August 24, 2009
How Much Imaging Training Does a Radiation Oncologist Need?
By Dan Harvey
Vol. 10 No. 15 P. 12
Professionals weigh in on how to better connect radiation oncology and imaging technology.
A little less than a year ago, at the 50th annual meeting of the American Society for Radiation Oncology (ASTRO), discipline professionals convened for a panel discussion titled “Opportunities in Imaging for Radiation Oncology.”
Participating panelists in this 2008 dialogue—including Robert Atcher, PhD; N. Reed Dunnick, MD; Bruce G. Haffty, MD; and Anwar Padhani, MBBS—noted how the radiation oncology field is a “significant consumer” of advanced imaging technology. Panel members focused a good part of their discussion on imaging education for radiation oncologists. In particular, they noted how rapid development and adoption of new radiation therapy techniques appear to outpace existing imaging education opportunities for radiation oncologists.
The discussion raised several questions: How should aspiring radiation oncologists (residents) acquire a better understanding of imaging technology? Can bridges be built to connect radiation oncology and radiologic imaging? If so, would more formalized education for residents provide the supporting structure that forms that bridge? Further, what specific education changes might foster better understanding of radiologic imaging as it applies to radiation oncology?
“The radiation oncology and radiology fields both have witnessed numerous changes and advancements,” says Haffty, a professor and the chairman of the radiation oncology department at the University of Medicine & Dentistry of New Jersey-Robert Wood Johnson Medical School. “At the same time, radiation oncologists rely more on imaging technology for precise targeting, and I feel that this is appropriate. But we don’t have a formal curriculum that defines what we need to know, as both fields move forward.”
While they didn’t provide definitive answers to the questions posed, participants raised awareness about the issues, and they initiated a discussion that, by its nature, assures its continuance.
“Another conference is scheduled for the next RSNA meeting, and the discussion will be less broad,” says Haffty, who is also associate director of The Cancer Institute of New Jersey. The ongoing dialogue is expected to cover specific elements such as direction, curriculum development, and formal benchmarks. “We’ll try and determine the importance of these elements and how to get from where we are now to where we need to go,” he says.
“The two disciplines emerged from the same trade, so to speak, but a divergence began in the 1960s that created a chasm,” says Richard T. Hoppe, MD, a professor and the chair of radiation oncology at Stanford University, who didn’t participate in the ASTRO discussion but still offers an informed historical perspective. “However, in recent years, there has been an increasing convergence, and that was an issue the ASTRO discussion addressed.”
The convergence came about through advances in radiation oncology. “Imaging technology is increasingly used to affect improved radiation therapy planning and treatment,” Hoppe says, noting that this includes the identification of anatomical areas impacted by tumors via modalities such as CT, MRI, and PET and fusion technology.
As these all complement treatment monitoring, radiation oncologists need to deploy a lot more imaging awareness, if not skills, toward more effective patient treatment. “Even though that has become a given, we’ve let radiology fall to the wayside as far as radiation oncologist training programs,” he adds.
But Hoppe is quick to point out that this doesn’t imply a deficiency in overall radiation oncologist training. “Far from it,” he says. “It’s just that as radiation oncologists witness tremendous technological treatment delivery advances—and, of course, their training keeps them on par with that—their formal training really hasn’t kept pace with the kind of diagnostic imaging advances that provide them valuable tools in their practice.”
“While the 2008 ASTRO discussion had a broad scope, we talked about how imaging has assumed an increasingly larger and more complex role in terms of patient treatment,” says Haffty. “More sophisticated treatment planning techniques require more sophisticated imaging techniques, and better education would ensure that we’re doing everything right.”
How Much Is Enough?
But Haffty emphasizes this point: While increased education is important, no one is trying to train radiation oncologists to become better imagers. “It’s not the radiation oncologist’s job to interpret x-rays and diagnostic findings,” he says. “You can’t make a radiologist out of a radiation oncologist any more than you could transform a surgeon into an internist. Also, we simply can’t expect radiation oncologists to learn all there is to need to know about imaging.”
So, it’s not about incorporating comprehensive imaging training into the radiation oncology discipline; rather, it’s about providing a reasonable amount of training. “As radiation oncologists garner more knowledge about imaging technology, they should simultaneously be aware of their own limitations as far as drawing and targeting tumor volumes while increasing their capabilities,” says Hoppe.
That leads to the inevitable training question: Just how much imaging education is necessary, desirable, or reasonable? “You can’t put the residents through two years of diagnostic imaging,” says Haffty. “Not only is that never going to happen; it’s not a good use of anyone’s time.”
For about two decades, the Residency Review Committee for Radiation Oncology has required one month of formal diagnostic imaging training or an equivalent, according to Haffty. “The equivalent can include time spent at tumor boards or forums where a diagnostic imaging professional is present and films are shown,” he explains.
