Residency Training Program in Radiation Oncology

Residency Training Program in Radiation Oncology

University of Rochester Medical Center Strong Memorial Hospital

Last updated: October 2009

The information presented in this handbook is subject to change at any time

TABLE OF CONTENTS

Welcome to the University of Rochester Radiation Oncology Residency Program

Setting for the Residency Program

ROCHESTER . . . Made For Living University of Rochester Medical Center

Department of Radiation Oncology

Radiation Oncology Residency Program Mission Statement

Commitments of Faculty Commitments of Residents

Radiation Oncology Residency Program Core Curriculum

New Resident Orientation

DRO Faculty & Staff Orientation

Patient Trails Physics/Dosimetry/Therapy (PDT) Rotation

Competencies ACGME Outcome Project

Timeline Competency and Assessment Glossary

Objectives

Residency Program Objectives Organization of the Residency Program

Core Rotations Green Service

Yellow Service Red Service

Purple Service Orange Service White Service Blue Service HH Service

Required Rotations Medical Oncology

Dosimetry Diagnostic Imaging

Palliative Care Oncologic Pathology

Clinical Investigation and Research Research Rotation

Possible Research Projects

Resident Electives Elective Opportunities

Responsibilities of the Resident

Resident responsibilities Additional Training Content

Didactic Education

Education Calendar Master Schedule Basics of Radiation Oncology Course

Introduction to Radiology Course Introduction to Physics & Dosimetry Course

New Pt Presentations New Pt Chart Rounds

Clinical Oncology Lecture Series Mock Oral Boards

Onco-Anatomy Seminar Series Clinical Biostatistics Course

Stress-Fatigue Seminars Quality Assurance & Improvement Conference

Journal Club Pain Management Seminar Series Radiation-Cancer Biology Course Practical Dosimetry Lecture Series

Radiation Physics Course Palliative Care Modules

APS Patient Safety Modules ACLS/PALS Certification

SBP Project

Resident Book List Required Reading

Supplemental Reading

Resident Evaluations

Summary of Intent for Residency Training

Radiation Oncology Requirements ACGME Program Requirements for Residency Education in Radiation Oncology

ACGME Common Duty Hour Standards Unsealed Radionuclide Therapy Administration

American Board of Radiology Study Guide Radiation Oncology Resident Training Guidelines for Cancer and Radiation Biology

ASTRO’s Core Physics Curriculum for Radiation Oncology Residents

Department of Radiation OncologyUniversity of Rochester Medical Center

Letchworth State Park Ontario Beach Park

Rochester, NY

WELCOME TO ROCHESTER, NY

ROCHESTER – Made For Living

Lake Ontario Beach Park

Rochester is an ideal place in which to live and work – and enjoy life. Thanks to the effortsof individuals like lens-grinders Bausch and Lomb, chemist George Eastman (Kodak), andJoseph Wilson, promoter of the dry copying process that developed into Xerox Corporation,Rochester is known as an international center for research and development and high technology.The area is developing into a hub of major activity in biotechnology, imaging and othertechnology areas.

High Falls District, Downtown Rochester

Scenic Finger Lakes Wine Country

The Rochester area is noted for its high proportion of home ownership. The supply of homesis excellent, and prices are lower than in many similar areas across the country. Available homesare located throughout the area, in the city, suburbs, and beyond. The mix of styles, sizes, andlocations makes home ownership practical for most house staff families. Rental housing is alsoabundant, and there is reasonable opportunity to find attractive apartments at affordable prices.The University offers reasonably priced rental units in considerable variety and quantity.

The city of Rochester is located inupstate New York, on the shores of LakeOntario, The city’s climate – influenced to agreat extent by its proximity to the GreatLake – is the genuine four-season variety.Summers are warm and pleasant; winters arecold and snowy; and spring and fall aretemperate and colorful.

The city itself is a pleasant blend oftraditional and contemporary styles, including alarge number of historic commercial buildingsand residences of great historic value andinterest. There is a strong, ongoing program ofneighborhood restoration. Attractive residentialsuburbs surround the city on the east, west, andsouth. Lake Ontario is to the north.

Beyond the suburbs is rollingfarmland and orchard country,including the Finger Lakes andthe wine country.

Public parks in great numbersin the city and county add apleasant dimension to living allyear round. Excellent restaurantsof many types add a great deal tothe amenities of living.

University of Rochester

Urban and suburban school systems compare favorably with any in the country. Cooperativeurban-suburban transfer programs are a feature of the area’s educational system; “magnet”schools in the city attract children interested in such special fields as technology and performingarts. Excellent private and parochial schools are available and there are many nursery schoolsfrom which to choose.

In addition to the University, the area is home for several other institutions of highereducation, including St. John Fisher, Nazareth, Roberts Wesleyan, and Monroe Communitycolleges, and Rochester Institute of Technology. Units of the State University of New York arelocated nearby in Brockport and Geneseo.

Transportation in and out of Rochester is available by air, rail, and bus. A modern airportserved by a number of major airlines is minutes from the University. The New York StateThruway is just a few miles to the south. New York City is less than an hour away by air. Theinternational attractions of Toronto, Canada are within a few hours’ drive or a short flight acrossLake Ontario. A ferry is planned between Rochester and Toronto, which will significantlydecrease travel time between the two cities.

Eastman Theatre

The arts are an important aspect of lifein Rochester. The presence of the EastmanSchool of Music, a college of theUniversity, helps make Rochester a leadingcenter for fine music. The RochesterPhilharmonic Orchestra is one of the majorsymphony orchestras in North America.Other musical organizations that performhere regularly are the EastmanPhilharmonic, Rochester Chamber OratorioSociety. National musical and dancegroups on tour make frequent appearancesin Rochester.

George Eastman House

The Memorial Art Gallery of the University of Rochester has a permanent collection of 9,000works representing all important periods of art and offers the public many creative workshops inthe arts and crafts. The Albright-Knox Gallery, in nearby Buffalo, features contemporary works.The Rochester Museum and Science Center is also a major attraction, and its StrasenburghPlanetarium is one of the finest facilities of its kind in the world.

Genesee Country Village Museum

The varied climate in the area provides opportunities for a variety of sports and outdooractivities. Lake Ontario and the nearby Finger Lakes area offer camping, fishing, water skiing,sailing, and swimming. Excellent downhill and cross-country skiing and ice skating facilities arelocated near the city; as well as facilities for golf, tennis and other popular sports. Rochester ishome to International League baseball (the Rochester Redwings) and American League Hockey(the Americans), and A-league soccer’s Rochester Rhinos. The NFL Buffalo Bills and NHLBuffalo Sabres are readily accessible 70 miles west of Rochester, as is Big East Conferencebasketball and top-ranked national collegiate football and lacrosse at Syracuse University, 90miles to the east.

A local professional repertory company,Geva Theatre, presents stage productions.There are also several community theatregroups. National companies on tourfrequently perform in Rochester theaters. Inaddition, there are motion picturepresentations of unusual interest. TheDryden Theatre at the International Museumof Photography at George Eastman Houseoffers a series of film classics rivaled only bya similar collection in Paris.

The Genesee County Museum is arestored settlement of the early nineteenthcentury featuring nearly 50 buildings,ranging from a small log cabin to amansion.

The University of Rochester Medical Center is at the heart of medical knowledge and expertise for

Central New York State and the Finger Lakes region of Upstate New York. It includes the University of

Rochester School of Medicine and Dentistry, the School of Nursing, the Eastman Dental Center, the

University of Rochester Medical Faculty Group, Strong Memorial Hospital and the Children’s Hospital at

Strong. Together, we have committed our individual strengths to a shared promise: to improve health,

both locally and globally, within a balanced framework of high quality and affordability.

We’re Upstate New York’s Unique Health Care Resource

The regional Perinatal Center

The regional Trauma Center

The regional Burn Center

Upstate New York’s only Liver Transplant Center and Comprehensive

Epilepsy Center

The region’s only Cardiac Transplant Center, AIDS Treatment Center, and

NIH-designated AIDS Vaccine Evaluation Unit

A nationally recognized Cancer Center

The nation’s only Shaped-Beam Radiosurgery Center

Strong Health is one of the nation’s top academic

health systems and the region’s premier health care

system, offering a full range of high-quality health

care services, enriched by world-class research and

professional education. With more than 1,000 af-

filiated physicians and other health professionals,

we provide a full range of care from preventive and

wellness services. Throughout our healthcare sys-

tem, medical professionals touch thousands of lives

each year. Our commitment is to offer compassion-

ate, state-of-the-art care to our community, one in-

dividual and family at a time.

One of the most distinguished schools of medicine

in this country, the School of Medicine and Den-

tistry is dedicated to the highest quality of educa-

tion, research, and patient care.

Pioneering new research, shaping thefuture of medical technology...

In the year 2000, the James P. Wilmot CancerCenter opened the nation’s first radiosurgerytreatment center that employs Novalis shapedbeam technology (Brain Lab-Germany). At thehelm of the Robert J. Flavin Shaped Beam Sur-gery Center at the JWCC are two of the mosthighly acclaimed physicians and researchers in thefield of stereotactic radiosurgery and radiotherapy.Serving as co-directors of the Shaped BeamSurgery Center, Dr. Paul Okunieff and Dr. WebsterPilcher are two internationally renowned lecturersand clinical investigators in the fields of radiosur-gery, radiation oncology, and neurosurgery. Bothhave authored and published hundreds of clinicalstudies, abstracts, and reports on related topics.Together, with their expert team of radiationoncologists, physicists, nurses, and technicians,Drs. Okunieff and Pilcher are using NovalisShaped Beam Surgery to treat cancers and otherdiseases in new, more effective ways—all produc-ing a higher level of care and cure for patients.This state-of-the-art technology was originallydesigned to treat brain tumors, where pinpointprecision is vital to focus radiation treatment ontumors located close to critical structures withinthe brain that control vital functions such asspeech, memory, sight, and motor skills.Now, the radiosurgery team is perfecting tech-niques that successfully employ this technology totreat tissues and structures outside the brain, suchas bone, liver, and lungs. In addition, a clinicalresearch project is underway to investigate shapedbeam treatment of metastatic lesions, which areoften more threatening than the original tumors.There is great hope that these breakthroughs willhelp reduce the number of cancer patients cur-rently considered incurable.

University of Rochester Medical Center

Radiation Oncology Publications, 2002

The James P. Wilmot Cancer Center strives to provide

outstanding care for people with cancer by offering the

latest and most effective therapies in a compassionate

setting. Meaningful new modulation, prevention and

therapeutic studies are developed through an environment

that nurtures innovative, interdisciplinary cancer research.

Additionally, our Cancer Center offers superior education

and training programs for students, residents and fellows

in areas related to cancer research and clinical care.

The James P. Wilmot Cancer Center (JWCC) is the major

resource for comprehensive cancer care, research, educa-

tion, and community outreach in central New York State.

It provides patient treatment and care to a 13 county area

consisting of approximately 1.4 million people; each year

over 2000 new patients from New York state and beyond

come to the Cancer Center seeking the latest and best in

cancer treatment.

The JWCC has 120 highly trained and skilled faculty

members from all clinical and basic science departments

of the University of Rochester Medical School. Two

years ago, the University of Rochester Medical Center

declared the JWCC a major priority and has supported an

aggressive expansion of its faculty, its clinical and science

programs, its basic research laboratories and its clinical

inpatient and outpatient facilities. Since that time, 17 new

faculty have been recruited, 27,000 sq. ft of new labora-

tory space has been built and 4 new research programs

have been established. Directors for every leadership

position were recruited from other major centers. Six

research cores provide support for 3 established basic

science programs and 4 topic or organ specific compre-

hensive clinical oncology programs that consist of 3

components: basic research, clinical research and popula-

tion studies/cancer control. There is a central Clinical

Trials Office for reviewing, monitoring and administering

national and local clinical research protocols. The JWCC

consists of 126,500 sq. feet of committed and defined

space that houses administrative and clinical trials offices,

physician offices for medical and radiation oncology,

radiation therapy facilities and outpatient clinics.

Treating patients from across the countryand around the corner...

The Department of Radiation Oncology (DRO) is a

recognized leader of clinical and scientific radiation-

related directives. It is a component of the James P.

Wilmot Cancer Center (JWCC) at the University of

Rochester, which was conceived in order to bring the

various key oncologic disciplines together in one

geographic area and provide an environment for the

multidisciplinary care of cancer patients. The interdis-

ciplinary Department of Radiation Oncology achieved

departmental status in 1992, the only division or unit

within the Cancer Center to achieve this status. The

DRO is responsible for its own policies of treatment,

research, education, training, faculty recruitment, and

financial management. Its activities are central to

patient care.

The Radiation Oncology program is a major research

focus at the Cancer Center. Scientists strive to cure

more patients and improve their quality of life with the

use of new technology. Working with other oncologic

specialties, radiation oncologists provide comprehen-

sive clinical care, as well as conduct clinical and basic

research in order to further our understanding of cancer

and increase its curability.

The comprehensive goals of theDepartment of Radiation Oncology

To provide optimal radiation therapy for the patients at theJames P. Wilmot Cancer Center, curing patients when pos-sible, but always aiming to improve the patient’s quality oflife.

To conduct clinical and basic research in order to further ourunderstanding of cancer.

To increase cancer’s curability while minimizing the adversenormal tissue effects of cytotoxic therapy.

To train physicians to provide excellent oncologic care andconduct meaningful research while encouraging them toorient their careers in the direction of academic radiationoncology.

