heavy clinical workload (49%), lack of time (37%), and the fact that too much emphasis is placed on passing examinations (32%). Ninety-seven percent of respondents felt that it was important or very important that some elements of BT be included in the mainstream radiation oncology curriculum. Eighty percent of respondents were in agreement with the development of a formal credentialing process by the Royal College of Physicians and Surgeons of Canada, which would lead to separate certification in BT. CONCLUSIONS: The results of this study show the importance of developing specific BT curriculum and emphasize the need for a credentialing process.

Integrating anatomy training into radiation oncology residency: considerations for developing a multidisciplinary, interactive learning module for adult learners.

Radiation oncologists require an in-depth understanding of anatomical relationships for modern clinical practice, although most do not receive formal anatomy training during residency. To fulfill the need for instruction in relevant anatomy, a series of four multidisciplinary, interactive learning modules were developed for a cohort of radiation oncology and medical physics residents. Instructional design was based on established learning theories, with the intent of integrating knowledge of specific anatomical regions with radiology and radiation oncology practice. Each session included presentations by a radiologist and a radiation oncologist, as well as hands-on exploration of anatomical specimens with guidance from anatomists. Pre- and post-tests distributed during each session showed significant short-term knowledge retention. According to qualitative surveys and exit interviews, participants felt more comfort' with delineating structures, gross anatomy, and radiograph interpretation at the end of each session. Overall participant experience was positive, and the modules were considered effective for learning radiologic anatomy. Suggestions for future interventions include more time, increased clinical application, additional contouring practice and feedback, and improved coordination between each of the three disciplines. Results and conclusions from this study will be used to inform the design of a future multi-day national workshop for Canadian radiation oncology residents.

Evaluating the impact of a Canadian national anatomy and radiology contouring boot camp for radiation oncology residents.

BACKGROUND: Radiation therapy treatment planning has advanced over the past 2 decades, with increased emphasis on 3-dimensional imaging for target and organ-at-risk (OAR) delineation. Recent studies suggest a need for improved resident instruction in this area. We developed and evaluated an intensive national educational course ("boot camp") designed to provide dedicated instruction in site-specific anatomy, radiology, and contouring using a multidisciplinary (MDT) approach. METHODS: The anatomy and radiology contouring (ARC) boot camp was modeled after prior single-institution pilot studies and a needs-assessment survey. The boot camp incorporated joint lectures from radiation oncologists, anatomists, radiologists, and surgeons, with hands-on contouring instruction and small group interactive seminars using cadaveric prosections and correlative axial radiographs. Outcomes were evaluated using pretesting and posttesting, including anatomy/radiology multiple-choice questions (MCQ), timed contouring sessions (evaluated relative to a gold standard using Dice similarity metrics), and qualitative questions on satisfaction and perceived effectiveness. Analyses of pretest versus posttest scores were performed using nonparametric paired testing. RESULTS: Twenty-nine radiation oncology residents from 10 Canadian universities participated. As part of their current training, 29%, 75%, and 21% receive anatomy, radiology, and contouring instruction, respectively. On posttest scores, the MCQ knowledge scores improved significantly (pretest mean 60% vs posttest mean 80%, P<.001). Across all contoured structures, there was a 0.20 median improvement in students' average Dice score (P<.001). For individual structures, significant Dice improvements occurred in 10 structures. Residents self-reported an improved ability to contour OARs and interpret radiographs in all anatomic sites, 92% of students found the MDT format effective for their learning, and 93% found the boot camp more effective than educational sessions at their own institutions. All of the residents (100%) would recommend this course to others. CONCLUSIONS: The ARC boot camp is an effective intervention for improving radiation oncology residents' knowledge and understanding of anatomy and radiology in addition to enhancing their confidence and accuracy in contouring.

SPECT-based functional lung imaging for the prediction of radiation pneumonitis: a clinical and dosimetric correlation.

INTRODUCTION: When we irradiate lung cancer, the radiation dose that can be delivered safely is limited by the risk of radiation pneumonitis (RP) in the surrounding normal lung. This risk is dose-dependent and is commonly predicted using metrics such as the V20, which are usually formulated assuming homogeneous pulmonary function. Because in vivo pulmonary function is not homogeneous, if highly functioning lung can be identified beforehand and preferentially avoided during treatment, it might be possible to reduce the risk of RP, suggesting the utility of function-based prediction metrics. METHODS: We retrospectively identified 26 patients who received ventilation and perfusion single photon emission computed tomography (SPECT-CT) immediately prior to curative-intent radiation therapy. Patients were separated into non-RP and RP groups. As-treated dose-volume histogram (DVH), perfusion-SPECT-based and ventilation-SPECT-based dose-function histogram (DFH) parameters were defined for each group and were tested for differences. The relative utilities of ventilation-based and perfusion-based DFH metrics were assessed using receiver operating characteristic (ROC) analysis. RESULTS: The standard mean lung dose (MLD) was significantly higher in the RP group; the standard V20 and V30 were higher in the RP group but not significantly. Perfusion-weighted and ventilation-weighted values of the MLD, V20 and V30 were all significantly higher in the RP group. ROC analysis suggested that SPECT-based DFH parameters outperformed standard DVH parameters as predictors of RP. CONCLUSIONS: SPECT-based DFH parameters appear to be useful as predictors of RP.