Elsevier

Brachytherapy

Volume 19, Issue 6, November–December 2020, Pages 787-793
Brachytherapy

The American Brachytherapy Society prostate brachytherapy LDR/HDR simulation workshops: Hands-on, step-by-step training in the process of quality assurance

https://doi.org/10.1016/j.brachy.2020.10.001Get rights and content

Abstract

Purpose

Education and training on prostate brachytherapy for radiation oncology and medical physics residents in the United States is inadequate, resulting in fewer competent radiation oncology personnel to perform implants, and is a factor in the subsequent decline of an important, potentially curative cancer treatment modality for patients with cancer. The American Brachytherapy Society (ABS) leadership has recognized the need to establish a sustainable medical simulation low-dose-rate (LDR) and high-dose-rate (HDR) brachytherapy workshop program that includes physician–physicist teams to rapidly translate knowledge to establish high-quality brachytherapy programs.

Methods

The ABS, in partnership with industry and academia, has held three radiation oncology team–based LDR/HDR workshops composed of physician–physicist teams in Chicago in 2017, in Houston in 2018, and in Denver in 2019. The predefined key metric of success is the number of attendees who returned to their respective institutions and were actively performing brachytherapy within 6 months of the prostate brachytherapy workshop.

Results

Of the 111 physician/physicist teams participating in the Chicago, Houston, and Denver prostate brachytherapy workshops, 87 (78%) were actively performing prostate brachytherapy (51 [59%] HDR and 65 [75%] LDR).

Conclusions

The ABS prostate brachytherapy LDR/HDR simulation workshop has provided a successful education and training structure for medical simulation of the critical procedural steps in quality assurance to shorten the learning curve for delivering consistently high-quality brachytherapy implants for patients with prostate cancer. An ABS initiative, intended to bend the negative slope of the brachytherapy curve, is currently underway to train 300 new competent brachytherapy teams over the next 10 years.

Introduction

Education and training on prostate brachytherapy for radiation oncology and medical physics residents in the United States is inadequate, resulting in fewer competent radiation oncology personnel to perform implants, and is a factor in the subsequent decline of an important, potentially curative cancer treatment modality for patients with cancer (1, 2). Brachytherapy is a well-established standard-of-care approach to the treatment of prostate cancer, and Level I evidence demonstrates its importance in the management of high-risk disease (3). For appropriately selected patients, the outcomes after brachytherapy are as good as, if not superior to, any other method of prostate cancer treatment, achieving the “trifecta” of high cure rates, excellent quality of life, and high value (4). However, when brachytherapy is performed without adequate training and an effective quality assurance program, disease control and quality of life can be inferior to widely accepted outcomes (5).

Education-governing bodies such as the Accreditation Council for Graduate Medical Education, American Board of Radiology, and the Radiation Oncology Residency Review Committee provide a critical structure to ensure that radiation oncologists are appropriately trained, certified, and credentialed for patient care. However, over the past 3 decades, the requirements for board certification in radiation oncology specify that only five interstitial implants need to have been performed. Moreover, the required interstitial implants are not specific to prostate brachytherapy, and thus are clearly inadequate for competency training. The Seattle Prostate Institute aimed to fill the gap in education and training by providing short courses and up to 2-month fellowships for practitioners worldwide during the 1990s and early 2000s. Since that time, several low-dose-rate (LDR) techniques in prostate brachytherapy have emerged, including preplanning and intraoperative planning, loose seed and stranded seed deposition, and a choice of isotope selection (125iodine, 103palladium, and 131cesium) (6,7,8). Other alternative standard-of-care modalities involving implantation of temporary high-dose-rate (HDR) 192iridium sources have emerged during that interval as well (3,9).

In 2009, the consequences of a lack of quality assurance procedures for brachytherapy at the Veterans Affairs (VA) Medical Center in Philadelphia, PA were discovered, exposed, and highlighted by the NY Times (5). Further investigation of prostate brachytherapy experiences at VA hospitals around the country revealed poorly defined quality procedures for LDR prostate brachytherapy and poor quality assurance practices at some of the VA hospitals, which led to shutting down most of the brachytherapy programs for veterans. Although published data confirmed that high-quality brachytherapy was being performed at some academic and high-volume community practices, a significant gap in knowledge and training had been exposed that was not being filled by the education and training regulatory bodies (e.g., the American Board of Radiology, Accreditation Council for Graduate Medical Education, the Radiation Oncology Residency Review Committee) or advocacy colleges and societies (e.g., the American Brachytherapy Society [ABS], American Society for Radiation Oncology [ASTRO], American Radium Society, American College of Radiology, or the American College of Radiation Oncology). Additional negative pressures on prostate brachytherapy came from decreasing reimbursement of brachytherapy, enhanced reimbursement of intensity-modulated radiation therapy, and the establishment of urology-owned radiation oncology practices (10). In the subsequent years, both the Surveillance, Epidemiology and End Results database and the National Cancer Database recorded declines in the use of brachytherapy, either as monotherapy or in combination with external beam radiation, in both community and academic settings (11, 12).