The DRO is thus dedicated to clinical andscientific excellence. Inherent in this orienta-tion is a striving for innovation in research andtraining, with the goal of translating accom-plishments into practical applications thatreduce cancer morbidity and mortality. TheDRO aims to strengthen the framework of theCancer Center while providing leadership tocatalyze the movement of scientific discover-ies into applied clinical research while creatingnew directions in basic scientific researchoriented toward understanding observationsderived from the clinical arena.The DRO is a major promoter and participantin the pursuit of interdisciplinary scientificresearch. It contributes to and takes maximumadvantage of institutional resources andscientific opportunities.

Providing definitive treatment,significant results...

The University of Rochester Medical Center is at the heart of medical knowledge and expertise for

Central New York State and the Finger Lakes region of Upstate New York. It includes the University of

Rochester School of Medicine and Dentistry, the School of Nursing, the Eastman Dental Center, the

University of Rochester Medical Faculty Group, Strong Memorial Hospital and the Children’s Hospital at

Strong. Together, we have committed our individual strengths to a shared promise: to improve health,

both locally and globally, within a balanced framework of high quality and affordability.

We’re Upstate New York’s Unique Health Care Resource

The regional Perinatal Center

The regional Trauma Center

The regional Burn Center

Upstate New York’s only Liver Transplant Center and Comprehensive

Epilepsy Center

The region’s only Cardiac Transplant Center, AIDS Treatment Center, and

NIH-designated AIDS Vaccine Evaluation Unit

A nationally recognized Cancer Center

The nation’s only Shaped-Beam Radiosurgery Center

Strong Health is one of the nation’s top academic

health systems and the region’s premier health care

system, offering a full range of high-quality health

care services, enriched by world-class research and

professional education. With more than 1,000 af-

filiated physicians and other health professionals,

we provide a full range of care from preventive and

wellness services. Throughout our healthcare sys-

tem, medical professionals touch thousands of lives

each year. Our commitment is to offer compassion-

ate, state-of-the-art care to our community, one in-

dividual and family at a time.

One of the most distinguished schools of medicine

in this country, the School of Medicine and Den-

tistry is dedicated to the highest quality of educa-

tion, research, and patient care.

Pioneering new research, shaping thefuture of medical technology...

In the year 2000, the James P. Wilmot CancerCenter opened the nation’s first radiosurgerytreatment center that employs Novalis shapedbeam technology (Brain Lab-Germany). At thehelm of the Robert J. Flavin Shaped Beam Sur-gery Center at the JWCC are two of the mosthighly acclaimed physicians and researchers in thefield of stereotactic radiosurgery and radiotherapy.Serving as co-directors of the Shaped BeamSurgery Center, Dr. Paul Okunieff and Dr. WebsterPilcher are two internationally renowned lecturersand clinical investigators in the fields of radiosur-gery, radiation oncology, and neurosurgery. Bothhave authored and published hundreds of clinicalstudies, abstracts, and reports on related topics.Together, with their expert team of radiationoncologists, physicists, nurses, and technicians,Drs. Okunieff and Pilcher are using NovalisShaped Beam Surgery to treat cancers and otherdiseases in new, more effective ways—all produc-ing a higher level of care and cure for patients.This state-of-the-art technology was originallydesigned to treat brain tumors, where pinpointprecision is vital to focus radiation treatment ontumors located close to critical structures withinthe brain that control vital functions such asspeech, memory, sight, and motor skills.Now, the radiosurgery team is perfecting tech-niques that successfully employ this technology totreat tissues and structures outside the brain, suchas bone, liver, and lungs. In addition, a clinicalresearch project is underway to investigate shapedbeam treatment of metastatic lesions, which areoften more threatening than the original tumors.There is great hope that these breakthroughs willhelp reduce the number of cancer patients cur-rently considered incurable.

University of Rochester Medical Center

Radiation Oncology Publications, 2002

SETTING FOR THE RESIDENCY PROGRAM

The Radiation Oncology Residency Program is based at the James P Wilmot Cancer Center (JPWCC). The JPWCC has a broad spectrum of clinical and scientific resources available directed toward multidisciplinary care, education and research. It is located within the University of Rochester School of Medicine and Dentistry, a comprehensive tertiary care center recognized for its excellence in both clinical care and basic science research. Accordingly, the resources of the entire University Medical Center, of which Strong Memorial Hospital is the primary hospital, are dynamically involved in providing an environment for the resident in which the goals of our program can be accomplished. The JPWCC is a multidisciplinary facility with several interactive divisions, which include Clinical Services (radiation, medical, pediatric, surgical and psychosocial oncology), Basic Science, Nursing Oncology, Cancer Education, and Experimental Therapeutics. Multidisciplinary Oncologic Clinics are offered in the majority of disease sites. The JPWCC serves patients in the Rochester Metropolitan area and the Genesee Valley-Finger Lakes region of New York State, as well as patients referred from more distant outlying areas. The JPWCC also maintains a tumor registry and research facilities in molecular biology, immunology, cell biology and biophysics. Additional facilities ancillary to the Cancer Center include those for xenograft/animal tumor research (including transgenic mice), biostatistics, cell separation/flow cytometry, experimental pathology-ultrastructure, nuclear magnetic resonance, and tissue culture/gene characterization. The University of Rochester Medical Center has advanced state-of-the-art capabilities for bone marrow and organ transplantation, radiology and nuclear medicine and continues to greatly expand its research commitment in a number of key areas, especially oncology, with the development of a number of nationally-recognized research initiatives. A residency program has existed at the University for more than four decades. Specialized training in therapeutic radiology has been offered since 1957 in addition to the general radiology training with which radiation therapy was associated until 1971. The University of Rochester was amongst the first centers, in the early sixties, to receive a NCI Radiation Oncology training grant to build the academic base for our specialty. The de facto autonomy of the free standing Division of Radiation Therapy, created at the time of the founding of the JPWCC, stimulated its transition to the independent Department of Radiation Oncology in 1992. The Department has a tradition of providing fine medical care, teaching both medical and graduate students, training residents and fellows, investigating new treatment strategies both independently and as a member of several multi-institutional cooperative groups (including the South West Oncology Group (SWOG), Radiation Therapy Oncology Group (RTOG), and the Children’s Oncology Group (COG)), and accomplishing basic research endeavors.

The facilities in which the residents train are well equipped. The Department is clinically and academically broad in terms of teaching conferences, research laboratories, and clinical activities. In brief, the Department sees approximately 1,200 new consults and 3,200 previously treated (follow-up) patients each year. Our resources comprise a 30,000-square-foot facility, which provides an environment appropriate for the needs of these patients. There is an ambulatory clinic for new patient and follow-up examinations, treatment facilities, hematology and laboratory services, and facilities for psychosocial counseling and family-patient education.

It includes three state-of-the-art Varian linear accelerators with photon energies ranging from 6 to 16 MV and a wide range of electron energies from 6-20 MeV, a Novalis shaped beam radiosurgery unit, a Tomotherapy unit, a Varis Seed prostate implant system, and a Nucletron High Dose Rate (HDR) brachytherapy unit, which is an automated remote afterloading device for provision of brachytherapy on an outpatient basis. Residents are trained on Varian’s Eclipse planning system (CAD-plan), on SOMA vision, (image fusion and

correlation) and on BrainLab’s Novalis system (image fusion, IMRT and radiosurgery). The CAD-plan system is capable of calculating dose distributions from non-coplaner beams and arbitrary geometries. In addition, the Department possesses all the necessary equipment for traditional after-loading intracavitary and interstitial therapy, permanent interstitial applications, and intravenous or intracavitary radiopharmaceutical installations, and we have an active prostate seed brachytherapy service. In addition, the Department of Radiation Oncology performs treatments for prevention of heterotopic ossification. Our facility at the affiliated Highland Hospital (where residents also rotate) is the focus for the gynecologic-oncology services at the University of Rochester. In addition to two linear accelerators and a simulator, Highland Hospital has facilities for image-guided radiation therapy, stereotactic central nervous system implantation, and endocavitary treatment of rectal cancers. Additional resident training experience is gained in gynecologic-oncology, rectal cancer, thyroid cancer and other areas. The delivery of clinical radiation therapy is the major concern of this division. In the year 2008, the Department of Radiation Oncology performed over 18,000 radiation treatment procedures.

7

At Strong Memorial Hospital, approximately 1,200 new patients are consulted each year, of whom 85% are accepted for treatment. This allows for approximately 1,000 new patients annually in addition to ongoing treatments and patient recurrences, all of which translates into a workload of approximately 100 patients daily. In order to treat the many varied cancers and non-malignant disease, innovative approaches to treatment have been carefully introduced, such as total body irradiation, prophylactic hip irradiation to prevent heterotropic bone formation, high dose rate brachytherapy, and stereotactic radiation therapy.

The Department of Radiation Oncology utilizes the James P Wilmot Cancer Center’s general ambulatory facility for consultations and follow-ups. Multidisciplinary clinics and conferences have been organized with divisions of the Departments of Medicine (including Hematology for bone marrow transplantation), Pediatrics, Surgery, and Surgical subspecialties (such as Urology, Neurosurgery, Otolaryngology, Orthopedic, Thoracic, and Gynecology). In addition, there are weekly conferences with the Departments of Radiology, Pathology and Nuclear Medicine (bone metastases and thyroid malignancies). Both triage and new patient decision-making occurs on an interdisciplinary basis, as does follow-up and selected treatment.

Programs unique to the Department of Radiation Oncology include linear accelerator-based radiosurgery for brain tumors and arteriovenous malformations, high dose-rate brachytherapy for gynecologic and thoracic tumors, total body irradiation in the setting of bone marrow transplantations and pediatric radiation therapy.

Radiation Oncology Research The basic working relationship between scientists and clinicians that has evolved in the Department of Radiation Oncology has become the translational research model of the James P Wilmot Cancer Center (JPWCC) at the University of Rochester. The interactions between these investigators have led to the clinical investigation of laboratory-derived ideas. Such concepts are tested in small, high quality controlled pilot studies to determine if they should be mounted in larger clinical trials of the national cooperative groups. It can be said that the development and conduct of pilot studies at the institutional level is the backbone of national cooperative group trials. Throughout the past several years, we have developed the resources, facilities, and support personnel to conduct Phase I and II feasibility studies while searching for efficient and effective treatment schedules and combinations. The important feature of our work has been the establishment of a mechanism for developing studies that we believe represent the leading edge in radiation oncology research. The research programs constitute the major investigative activities of the Department of Radiation Oncology and rely heavily on the laboratory to model and simulate clinical and physiopathological effects of radiation on human malignant disease and normal tissues. All research programs are discussed at weekly conferences allowing for a continuing exchange of ideas for protocol development. The major strength of the research programs is the ability of the basic and clinical scientific faculty to interact in a synergistic fashion.

The intellectual integration of faculty into a coherent, yet individualized, scientific research program is realized by our carefully selected set of scientific themes: cellular and molecular mechanisms and diagnostics, chemo-prevention and intervention, the monitoring of late effects and their prevention, biologic response modifiers, and psychosocial interventions. There has also been some specialization in systems or organs where we have a degree of expertise (lung, brain, bone and bone marrow), although these are not exclusive.

Our laboratory space design permits the juxtaposition of research laboratories for radiation oncology, radiation biology and radiation physics, with the involvement of investigators, post-doctoral and pre-doctoral students, fellows and residents. The ‘T’ wing section of the Medical School was the original space of the Department of Radiation Oncology and housed the first linear accelerator in Rochester. The Department of Radiation Oncology moved to our former Cancer Center in 1980, which allowed the ‘T’ wing to be renovated into 11 research laboratories consisting of 6350 sq ft. A deliberate and successful attempt to form investigative teams, consisting of a basic scientist and a clinical investigator, has been the essential building block leading to larger research teams involving faculty of other departments. In addition to a wide variety of support services and patient care facilities, an NIH-designated Clinical Research Center is available at Strong Memorial Hospital to assist with conducting high risk pilot studies in an atmosphere conducive to performing sophisticated biologic studies as well as to providing optimum patient care.

Clinical Investigative Radiation Oncology This clinical division of the Department of Radiation Oncology encompasses investigative programs related to humans in which radiation therapy is used, including clinical trials in national cooperative groups (SWOG, RTOG and COG) and unique JPWCC Phase I/II clinical trials. The Department of Radiation Oncology has played a leading role in the protocol design activities of the RTOG and SWOG and in the development of clinical trials in a variety of tumor sites, including lung cancer in localized stages, GI malignancies, head and neck cancers, Hodgkin’s Disease, non-Hodgkin’s lymphoma, pediatric neoplasms and gynecologic cancers. An integral component of many of our clinical protocols are radiation oncology-based laboratory techniques, including cell elutriation and cell-sorting techniques, identification of hypoxic fractions, and various tumor assays designed to predict radiation effectiveness and responsiveness. The current thrust of a new group of Department of Radiation Oncology clinical trials is to study the role of cytokines as correlates or indicators of late toxicity in patients undergoing radiation treatment to the lung or the brain. Protocols focusing on therapy-induced normal tissue damage have also emerged as an area of interest, particularly with regard to neuroendocrine, pulmonary, bone marrow and CNS systems. LENT – Late Effects of Normal Tissue National Conferences, sponsored by the NCI to redesign late effects scoring and scales, were co-chaired by Philip Rubin MD and Louis S Constine MD results were published in 1995 and 2008. Second malignant tumors are a major new focus, along with chemoprevention and clinical trials using intermediate oncologic markers as endpoints. Trials are conducted in cooperation with such national groups as the South West Oncology Group (SWOG), the Radiation Therapy Oncology Group (RTOG), and the Children’s Oncology Group (COG). The Department of Radiation Oncology has played a leading role in the protocol design of the RTOG and COG. Unique Cancer Center trials are also conducted by this division.

