Clinical Investigation
Head-and-Neck Target Delineation Among Radiation Oncology Residents After a Teaching Intervention: A Prospective, Blinded Pilot Study

https://doi.org/10.1016/j.ijrobp.2008.04.028Get rights and content

Purpose

We conducted this study to determine the feasibility of incorporating a teaching intervention on target delineation into the educational curriculum of a radiation oncology residency program and to assess the short-term effects on resident skills.

Methods and Materials

The study schema consisted of a baseline evaluation, the teaching intervention, and a follow-up evaluation. At the baseline evaluation, the participants contoured three clinical tumor volumes (CTVs) (70 Gy, 59.4 Gy, and 54 Gy) on six contrast-enhanced axial computed tomography images of a de-identified patient with Stage T2N2bM0 squamous cell carcinoma of the right base of the tongue. The participants attended a series of head-and-neck oncology and anatomy seminars. The teaching intervention consisted of a didactic lecture and an interactive hands-on practical session designed to improve the knowledge and skills for target delineation in the head and neck. At the follow-up evaluation, the residents again contoured the CTVs.

Results

Of the 14 eligible residents, 11 (79%) actually participated in the study. For all participants, but especially for those who had not had previous experience with head-and-neck target delineation, the teaching intervention was associated with improvement in the delineation of the node-negative neck (CTV 54 Gy contour). Regardless of clinical experience, participants had difficulty determining what should be included in the CTV 59.4 Gy contour to ensure adequate coverage of potential microscopic disease.

Conclusion

Incorporating a teaching intervention into the education curriculum of a radiation oncology residency program is feasible and was associated with short-term improvements in target delineation skills. Subsequent interventions will require content refinement, additional validation, longer term follow-up, and multi-institutional collaboration.

Introduction

Intensity-modulated radiotherapy (IMRT) is a complex technology that has been rapidly adopted in the treatment of head and neck cancer. The highly conformal dose distributions produced by modulation of the beam intensity require careful delineation of the gross tumor targets and surrounding normal tissue. Inadequate delineation of the target volumes can diminish tumor control or increase toxicity. The complexity of the head-and-neck anatomy and evidence of variation in target delineation by expert clinicians has prompted calls for specialized training during residency programs in head-and-neck target delineation 1, 2, 3, 4, 5.

The current model of radiation oncology residency training is based primarily on apprenticeship rather than specifically designed curricula. For example, at the Memorial Sloan-Kettering Cancer Center, radiation oncology residents are taught head-and-neck radiation oncology through 3-month clinical rotations. During these rotations, residents work one-on-one with a faculty member who sees head-and-neck patients in the clinic. In addition, the residents attend a 1-month head-and-neck oncology seminar series. Through didactic lectures and hands-on training, the residents are expected to develop clinical expertise and competency in all aspects of head-and-neck radiotherapy, of which target delineation is an essential component. Similarly, a recent survey of residents at accredited radiation oncology programs in the United States found that most were exposed to IMRT through didactic lectures and hand-on training for head-and-neck cancers (4).

However, the Institute of Medicine has emphasized a shift in medical education, from the traditional experienced-based model to more rigorous educational programs that can be shown to improve the quality of care delivered to patients 6, 7, 8. The American College of Radiology has also endorsed the development and evaluation of new approaches to graduate medical education that measure specific educational outcomes (9). To date, however, only limited research has described educational interventions within the radiation oncology field.

Given the importance of adequate target delineation in the provision of high-quality radiotherapy for patients with head-and-neck cancers, we conducted this study to determine the feasibility of incorporating a teaching intervention on target delineation into the educational curriculum of a radiation oncology residency program and to assess the short-term effects of the teaching intervention on resident skills.

Section snippets

Study participants

We had 15 residents in the radiation oncology residency program at the Memorial Sloan-Kettering Cancer Center during the 2007–2008 academic year. As a part of their annual educational curriculum, the residents participated in a head-and-neck oncology seminar series in August 2007. The teaching intervention occurred as an addition to this seminar series. All residents were eligible to participate, except for the chief resident (a fourth-year resident with a previous head-and-neck clinical

Feasibility

Of the 14 eligible residents, 3 (a first-year resident without a previous head-and-neck rotation, a second-year resident without a previous head-and-neck rotation, and a third-year resident with a previous head-and-neck rotation) were excluded because they were unavailable for part of the study period owing to vacation. Therefore, 11 (79%) of the 14 eligible residents actually participated in the study.

Of the 11 study participants, 10 attended both parts of the teaching intervention. One

Discussion

We undertook this study to determine the feasibility of incorporating a teaching intervention on head-and-neck target delineation into the educational curriculum of a radiation oncology residency program and to assess its short-term effects. We found that nearly 80% of eligible residents participated in the intervention and that the intervention was associated with short-term improvements in several aspects of target delineation for a patient with Stage T2N2bM0 squamous cell carcinoma of the

Conclusion

The results of our study have shown that incorporating a teaching intervention into the educational curriculum of a radiation oncology residency program is feasible and associated with short-term improvements in target delineation skills. Subsequent interventions will require content refinement, additional validation, longer term follow-up, and multi-institutional collaboration.

Acknowledgments

We thank the 2007/2008 residents of the Memorial Sloan-Kettering Cancer Center for participating in this study. The following Memorial Sloan-Kettering Cancer Center faculty led seminars for the residents as a part of the annual head-and-neck oncology curriculum of the Department of Radiation Oncology: Mathew G. Fury, M.D. (Medical Oncology); Sasan Karimi, M.D. (Diagnostic Radiology); Dennis H. Kraus, M.D. (Surgery); and Hilda E. Stambuk, M.D. (Diagnostic Radiology). We acknowledge the

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  • Cited by (54)

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      Citation Excerpt :

      To our knowledge there is no comparable work in France in the field of radiotherapy. Some studies have shown an improvement in delineation after training residents in radiation therapy [18,19]. A homogenization of the delineation of head and neck cancers was observed among eleven residents after teaching.

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    Conflict of interest: none.

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