The British Columbia Cancer Agency Prostate Brachytherapy program helped to articulate key components of robust quality assurance procedures that could be applied to any brachytherapy program (13). These components included a unified eligibility criterion and planning system, a comprehensive database, physics and oncologist training and mentorship programs, a peer review process, an individual's performance outcomes and feedback process, structured continuing education and routine assessment of the program's dosimetry, toxicity, and prostate-specific antigen outcomes, and administration and program leadership that promotes a strong culture of patient safety.

In 2011, the ABS and The University of Texas MD Anderson Cancer Center collaborated to define the process of quality assurance, with an emphasis on education and training in prostate brachytherapy. A six-step process was developed that included the following: (1) appropriate patient selection, (2) ultrasound simulation, (3) treatment planning, (4) implantation, (5) postimplant quality assessment, and (6) followup side effect management (14). The brachytherapy community has acknowledged that several different approaches can all deliver consistently high-quality implants, including “preplanning,” or “intraoperative planning,” or “preplanning with intraoperative optimization.” The reduction in number of brachytherapy cases in residency programs and the lack of infrastructure for ultrasound simulation training highlighted the knowledge gap regarding barriers to achieving consistently high-quality implants. To address critical gaps in knowledge of the quality assurance process, a Prostate Phantom Simulator Training Program was developed at MD Anderson to provide residents, fellows, and faculty a method for performing steps 2–5 of the quality assurance process (15).

In 2014–2016, the ABS collaborated with ASTRO to establish the first Prostate Brachytherapy LDR Simulation Workshop, to be held at the ASTRO annual meeting for radiation oncologists. This workshop was to include required and suggested reading, required static ultrasound and/or MRI and CT image patient prostate contouring, a precourse test, anatomic lectures, prostate phantom ultrasound simulation and implants, and a postcourse test. This ABS–ASTRO collaboration was unfortunately terminated because of high organizational costs that resulted in high registration fees being required to cover administrative overhead. The ABS leadership recognized the need to establish a sustainable medical simulation brachytherapy workshop program that included physician–physicist teams, as opposed to physicians alone, to rapidly translate knowledge to establish high-quality programs within 6 months of completing the workshop. The ABS initiated a workshop as an adjunct to the ABS 2016 annual meeting in San Francisco; from 2017 through 2019, the ABS, in partnership with industry and academia, held three radiation oncology team–based LDR/HDR workshops composed of physician–physicist teams—the first in Chicago in 2017, the second in Houston in 2018, and the third in Denver in 2019. The remainder of this report presents our findings from these workshops and our conclusions on future directions for this new way of educating the next generation of brachytherapists.

Section snippets

Brachytherapy phantom-based workshop structure: 2016–2019

The ABS collaborated with ASTRO to create a hands-on simulation workshop for physicians at ASTRO's 57th (2015) and 58th (2016) annual meetings (Fig. 1). The goal of the simulation workshop was to address the education gap in existing courses and lack of training in residency programs. The workshop required the participants, limited to 30, to complete homework and a pretest before attending the course. The homework consisted of reading materials including guidelines and journal articles as well

Postworkshop survey assessments: 2017–2019

Each physician–physicist team completed a posttest and workshop survey to provide feedback on the workshop structure, quality, and areas needing improvement. Faculty members were also sent a postworkshop survey to provide feedback on the course and identify areas for future improvement. Team responses to the surveys given after the 2017 (Chicago), 2018 (Houston), and 2019 (Denver) workshops are described in the next few paragraphs and depicted graphically in Fig. 4.

ABS metrics of success and future directions

The ABS leadership had predefined a key metric of success for the simulation workshop, that is, the number of attendees who returned to their respective institutions and were actively performing high-quality brachytherapy within 6 months of the prostate brachytherapy workshop. For this reason, the team approach for attendees was felt to be very important. Trying to change practice can be both a difficult and a lonely task, even after the most stimulating learning experience, such as traveling

Acknowledgments

We thank Melissa Pomerene of the American Brachytherapy Society and Lory Bradley at Theragenics Corporation for outstanding administrative support and industry collaboration. We also thank the ABS workshop faculty, whose years of experience will guide the next generation of brachytherapists.

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Funding: Supported in part by Cancer Center Support (Core) Grant P30 CA016672 from the National Cancer Institute, National Institutes of Health, to The University of Texas MD Anderson Cancer Center.

Disclosures: Dr. Frank reports receiving fees as a consultant and advisory board member of Varian, as a director and founder of C4 Imaging, as an advisor for Hitachi, as honoraria from Boston Scientific, and as a member of the board of directors of the National Comprehensive Cancer Center (NCCN). Dr. Frank also sits on the scientific advisory board for Breakthrough Chronic Care and has research grants from C4 Imaging, Eli Lilly, Elekta, and Hitachi. Dr. Ma receives research support from and has intellectual property licensing to Siemens Healthineers and GE Healthcare and is a consultant for C4 Imaging. Dr. Cox is a private equity shareholder at C4 Imaging. No other authors report any conflicts of interest.

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