Education Division The activities of this division involve both active teaching and the publication of a wide variety of material pertinent to the field of radiation oncology. The central programs include residency training, medical student instruction (both through courses and elective rotations), and continuing postgraduate education for fellows, faculty and practitioners. The Education Division is uniquely designed to provide education for a broad range of health care practitioners and patients. Above all else, the University of Rochester is a teaching institution as well as a center for delivering patient care. The Education Division strives to be comprehensive in its educational offerings by providing a diversity of programs serving a wide range of students, practitioners, and patients. Through flexibility, creativity, and variety, the Education Division Meets the life-long educational needs of these individuals by keeping them abreast of the rapidly changing medical and scientific knowledge. In addition, programs in postgraduate education, medical school courses, medical student elective rotations, dosimetry training, in-service lectures and courses, continuing medical education (CME) offerings, education grants, and publications and special projects are developed by this division.

All departmental faculty members participate in development and implementation of the numerous educational programs, courses, and publications. Specific faculty members have been appointed by the Chairman to direct each of the specialized programs.

The Radiation Oncology Residency Program at the

University of Rochester is committed to providing its residents with

the educational experiences necessary in order to attain

competence in:

Patient Care

that is compassionate, appropriate, and effective for the treatment of

health problems and the promotion of health;

Medical Knowledge

about established and evolving biomedical, clinical, and cognate (eg,

epidemiological and social-behavioral) sciences and the application of

this knowledge to patient care;

Practice-Based Learning and Improvement

that involves investigation and evaluation of their own patient care,

appraisal and assimilation of scientific evidence, and improvements in

patient care;

Interpersonal and Communication Skills

that result in effective information exchange and teaming with

patients, their families, and other health professionals;

Professionalism

as manifested through a commitment to carrying out professional

responsibilities, adherence to ethical principles, and sensitivity to a

diverse patient population;

Systems-Based Practice

as manifested by actions that demonstrate an awareness and

responsiveness to the larger context and system of health care and the

ability to effectively call on system resources to provide care that is of

optimal value.

COMMITMENTS OF FACULTY

1. As role models for our residents, we will maintain the highest standards of care,respect the needs and expectations of patients, and embrace the contributions of allmembers of the healthcare team.

2. We pledge our utmost effort to ensure that all components of the educationalprogram for resident physicians are of high quality, including our own contributionsas teachers.

3. In fulfilling our responsibility to nurture both the intellectual and the personaldevelopment of residents, we commit to fostering academic excellence, exemplaryprofessionalism, cultural sensitivity, and a commitment to maintaining competencethrough life-long learning.

4. We will demonstrate respect for all residents as individuals, without regard togender, race, national origin, religion, disability or sexual orientation; and we willcultivate a culture of tolerance among the entire staff.

5. We will do our utmost to ensure that resident physicians have opportunities toparticipate in patient care activities of sufficient variety and with sufficientfrequency to achieve the competencies required by their chosen discipline. We alsodo our utmost to ensure that residents are not assigned excessive clinicalresponsibilities and are not overburdened with services of little or no educationalvalue.

6. We will provide resident physicians with opportunities to exercise gradedprogressive responsibility for the care of patients so that they can learn how topractice their specialty and recognize when, and under what circumstances, theyshould seek assistance from colleagues. We will do our utmost to prepare residentsto function effectively as members of healthcare teams.

7. In fulfilling the essential responsibility we have to our patients, we will ensure thatresidents receive appropriate supervision for all of the care they provide during theirtraining.

8. We will evaluate each resident’s performance on a regular basis, provideappropriate verbal and written feedback, and document achievement of thecompetencies required to meet all educational objectives.

9. We will ensure that resident physicians have opportunities to partake in requiredconferences, seminars and other non-patient care learning experiences and that theyhave sufficient time to pursue the independent, self-directed learning essential foracquiring the knowledge, skills, attitudes, and behaviors required for practice.

10. We will nurture and support residents in their role as teachers of other residents andor medical students.

This compact serves both as a pledge and as a reminder to resident physicians and theirteachers that their conduct in fulfilling their obligations to one another is the mediumthrough which the profession perpetuates its standards and inculcates its ethical values

COMMITMENTS OF RESIDENTS

1. We acknowledge our fundamental obligation as physicians—to place ourpatients’ welfare uppermost; quality health care and patient safety will always beour prime objectives.

2. We pledge our utmost effort to acquire the knowledge, clinical skills, attitudesand behaviors required to fulfill all objectives of the educational program and toachieve the competencies deemed appropriate for our chosen discipline.

3. We embrace the professional values of honesty, compassion, integrity, anddependability.

4. We will adhere to the highest standards of the medical profession and pledge toconduct ourselves accordingly in all of our interactions. We will demonstraterespect for all patients and members of the health care team without regard togender, race, national origin, religion, economic status, disability or sexualorientation.

5. As physicians in training, we learn most from being involved in the direct care ofpatients and from the guidance of faculty and other members of the healthcareteam. We understand the need for faculty to supervise all of our interactions withpatients.

6. We accept our obligation to secure direct assistance from faculty or appropriatelyexperienced residents whenever we are confronted with high-risk situations orwith clinical decisions that exceed our confidence or skill to handle alone.

7. We welcome candid and constructive feedback from faculty and all others whoobserve our performance, recognizing that objective assessments areindispensable guides to improving our skills as physicians.

8. We also will provide candid and constructive feedback on the performance of ourfellow residents, of students, and of faculty, recognizing our life-long obligationas physicians to participate in peer evaluation and quality improvement.

9. We recognize the rapid pace of change in medical knowledge and the consequentneed to prepare ourselves to maintain our expertise and competency throughoutour professional lifetimes.

10. In fulfilling our own obligations as professionals, we pledge to assist both medicalstudents and fellow residents in meeting their professional obligations byservicing as their teachers and role models.

This compact serves both as a pledge and as a reminder to resident physicians andtheir teachers that their conduct in fulfilling their obligations to one another is themedium through which the profession perpetuates its standards and inculcates itsethical values

Radiation Oncology Residency Program

Core Curriculum

Clinical Educational Curriculum

Green = Genitourinary oncology Yellow = Gastrointestinal oncology Red = Breast oncology = Breast oncology Purple = Thoracic oncology, CNS, SRS Orange = CNS, SRS White = Thoracic oncology HH = Gynecologic & breast oncology = Head & Neck oncology = LDR/HDR brachytherapy Blue = Pediatric oncology = Colorectal oncology = Lymphoreticular oncology = Radioimmunotherapy/ = Reticuloendothelial oncology Unsealed radioactivity

YEAR 1 (PGY-2)

Jul Mth 1 Orientation / Patient Trails / Physics-Dosimetry-Therapy Rotation Green Service Rotation

Aug Mth 2 Green Service Rotation Sept Mth 3 Green Service Rotation Oct Mth 4 Yellow Service Rotation Nov Mth 5 Yellow Service Rotation Dec Mth 6 Yellow Service Rotation Jan Mth 7 Red Service Rotation Feb Mth 8 Red Service Rotation Mar Mth 9 Red Service Rotation Apr Mth 10 Purple Service Rotation May Mth 11 Purple Service Rotation Jun Mth 12 Purple Service Rotation

YEAR 2 (PGY-3)

Jul Mth 1 Orange Service Rotation / Research Rotation Aug Mth 2 Orange Service Rotation / Research Rotation Sept Mth 3 Orange Service Rotation / Research Rotation Oct Mth 4 White Service Rotation Nov Mth 5 White Service Rotation Dec Mth 6 White Service Rotation Jan Mth 7 Blue Service Rotation Feb Mth 8 Blue Service Rotation Mar Mth 9 Blue Service Rotation Apr Mth 10 Medical Oncology Rotation (2 weeks) / Dosimetry Rotation (2 weeks) May Mth 11 Radiology Rotation (3 weeks) / Palliative Care (2 weeks) Jun Mth 12 Pathology (4 weeks)

This rotation schedule acts as a guide for each resident to identify the expectations for their responsibilities for each year of residency. Although each resident will not necessarily rotate through these core and required rotations in this precise order, they will complete each of these rotations during the course of their residency. In general, each resident will rotate through Green, Yellow, Red and Purple first, followed by Orange, White and Blue and they will complete the HH rotations in their 3rd and 4th years of residency.

YEAR 3 (PGY-4)

Jul Mth 1 Green Service Rotation Aug Mth 2 Green Service Rotation Sept Mth 3 Green Service Rotation Oct Mth 4 Yellow Service Rotation Nov Mth 5 Yellow Service Rotation Dec Mth 6 Research / Elective / Remediation Jan Mth 7 Research / Elective / Remediation Feb Mth 8 Red/Orange Service Rotation Mar Mth 9 Red/Orange Service Rotation Apr Mth 10 HH Service Rotation May Mth 11 HH Service Rotation Jun Mth 12 HH Service Rotation

YEAR 4 (PGY-5)

Jul Mth 1 Blue Service Rotation Aug Mth 2 Blue Service Rotation Sept Mth 3 Blue Service Rotation Oct Mth 4 HH Service Rotation Nov Mth 5 HH Service Rotation Dec Mth 6 HH Service Rotation Jan Mth 7 Purple Service Rotation Feb Mth 8 Purple Service Rotation Mar Mth 9 Research / Elective / Remediation Apr Mth 10 Research / Elective / Remediation May Mth 11 White Service Rotation Jun Mth 12 White Service Rotation

Didactic Educational Curriculum:

Summer Course Fall Course Spring Course

(July-Aug) Hours (Sept-Jan) Hours (Feb-Jun) Hours

YEAR 1 10 Clinical Oncology I 20 Clinical Oncology I 20

Onco-Anatomy/ LENT Radiation/Cancer Biology I 18 Radiation/Cancer Biology I 18

Practical Dosimetry I 18 Clinical Biostatistics I 10 Radiation Physics II 10 Radiation Physics II 10 TOTAL 10 TOTAL 66 TOTAL 58 134

YEAR 2 10 Clinical Oncology II 20 Clinical Oncology II 20

Onco-Anatomy/ LENT Radiation Physics I 18 Radiation Physics I 18

Radiation/Cancer Biology II 12 Radiation/Cancer Biology II 12 Radiology I 10 Pain Management I 4 TOTAL 10 TOTAL 60 TOTAL 54 124

YEAR 3 Clinical Oncology I 20 Clinical Oncology I 20

Onco-Anatomy/ LENT Radiation/Cancer Biology I 18 Radiation/Cancer Biology I 18

Practical Dosimetry I 18 Clinical Biostatistics I 10 Radiation Physics II 10 Radiation Physics II 10 TOTAL 10 TOTAL 66 TOTAL 58 134

YEAR 4 Clinical Oncology II 20 Clinical Oncology II 20

Onco-Anatomy/ LENT Radiation Physics I 18 Radiation Physics I 18

Radiation/Cancer Biology II 12 Radiation/Cancer Biology II 12 Pathology I 2 Palliative Care I 6 TOTAL 10 TOTAL 52 TOTAL 56 118

PGY-2 Orientation/Pt Trails/PDT Rotation Basics of Radiation Oncology 6 hrs Introduction to Radiology 4 hrs Introduction to Physics/Dosimetry 5 hrs APS Module 1 1 hr ACLS Certification PALS Certification ACR In-Training Exam 4 hrs

Orientation = 1st 2 weeks Patient Trails = 1st 4 weeks (Secretaries Reception Consults

SIMs Dosimetry Clinical Research Therapy Follow-ups Billing) Physics-Dosimetry-Therapy Rotation = 1st 3-month rotation; 2-3 hours per week (3 rotations with Simulation Therapists; 3 rotations

with Dosimetry and 3 rotations with Treatment Therapists, plus

physics and brachytherapy planning & QA when available) PGY-3 Research Rotation 3 mths APS Modules 2 & 3 2 hrs External Recommendations

Medical Oncology Rotation 2 wks Dosimetry Rotation 2 wks PGY-3 USMLE Step III Diagnostic Imaging Rotation 3 wks Palliative Care Rotation 2 wks Oncologic Pathology Rotation 4 wks ACR In-Training Exam 4 hrs PGY-4 Research Rotation 2 mths PGY-4 APS Module 4 1 hr Physics/Biology Tutorials/Reviews DRO Grand Rounds ACLS Re-certification PALS Re-certification ACR In-Training Exam 4 hrs Chief Resident Training Workshop

Maryland Biology & Physics Board Review Course 24 hrs

PGY-5 Research Rotation 2 mths PGY-5 Biology & Physics Written Board Exams APS Module 5 1 hr SBP Improvement Project Career Planning DRO Grand Rounds ACR In-Training Exam 4 hrs Practice Management

