RAS6033.doc

REGIONAL COOPERATIVE AGREEMENT

INTERNATIONAL ATOMIC ENERGY AGENCY

IAEA/RCA Consultants’ Meeting & Validation Workshop on the Applied Sciences of Radiation Oncology (ASO)

Pilot Course

RCA PROJECT RAS/6/033 WITH THE PARTICIPATION OF AFRA AND ARCAL

Kuala Lumpur, Malaysia

31 January – 3 February 2005

Background

This distance learning project was conceived by RCA to address severe shortages in trained radiation oncology personnel, and in particular a lack of teaching resources in the Applied Sciences of Radiation Oncology in many Member States. A project formulation meeting was held in Kuala Lumpur in December 1999 under IAEA Technical Cooperation Project RAS/6/027. Representatives of ARCAL and AFRA attended this meeting, as the concept also had applicability in their regions.

The meeting decided that interactive teaching material on the Applied Sciences of Oncology (ASO) would contribute to the solution of the problem. The project coordinating group devised an initial list of eight subjects, comprising 64 modules within those subjects, to cover the most important educational deficiencies.

A program to cover seven years was developed. It included: -

Development of English-language materials

Validation by expert review

Piloting of the materials in 3 countries in RCA and countries in AFRA and ARCAL.

Ongoing review

Translation and

Implementation

In 2001 this project was approved for continuation under the new project designation RAS/6/033.

In June 2003 the 2nd Project Coordinators Meeting (PCM) in Seoul, Republic of Korea, reviewed the development of the course, critically evaluated the content of the teaching materials to that date via a beta-version CD-ROM and planned activities for the 2003/2004 biennium and beyond, including the conduct of the pilot course in 2004.

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PILOT COURSE 2004

The ASO course was piloted in three RCA Member States (MAL, PAK, PHI), two AFRA Member States (EGY, MOR) and two ARCAL Member States (ARG, URU). Twenty-five students participated in the pilot, including two students from Costa Rica who were studying in Argentina.

Copies of the Pilot CD were sent direct to the National Course Coordinators (NCCs) of participating countries in January 2004, for distribution to individual students. At the request of the IAEA, supporting reference texts for each host institution were bulk-purchased in Australia and shipped to the relevant UNDP offices in the participating countries in early March. Unfortunately not all the texts reached their intended institutions. In particular, the delivery to Pakistan was mislaid in the UNDP Office in Islamabad and eventually reached the NCC two months late, and then only after considerable effort had been expended to trace it. Some books had been given away by UNDP staff to other Pakistani institutions not involved in project RAS/6/033, and have not so far been recovered. (It appears that the UNDP is not always the most secure supply channel). Egypt also experienced problems with textbook supply.

Further revision of the course material was halted at the end of December 2003 to permit the course to be piloted as planned during the 2004 academic year. The module count increased from 68 at the time of the 2nd PCM in 2003 to 71 modules and sub-modules in the Pilot CD-ROM. In part this increase was to achieve a better content layout. As well, certain large modules were split into two so that each part could be completed in a (nominal) one-hour period. A list of the modules on the two CD-ROMs is provided at Appendix 1.

The few modules that could not be finalised in time were issued as interim modules on the Pilot CD. In consequence, a Supplementary CD-ROM was issued in November 2004 which updated all but two of the interim modules and incorporated various improvements, including progress tracking and bookmarking, to solve technical problems reported by students during the earlier part of 2004.

Assurances had previously been given that each student would have a dedicated IBM-format desktop PC or laptop computer available to them, and consequently the Pilot CDs were configured for single use. However some students were obliged to share equipment and as a result experienced difficulties with automated progress recording. This matter was also addressed in the Supplementary CD, which demonstrated multi-user programming.

Monthly progress reports were sought from participants; however the conduct of the course was characterised by poor reporting by a number of students. A contributing factor was the need for many students to study in their own private time due to clinical demands, despite earlier promises of quarantined study time.

All students who participated in the workshop in Kuala Lumpur (KL) met the 80 per cent completion prerequisite set for meeting attendance. However not all had fully completed the pilot course by this time. The main reason for this was late starting due to:

the Malaysian academic year beginning in July, and

a very few students replacing initial nominees part way through the year.

As well, the use of English language in the pilot course provided an additional level of complexity for the French and Spanish speakers. Despite this challenge, all ARCAL participants completed the course by the time of the meeting in KL. It is noteworthy that the Spanish speaking students in ARG studied as a group, and provided combined progress reports. This may prove a valuable model for those course participants in the future for whom English is a second language.

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CONSULTANTS’ MEETING & VALIDATION WORKSHOP

Purpose of the Consultants’ Meeting and Validation Workshop:

The main purposes of the meeting were:

(1) To review the conduct and efficacy of the ASO distance learning pilot course,

(2) To provide pilot students with supplementary training on the ASO, and

(3) To provide feedback and recommendations as to improvements in the course material.

Pre-meeting student survey

A pre-meeting questionnaire was circulated to students in early December 2004 to identify areas where they felt they would personally benefit from additional teaching and discussion on the eight subject areas. They were also asked to rate each subject on ease of use of the course material, relevance of content, and depth of knowledge.

Responses from twelve participants (8 individuals and one group of four who studied together) were received in sufficient time for academic faculty to focus their teaching and discussion sessions. Two further responses received shortly prior to the meeting supported the intended emphasis.

Ease of use: 1= difficult; 5 = easyRelevance of content: 1 = Irrelevant; 5 = Very relevantDepth of knowledge: 1 = Too superficial, 3 = Just about right, 5 = Too detailed

Critical Appraisal, Physics and Radiobiology were felt to be the hardest subjects. This is not surprising as much of the content is unfamiliar to many clinicians. However the overall relevance was rated highly and depth of knowledge was considered appropriate for all subjects. It was encouraging that even though some students found certain subject areas challenging, there was overall satisfaction with both course content and depth. For full details of all 14 responses see Appendix 2.

