Simulation Training in the Treatment of Gynecological Malignancies with
Brachytherapy: A Multi-Disciplinary Program
Team:
Lisa Singer, MD, PhD1
Steve Braunstein, MD, PhD1
Carly Hoffman, NP1
Tracy Sherertz, MD1
Lee-may Chen, MD2
Adam Cunha, PhD1
Christopher McGuinness, PhD1
1
Department of Radiation Oncology, University of California, San Francisco,
San Francisco
2
Department of Obstetrics, Gynecology, and Reproductive Sciences, University of
California, San Francisco
1
Overview
Brachytherapy plays a crucial, cost-effective role in the treatment of
gynecological malignancies1-4. It allows for the precise delivery of a high dose of
radiation therapy to the tumor while minimizing dose to surrounding normal tissues.
Cervical cancer is the third most common cancer in women world-wide. For
locally advanced cervical cancer, when combined with external beam radiation therapy,
brachytherapy is considered an irreplaceable standard of care. Despite the importance of
brachytherapy, reviews of practice patterns in the United States have identified a decrease
in brachytherapy use in clinically appropriate patient populations, with an associated
decrease in overall survival with omission of brachytherapy 2,3. Brachytherapy requires
technical training and interdisciplinary collaboration and this project aims to address the
gap between brachytherapy needs and brachytherapy utilization by developing a novel
simulation training (ST) program.
ST in the use of brachytherapy for treatment of gynecological malignancies will
provide trainees with a comprehensive, longitudinal training opportunity. Few ST
programs currently exist in radiation oncology 5 and a review of the literature could not
identify current programs in gynecological brachytherapy, representing an opportunity
for educational innovation. The multi-disciplinary ST program will involve training in the
gynecological physical exam, interstitial and intracavitary brachytherapy procedures, and
treatment planning. Since a simulator for brachytherapy procedures could not be
identified on the current market, the simulator used for physical exam teaching will be
adapted to allow for procedural-specific skill training. The interdisciplinary nature of
brachytherapy, as well as the use of manual ultrasound-guidance present challenges for
2
ST. To help overcome these challenges, the training team consists of clinicians in
gynecological oncology and radiation oncology to provide support for brachytherapy and
physical exam training, as well as medical physicists with medical device development
experience to assist in treatment planning, brachytherapy physics education, and
simulator design. By integrating training in treatment planning with procedural training,
ST will strongly root a foundational science – physics – in clinical practice.
In a recent survey of radiation oncologists, lack of guidance, lack of time, and
emphasis on passing exams were cited as barriers to brachytherapy teaching6. ST will
address each of these barriers by providing multi-disciplinary guidance, a portable
opportunity for learning at opportune times throughout training, and an emphasis on the
need for procedural training. Currently, residents in radiation oncology are required by
the Accreditation Council for Graduate Medical Education to perform 5 interstitial and 15
intracavitary brachytherapy cases over four years. At UCSF, the treatment of
gynecological malignancies involves both interstitial and intracavitary brachytherapy
techniques7. ST will provide residents with both an increased number of learning cases
and a non-clinical environment in which skills can be practiced and mastered. Portability
of the ST program could allow for dissemination to other sites, including developing
countries, where high cervical cancer rates in young women make brachytherapy training
highly valuable.
The proposed ST represents a multi-disciplinary collaboration on an innovative
teaching method, with the goal of training physicians to safely and skillfully address the
gap between brachytherapy needs and utilization in the treatment of gynecological
malignancies.
3
Evaluation
An online survey will be administered to participants before and after ST, asking
trainees to rate confidence in skills related to physical exam, brachytherapy procedure,
and treatment planning. Trainees will also have the opportunity to provide anonymous
feedback regarding the program. A post-test will also be administered asking trainees to
answer multi-choice questions related to short clinical vignettes and requiring use of
skills addressed in ST. Survey results and post-test performance will be used to evaluate
the ST program.
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1.
Kumar RV, Bhasker S. Optimizing cervical cancer care in resource-constrained
developing countries by tailoring community prevention and clinical management
protocol. Journal of Cancer Policy. 2014;2(2):63-73.
doi:10.1016/j.jcpo.2013.11.002.
2.
Han K, Milosevic M, Fyles A, Pintilie M, Viswanathan AN. Trends in the
Utilization of Brachytherapy in Cervical Cancer in the United States. International
Journal of Radiation Oncology*Biology*Physics. 2013;87(1):111-119.
doi:10.1016/j.ijrobp.2013.05.033.
3.
Gill BS, Lin JF, Krivak TC, et al. National Cancer Data Base Analysis of Radiation
Therapy Consolidation Modality for Cervical Cancer: The Impact of New
Technological Advancements. International Journal of Radiation
Oncology*Biology*Physics. 2014;90(5):1083-1090.
doi:10.1016/j.ijrobp.2014.07.017.
4.
Tanderup K, Eifel PJ, Yashar CM, Pötter R, Grigsby PW. Curative radiation therapy
for locally advanced cervical cancer: brachytherapy is NOT optional. Int J Radiat
Oncol Biol Phys. 2014;88(3):537-539. doi:10.1016/j.ijrobp.2013.11.011.
5.
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simulation: a novel educational approach to preparing radiation oncology residents
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2014;90(3):705-706. doi:10.1016/j.ijrobp.2014.06.053.
6.
Gaudet M, Jaswal J, Keyes M. Current state of brachytherapy teaching in Canada: A
national survey of radiation oncologists, residents, and fellows. Brachytherapy.
2015;14(2):197-201. doi:10.1016/j.brachy.2014.11.004.
7.
Tinkle CL, Weinberg V, Chen L-M, et al. Inverse Planned High-Dose-Rate
Brachytherapy for Locoregionally Advanced Cervical Cancer: 4-Year Outcomes. Int
J Radiat Oncol Biol Phys. 2015;92(5):1093-1100. doi:10.1016/j.ijrobp.2015.04.018.
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