Osler Institute Clinical Radiation Oncology Board Review Course 32 hrs

Graduation Clinical Written Board Exams 1 year post-graduation Oral Board Exams

Resident Courses, Classes, Tumor Boards & Conferences

Mandatory Courses, Classes & Conferences Schedule Day Time New Pt Presentations Sept-June Mon 8.00 am Resident Meetings Monthly Mon 4.30 pm IMRT & Chart Rounds Weekly Tues 8.00 am Clinical Oncology Lecture Series Sept-June Tues 4.30 pm (incl. self-study assignments, RT techniques, oncologic imaging/pathology, late effects, ITE review, board review) alt. Thursday Onco-Anatomy/LENT Summer Seminar Series July-August Tues 4.30 pm Radiation Physics Course Sept-June biannually Wed 8.00 am Radiation/Cancer Biology Course Sept-June biannually Wed 8.00 am Stress Mgmt & Fatigue Awareness Seminars Semi-annually Wed 4.30 pm Radiation Oncology Grand Rounds Occasionally Wed 4.30 pm QA Meetings Monthly 3rd Wed 4.30 pm Clinical/Ethical/EBM Journal Clubs Monthly 4th Wed 4.30 pm Medical Oncology Pathology Conferences Weekly Thurs 12.00 pm GYN-Onc Tumor Boards Monthly Fri 7.30 am Pediatric Oncology Multidisciplinary Conferences Weekly/Bi-weekly Fri 4.00 pm Practical Dosimetry Lecture Series Sept-June biannually Radiation Physics Labs Sept-June biannually CBARMFI Lectures & Wet Labs Series Sept-June biannually Clinical Biostatistics Course Sept-June biannually ACR In-Training Exams March annually RTOG/SWOG/COG Protocol Updates 4 per year Compliance Updates 2 per year Library Update 1 per year Stress/Fatigue Seminars 2 per year ACLS/PALS Mock Codes 2 per year Clinical Oncology Mock Oral Boards June annually Radiation Safety Training Annually White Service Presentation 4 per rotation Blue Service Seminar Ad hoc basis

Topic-dependent Conferences Day Time Palliative Care Conference (Clinical Ethics/Schwartz/Palliative Care) Wed 12.00 pm Hem/Onc Fellowship Conference Thurs 8.00 am Imaging Sciences Grand Rounds Thurs 4.00 pm Fellows Oncology Teaching Conference Fri 8.00 am Cancer Center Grand Rounds Fri 12.00 pm Service-specific Tumor Boards/Conferences Service Schedule Day Time Breast Tumor Board Red Weekly Mon 7.30 am Pediatric Brain Tumor Pre-Clinic Conference Blue Weekly Tues 12.00 pm Lymphoma Tumor Board Blue 2nd & 4th Tues 12.30 pm GI Pre-Clinic Conference Yellow Weekly Tues 5.00 pm GU Pre-Clinic Conference Green Weekly Wed 9.00 am Breast Conference Red Weekly Wed 11.30 am GU Tumor Board Green 1st & 3rd Wed 12.30 pm Head & Neck Tumor Board White Weekly Wed 4.00 pm Neuroscience/Neuro-oncology Conference Monthly 2nd Thurs 7.30 am Brain Tumor Pre-Clinic Conference

Purple/ Orange Weekly Thurs 8.00 am

Thoracic Pre-Clinic Conference Weekly Thurs 12.00 pm Thoracic Tumor Board

Purple/ White 1st & 3rd Thurs 4.00 pm

Hepato-Biliary Tumor Board Yellow 1st & 3rd Fri 8.00 am Service Team Meetings ALL Weekly

Radiation Oncology

Residency Program


CLAdmin/Okunieff/Recruitment/DRO Faculty and Staff

UNIVERSITY OF ROCHESTER SCHOOL OF MEDICINE & DENTISTRY

DEPARTMENT OF RADIATION ONCOLOGY FACULTY & STAFF

Clinical Faculty:

Strong Memorial Hospital: Tel: (585) 275-5575

Ralph A Brasacchio MD Associate Professor, Radiation Oncology Residency Program Director (Green Service – GU) [email protected] Yuhchyau Chen MD PhD Professor, Radiation Oncology (White Service – thoracic, head & neck) [email protected] Louis S Constine MD Professor, Radiation Oncology & Pediatrics Associate Chair, Radiation Oncology Fellowship Program Director (Blue Service – CNS, lymphomas, sarcomas, Hodgkins & pediatrics) [email protected] Alan Katz MD MPH Assistant Professor, Radiation Oncology (Yellow Service – GI & Breast) [email protected] Marilyn Ling MD Assistant Professor, Radiation Oncology (Red Service- Breast) [email protected] Michael T Milano MD PhD Assistant Professor, Radiation Oncology (Purple Service – CNS & SRS, Thoracic) [email protected]


Paul Okunieff MD Professor & Chair, Radiation Oncology (Orange Service – CNS & SRS) [email protected]

Philip Rubin MD Professor Emeritus

Deepinder Singh MD Assistant Professor, Radiation Oncology (White Service- head & neck, thoracic) [email protected] Kenneth Usuki MD Assistant Professor, Radiation Oncology (Orange Service- CNS) [email protected]

Hong Zhang MD PhD Assistant Professor, Radiation Oncology (White Service- thoracic, head & neck) [email protected]


Other Affiliated Institutions: Highland Hospital/Park Ridge Hospital/Sands Cancer Center

Joy Anderson MD Clinical Instructor, Radiation Oncology, Highland Hospital (HH Service – GYN, GI, thyroid) [email protected] Bingren (Ben) Liu MD Assistant Professor, Radiation Oncology Highland Hospital & Unity Hospital [email protected] Muammer Tasbas MD Assistant Professor, Radiation Oncology Sands Cancer Center & Highland Hospital [email protected]

Deepinder Singh MD Assistant Professor, Radiation Oncology, Unity Hospital [email protected] Hong Zhang MD PhD Assistant Professor, Radiation Oncology, Unity Hospital [email protected]


Radiation Biology Faculty:

Bruce Fenton PhD Professor, Radiation Oncology (Tumor vascular biology & angiogenesis) [email protected]

Peter Keng PhD Professor, Radiation Oncology (Radiation biology & cell cycle) [email protected]

Jacky Williams PhD Research Associate Professor, Radiation Oncology (Radiation late effects – lung & cardiovascular irradiation) [email protected]

Lurong Zhang MD PhD Professor, Radiation Oncology (Novel hypoxic drug therapy) [email protected]


Radiation Physics Faculty:

Rami Abu-Aita MS Associate Division of Radiation Physics, Radiation Oncology [email protected]

Douglas Clark MS Associate Division of Radiation Physics, Radiation Oncology [email protected]

Alex Gray MS DABR Associate Division of Radiation Physics, Radiation Oncology [email protected] Rob Meiler PhD Assistant Professor of Clinical Radiation Oncology Division of Radiation Physics, Radiation Oncology [email protected]

Walter O’Dell PhD Research Assistant Professor Division of Radiation Physics, Radiation Oncology [email protected] Douglas Rosenzweig PhD Associate Professor & Director of Clinical Radiation Physics Division of Radiation Physics, Radiation Oncology [email protected]

Michael Schell PhD Professor & Director of Radiation Physics Division of Radiation Physics, Radiation Oncology [email protected]


Other Faculty & Section Leaders/Chiefs:

George Uschold EdD Associate Professor, Director of Clinical Operations Administrator, Radiation Oncology [email protected]

Sharon Pieper Clinical Manager, Radiation Oncology [email protected] Mary Pat Allen Clinical Coordinator, Radiation Oncology [email protected]

Wendy Malorzo Residency Program Administrator, Radiation Oncology [email protected]

Ann Muhs Section Chief, Clinical Research, Radiation Oncology [email protected] Molly Shanto RN Nurse Leader, Radiation Oncology [email protected] Tracey Jones RTT Chief Therapist, Radiation Oncology

[email protected] Residents & Fellows:

Kevin Bylund MD PGY-2 Resident Michael O’Neill MD PGY-2 Resident

Praveena Cheruvu MD PGY-3 Resident

Sughosh Dhakal MD PGY-3 Resident

Sheema Chawla MDPGY-4 Resident

Su Metcalfe MD MPH PGY-5 Resident

Orientation Schedule:

DAY/TIME NAME TOPIC

July 1st INSTITUTIONAL ORIENTATION 30 mins Lead Manager, Page Office Communications Center Services 1 hr Miner Library Liaison Library Services 1 hr Chairman Welcome to the Department 2 hrs Program Director Welcome to the Residency Program:

• Overview of residency training requirements 30 mins Program Administrator • Checklist & Workstation 1 hr Clinical Manager/

Dept Administrator • Tour of department • Clinical operations & billing-related issues

30 mins Clinical Office Coordinator Patient notes, transcriptions, chart flow, QA, etc 30 mins Nurse Leader Clinical survival skills:

• Tour of clinic area • Tour of basement tx area

30 mins Chief Therapist Patient scheduling, etc: • Radiation Chart • How to prepare & schedule SIMs • Treatment machines

30 mins Lead Dosimetrist Dosimetry and treatment planning • Dosimetry treatment plans • Eclipse workstation • Isodose lines

30 mins Chief Physicist Physics procedures & radiation safety 30 mins Oncology social workers Social Work Office 30 mins Clinical Research Manager Protocols & clinical research 30 mins Chief Physicist Orientation to systems 1 hour Clinical Manager Aria training 1 hr Program Administrator ACGME Case log system & E*Value 1 hr Chief Resident(s) • Discuss flow of week on service

• Resident responsibilities - Attending on-service Review pts with resident leaving service and/or attending Online training modules MyVarian.com:

• Eclipse Workstation • Patient Manager • Offline Reviews HSPP Radiation Safety

Patient Trails:

Key to Core

Competencies:

1 = Patient Care 2 = Medical Knowledge 3 = Practice-Based Learning & Improvement 4 = Interpersonal & Communication Skills 5 = Professionalism 6 = Systems-Based Practice

Objective: Competency: To provide new residents with an overview of the department, and the system we use to provide quality patient care, as well as orienting new residents to the responsibilities and required procedures to follow.

1,4,6

Week 1

1 hr Clerical Rotation

• Consult scheduling • Insurance information • General pt issues • Chart organization & locations & archives • Ordering & scheduling tests • Preparation for clinics & F/U

30 mins Patient Check-in

• Pt check-in and registration • Blood work • Pt exam room • Pt check-out, ordering tests, scheduling

- Consultation

Incorporated into service requirements

3 hrs Dosimetry (& PDT)

General overview: • Rx writing • Volume contours • Planning equipment

Week 2 3 hrs SIM Room (& PDT)

• Scheduling • SIM techniques • Immobilization devices • Pt identification & time-out • Field marking (tattoo) • Charting • Measurements for tx planning

Week 3-4 1 hr Clinical Research

• RTOG, SWOG, COG, URCC • Identify pts for protocols & preparation • Research projects, abstracts & manuscripts

2 hrs Therapy (& PDT)

• Treatment delivery • Radiation safety and protection procedures • Patient identification • Treatment procedures • Treatment prescriptions • Quality assurance Scheduling • Standard set-ups • CT fusions

1 hr Billing

Hospital & Private practice • Responsibilities • Codes & forms

- Follow-Up Incorporated into service requirements RESIDENT EVALUATION/SURVEY REQUIRED:

Each resident will be asked to complete an evaluation at the end of his/her rotation. These evaluations will be used to make improvements to future rotations.

Physics-Dosimetry-Therapy (PDT) Rotation:

Key to Core

Competencies:


Learning Objectives: Competencies: • Become knowledgeable and proficient in all technical aspects of radiation therapy

treatment planning, delivery, and documentation. • Understand all technical availabilities and limitations with regard to patient set-up and

beam delivery.

• 2,6 • 2,6

Physics Rotation: Participate in Physics treatment planning, QA procedures and monthly checks, including the following QA activities: • Daily QA • Weekly QA • Monthly QA • Annual QA • Brachytherapy QA • SRS QA

Dosimetry Rotation (3 hrs): 1st rotation – General Overview: • Rx writing • Volume contours • Planning equipment 2nd & 3rd rotations: • Diacom data/fusions • Treatment charting and

documentation • Isodose generation • Treatment calculations • Verification of plan

implementation

SIM Rotation (3 hrs): • Scheduling • SIM techniques • Immobilization devices • Pt identification & time-out • Field marking (tattoo) • Charting • Measurements for tx planning

Therapy Rotation (2 hrs each): 1. Linac 1 (2100IX – portal imaging, kV imaging) 2. Linac 2 (2100IX – portal imaging, kV imaging, cone

beam imaging) 3. Linac 3 (2100EX – portal imaging, ultrasound) 4. Novalis 5. Tomotherapy 6. Optional (anything you want to learn more about or

need more time to understand)

• Treatment delivery • Radiation safety and protection procedures • Patient identification • Treatment procedures • Treatment prescriptions • Quality assurance Scheduling • Simulations • Standard set-ups • CT fusions

REQUIRED READING:

• ‘Treatment Planning & Dose Calculation in Radiation Oncology’. Gunilla C Bental, Charles E Nelson PhD, K Thomas Noell MD. 3rd or 4th edition.

• ‘The Physics of Radiation Therapy’. Faiz M Khan. 2nd or 3rd edition. SUPPLEMENTAL READING:

• ‘Medical Images Physics’. William Hendee, Russell Ritenour. 3rd edition. • ‘Clinical Oncology’. Philip Rubin. 8th edition.

ROTATION REQUIREMENTS:

To satisfactorily complete this rotation, the resident must: • complete and submit a case log of all patients seen and their diagnosis; • receive a satisfactory evaluation from his/her preceptors; • complete an evaluation at the end of his/her rotation (these evaluations will be

used to make improvements to future rotations).

General CompetenciesAt its February 1999 meeting, the ACGME endorsed general competencies for residents in the areas of:

patient care,

medical knowledge,

practice-based learning and improvement, and

interpersonal and communication skills,

professionalism,

systems-based practice.