Some quotes from the students offer a qualitative picture of the value of the program.

“(The modules are) an eye opener to us that radiation oncology is not just prescribing radiation but part of a multi disciplinary approach to further research in order to provide better survival to patients and (to emphasise the importance of) primarily prevention.”

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“(We would benefit from supplementary teaching on) communication issues in different cultures, because there is marked difference between the roles that we are sticking to and those mentioned in the module.”

“This (Critical Appraisal) module is very helpful because it helps us analyse journals and studies more objectively. The subjects contained in this module were also not taught formally in our medical school.”

“Would be better if there are more radiological examples (in Functional Anatomy modules) to aid us (to) identify lesions & abnormalities”

“Analgesia is too difficult; the rest (of Patient Care) is easy.”

“I think many of us will benefit from a workshop on the new (Medical Physics) techniques eg. IMRT, SRS & SRT”

Meeting organisation

Our host Dr Fuad Ismail of Hospital Universiti Kebangsaan Malaysia (HUKM), in cooperation with the Government of Malaysia through the Universiti Kebangsaan Malaysia (UKM), provided coordination, an excellent and cost-effective venue at the Vistana Hotel Kuala Lumpur and all necessary support services.

At the initiative of Dr Fuad, each participant was provided with a CD-ROM at the end of the meeting, containing copies of all teaching materials, presentations and official and unofficial meeting photographs. We are sure that this will prove to be a valuable resource for all who attended.

Meeting participants

The meeting was attended by 23 of the 25 pilot course participants from the seven participating member states in RCA, AFRA and ARCAL, and by their National Coordinators. Technical Experts from Australia, the IAEA Technical Officer and Academic Faculty from the host country Malaysia facilitated the teaching and workshop sessions over the four days. A full list of meeting participants and their affiliations is attached at Appendix 3.

Meeting activities

Following the welcome by the Academic Consultant, Dr Barton, and the representative of the Host State, Dr Fuad, the Technical Officer Mr Hendry provided an introduction to the role of the IAEA and raised some issues regarding the format of the CD-ROM. The Academic Consultant and Regional Course Coordinator reviewed the project to date.

The bulk of the meeting activities were given over to learning and review activities as detailed in the attached program at Appendix 4.

A great deal of enthusiasm for the course was shown by meeting participants. They confirmed that the Supplementary CD-ROM issued in November 2004 had provided substantial improvements in functionality over the Pilot CD issued in February 2004, removing many of the technical nuisances that could not be resolved in time to meet the 2004 project deadline for the earlier version.

It was very disappointing that the intended Presentation Ceremony to the student participants was not possible, due to the non-arrival of the Certificates of Completion from Vienna. When located and countersigned by the Academic Consultant, these will be posted to students from Sydney.

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Findings

The following findings were agreed unanimously by the National Coordinators at the conclusion of the Meeting.

1. Students participating in the pilot course were a representative cross-section of trainee radiation oncologists, at a similar educational level both within and between countries.

2. Students showed competent knowledge at Part 1 level, a result due both to the contents of the two CDs and to the reference texts provided by the IAEA.

3. Student feedback was overwhelmingly favourable. Specific items noted include:-

a) Overall a good course, suitable for the teaching of others.

b) Best undertaken at start of specialist training.

c) Some or all of the ASO course was done at home because of time pressures at work, so a set of texts for every participant is desirable.

d) An additional text is needed for Critical Appraisal/Epidemiology.

e) Translations must include appropriate reference texts in the relevant languages.

f) The ASO course should be accompanied and supported by a website.

4. Amendments of both academic and technical nature are needed to the Pilot CD to fill in information gaps, to make specific corrections, and to cull superfluous content. See Appendix 5 for details.

5. There is a need for a limited number of extra course modules (see recommendations below)

6. The representatives of AFRA and ARCAL recommended that the course material should be translated into French and Spanish.

National Coordinators also noted that there may be a case for translation into other languages such as Chinese and Russian, and perhaps Korean given the advanced state of electronic learning in the Republic of Korea, but such a recommendation was well beyond the scope of the present meeting and should be taken up at the 3rd PCM later in 2005.

7. The workshop in Kuala Lumpur was useful to the pilot students.

8. Material in the two CDs is already being used to train other students in the pilot countries.

9. Malaysian academic faculty at this meeting found the course material was useful and appropriate.

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Actions

The following actions were agreed unanimously by the National Coordinators at the conclusion of the Meeting.

ACTIONS Responsibility

1. Part 1 pass rates of students who did and did not participate in the course should be compared.

RCC, AC, NCCs

2. Existing course material should be revised as specified in the detailed revision sheets that will be published following the KL meeting.

RCC, authors, MediWorld

3. Technical problems should be corrected, with functionality at least up to the standard of the Supplementary CD.

RCC, MediWorld

4. The list of reference texts should be reviewed with particular attention to texts in other languages.

All

5. Existing IAEA reports, TecDocs, etc should be reviewed and incorporated into the CD as appropriate.

Kron

6. Web-based resources should be investigated, to determine if/when it might be appropriate for the ASO course to partly or fully migrate to the Internet.

Fuad

7. All RCA National Project Coordinators should now receive copies of the two interim version CD-ROMs.

RCC

Recommendations

1. The Applied Sciences of Radiation Oncology distance learning course should be adopted, disseminated and translated.

2. For the course to be of most benefit, students should be in their first year, or at least no later than their second year of training for the speciality of Radiation Oncology.

3. There should be additional modules added to the existing course content, refer Appendix 6.

4. A web-based resource should be made available.

5. All RCA National Project Coordinators should be invited to the third Project Coordinators Meeting, which should be held in Manila in the second week of November 2005.