But, he adds, that requirement doesn’t go far in filling the perceived need, nor was that the intention. “It was designed to provide radiation oncologists exposure to diagnostic imaging, but that’s about it,” says Haffty. “But with this approach, aspiring radiation oncologists don’t receive all that they really need to know.”
Currently, much of radiation oncology residents’ imaging experience is garnered in the clinical practice setting. “On a daily basis, the radiation oncologist residents look at the images and determine the target volume,” Haffty says. “They’ll review that with an attending physician. If they should get stuck on a question, they consult a radiologist, who could help better define target volumes, as they better understand the imaging technology. So, essentially, residents garner most of their imaging education through an on-the-job training scenario during their four-year course.”
And, so far, the approach has worked reasonably well. But as imaging technology improves treatment accuracy, doctors would benefit from more training to use imaging more effectively.
“Now, I think we need to step back and determine some specific benchmarks, such as the tasks the radiation oncologist should be able to perform,” says Haffty. “Perhaps a more formalized learning structure would be appropriate.”
The structure may involve as much as three to six months spent in diagnostic imaging. “Then again, things may be just fine as they are,” says Haffty. “Right now, we really don’t know. That’s why we need further discussion. After all, at this point, nothing has been truly standardized.”
Hoppe believes that three months included within the context of four-year training would be both realistic and useful. “There’s a lot of competing demands on a resident’s time, so you can’t simply say that they need to spend a year in radiology. But a concentrated three months would probably be very effective,” he says.
However, Hoppe concedes that one month of basic exposure expanded to three months of concentrated exposure would entail significant challenges. One involves turf and control considerations. Most likely, existing residential training programs would be reluctant to surrender residents’ assignment time. To properly function, such training programs need residents to be available in the clinic and elsewhere.
“Residents already become involved in existing electives or outside rotations, so where could you pull out this three-month time?” asks Hoppe. “If you pull it from the residents’ elective time, clinic time, or their assigned external rotations, someone somewhere is going to be impacted—and they’re not going to be happy.”
So, that’s one major challenge in expanding imaging education time. Another challenge involves the functional engagement of radiology programs and departments. “They’d be the source for this additional training, thus they’d need to supply additional time and resources,” Hoppe says. “You’d be imposing an incremental expectation into their discipline. They may already be overburdened and heavily involved in training their own residents. So they may not even be interested in teaching residents from another discipline. And even if that’s possible, who will compensate and how?”
Those two challenges provide major hurdles, but there’s more. Consider this situation: “If the Residency Review Committee for Radiation Oncology requires such a relationship to develop, and if a radiology department determines that it can’t do it—and, in turn, refuses to do it—then a radiation oncology program could no longer be certified,” says Hoppe. “So you could enter into a very tricky area, where a treatment component exists outside of a discipline and a department has no control.”
It’s hard to say how this could play out. Right now, the two organizations that could exercise the most influence (the American Board of Radiology and the Residency Review Committee for Radiation Oncology) are holding back. “Either one of these organizations could assume the responsibility but, given the aforementioned challenges, neither has appeared likely to approach the task,” says Hoppe.
Hoppe suggests a potentially workable solution. “An additional learning opportunity for radiation oncologists in diagnostic imaging could be established at a central site, either towards the end of their training or after their training,” he says. “For instance, the American College of Radiology has an educational facility in Reston, Va., where it offers many radiology CME courses that require a good deal of hands-on participation. It has set up network stations that radiologists use. Conceivably, these networks also could serve new programs for radiation oncologists.”
In this way, residents reaching the end of their training could experience a concentrated immersion into imaging that may last a week or several weeks. Likewise, programs could be established for practitioners, explains Hoppe. “These programs could serve those already established in practice but who find that they need additional understanding related to the images they’re viewing. So, resources for potential alternatives to formalized training (either during or after residency) exist,” he says.
In the meantime, Haffty believes programs need to maintain a focus on the basics of what a radiation oncologist needs to know and how they should apply what they know. “In my view, I think we should probably stick with what we’ve done so far,” he says. “With existing approaches, people eventually learn what they need to know.”
But he concedes that the lack of formalized approach and standardized curriculum fosters the need for further discussion. In particular, the so-called one-month requirement is minimal and ill defined. “Does that mean you spend a month in diagnostics or a month in CT or MRI or mammogram? What is the course structure? What are the required lectures?” he asks.
But the dialogue has begun at least. “We are trying to determine the best approach,” says Haffty. “At the end, we may determine that the current approach is quite appropriate, or we may determine that several viable alternative approaches present themselves. But I don’t think we will ever get to the point where we say a resident needs to spend a year or more in diagnostic imaging in order to become a radiation oncologist. No one is saying that right now, and I don’t think anyone will ever say it.”
— Dan Harvey is a freelance writer based in Wilmington, Del., and a frequent contributor to Radiology Today.