Identification of general competencies is the first step in a long-term effort designed to emphasize educational outcome assessment inresidency programs and in the accreditation process. During the next several years, the ACGME’s Residency Review and InstitutionalReview Committees will incorporate the general competencies into their Requirements. The following statements will be used as a basisfor future Requirements language. If you have any questions, comments and other requests for assistance, please address them [email protected].

ACGME GENERAL COMPETENCIES Vers. 1.3(9.28.99)

The residency program must require its residents to develop the competencies in the 6 areas below to the level expected of a newpractitioner. Toward this end, programs must define the specific knowledge, skills, and attitudes required and provide educationalexperiences as needed in order for their residents to demonstrate the competencies.

PATIENT CARE

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems andthe promotion of health. Residents are expected to:

ß communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their familiesß gather essential and accurate information about their patientsß make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date

scientific evidence, and clinical judgmentß develop and carry out patient management plansß counsel and educate patients and their familiesß use information technology to support patient care decisions and patient educationß perform competently all medical and invasive procedures considered essential for the area of practiceß provide health care services aimed at preventing health problems or maintaining healthß work with health care professionals, including those from other disciplines, to provide patient-focused care

MEDICAL KNOWLEDGE

Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to:

ß demonstrate an investigatory and analytic thinking approach to clinical situationsß know and apply the basic and clinically supportive sciences which are appropriate to their discipline

PRACTICE-BASED LEARNING AND IMPROVEMENT

Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improvetheir patient care practices. Residents are expected to:

ß analyze practice experience and perform practice-based improvement activities using a systematic methodologyß locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problemsß obtain and use information about their own population of patients and the larger population from which their patients are drawnß apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic

and therapeutic effectivenessß use information technology to manage information, access on-line medical information; and support their own educationß facilitate the learning of students and other health care professionals

INTERPERSONAL AND COMMUNICATION SKILLS

Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teamingwith patients, their patients families, and professional associates. Residents are expected to:

ß create and sustain a therapeutic and ethically sound relationship with patientsß use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing

skillsß work effectively with others as a member or leader of a health care team or other professional group

PROFESSIONALISM

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to adiverse patient population. Residents are expected to:

ß demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professionaldevelopment

ß demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patientinformation, informed consent, and business practices

ß demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities

SYSTEMS-BASED PRACTICE

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability toeffectively call on system resources to provide care that is of optimal value. Residents are expected to:

ß understand how their patient care and other professional practices affect other health care professionals, the health careorganization, and the larger society and how these elements of the system affect their own practice

ß know how types of medical practice and delivery systems differ from one another, including methods of controlling health carecosts and allocating resources

ß practice cost-effective health care and resource allocation that does not compromise quality of careß advocate for quality patient care and assist patients in dealing with system complexitiesß know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and

know how these activities can affect system performance

General Competencies Assessment Glossary

Competencies

1. Patient Care - Gather data; order diagnostic tests; interpret data; make decisions; perform procedures; manage patient therapies; work with others to provide patient-focused care

2. Medical Knowledge - Fund of knowledge; active use of knowledge to solve medical problems 3. Practice-Based Learning & Improvement - Analyze practice performance and carry out needed

improvements; locate and apply scientific evidence to the care of patients; critically appraise the scientific literature; use the computer to support learning and patient care; facilitate the learning of other health care professionals

4. Interpersonal & Communication Skills - Develop a therapeutic relationship with patients and their families; use verbal and non-verbal skills to communicate effectively with patients and their families; work effectively as a team member or leader

5. Professionalism - Demonstrate integrity and honesty; accept responsibility; act in the best interest of the patient; demonstrate sensitivity to patients' ethnicity, age, and disabilities

6. Systems-Based Practice - Demonstrate awareness of interdependencies in the health care system that affect quality of care; provide cost-effective care; advocate for quality patient care; work with hospital management and interdisciplinary teams to improve patient care

Assessment Methods

1. Clinical Performance Ratings - Monthly, rotation, semi-annual or annual ratings of resident performance 2. Focused Observation and Evaluation - Supervisor/attending observation of individual resident-patient

encounters, operations, specimen preparation, etc., and concurrent (same day) evaluation 3. 360 Assessments - Evaluation by MDs (supervisors, residents, medical students) and non-MDs (nurses,

technicians, social workers, PAs ) using the same or similar evaluation forms 4. Evaluation Committee - Evaluation of resident performance in a small group discussion format, e.g.,

Evaluation Committee 5. Structured Case Discussions - An informal structured mini-oral exam consisting of a small set of pre-

determined questions; the exam occurs during a resident's case presentation to his/her supervisor 6. Stimulated Chart Recall - Uses a resident's patient records in an oral exam-like format to explore

decisions made and patient management; is conducted "after the fact" using patient charts to stimulate memory of the case

7. Standardized Patient - The resident provides care to an SP as if (s)he were a real patient and is evaluated concurrently by the SP or another trained observer; the SP is a well person or actual patient trained to present a case in a standardized way

8. OSCE - A multi-station exam of simulated clinical tasks, which might include SPs, anatomical models, X-ray interpretation, lab test interpretation, etc.; a resident performs the tasks and is evaluated concurrently by a trained observer

9. High Tech Simulators/Simulations - Residents' performance of procedures on a high-tech simulator (e.g., Harvey) is evaluated; this may involve built-in evaluation by the simulator or observation and concurrent evaluation.

10. Anatomic or Animal Models - Residents' performance of procedures on non-computerized, 3-dimensional models that replicate the properties of human anatomical structures is observed and evaluated concurrently

11. Role-play or Simulations - Residents are evaluated based on their performance on assigned responsibilities in a staged replica of a potentially real situation, e.g., mobilization of medical team in a multi-victim accident, confrontation of an "impaired" colleague, negotiation with administration regarding facilities and equipment upgrade

12. Formal Oral Exam - "Mock" oral exam in which an examiner asks residents questions about what to do in a clinical scenario presented verbally or role played by the examiner

13. In-training Exams - A multiple-choice exam developed by an external vendor 14. In-house Written Exams - A multiple choice exam developed by residency program faculty 15. Multimedia Exam - A computer based multiple choice or branching question exam in which authentic

visual and auditory patient information is presented as question information 16. Practice/Billing Audit - Educational equivalent of physician profiling; this data-based process

benchmarks individual resident billing data against peers in the office, hospital, or managed care setting 17. Review of Case or Procedure Log - Review of number of cases or procedures performed and

comparison against minimum numbers required 18. Review of Patient Chart/Record - Involves abstraction of information from patient records, such as tests

ordered, and comparison of findings against accepted patient care standards 19. Review of Patient Outcomes - Aggregation of outcomes of patients cared for by a resident and

compared against a standard

20. Review of Drug Prescribing - Systematic review of drug prescribing for selected conditions to determine adherence to protocol

21. Resident Project Report (Portfolio) - Evaluation of resident work products, such as reports of research studies, practice improvement, or systems-based improvement

22. Resident Experience Narrative (Portfolio) - Evaluation of performance based on residents' narratives of critical incidences or other experiences, usually accompanied by reflection on the event, e.g., what happened, why, what could have been done differently

23. Other Portfolio - Evaluation of resident performance based on other work/performance products not included above, e.g., audiotapes, slide presentations

Educational Activities

1. Clinical Teaching - teaching that occurs in the clinic, EDs, ORs, laboratories, or other medical settings and addresses issues related to residents’ current patient cases or clinical responsibilities.

2. Clinical Experiences - direct, hands-on clinical or patient care activities. This may include surgery, patient exams, the reading of radiographs and preparation of pathology assays.

3. Performance Feedback - information provided to a resident that describes what (s)he has done well or poorly and provides specific guidance as to how performance might be improved.

4. Departmental Conferences, Lectures or Discussions - formal, classroom instruction on a specific topic or method, led by one or more faculty, residents, or staff, etc.

5. Institutional Conferences, Lectures, or Discussions - formal educational event involving institution-sponsored grand rounds, lectures, discussions, or workshops for residents and/or faculty from multiple specialties; may be part of an institutional core curriculum (i.e. a set or course of learning activities arranged to impart knowledge and skills in fundamental domains, for example, communication skills, legal issues, ethics).

6. Individual or Group Projects - multi-step, multi-component tasks performed as vehicles for learning and applying knowledge and skills. Projects should result in a product. Examples are literature reviews, research, clinical quality improvement projects, and community health advocacy work.

7. Computer Modules - computer-based instructional units that present medical knowledge or clinical tasks, etc, that residents work through independently. These modules are developed either by the institution/program or purchased from commercial vendors.

8. Standardized Patients - professional actors or real patients trained to present realistically and reliably a medical condition and/or specific patient behaviors; the standardized patient provides instruction to the resident or feedback about his/her performance

9. High-Tech Simulators/Simulations - 3-dimensional, high tech, computerized devices that represent human anatomy and physiological responses (simulators) are used by residents to learn procedures and operations. Or realistic patient care scenarios are generated using high tech/virtual reality devices (simulations). Residents engage in the scenario as in real life to learn or apply clinical or teamwork skills.

10. Anatomic or Animal Models - non-computerized, 3-dimensional devices that replicate the properties of human anatomical structures are used by residents to learn procedures.

11. Role Play or Simulations - staged replicas of potentially real situations are engaged in by residents to learn, practice or rehearse skills needed in those situations. This method is often used in difficult or high-risk situations, e.g. mobilization of a medical team in a multi-victim accident or confrontation of an “impaired “ colleague.

12. Games - informal activities with goals, rules, rewards and penalties for various courses of action. Games may be computerized, played individually or in groups, facilitated or self-paced.

13. Role Modeling - portrayal of desired professional behaviors, communication skills, or clinical skills, etc. by attending/supervising physician with the expectation that residents will learn these behaviors and skills by observing the role models.

Assessment Terminology

1. Criteria - specific behaviors, actions, outcomes, or product characteristics that are indicative of how well clinical work or learning tasks have been performed and are used as standards for evaluating performance. Points on a rating scale, such as "satisfactory " or "unsatisfactory " are not criteria.

2. Evaluator training - occurs (minimally) if evaluators review and discuss the criteria and (more robustly) if they practice using the criteria and resolve differences in evaluations of the same sample performance.

3. Objective standards - pre-determined scores, ratings, or patterns of ratings and comments that trigger specific educational decisions such as a requirement for remediation or denial of promotion to the next level of training.

Improvements

1. Learning Objectives - statements that describe the specific knowledge, skills, and attitudes residents are expected to obtain as a result of participating in educational activities.

2. Faculty Development - formal educational activities in the form of workshops, discussions, or lectures which have as their goal improving faculty knowledge about the General Competencies and their ability to teach and assess the competencies.

3. Clinical Experiences - direct, hands-on clinical or patient care activities. This may include surgery, patient exams, the reading of radiographs and preparation of pathology assays.

4. Clinical Teaching - teaching that occurs in the clinic, EDs, ORs, laboratories, or other medical settings and addresses issues related to residents' current patient cases or clinical responsibilities.

5. Performance Feedback - information provided (orally or in writing) to a resident that informs him or her of what (s)he has done well or poorly and provides specific guidance as to how performance might be improved.

6. Departmental Conferences, Lectures or Discussions - formal, classroom instruction on a specific topic or method, led by one or more faculty, residents, or staff, etc.

7. Institutional Conferences, Lectures, or Discussions - formal educational event involving institution-sponsored grand rounds, lectures, discussions, or workshops for residents and/or faculty from multiple specialties; may be part of an institutional core curriculum (i.e. a set or course of learning activities arranged to impart knowledge and skills in fundamental domains, for example, communication skills, legal issues, ethics).

8. Required Reading - Required Reading 9. Individual or Group Projects - multi-step, multi-component tasks performed as vehicles for learning and

applying knowledge and skills. Projects should result in a product. Examples are literature reviews, research, clinical quality improvement projects, and community health advocacy work.

10. Computer Modules - computer-based instructional units that present medical knowledge or clinical tasks, etc, that residents work through independently. These modules are developed either by the institution/program or purchased from commercial vendors.

11. Standardized Patients - professional actors or real patients trained to present realistically and reliably a medical condition and /or specific patient behaviors; the standardized patient provides instruction to the resident or assesses performance and provides feedback.

12. High-Tech Simulators/Simulations - 3-dimensional, high tech, computerized devices that represent human anatomy and physiological responses (simulators) are used by residents to learn procedures and operations. Or realistic patient care scenarios are generated using high tech/virtual reality devices (simulations). Residents engage in the scenario as in real life to learn or apply clinical or teamwork skills.

13. Anatomic or Animal Models - non-computerized, 3-dimensional devices that replicate the properties of human anatomical structures are used by residents to learn procedures.

14. Role-Play or Simulations - staged replicas of potentially real situations are engaged in by residents to learn, practice or rehearse skills needed in those situations. This method is often used in difficult or high-risk situations, e.g. mobilization of a medical team in a multi-victim accident or confrontation of an "impaired" colleague.

15. Games - informal activities with goals, rules, rewards and penalties for various courses of action. Games may be computerized, played individually or in groups, faciliated or self-paced.

16. Clinical Performance Ratings - new or revised monthly, rotation, semi-annual or annual ratings of resident performance.

17. Focused Observation & Evaluation - formal, concurrent (same day) written evaluation following supervisors / attending observation of individual resident-patient encounters, operations, specimen preparation, etc.; might involve videotaping and formal, current, written assessment of the videotaped performance.