6. Member States should be invited to use the existing course material on an interim basis.

7. AFRA and ARCAL should set up projects to translate and implement the CD-ROM based ASO course.

8. Use of the CD in other professions, eg medical physics, should be investigated.

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Next meeting

The meeting recommended that the 3rd PCM be held in Manila, the Philippines, in the second week of November, namely the week of 7th to 11th November.

It was noted that November is a popular time for medical conferences in Manila, so a booking would need to be made as soon as possible. Dr Vega will investigate possible venues and advise with some urgency.

Proposed AGENDA for 3rd PCM

1. Review of ASO distance learning program – aims and design

2. Review of pilot course

3. Implementation of the ASO course:-

a. In RCA

b. In other Regions

4. Possible ASO website

5. Translation(s)

6. Technical considerations (DVD, etc)

7. Maintenance and Update strategy

8. Continuing Professional Development (CPD). The course permits Radiation Oncologists etc to undertake refresher courses, and may represent an avenue for ongoing funding of the course beyond usual IAEA/RCA funding timescales.

9. Incentives for students to participate in and complete the ASO course. This would probably be on a country by country basis, depending on individual circumstances, and might involve the requirement of a completed ASO distance learning course before students would be permitted to sit Part 1.

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APPENDICES

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Appendix 1

ASO English-language pilot course, 2004

Pilot CD-ROMSubject/module name

Supplementary CD-ROM

CommunicationsCOM-IntroCOM-1 Breaking bad news 1COM-2 Communication with patients 1COM-3 Communication issues in different cultural

settings1

COM-4 Communication with colleagues 1

Critical AppraisalCRI-IntroCRI-1 Cancer epidemiology 1CRI-2 Searching for evidence 1CRI-3 Clinical trial designs 1CRI-4 Critical appraisal of studies of treatment 1CRI-5 Survival analysis 1CRI-6 Patient-based endpoints in clinical trials 1CRI-7 Systematic review & meta analysis -

benefits & pitfalls1 UPDATED

CRI-8 Clinical decision analysis 1CRI-9 Prognostic indices 1

Functional Anatomy

FUN-IntroFUN-1 CNS and peripheral nerves 1FUN-2 Head and neck I 1 UPDATEDFUN-3 Head and neck II 1 UPDATEDFUN-4 Lung and thorax 1FUN-5 Gastrointestinal 1 REPLACEDFUN-6 Genitourinary 1FUN-7 Gynaecological anatomy 1FUN-8 Anatomy of the breast 1FUN-9 Lymphatics 1

Molecular Biology, pathology and pathogenesis

MOL-IntroMOL-1 Genes and cancer 1MOL-2 Colorectal and breast cancer 1 UPDATEDMOL-3 Pathology: molecular diagnosis and new

diagnostic techniques1 UPDATED

MOL-4 Infections associated with malignancy 1MOL-5 Familiar aspects of cancer 1

Patient Care

PAT-Intro

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PAT-1 Part 1

Analgesia - Part 1 1

PAT-1 Part 2


PAT-2 Bones, bisphosphonates and hypercalcemia

1

PAT-3 Symptom control 1PAT-4 Infections in the cancer patient 1

Physics and radiation technology

PHY-IntroPHY-1 Radioactivity 1PHY-2 Photon generation 1PHY-3 Photon Interactions with matter 1PHY-4 Electron beam generation and interactions 1

PHY-5 Dosimetry of ionising radiation 1PHY-6 Photon beam radiotherapy treatment

planning1

PHY-7 Intensity modulated radiotherapy (IMRT) 1PHY-8 Computers in radiotherapy 1PHY-9 Stereotactic radiosurgery (SRS) and

radiotherapy (SRT)1

PHY-10 Brachytherapy techniques 1PHY-11 Radiation protection 1PHY-12 Quality assurance 1 REPLACEDPHY-13 Dose reporting 1PHY-14 Intro

Introduction - Advanced treatment aids 1

PHY-14a Dynamic wedge 1PHY-14b Multi-leaf collimators (MLC) 1PHY-14c Organ motion and patient immobilisation 1PHY-14d EPIDs 1PHY-14e Tomotherapy 1PHY-14f Proton radiotherapy 1

Radiobiology

RAD-IntroRAD-1 Principles of X-ray therapy 1RAD-2 Acute effects 1RAD-3 Late effects 1RAD-4 Tumours 1RAD-5 Fractionation 1RAD-6 Treatment time effects 1RAD-7 Dose rate effects 1RAD-8 Molecular effects and apoptosis 1RAD-9 Interactions with chemotherapy and

chemical modifiers of radiation response1

Systemic therapy

SYS-IntroSYS-1 Principles of cytotoxic treatment 1SYS-2 Cytotoxic drugs: mechanisms of action 1 REPLACEDSYS-3 Administering chemotherapy 1

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SYS-4 Acute complications 1SYS-5 Late complications 1SYS-6 Alkylators/platinums/antibiotics 1 REPLACEDSYS-7 Antimicrotubule agents and

epipodophyllotoxins1

SYS-8 Anti-metabolites 1SYS-9 Endocrine therapy 1SYS-10 Immunomodulators and anti-growth factors 1SYS-11 Preclinical drug development 1

TOTAL 71

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Appendix 2

ASO Pre-workshop feedback - December 2004

Subject Learning module Ease of use Relevance of content

Depth of knowledge Individual comments

& topics to emphasise1= difficult; 5 = easy

1 = Irrelevant;5 = Very relevant

1 = Too superficial, 3 = Just about right,

5 = Too detailed

n Average n Average n Average GENERAL: I really appreciate the modules because it serves as an eye opener to us that radiation oncology is not just prescribing radiation but a part of multi disciplinary approach to further research in order to provide better survival to patients and primarily prevention

Number of replies = 11 (14 respondents from all 7 countries; one response from group of four students)

Communications 10 3.9 10 4.5 9 3.1

Median = 3.5 Median =5 Median = 3Range = 2.5 - 5 Range = 3 - 5 Range = 3 - 4

Cultural differences for me is the major obstacle in dealing with a lot of patients specially in the Philippines were there are a lot of nationals (Chinese , Caucasians, Koreans etc).Most of the time especially among Filipinos, the relatives instruct the caregiver and doctors not to inform patients regarding the situation.