18. 360 Assessment - evaluation by MDs (supervisors, residents, medical students) and non-MDs (nurses, technicians, social workers, PAs) using the same or similar evaluation forms.

19. Formal Oral Exam - "Mock" oral exam in which an examiner asks residents questions about what to do in a clinical scenario presented verbally or role played by the examiner.

20. Portfolio Assessment - evaluations of resident learning or performance based on resident work products, such as reports of research studies, improvement projects, presentation slides or on residents' narratives of critical incidences or other experiences

RESIDENCY PROGRAM OBJECTIVES

The Radiation Oncology Residency Program at the University of Rochester Medical Centeris dedicated to the education and training of residents in the clinical care of patients with cancerand the use of radiation therapy in their management. The Program is oriented toward providingresidents with a solid foundation for understanding the scientific advances that are constant inthis field.

Emphasis is placed on the development and assessment of residents’ skills in each of thefollowing competencies, as is also required by the Accreditation Council for Graduate MedicalEducation (ACGME):

• Patient Care – Residents must be able to provide patient care that is compassionate,appropriate, and effective for the treatment of health problems and the promotion of health;

• Medical Knowledge – Residents must demonstrate knowledge about established andevolving biomedical, clinical, and cognate (eg, epidemiological and social-behavioral)sciences and the application of this knowledge to patient care;

• Practice-based Learning & Improvement – Residents must be able to investigate andevaluate their patient care practices, appraise and assimilate scientific evidence, andimprove their patient care practices;

• Interpersonal & Communication Skills – Residents must be able to demonstrateinterpersonal and communication skills that result in effective information exchange andlearning with patients, their patients’ families, and professional associates;

• Professionalism – Residents must demonstrate a commitment to carrying out professionalresponsibilities, adherence to ethical principles, and sensitivity to a diverse patientpopulation;

• Systems-based Practice – Residents must demonstrate an awareness of and responsivenessto the larger context and system of health care and the ability to effectively call on systemresources to provide care that is of optimal value.

The clinical training in radiation oncology is appropriately broad in scope and directed towardproviding the resident with a firm understanding of the following:

• The etiology, epidemiology and natural history of malignant disease• Special considerations unique to each cancer type• Indications for and outcomes of radiation therapy• Thoughtful treatment planning to optimize the delivery and distribution of radiation• Standard radiation therapy techniques for dose delivery• The use of innovative and investigational therapeutic modes, including conformal,

stereotactic and intensity modulated radiation techniques• Normal tissue radiosensitivity and tumor radioresponsiveness• Integration of the other standard therapeutic modalities (surgery and systemic therapy) in

disease eradication within a multidisciplinary framework• Creative laboratory modeling to simulate clinical problems

More specifically, residents are trained in the use of various external radiation techniques(megavoltage photon and electron therapy), computerized treatment planning and simulation,intracavitary and interstitial brachytherapy techniques, brain and body stereotactic radiosurgerytechniques, and the use and/or understanding of altered fractionation schemes, total bodyirradiation in the setting of bone marrow transplantation, radiosensitizers and protectors, andradiolabelled antibody therapy.

During the course of training, residents are expected to become familiar with clinicalinvestigation, biostatistics, epidemiology, computer data management and analysis, ethicalconsiderations in investigation, and biomedical writing. This is accomplished through thedevelopment of a research project with the guidance of a faculty mentor, leading to presentationand publication.

ORGANIZATION OF THE RESIDENCY PROGRAM The Residency Program currently consists of six residents distributed among the PG-2 through PG-5 years. Training at the first postgraduate year level is not offered, but must be completed prior to entering the residency. The training program is organized according to the structure of the Department of Radiation Oncology. Patients are divided among seven primary clinical services denoted Green, Red, Yellow, Purple, Orange, White, and Blue. It is noteworthy that each service has a clinical secretary, an assigned nursing team and dedicated physics/ dosimetry support. The distribution of patients is as follows:

Green Service - Dr Ralph Brasacchio

Genitourinary cancers.

Yellow Service – Dr Alan Katz Gastrointestinal, breast cancers.

Red Service - Dr Marilyn Ling

Breast cancers.

Purple Service - Dr Michael Milano Shaped beam radiosurgery, new modalities, CNS, thoracic cancers.

Orange Service – Dr Paul Okunieff (Chairman)/Dr Kenneth Usuki Shaped beam radiosurgery, new modalities; CNS.

White Service - Dr Yuhchyau Chen/Dr Deepinder Singh/Dr Hong Zhang Head and neck, thoracic cancers.

Blue Service - Dr Louis Constine Hematological, pediatric CNS, pediatric and sarcomatous cancers, Hodgkin's and non-Hodgkin's lymphomas, patients treated with total body irradiation for bone marrow transplantation, and pituitary tumors.

The great majority of rotations are at Strong Memorial Hospital. Residents in PGY2-5 complete two rotations on each of the seven primary clinical services. Thus, they will gain broad exposure to the entire spectrum of oncology patients and their treatment. This organization has the strength of providing the resident with a limited number of cancer types toward which to devote his/her learning energies at any one time, and ensures individual attention from an attending physician who can provide a consistent, methodical educational experience. Depending on the PGY level and demonstrated level of competence, the resident is given progressively greater responsibility for patient management. In the 3rd and 4th years of residency, additional experience is gained at our affiliated hospital, Highland Hospital (within a short drive of the University of Rochester), including experience in gynecologic-oncology and involvement in the internationally renowned clinic for treating rectal cancers with endocavitary therapy. HH Service – Dr Joy Anderson Gynecologic-oncology, including brachytherapy; gastrointestinal cancers; thyroid cancers; miscellaneous malignancies and prostate brachytherapy. The PGY4&5 residents are additionally each designated and serve as ‘chief resident’. The chief resident performs academic and administrative responsibilities, which include organization of the educational conference schedule, assignment of clinical rotations and performance of other administrative matters. The PGY4&5 residents also oversee the educational experience of the more junior residents and assume an increased level of clinical responsibility under the guidance of the attending physicians, and oversee the functioning of an individual service when the attending physician is absent, although are under the guidance of a covering attending.



GREEN SERVICE

Learning Objectives: See attached (Please see Education Calendar for other weekly conferences) Weekly Service Schedule:

MON TUES WED THURS FRI Weekends

Didactic

Education

8.00-9.00 am Resident Presentation

8.00-9.00 am Chart Rounds

8.00-9.00 am Lecture

Clinical

Education

Suite A (G/U Clinic)

PSIs Team Meeting 11:00-12:00pm

GU Pre Clinic Conference SIMs

OTV

Didactic

Education

12:30-1:30 GU Tumor Board

12.00-1.00 pm Pathology Conference

Clinical

Education

Suite A (G/U Clinic)

F/Up Clinic

OTV

Didactic

Education

4.30-6.00 pm Lecture


4.30-6.00 pm Conference

4.00-5.00 pm Pediatric Oncology Tumor Board

End of day

unscheduled

activities

• Dictations, including treatment summaries • Treatment planning •

Evenings

Assessments/Evaluations:

RESIDENT EVALUATION/SURVEY REQUIRED:

• End-of-rotation evaluation • Attending evaluation • Peer evaluation of rotation hand-over

TEST/EXAM REQUIRED: • Mock oral board-type review of appropriate disease site(s)

Key to Core Competencies: 1 = Patient Care

2 = Medical Knowledge 3 = Practice-Based Learning & Improvement 4 = Interpersonal & Communication Skills 5 = Professionalism 6 = Systems-Based Practice

Service Responsibilities/Assignments: Responsibility: Competency: • Completion of weekly patient-on-treatment service list, staging sheets and treatment

summaries. • Appropriate preparation for weekly chart rounds. • Complete 2 Mini-CEX evaluations for each rotation. • Completion of monthly QA service list. • Present 1 hallmark article for each disease site relevant to the service & be prepared

to discuss why this article is relevant to current patient care or how it changed current patient care for that disease site.

• Present 1 current article for each disease site relevant to the service & be prepared to discuss how this article will change current treatment and current thought regarding patient care for that disease site.

• Appropriate hand-over pts at end of rotation (this should not be only a transfer of information, but rather a higher level information exchange and discussion).

• 1,3,4 • 1,2 • 5 • 1,2,3,6 • 2,3,6 • 2,3,6 • 1,4,5,6

Additional Responsibilities:

• Clinical educational opportunities – Each resident should maximize his/her case log and patient care experience by participating in patient care activity opportunities on other services where there is no resident assigned, during times when there are no scheduled patient care activities on his/her own service. The resident must obtain the service attending’s approval to participate in these clinical opportunities. The NP or PA on the service will assist the service attending during the resident’s absence.

• Multidisciplinary conferences & tumor boards – Each resident should participate in all multidisciplinary conferences and tumor boards related to other services, providing they do not conflict with their service activities.

Attending Responsibilities:

• Describe learning objectives and expectations to the new resident on service at the beginning of the rotation.

• Conduct 1-on-1 discussions with the resident on service regarding disease management, with pre-assigned reading.

• Provide interim feedback on resident’s performance, including areas requiring improvement and quality of dictations.

• Conduct end-of-rotation test of resident’s knowledge and understanding of patient care on service. • Conduct end-of-rotation review and evaluation of resident’s performance.

GREEN SERVICE - OBJECTIVES

Ralph A Brasacchio MD

All PGY Levels

Residents will evaluate adult patients with genitourinary neoplasms, including prostate, bladder, testicular, renal/ureteral and urethra/penile cancers. These patients are seen primarily in a multidisciplinary context, together with urologic/surgical oncologists, medical oncologists and other support personnel. The rotation therefore provides opportunities for enhancing the resident’s multidisciplinary knowledge and management abilities for patients with these conditions. The focus is on patients with prostate cancer, but experience is also gained in the other malignancies, primarily testis and bladder cancer, and renal neoplasms. In addition, the resident gains training experience and eventual proficiency in the management of genitourinary patients during consultation of patients outside the multidisciplinary clinic, weekly patient-under-treatment visits, and follow-up clinics. The resident is expected to see each patient under treatment on a weekly basis and a majority of the follow-up patients, under the supervision of the attending. The resident is expected to gain training experience and eventual proficiency in the simulation and treatment planning of patients with genitourinary malignancies using external beam techniques, including 3-D conformal therapy (3-D CRT) and intensity-modulated radiation therapy (IMRT), in addition to technical abilities and understanding of treatment planning in prostate brachytherapy. While the resident will not likely gain direct experience in every site and/or stage of disease, it is expected that enough experience will have been gained during the rotation for the resident to be able to apply the knowledge and experience to the unique situation when it presents itself.

Service-specific Topics for Resident Presentation

• Low risk prostate cancer • Intermediate risk prostate cancer • Seminoma: early stage • Bladder cancer: bladder preservation • Adjuvant or salvage post-operative radiation • Brachytherapy • Conformal radiation and IMRT for prostate cancer • Hormonal therapy and radiation for prostate cancer



1st Rotation (PGY2-3)

For each of the disease sites/categories listed below, the resident is expected to acquire the appropriate knowledge/skills, as described:

o Prostate cancer o Bladder cancer o Testicular cancer o Kidney (renal cell carcinoma) o Urethra, penis

Medical Knowledge

• Describe the anatomic features and relevant regional anatomic structures (draining

lymphatics). • Explain the radiation effects and response on organ of interest and surrounding normal tissue:

acute and chronic radiation effects; complications. • Identify epidemiologic and etiologic risk factors, tumor markers/molecular genetics,

including prevention and screening methods. • Discuss the natural history, clinical presentation, and detection, histology/pathology,

diagnostic work-up and staging. • Describe the principles of multidisciplinary treatment and management and role(s) of

radiation therapy for each of the disease sites/categories, including: o Early stage/low risk prostate cancer: role of brachytherapy, external beam therapy,

including 3-D CRT and IMRT; o Intermediate risk and high risk (locally-advanced) prostate cancer: role of external

beam therapy, including 3-D CRT and IMRT, and/or brachytherapy; adjuvant use of hormonal therapy;

o Post-operative treatment of prostate cancer with radiation: adjuvant vs. salvage radiation +/- hormonal therapy;

o Metastatic prostate cancer: role of radiation and/or hormonal therapy; o Bladder cancer: definitive radiation; pre-operative and post-operative radiation, role

of definitive chemoradiation for invasive carcinoma; o Testicular cancer: seminoma; o Renal neoplasms: role of radiation for renal cell carcinoma.

• Discuss the principles of treatment of primary site and lymph node regions for each of the

disease sites and stage of disease.

• Determine and apply principles of radiological physics and radiobiology as appropriate to radiation therapy for each of the disease categories:

o Importance of time-dose factors for bladder cancer; o Principles of radiation sensitization with hormonal therapy (prostate cancer) and

chemotherapy (bladder cancer). • Acquire basic knowledge of areas of controversy in each of the disease categories:

o Prostate cancer: Role of treatment of lymph node region for early stage prostate cancer;

locally-advanced, post-operative prostate cancer; Observation for early stage prostate cancer; Hormonal therapy vs. observation vs. salvage for biochemical failure

following radiation therapy or brachytherapy; o Bladder cancer:

Chemoradiation for invasive bladder carcinoma vs. cystectomy; o Testis:

Role of surveillance in Stage I carcinoma; Controversies in the determination of treatment volume and dose (para-aortic

only vs. hockey-stick); Issue regarding sterility and second malignant tumor that may be associated

with the disease and with radiation treatment. Patient Care

• Be able to gather and organize essential important information about a genitourinary cancer

patient, including taking an accurate history of present illness, past medical/surgical history, allergies, social/family history, particularly as they pertain to the current illness.

• Complete a full physical examination and be able to evaluate all hematological, biochemical,

and radiologic studies used to assess the genitourinary cancer patient. • Be able to determine whether radiation is appropriate, based on diagnostic information and

medical/scientific information, using clinical judgment. • Be able to complete chart appropriately, including timely completion of staging sheets,

consultation notes, treatment notes, and summaries. • Develop and implement patient management plans for:

o Prostate cancer patients with early stage prostate cancer, locally advanced prostate cancer, adjuvant/salvage radiation therapy, and metastatic prostate cancer, including determination of intent of treatment (definitive vs. palliative), use of combined hormonal therapy and radiation treatment.

o Invasive bladder cancer patients, including use/role of bladder presentation therapy and intent of treatment (definitive vs. palliative).

o Testicular cancer patients with early stage seminoma (Stage I and Stage II).

• Perform radiation therapy techniques (including brachytherapy, as applicable), perform simulations, formulate prescriptions and evaluate treatment plans for each of the disease categories, according to stage of disease and clinical situation. This includes determination of volume treatment portals/doses for both the initial phase of treatment and ‘boost’ phase (in addition to knowledge of alternative treatment techniques):

o Prostate cancer: • Determination of volume to be treated, including lymph node regions, if

necessary, and dose to be administered for newly diagnosed prostate cancer, and in the post-operative setting, including 3-D conformal radiation therapy and intensity modulated radiation therapy (as applicable);

• Interstitial irradiation/prostate brachytherapy for early stage and intermediate stage prostate cancer (with EBRT);

o Bladder cancer: • Determination of volume to be treated, including lymph node regions and

dose to be administered; simulation techniques; o Testicular cancer (seminoma):

• Determination of volume to be treated and doses to be delivered for Stage I/II seminoma;

o Metastatic genitourinary cancer: • Metastatic prostate cancer, including use of radionuclide therapy

(Strontium/Samarium); • Large field radiation/hemi-body radiation.

• Determine basic critical organ dose parameters and begin to integrate this information into

the patients radiation therapy treatment plan. • Identify and manage side effects of patients under treatment and in follow-up, and to

counsel/supervise patients on appropriate follow-up measures for each of the disease categories:

o Dermatitis; o GI side-effects; o GU side-effects, including ED; o Fatigue.

• Demonstrate caring behaviors, counsel, communicate effectively with GU cancer patients

and their families, and work effectively with other health care providers: including with regard to the unique psychosocial and sexual issues of seminoma patients and prostate cancer patients.

Practice-based Learning & Improvement

Interpersonal & Communication Skills

Professionalism

Systems-based Practice

The PGY 2-3 resident is expected to begin acquiring experience in those aspects of practice-based learning & improvement, interpersonal & communication skills, professionalism, and systems-based practice, as may be appropriate for patients with these cancers.


• Begin to locate, appraise and assimilate evidence from scientific studies related to

genitourinary cancer patients, ie, become familiar with scientific evidence as may be presented in a standard textbook.

• Begin to apply knowledge of study design and statistical methods in order to appraise clinical

studies and other information on diagnostic and therapeutic effectiveness. Describe study design of major (randomized) studies that support the use of radiation and hormonal therapy for prostate cancer and chemoradiation for bladder cancer. Also describe studies regarding treatment of testicular cancer, particularly seminoma.

• Use information technology to manage information, access online medical information and

support own education. • Assist/facilitate the learning of students and other health care providers, including nurses,

therapists, and other junior residents.


• Begin developing and sustaining a therapeutic ethically sound relationship with genitourinary

cancer patients. This is begun during consultation, continues during simulation, and develops during the course of treatment.

• Begin using effective listening, non-verbal, explanatory, questioning, and writing skills to

elicit and provide information to and about genitourinary cancer patients. • Work effectively with others as a member of, or leader of a health care team, eg, attendance

and participation at radiation therapy and multidisciplinary team meetings.

Professionalism

• Demonstrate respect, compassion, integrity, and responsiveness to the needs of the

genitourinary cancer patient.

• Begin to be able to obtain informed consent from genitourinary cancer patients, including those entering protocols.

• Begin to demonstrate commitment to ethical principles pertaining to permission/withholding

of clinical care to genitourinary cancer patients, especially those treated with palliative intent. • Begin, under the guidance of the attending, to gain experience in billing issues. • Demonstrate sensitivity/responsiveness to the genitourinary cancer patients’ background,

culture, and age.


• Begin to determine how his/her patient care and other professional practices affect other

health care providers (eg, nurses and therapists). • Begin to practice health care that is cost-effective, and begin to learn how to allocate

resources, while not compromising quality of care. • Begin to help patients deal with health system complexities, eg, scheduling issues.



2nd

Rotation (PGY4-5)

In addition to developing proficiency in the skills associated with each of the competencies outlined in the Goals and Objectives for the PGY2-3 rotation, the PGY4-5 resident is expected to acquire knowledge and gain additional proficiency in the following areas associated with each of the competencies.

Medical Knowledge

• Classify the pertinent scientific literature and particularly the randomized studies (eg, RTOG)

related to the role of radiation therapy for the various presentations/stages of prostate cancer, bladder cancer, testicular cancer (seminoma and non-seminoma), and renal cell carcinoma, as applicable.

• Explain the role of radiation therapy in renal pelvis/ureter and penile/urethral cancers, and

non-seminomatous testicular carcinoma. • Proficiency in identifying the prognostic factors for prostate cancer, bladder cancer, testicular

cancer, and renal cell carcinoma. • Thoroughly discuss controversial areas in the treatment of genitourinary malignancies:

o Treatment of lymph nodes region in early stage prostate cancer, advanced stage prostate cancer, and post-operative prostate cancer;

o Controversies in the use of hormonal therapy in locally-advanced and metastatic prostate cancer;

o Use of systemic therapy in metastatic prostate cancer and high risk prostate cancer; o Controversies in the role of radiation for salvage vs. adjuvant post-prostatectomy

setting; o Salvage brachytherapy/prostatectomy/cryotherapy after radiation therapy; o Particle beam therapy for prostate cancer; o IMRT/3-D CRT for prostate cancer; o Pros and cons of bladder preservation for bladder cancer; o Controversies in the management of pure seminoma:

Elective radiation vs. surveillance in Stage I seminoma; Elective irradiation of mediastinal supraclavicular nodes in Stage I/II

testicular cancer; Bulky abdominal disease management of non-seminoma: chemotherapy and

role of radiation. • Differentiate unusual genitourinary neoplasms: renal pelvis, ureter (transitional cell

carcinoma), urethral cancer, penile cancer, non-seminomatous testicular carcinoma and other unusual testicular neoplasms.

• Differentiate the need for the use of systemic chemotherapy, gene therapy, immunotherapy

and other new/developing modalities appropriate to genitourinary oncology patients, as well as opportunities for clinical and translational research in this area.

Patient Care

• Undertake all aspects of patient care related to genitourinary cancer patients, including initial

assessment, formulation and implementation of treatment plans, discussion with family members and referring physicians, treatment prescription and interpretation with other treatment modalities.

• Maturation of written consultations is expected, with emphasis on delineation of plan of

management and, when appropriate, reference to pertinent literature to substantiate recommendations.

• Identify critical organ dose parameters, including DVH analysis, affect of chemotherapy and

other factors, and fully integrate this information into patients’ radiation therapy treatment plans.

• Gain proficiency in managing side-effects during and after therapy and in counseling patients

and their families on issues related to genitourinary cancers, and their treatment and side effects/complications of treatment.

• Gain proficiency in performing techniques and prescriptions (including alternative treatment

arrangements), formulate treatment plans and dosimetry according to accepted guidelines for each of the disease sites, according to stage of disease and the clinical situation.

• In addition to gaining proficiency in the unusual genitourinary sites listed for PGY2-3,

experience may also be gained in the following disease sites: o Penile urethral carcinoma; o Renal pelvis/ureter; o Unusual testicular neoplasms.


• Analyze practice experience and perform practice-based improvement activities (ie,

suggestions for improving the service and rotation). • Obtain information from the larger population from which the genitourinary cancer patients

are drawn.


• Fully sustain a therapeutic and ethically sound relationship with genitourinary cancer

patients. • Use effective listening, non-verbal, explanatory, questioning and writing skills to elicit and

provide information to and about genitourinary cancer patients. • Work effectively with other health care providers as a member and leader of the health care

team. The PGY4-5 resident is expected to lead the weekly patient-under-treatment rounds.

Professionalism

• Responsiveness to societal needs that supercedes self-interest. • Commitment to excellence and ongoing professional development.


• Identify his/her health care practices affect health care providers and the larger society, and how elements of the system affect his/her own practice.

• Partner with health care managers and providers to assess, coordinate and improve health

care, and describe how these activities affect system performance.



YELLOW SERVICE

Learning Objectives: See attached (Please see Education Calendar for other weekly conferences) Weekly Service Schedule:


Didactic

Education

7:30 am Breast Tumor Board 8.00-9.00 am Resident Presentation



Clinical

Education

FU Consults

OTV

Breast Clinic Suite A (GI Clinic)

Didactic

Education

11:30 am Breast Pre Clinic Conference


Clinical

Education

Breast Clinic OTV SIMs 1:30 Team meeting

Didactic

Education


4.30-6.00 pm Lecture 5:00-6:00 GI Pre Clinic conference


4.00-5.00 pm Pediatric Oncology Conference

End of day

unscheduled

activities

• Dictations, including treatment summaries • Treatment planning • Review port films • Reading/study

Evenings







Service Responsibilities/Assignments: Responsibility: Competency: • Complete four service presentations (2 head & neck cancer cases, 2 lung cancer

cases) during the three-month rotation, as described in the attached objectives. • Completion of weekly patient-on-treatment service list, staging sheets and treatment





• 1,2,3,4,5,6 • 1,3,4 • 1,2 • 5 • 1,2,3,6 • 2,3,6 • 2,3,6 • 1,4,5,6









YELLOW SERVICE - OBJECTIVES

Alan W Katz MD

All PGY Levels

Residents will evaluate adult patients with breast neoplasms and adult patients with gastrointestinal neoplasms, including esophageal, gastric/pancreatic, hepatobiliary, colorectal, and anal cancers. These patients are seen primarily in a multidisciplinary context, together with surgical oncologists and medical oncologists, gastroenterologists, radiologists, pathologists, and other support personnel. The weekly Multidisciplinary Breast Conference is an integral part of the learning experience. The rotation therefore provides opportunities for enhancing the resident’s multidisciplinary knowledge and management abilities for patients with these malignancies. In addition, the resident gains training experience and eventual proficiency in the management of breast cancer patients and patients with gastro-intestinal malignancies during consultation of patients outside the multidisciplinary clinic, weekly patient-under-treatment visits, and follow-up clinics. The resident is expected to see each patient under treatment on a weekly basis and a majority of the follow-up patients, under the supervision of the attending. The resident is expected to gain training experience and eventual proficiency in the simulation and treatment planning of patients with breast cancer and patients with gastrointestinal malignancies using external beam techniques, including 3-D conformal therapy (3-D CRT), and intensity-modulated radiation therapy (IMRT), in addition to experience in brachytherapy techniques as applicable to this population of patients, within the context of the multi-modality approach. While the resident will not likely gain direct experience in every site and/or stage of disease, it is expected that enough experience will have been gained during the rotation for the resident to be able to apply the knowledge and experience to the unique situation when it presents itself.


Breast Neoplasms Gastrointestinal Malignancies • Ductal carcinoma in-situ • Role of radiation therapy in breast

conservation therapy (BCT) • Selection factors and contra-indications to

BCT • Management of lymph node regions • Locally advanced breast cancer • Inflammatory breast cancer • Role of radiation therapy post-mastectomy • Salvage of isolated locoregional recurrence

after mastectomy

• Adjuvant chemoradiation therapy for gastric cancer

• Chemoradiation therapy in the management of pancreatic cancer

• Chemoradiation therapy for anal cancer • Adjuvant therapy of rectal cancer • Radiation therapy for esophageal cancer • Radiation therapy for liver metastasis • Radiation therapy in the management of

cholangiocarcinoma


Alan W Katz MD


For each of the disease categories and sites listed below, the resident is expected to acquire the appropriate medical knowledge, as outlined:

o Breast o Esophagus o Stomach o Pancreas o Hepatobiliary tract o Colon o Rectum o Anal canal o Heterotopic bone radiation

Medical Knowledge


lymphatics). • Explain the radiation effects and response on organ of interest and surrounding normal tissue:

acute and chronic radiation effects; complications. • Identify epidemiologic and etiologic risk factors, tumor markers/molecular genetics, potential

preventative and screening methods. • Discuss natural history, typical clinical presentations, diagnostic workup and staging, and

clinicopathologic manifestations. • Describe the principles of multidisciplinary treatment and management and role(s) of

radiation therapy for each of the disease sites and categories, including: o Early stage breast cancer

• Ductal carcinoma in-situ (DCIS); • Early stage invasive carcinoma; • The role of radiation therapy in breast conservation therapy (BCT) for early stage

breast cancer (DCIS and invasive); • Surgical techniques: breast conserving surgery; axillary dissection; sentinel node

biopsy; • Selection factors and contra-indications to BCT; • Appropriate management of lymph node regions.

o Locally advanced breast cancer; o Inflammatory breast cancer; o Types/use of systemic therapy (chemotherapy, hormonal therapy);

o Role of radiation therapy (post-mastectomy). o Esophageal cancer:

• Definitive or palliative treatment for distal and proximal esophageal cancer, including surgery, radiation therapy alone, pre-operative and post-operative radiation therapy and chemotherapy and definitive chemoradiation therapy;

o Pre-operative/post-operative radiation therapy for stomach cancer; o Pancreatic cancer:

• Post-operative radiation therapy/chemotherapy for pancreatic cancer; • Chemoradiation for unresectable pancreatic cancer;

o Rectal cancer: • Adjuvant radiation therapy for rectal cancer; • Pre-operative/post-operative radiation therapy;

o Chemoradiation for anal canal cancer. • Describe expected therapeutic outcomes of treatments, including expected control rates. • Discuss the principles of treatment of primary site lymph node region for each of the disease

categories and stage of disease. • Determine and apply principles of radiological physics and radiobiology appropriate to

radiation therapy for each of the disease categories, including: o The importance of time dose factors, including radiotherapy timing in relation to

surgery; integration of radiotherapy and systemic therapy; o Basic isodose distributions for various sized electron fields for different electron beam

energies. o Isodose distributions for irradiation of intact breast, including use of wedge

compensators. o Principles of chemoradiation sensitization.