This module is truly an eye-opener for me because the subjects contained here were not taught to us in medical school. This is very practical.

Breaking bad news

Communication issues in different cultures, because there is marked difference between the roles that we are sticking to and those mentioned in the module

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Critical Appraisal 10 2.4 9 4.0 9 3.5 I believe more discussion about evidence based medicine would be very beneficial

Median = 2.5 Median =4 Median = 3Range = 1 - 4 Range = 3 - 5 Range = 3 - 5

During our training clinical epidemiology was the least of our priority which is supposed to be emphasized considering that treating cancer patients is based all on clinical trials. Sir, if you can emphasized on all these aspects.

This module is very helpful because it helps us analyse journals and studies more objectively. The subjects contained in this module were also not taught formally in our medical school. Clinical trial designs

Survival analysis

Systematic review & meta analysis - benefits & pitfalls

Functional Anatomy 9 4.1 9 4.4 10 3.1 Would be better if there are more radiological examples to aid us identify lesions & abnormalities?

Median = 4 Median = 5 Median = 3 Everything is OK, no need for supplement.

Range = 3 - 5 Range = 3 - 5 Range = 1 - 4 Head and neck I

Head and neck II

Genitourinary

Gynaecological anatomy


9 3.9 9 4.2 8 3.3 All modules in subject (request by one participant)

Median = 4 Median = 4 Median = 3Range = 3 - 5 Range = 3 - 5 Range = 3 - 4

Patient Care 10 3.6 9 4.4 8 3.5 (Ease) Analgesia is too difficult, the rest is easy

Median = 3.5 Median = 4 Median = 4Range = 1 - 5 Range = 3 - 5 Range = 3 - 4

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Patient and doctor’s education are the most important to emphasized especially in giving central acting drugs. Hearing the word Morphine from the doctor has a very high resistance from the patient because they think its addicting and they are terminal already. In the Philippines the usage of Morphine is very low because of lack of education and fear, sad to say both for the doctors and the patient.

Physics and radiation technology 9 2.8 9 4.8 9 3.6 All modules (one participant)

Median = 3 Median = 5 Median = 3 Dosimetry of ionising radiation

Range = 1 - 5 Range = 4 - 5 Range = 3 - 5 Quality assurance

I think many of us will benefit from a workshop on the new techniques eg. IMRT, SRS & SRT

Radiobiology 9 2.8 9 5.0 9 3.4 Fractionation

Median = 2 Median = 5 Median = 3 Treatment time effects

Range = 2 - 4 Range = 5 - 5 Range = 3 - 5 Dose rate effects

Systemic therapy 9 3.6 9 4.3 9 3.3

Median = 4 Median = 4 Median = 3Range = 2 - 5 Range = 3 - 5 Range = 3 - 5

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IAEA/RCADistance Learning Project: Applied Sciences of Oncology

Appendix 3

Consultants' Meeting and Validation WorkshopMalaysia, Kuala Lumpur2005-01-31 - 2005-02-03

List of Participants(as of 2004-12-06)

1 Australia Mr Barton, Michael BernardLiverpool Health ServiceCCORE (Collaboration for Cancer Outcomes Research and Evaluation)Locked Bag 7103Liverpool 1871NSWAustralia

Tel.: +61 2 98286541Fax: +61 2 98286670Email: [email protected]: +61 0409 466 255

2 Australia Mr Thode, RichardLiverpool Health ServiceCCORE (Collaboration for Cancer Outcomes Research and Evaluation)Locked Bag 7103Liverpool 1871NSWAustralia

Tel.: +612 98286669Fax: +612 98286670Email: [email protected]

3 IAEA Hendry, Jolyon Hindson , IAEA, NAHU

4 Argentina Mr Ferraris, Alfredo EnriqueInstituto Municipal de Oncologia "Angel H. Roffo"Avenida San Martin 54811417 Buenos AiresArgentina

Tel.: +54 11 45010091Fax: +54 11 45013039Email: [email protected]

5 Argentina Dr Lemoine, GastonInstituto Municipal de Oncologia "Angel H. Roffo"Avenida San Martin 5481


mailto:[email protected]




1417 Buenos AiresArgentina

Tel.: +54 11 45802805Email: [email protected]

6 Argentina Dr Roth, Berta Maria CristinaInstituto Municipal de Oncologia "Angel H. Roffo"Avenida San Martin 54811417 Buenos AiresArgentina


7 Argentina Mr Blanco Saborio, Alejandro JoseInstituto Municipal de Oncologia "Angel H. Roffo"Avenida San Martin 54811417 Buenos AiresArgentina


8 Argentina Dr Cordero, Johaksho JoseInstituto Municipal de Oncologia "Angel H. Roffo"Avenida San Martin 54811417 Buenos AiresArgentina


9 Egypt Mr Boutrus, RimounCairo UniversityNational Cancer InstituteKasr El Ani StreetFom El KhaligCairo 11796Egypt


10 Egypt Ms Eissa, HebaCairo UniversityNational Cancer Institute








Kasr El Ani StreetFom El KhaligCairo 11796Egypt


11 Egypt Mr Mostafa, SamyCairo UniversityNational Cancer InstituteKasr El Ani StreetFom El KhaligCairo 11796Egypt


12 Australia Mr Kron, TomasPeter MacCallum Cancer InstituteDepartment of Physical SciencesLocked Bag 1, A’Beckett StreetMelbourne VIC 8006Australia

Tel.: +61 3 9656 1907 Fax: +61 3 9650 4870Email: [email protected]

13 Malaysia Ms Abdul Malik, RozitaJalan UniversitiUniversiti Malaya Medical CenterClinical Oncology UnitKuala Lumpur 50603Malaysia

Tel.: +60 3 7950 2185Fax: +60 3 7956 3072Email: [email protected]

14 Malaysia Mr Ismail, FuadNational University of MalaysiaUniversity HospitalDepartment of Radiotherapy and OncologyJalan Yaacob Latif56000 Kuala LumpurMalaysia







15 Malaysia Dr Lee Wei Luen, FabianJalan UniversitiUniversiti Malaya Medical CenterClinical Oncology UnitKuala Lumpur 50603Malaysia


16 Malaysia Dr Rashidi, YangJalan UniversitiUniversiti Malaya Medical CenterClinical Oncology UnitKuala Lumpur 50603Malaysia


17 Malaysia Dr Wan Ishak, Wan ZamaniahJalan UniversitiUniversiti Malaya Medical CenterClinical Oncology UnitKuala Lumpur 50603Malaysia


18 Morocco Prof. El Gueddari, Brahim El KhalilInstitut national d'oncologieSidi Mohamed Ben AbdellahB.P. 6213Rabat 10101Morocco









19 Morocco Ms Mesbah, LatifaInstitut national d'oncologieAvenue Allal Al Fassi - Madinat Al IrfaneHay RyadB.P. 6213 RIRabat 10101Morocco


20 Morocco Dr Nejjar, IkrameInstitut national d'oncologieAvenue Allal Al Fassi - Madinat Al IrfaneHay RyadB.P. 6213 RIRabat 10101Morocco


21 Pakistan Dr Basit, MuhammadKRL Hospital MauveAiwane Sanato, Tijarat G-9/1IslamabadPakistan


22 Pakistan Ms Javed, NabeelaNuclear Medicine, Oncology & Radiotherapy InstituteG-8/3P.O. Box 159044000 IslamabadPakistan


23 Pakistan Dr Khan, Khurshid AhmadNuclear Medicine, Oncology & Radiotherapy InstituteG-8/3P.O. Box 1590







44000 IslamabadPakistan


24 Pakistan Ms Mahmood, HumeraPakistan Atomic Energy CommissionNuclear Medicine, Oncology and Radiotherapy Institute (NORI)P.O. Box 1590Islamabad 44000Pakistan

Tel.: +92 51 9260611 5Fax: +92 51 9260616Email: [email protected]

25 Pakistan Dr Maken, Rab NawazNuclear Medicine, Oncology & Radiotherapy InstituteG-8/3P.O. Box 159044000 IslamabadPakistan


26 Pakistan Dr Muhammad, AunNuclear Medicine, Oncology & Radiotherapy InstituteOncology DepartmentG-8/3P.O. Box 159044000 IslamabadPakistan


27 Philippines Dr Bagis, FaiqhaPhilippines General HospitalTaft AvenueManila 1001Philippines









28 Philippines Dr Legaspi-Chavez, LoreleiPhilippines General HospitalDepartment of RadiologyTaft AvenueManila 1001Philippines


29 Philippines Dr Malabanan, Michael MartinMakati Medical Center2 Amorsolo StreetLegaspi VillageMakati City 1200Philippines


30 Philippines Mr Rivera, Jesus RandyJose Reyes Memorial Medical CenterRizal Avenue, San Lazaro CompoundTayuman, Santa CruzManila 1003Philippines

Tel.: +63 2 711 6939Email: [email protected]

31 Philippines Dr Uy, CharitoSaint Luke's Medical CenterRadiation Oncology Department279 E. Rodriguez Sr. Blvd.Cathedral HeightsP. O. Box 700Quezon City 1102Philippines


32 Philippines Dr Vega, Gaudencio P.University of the PhilippinesCollege of MedicinePhilippine General Hospital







Radiation Oncology Section, Department of RadiologyTaft Avenue, Ermita1000 ManilaPhilippines

Tel.: +632 3723439Fax: +632 5234372Email: [email protected]

33 Uruguay Mr Aguiar Vitacca, Sergio AndresHospital "Pereira Rossell"Instituto de Radiologia y Centro de Lucha Contra el CancerBv. Artigas 1550P.O. Box 6571Montevideo 11600Uruguay


34 Uruguay Mr Leborgne Deus, Jose HonorioCentro Hospitalario Pereira RossellH. Gutierrez Ruiz 1210Montevideo, Centro 11100Uruguay







Appendix 4

IAEA/RCA Consultants’ Meeting & Validation Workshop

LOCATION: Kuala Lumpur, MALAYSIADATES: 31 January to 3 February 2005

PARTICIPANTS: Overseas students 19National Coordinators (excl MAL) 5IAEA TC Officer/Radiobiology expert 1Physics expert (T Kron) 1Academic Consultant 1Regional Course Coordinator 1

Subtotal (core participants) 28

PLUS: Local students 4MAL National Coordinator (Fuad) 1Local teaching faculty 5

TOTAL: 38

VENUE: VISTANA HOTELNo. 9, Jalan Lumut,Off Jalan Ipoh,50400 Kuala Lumpur

Tel. No.: +60-3-40428000

Fax No. : +60-3-40411400

Info: http://www.holidaycity.com/vistana-kl/

Map: http://www.holidaycity.com/vistana-kl/map.html

<Hyperlinks checked 25 January 2005>


http://www.holidaycity.com/vistana-kl/map.html

http://www.holidaycity.com/vistana-kl/


Validation WorkshopSunday 30th

JanTIME MONDAY 31st Jan TUESDAY 1st Feb WEDNESDAY 2nd Feb THURS 3rd Feb

Arrival of participants

0900

Welcome MBB

Housekeeping Fuad

Introduction to IAEA JHH

SESSION - FUN Fuad SESSION - RAD-2 JHH SESSION – PHY-3 TK

(Whole day)1000 Pilot process RJT Discussion - FUN Fuad SESSION – CRI MBB

Discussion - Additional modules & additional subjects

MBB/TK

1030 BREAK BREAK BREAK BREAK

1100 SESSION - RAD-1 JHHSESSION – FUN

(CT anatomy) AAR

Course & CD-ROM feedback – RCC and pilot students RJT

Presentation of Certificates of Completion JHH/FuadSUMMARY & CLOSING

1200 Discussion - RAD JHH SESSION – SYS-1 GLSESSION – COM

MBB/WS

MEETING REPORT

(National coordinators)

1300 LUNCH LUNCH LUNCH LUNCH

1400 SESSION - PHY-1 TK SESSION – SYS-2 GS

Discussion- COM/CRI

MBB / WS(incl non-Western approaches)

1500 Discussion - PHY TK Discussion - SYS GS/GL SESSION – PHY-2TK

1530 BREAK BREAK BREAK

1600 SESSION - PAT EH SESSION – MOL MRH SESSION – RAD-3 JHH

Official Dinner - Vistana



SESSION AREA(S) OF EMPHASIS FACILITATOR

1. Radiobiology 1 Dose/treatment time/fractionation JHH

2.

Discussion - RAD

Feedback on Pilot CD modules

Interaction/supplementary teaching as necessary

JHH

3.Physics 1

Theory: Sources of radiation and interaction with matter

TK

4.

Discussion - PHY



TK

5.Patient care

Analgesia; management of acute conditions

MAL

6.Functional anatomy

Cross-sectional anatomy

CT/MRI/X-ray including abnormalitiesMAL

7.

Discussion - FUN



MAL

8. Functional anatomy CT anatomy MAL

9. Systemic Therapy 1 General review MAL

10. Systemic Therapy 2 General review MAL

11.

Discussion - SYS



MAL

12. Molecular biology General review MAL

13.Radiobiology 2

Dose-time-fractionation (continued)

Tumour radiosensitisersJHH

14.

Critical Appraisal

Evidence-based medicine (hand out papers for appraisal on Monday)

Survival analysis Meta-analysis Decision analysis

MBB

15. Course & CD-ROM feedbackGeneral discussion – Regional Course Coordinator and pilot students RJT

16.

Communications

Informed consent

Communication with patients (Singapore medicolegal paper as pre-reading)

MBB

17.Physics 2

Applied Medical Techniques: From brain to prostate

TK

18. Discussion – COM/CRI Feedback on Pilot CD modules MBB/WS



(incl non-Western approaches)


19. Radiobiology 3 Normal tissue injury JHH

20. Physics 3 Advanced Techniques: Images & IMRT TK

21. Discussion - Additional modules & additional subjects

What additional topics/subjects are needed in course?

MBB/TK

22. Presentation of Certificates of Completion SUMMARY & CLOSING

JHH/Fuad

23. MEETING REPORT National coordinators

List of FACULTY

LECTURER TITLE MODULE(S)

MBB Michael BARTON Academic Consultant Critical appraisal

Communications

TK Thomas KRON Radiation Oncology Physicist Physics

JHH Jolyon HENDRY IAEA Consultant Radiobiologist Radiobiology

AH ABDUL HAMID Abdul Rashid Professor in Anatomy Functional anatomy

GS G. SELVARATNAM Consultant Oncologist Systemic therapy

WS WAN SALWINA Wan Consultant Psychiatrist Communication

EH EDNIN Hamzah Palliative care consultant Patient care

AAR AMRAN Abdul Rahman Consultant Radiologist Functional anatomy

GL Gerard LIM Consultant Oncologist Systemic therapy

MRH Mohd ROSLAN Harun Consultant Physician Molecular biology



Appendix 5

document.doc

(Changes required in addition to simple corrections)

Pilot CD-ROMSubject/module name Proposed amendments

Communications

COM GeneralThe Communications modules caused quite a lot of discussion during the 2nd PCM in Seoul in 2003, in particular the two modules on communications with patients.

While an understanding of best practice communications in a “Western” context was considered useful and educative for RadOnc students, some country coordinators were concerned that such approaches were culturally and practically inappropriate in an “Asian” context. It also became apparent that there were differences in approach between different countries. It was proposed that after the pilot course in 2004, additional module(s) should be added that dealt with the different approaches of “Western” and non-Western cultures.

During the pilot course itself, students showed interest in knowing about alternative communications approaches, although some felt that generally it might not be possible to adopt such practices in their own countries.

One student comment in the pre-meeting survey was “Cultural difference for me is the major obstacle in dealing with a lot of patients especially in the Philippines where there are a lot of nationalities (Chinese, Caucasians, Koreans etc). Most of the time especially among Filipinos, the relatives instruct the caregiver and doctors not to inform patients regarding the situation.”

Dr Wan Salwina, a Malaysian psychologist who presented to the KL meeting on Communicating Bad News, felt that the CD is very useful to raise awareness of issues including cultural stereotypes, and differences between persons from the same culture in different settings eg Chinese living in the USA compared to Chinese living in China.



COM-1 Breaking bad news 1 The WHO guidelines on Communicating Bad News (1993) handed out by Dr Wan Salwina talk about three models of communication:-

No disclosure All disclosure Individualised disclosure

QUERY: Is this document a possible additional resource?

Subsequent to the KL meeting, we have learned that these guidelines have not been updated since their release in 1993. The guideline document is part of a series of WHO Behavioural Science Learning modules that are no longer being issued. Therefore, the use of other more recent resources should be examined.

COM-2 Communication with patients 1 The meeting discussed cultural and educational differences, as the current modules are quite “Western” oriented decision that additional module(s) are NOT required;

ADD explanation that module discusses various examples etc in different settings. The intent is to sensitise students to cultural differences/issues. There are many variations within cultures, including different levels of education, as well as between cultures

ADD section on use of interpreters to cultural module – interpretation is a potential problem for satisfactory communications, especially when translation is by family members.

DISCUSS relatives desire to protect patient from bad news. NB It is always possible to ask patients how much they WANT to know.

COM-3 Communication issues in different cultural settings

1

COM-4 Communication with colleagues 1

Additional COM material ADD pre-reading to Communications modules?

Michael Barton noted that there is a new emphasis on legal, regulatory and ethical concepts, including informed consent, and practitioners need to be suitably trained. A new module is proposed, which should include medico-legal issues related to informed consent (see separate list of proposed additional modules)

A second new COM module, targeted at junior doctors is proposed, addressing practical skills needed to control workload and prevent burnout, and on how to cope with death & dying, including an understanding of the concept of stages of grief.



Critical Appraisal

CRI GeneralMany students had only limited exposure to epidemiology & Evidence Based Medicine in Medical School, and found this subject area fairly hard going but valuable.

An additional module on medical writing was proposed (under COM, not CRI), which should also serve to enhance students’ understanding of and competence to appraise journal articles, guidelines, etc.

CRI-1 Cancer epidemiology 1CRI-2 Searching for evidence 1CRI-3 Clinical trial designs 1 Pre-meeting feedback requested additional teaching in KL on clinical trial designCRI-4 Critical appraisal of studies of treatment 1CRI-5 Survival analysis 1 Pre-meeting feedback requested additional teaching in KL on survival analysisCRI-6 Patient-based endpoints in clinical trials 1CRI-7 Systematic review & meta analysis -

benefits & pitfalls1

Pre-meeting feedback found this module difficult, requested additional teaching in KL

CRI-8 Clinical decision analysis 1 Pre-meeting feedback found this module difficult, requested additional teaching in KL. CRI-9 Prognostic indices 1

Functional AnatomyFUN

All modulesPre-meeting feedback requested extra teaching in KL, covering cross-sectional anatomy and radiographic imaging (CT/MRI/X-ray). Additional modules on imaging were proposed (see under Physics).

General need for some restructuring of anatomy modules.

Greater emphasis on radiographic images, in particular CT; possibly fewer diagrams Arrows: improve accuracy of interactive arrow placement (?as CT instead of diagram?);

should labels be listed alphabetically, or remain random?; Consider placing diagram and CT next to each other on a single screen; then zooming

image of interest More landmarks for planning, incl surface anatomy (skin) Provide markers on radiographic images (R, L) MCQ answer “The author disagrees” bothered at least some students, as there was no

explanation WHY the author disagreed (also see RAD). Berta Roth: ESTRO site has many good anatomical images available Amran Rahman would be happy to make his extensive slide-sets on cross-sectional



anatomy available for any future module(s) on normal vs pathological states.FUN-1 CNS and peripheral nerves 1FUN-2 Head and neck I 1 Considered too complex by some students (eg all the branches of facial nerves); more

emphasis requested on H&N lymphatics (here or in FUN-9?)

Perhaps provide hyperlink to RTOG atlas of H&N.

FUN-3 Head and neck II 1

FUN-4 Lung and thorax 1FUN-5 Gastrointestinal 1FUN-6 Genitourinary 1FUN-7 Gynaecological anatomy 1FUN-8 Anatomy of the breast 1FUN-9 Lymphatics 1 Still an INTERIM module, needs to be completed

(Need more H&N lymphatics, here or in FUN-2&3)


Overall depth & breadth is OK, according to A/Prof Roslan Harun, who conducted teaching session on MOL. He would like to see more diagrams in some modules.

MOL-1 Genes and cancer 1 Still an INTERIM module, needs to be completedMOL-2 Colorectal and breast cancer 1MOL-3 Pathology: molecular diagnosis and new

diagnostic techniques1 Harun would like more basic pathology eg H&E stains, epithelial, LCA etc. Asks would it be

useful to have a guide to diagnosis of undifferentiated tumours?

What is clinical relevance of test(s)? eg HER_2 for treatment, E6 and E7 proteins confer resistance to radiation, etc

MOL-4 Infections associated with malignancy 1MOL-5 Familiar aspects of cancer 1 When reviewing familial cancer module prior to his presentation in KL, Harun found it quite

difficult to understand. He notes that a few examples are laid out poorly within the CD, and it would be much better to have family tree graphs beside text on SAME screen.



Patient Care

PAT-1 Part 1

Analgesia - Part 1 1 Need to simplify module on analgesia.Opioid-responsive and opioid-resistant.Address opioid-“phobia” especially in some developing countriesAddress availability & cost of drugs eg morphine not available in some locations (in India?)Compliance.[Add neuropathic pain ladder? To match WHO opioid ladder]

PAT-1 Part 2


PAT-2 Bones, bisphosphonates and hypercalcemia

1

PAT-3 Symptom control 1PAT-4 Infections in the cancer patient 1


PHY-1 Radioactivity 1PHY-2 Photon generation 1PHY-3 Photon Interactions with matter 1PHY-4 Electron beam generation and interactions 1

PHY-5 Dosimetry of ionising radiation 1 Pre-meeting feedback from pilot students requested additional teaching in KL on dosimetry.

PHY-6 Photon beam radiotherapy treatment planning

1 NB: 50 % to 60% of meeting delegates have routine access to CT for planning

PHY-7 Intensity modulated radiotherapy (IMRT) 1 Discussion of IMRT “bandwagon”. Pushed too hard too early by equipment manufacturers prior to EBM studies. Comment from Brahim El-Gueddari: need to go slowly in developing world, until have good QA culture, etc, else can do WORSE using high tech equipment.

NB Need for back-up/alternatives in case of linac breakdown.

PHY-8 Computers in radiotherapy 1PHY-9 Stereotactic radiosurgery (SRS) and

radiotherapy (SRT)1

PHY-10 Brachytherapy techniques 1



PHY-11 Radiation protection 1PHY-12 Quality assurance 1 Pre-meeting feedback requested additional teaching in KL on QA and verification. Tomas

Kron canvassed four different approaches to a useful QA module:-

General overview of QA principles (ISO approach, used in current ASO module) General overview of QA in XRT (ESTRO approach) Accident prevention and dosimetry (IAEA approach) Examples of specific QA activities (AAPM approach)

A chain of quality is needed throughout a department, equipment QA is not enough.

Discussion as to whether an additional QA module was needed. At some point we go beyond the Applied Sciences and start addressing clinical practice, which is NOT the purpose of this course

NO to additional module, make ADDITIONS to existing one, incl:-

Training & qualifications, and HR issues External audit of clinicians’ performance Module should summarise info in embedded IAEA TecDoc

ADDITIONAL RESOURCE: Jolyon Hendry advises that the IAEA is planning a QA Symposium in Radiation Medicine for November 2006, and its Proceedings will be a useful extra QA text/resource that can be added during a future update of the ASO CD.

PHY-13 Dose reporting 1PHY-14 Intro

Introduction - Advanced treatment aids 1 Pre-meeting feedback requested additional teaching in KL in new techniques (valid also for modules on IMRT and SRS/SRT)

All modules on advanced techniques need to be reviewed by authors, as most were written in 2001 or 2002.

PHY-14a Dynamic wedge 1PHY-14b Multi-leaf collimators (MLC) 1PHY-14c Organ motion and patient immobilisation 1PHY-14d EPIDs 1PHY-14e Tomotherapy 1PHY-14f Proton radiotherapy 1



Radiobiology

Student feedback is that because of a lack of teachers in developing world, this is a particularly important subject area. Needs to be simplified but contain more content. ARG student commented that CD helped considerably as background to recent IAEA Teaching course on Radiobiology in Buenos Aires.

REFERENCE TEXT: There was a discussion on Hall vs Steel as the more appropriate reference text for radiobiology. This was not resolved, and will be raised again in Manila. Hall is comprehensive and covers radiobiological aspects of radiology and protection, as well as radiation oncology. Steel is directed solely to radiation oncologists, and is written by teachers on the ESTRO radiobiology course. Steel is more recent (2002) than Hall (2000), slimmer, and cheaper. Both have particular attributes, and perhaps both could be recommended. Other books, more introductory in nature e.g. Nias, are now getting somewhat out of date (pre 2000).

General agreement that a new module to provide a mathematics refresher including aspects needed for LQ modelling would be helpful; (see under Physics).

MCQs: answer “False” or “The author disagrees” bothered at least some students, as often there was no explanation WHY the author disagreed (also see FUN).

Regarding techniques and methodologies, it was recommended to study these in the textbooks rather than to extend or plan new modules.

RAD-1 Principles of X-ray therapy 1RAD-2 Acute effects 1RAD-3 Late effects 1 Should include that some agents now available that alleviate late effects, at least in pre-

clinical models eg ACE inhibitors, AII blockers, PUFAs, PTX. It should be noted that late effects do not stop appearing at 5 years.

ADD: Retreatment.RAD-4 Tumours 1 Add info on some new radiosensitisers e.g. EGFR blockers, Cox-2 inhibitors.RAD-5 Fractionation 1 In Pre-meeting feedback, pilot students advised that they found this module difficult and

requested additional teaching in KL.

Jolyon Hendry believes this module needs extra material, and examples of fractionation calculations would be useful.

RAD-6 Treatment time effects 1 Pre-meeting feedback requested additional teaching in KL on treatment time effects



RAD-7 Dose rate effects 1 Pre-meeting feedback requested additional teaching in KL on dose rate effects

RAD-8 Molecular effects and apoptosis 1 Pre-meeting feedback requested additional teaching in KL on molecular effects.

Suggestion that this module needs additional info on apoptosis, and /or glossary entries with diagrams to cover apoptosis, necrosis, reproductive/mitotic cell death.

RAD-9 Interactions with chemotherapy and chemical modifiers of radiation response

1

Systemic therapy

Too detailed for some students ACTION: separate or identify high-level content, incl pre-clinical drug development (module SYS-11).

More consideration of interactions with XRT

SYS-1 Principles of cytotoxic treatment 1 More drug interactions and interactions with ?chemotherapySYS-2 Cytotoxic drugs: mechanisms of action 1SYS-3 Administering chemotherapy 1SYS-4 Acute complications 1 Craig Lewis wishes to update this module as there are several new developments in clinical

management (e-mail 30 July 2004)SYS-5 Late complications 1SYS-6 Alkylators/platinums/antibiotics 1 ?Diagrams in wrong sequence?SYS-7 Antimicrotubule agents and

epipodophyllotoxins1

SYS-8 Anti-metabolites 1SYS-9 Endocrine therapy 1SYS-10 Immunomodulators and anti-growth factors 1SYS-11 Preclinical drug development 1

TOTAL FOR REWORK



Appendix 6

ASO additional modules - proposed KL, 3 Feb 2005.doc

Subject/module name Proposed content

Communications

COM-5 Informed consent 1COM-6 Burnout (& coping with dying) 1 Burnout of RadOncs and its impact; coping with

dyingCOM-7 Medical writing 1 Medical writing for journals

Critical Appraisal

CRI-10 Economic analysis 1 Basic economic analysis, including equipment decisions

Functional Anatomy

No additions requested

Molecular biology, pathology and pathogenesis


Patient CarePAT-5 Nutrition/cachexia/fatigue 1


PHY-15 Imaging using ionising radiation 1 CT/PETPHY-16 Imaging using non-ionising radiation 1 MRI/ultrasoundPHY-17 Image handling 1 Image fusion, window levels, DRRsPHY-18 Maths for the maths-phobic 1 Basics of physics, radiobiology, statistics and error

(uncertainty)

Radiobiology

RAD-10 Second cancers 1 Especially protection aspects <link from radiation safety module>

Systemic therapy


TOTAL 10


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