• Acquire basic knowledge of controversial areas or unusual situations in each of the disease

categories, including: o Adjuvant therapy of colon cancer; o Pros and cons of pre-operative and post-operative radiation for rectal cancer; o Chemoradiation for anal canal cancer.

Patient Care

• Gather and organize essential important information about breast cancer patients and patients

with gastrointestinal malignancies, including taking an accurate history of present illness, past medical/surgical history, allergies, social/family history, particularly as they pertain to the current illness.


and radiologic studies (eg, mammograms, bone scans, CT scans, ultrasound) used to assess breast cancer patients and patients with gastro-intestinal malignancies.

• Determine whether radiation is appropriate, based on diagnostic information and

medical/scientific information, using clinical judgment.

• Complete chart appropriately, including timely completion of staging sheets, consultation

notes, treatment notes, and summaries. • Develop and implement patient management plans for breast cancer patients with early stage,

locally advanced and metastatic disease, including determination of intent of treatment (palliative/definitive), and patients with gastrointestinal malignancies who will receive definitive radiation +/- chemotherapy or in the pre-operative or post-operative setting:

o Esophagus; o Stomach; o Pancreas; o Rectal; o Anal canal; o Metastatic and primary liver tumors.

• Perform radiation therapy techniques (including 3-D conformal radiation therapy [3-D CRT]

and intensity-modulated radiation therapy [IMRT] as they become integrated into the therapy of these patients), and formulate/evaluate treatment plans, prescription and dosimetry for each of the disease categories/sites according to stage of disease and clinical situation:

o Irradiation of the intact breast, including: • Determination of treatment volume clinically and on CT scans; • Alignment of tangential beam with chest wall contour, including determination

and calculation of isocenter point; • Boost field techniques (electron-field set-up and dose determination), assistance

and performance of interstitial brachytherapy (as this becomes available); • Determination of appropriate doses and fractionation, depending on

clinical/pathologic circumstances; • Irradiation technique of regional lymphatics, including supraclavicular, axillary

and internal mammary lymph nodes; o Irradiation of chest wall, including:

• Determination of treatment volumes clinically and on CT scan; • Field arrangements and matchline techniques, and doses, including use of electron

fields vs. tangential fields; • Set-up of supraclavicular/posterior axillary and internal mammary fields;

o A variety of palliative situations (CNS metastasis – brain, bone/spinal metastasis). o Esophageal:

• Including dose and volume consideration and field managements, depending on location (cervical esophagus, thoracic/distal esophagus);

• Simulation technique for each; o Stomach:

• Treatment volumes and doses in pre-operative and post-operative situations; o Pancreas:

• Treatment volumes and doses and field managements;

o Colorectal: • Treatment volumes and doses dependent on stage (extent) of disease;

o Anal canal: • Treatment volumes/doses and field managements, time-dose factors;

o Liver: • Treatment volumes/doses and field managements, time-dose factors, focusing on

SRT. • Determine basic critical organ dose parameters and begin to integrate this information into

the patient’s radiation therapy treatment plan. Particular attention should be paid to skin; breast; lung/heart tolerances.

• Identify and manage side effects of patients under treatment and in follow-up and to

counsel/supervise patients on appropriate preventative, treatment and follow-up measures for each of the disease categories, including:

o Mammograms/self breast exam; o Skin reaction/dermatitis/mucositis; o Esophagitis/dysphagia; o Nausea/vomiting; o Diarrhea; o Fatigue; o Cytopenia.

• Demonstrate caring behaviors and counsel and communicate effectively with this patient

population and their families and work effectively with other health care providers, including nurses, therapists, and social workers.



Professionalism


The PGY 2-3 resident is expected to begin acquiring experience in those aspects of practice-based learning & improvement, interpersonal & communication skills, professionalism, and systems-based practice, as may be appropriate for patients with these cancers:


• Begin to locate, appraise and assimilate evidence from scientific studies related to patients

with gastro-intestinal malignancies, ie, become familiar with scientific evidence as may be presented in a standard textbook.


studies and other information on diagnostic and therapeutic effectiveness. • Use information technology to manage information, access online medical information and

support own education.

• Assist/facilitate the learning of students and other health care providers, including nurses,



• Begin developing and sustaining a therapeutic ethically sound relationship with patients with

gastro-intestinal malignancies. • Begin using effective listening, non-verbal, explanatory, questioning, and writing skills to

elicit and provide information to and about patients with gastrointestinal malignancies. • Work effectively with others as a member of, or leader of a health care team.

Professionalism

• Demonstrate respect, compassion, integrity, and responsiveness to the needs of patients with

gastrointestinal malignancies. • Begin to be able to obtain informed consent from patients with gastrointestinal malignancies,

including those entering protocols. • Begin to demonstrate commitment to ethical principles pertaining to permission/withholding

of clinical care to patients with gastrointestinal malignancies. • Begin to gain experience in billing issues. • Demonstrate sensitivity/responsiveness to these patients’ background, culture, and age.



health care providers (eg, therapists). • Begin to practice health care that is cost-effective, and begin to learn how to alleviate

resources, while not compromising quality of care. • Begin to help patients deal with health system complexities.


Alan W Katz MD

2nd

Rotation (PGY4-5)

In addition to developing proficiency in the skills associated with each of the competencies outlined in the Goals and Objectives for the PGY2-3 rotation, the PGY4-5 resident is expected to acquire knowledge and gain proficiency in the following areas associated with each of the competencies:

Medical Knowledge

• Classify and integrate the pertinent supportive literature and studies related to the role of

radiation therapy and associated oncologic disciplines and the results/outcome of treatment for each of the disease categories/sites by stage (evidence-based medicine).

• Proficiency in identifying the prognostic factors for patients with gastrointestinal

malignancies. • Thoroughly discuss controversial areas in the treatment of breast cancer patients and patients

gastro-intestinal malignancies, including: o Sentinel lymph node surgery vs. axillary lymph node dissection; o Role/rationale of tumor bed boost; o Rationale of radiation to lymph node regions, including internal mammary nodes; o Sequencing of radiation treatment and chemotherapy; o Local/regional recurrence after breast conservation and after mastectomy: risk factors

for patients receiving radiation; o Breast conservation for locally advanced and inflammatory breast cancer; o Salvage of isolated locoregional recurrence after mastectomy. o Single modality vs. multimodality therapy for esophageal cancer; o Stomach cancer altered fractionation/conformal radiosensitizer agents; o Pancreatic cancer:

• Pre-operative chemoradiation therapy; • Radiosensitizer agents; • 3-D CRT;

o Pre-operative vs. post-operative radiation treatment and chemotherapy for respectable rectal cancer;

o Pre-operative radiation/chemotherapy for sphincter preservation; o Recurrent rectal cancer.

• Differentiate the need for the use of hormonal therapy, systemic chemotherapy,

radioprotectors, gene therapy and other new modalities as they are applicable to breast cancer.

• Identify unusual breast neoplasms and gastrointestinal malignancies, including their presentation, including history, etiologic factors, stage and management, including role(s) of radiation therapy:

o Lobular carcinoma in-situ; o Bilateral carcinoma; o Cystosarcoma phyllodes; o Axillary adenocarcinoma without detectable breast cancer primary; o Inflammatory breast cancer; o Breast cancer in males. o Small intestinal cancer; o Hepatobiliary malignancies:

• Gall bladder cancer; • Bile duct cancer; • Hepatocellular carcinoma; • Metastatic liver tumors.

• Describe the use of systemic chemotherapy/gene therapy, radiation sensitizers and other

new/developing modalities as they are applicable to gastrointestinal malignancies, including opportunities for chemoprevention and for clinical and translational research.

Patient Care

• Undertake all aspects of patient care related to breast cancer patients and patients with

gastrointestinal malignancies, including initial assessment, formulation and implementation of treatment plans, discussion with family members and referring physicians, treatment prescription and interpretation with other treatment modalities.





• Gain proficiency in managing side effects during and after therapy and in counseling patients

and their families on issues related to breast and gastrointestinal cancers, and their treatment and side effects/complications of treatment.





suggestions for improving the service and rotation). • Obtain information from the larger population from which patients with gastrointestinal

malignancies are drawn.


• Fully sustain a therapeutic and ethically sound relationship with patients with gastrointestinal

malignancies. • Use effective listening, non-verbal, explanatory, questioning and writing skills to elicit and

provide information to and about patients with gastrointestinal malignancies. • Work effectively with other health care providers as a member of the health care team.

Professionalism

• Responsiveness to societal needs supercedes self-interest. • Commitment to excellence and ongoing professional development.


• Identify how his/her health care practices affect health care providers and the larger society,

and how elements of the system affect his/her own practice. • Partner with health care managers and providers to assess, coordinate and improve health




RED SERVICE

Learning Objectives: See attached (Please see Education Calendar for other weekly conference information) Weekly Service Schedule:


Didactic

Education

7:30-8:30 am Breast Tumor Board 8.00-9.00 am Resident Presentation



Clinical

Education

Team Meeting 10:00-11:00 am

Breast Clinic

OTV

Didactic

Education

11.30am-1.00pm Breast Conference


Clinical

Education

SIMS OTV Breast Clinic

Didactic

Education





End of day

unscheduled

activities


Evenings












• 1,3,4 • 1,2 • 5 • 1,2,3,6 • 2,3,6 • 2,3,6 • 1,4,5,6









RED SERVICE - OBJECTIVES

Marilyn N Ling MD

All PGY Levels

Residents will evaluate adult patients with breast neoplasms. These patients are seen primarily in a multidisciplinary context with surgical and medical oncologists, radiologists, pathologists, and other support personnel. The weekly Multidisciplinary Breast Conference is an integral part of the learning experience. The rotation therefore provides opportunities for enhancing the resident’s multidisciplinary knowledge and management abilities for patients with breast malignancies. In addition, the resident gains training experience and eventual proficiency in the management of breast cancer patients during consultation of patients outside the multidisciplinary clinic, weekly patient-under-treatment visits, and follow-up clinics. The resident is expected to see each patient under treatment on a weekly basis and a majority of the follow-up patients, under the supervision of the attending. The resident is expected to gain training experience and eventual proficiency in the simulation and treatment planning of patients with breast cancer using external beam techniques, including conformal radiation and brachytherapy techniques as these become available. While the resident will not likely to gain direct experience in every site and/or stage of disease, it is expected that enough experience will have been gained during the rotations for the resident to be able to apply the knowledge and experience to the unique situation when it presents itself.


• Ductal carcinoma in-situ • Role of radiation therapy in breast conservation therapy (BCT) • Selection factors and contra-indications to BCT • Management of lymph node regions • Locally advanced breast cancer • Inflammatory breast cancer • Role of radiation therapy post-mastectomy • Salvage of isolated locoregional recurrence after mastectomy


Marilyn N Ling MD


Medical Knowledge

• Describe anatomy of breast, and relevant regional anatomic structures (draining lymphatics). • Explain radiation effects of the breast and surrounding normal tissue: acute/chronic radiation

effects; complications. • Identify epidemiologic and etiologic risk factors, tumor markers/molecular genetics for

breast cancer. • Discuss natural history, typical clinical presentations and diagnostic work-up, staging and

clinicopathologic manifestations of breast cancer. • Describe principles of multidisciplinary treatment and management for early stage breast

cancer, including: o Ductal carcinoma in-situ (DCIS); o Early stage invasive carcinoma; o The role of radiation therapy in breast conservation therapy (BCT) for early stage

breast cancer (DCIS and invasive); o Surgical techniques: breast conserving surgery; axillary dissection; sentinel node

biopsy; o Selection factors and contra-indications to BCT; o Appropriate management of lymph node regions.

• Discuss principles of multidisciplinary management and treatment of:

o Locally advanced breast cancer; o Inflammatory breast cancer; o Types/use of systemic therapy (chemotherapy, hormonal therapy); o Role of radiation therapy (post-mastectomy).

• Describe expected therapeutic outcomes of treatments, including expected control rates. • Determine and apply principles of radiological physics and radiobiology appropriate to

radiation therapy for breast cancer: o The importance of time dose factors, including radiotherapy timing in relation to

surgery; integration of radiotherapy and systemic therapy; o Basic isodose distributions for various sized electron fields for different electron

beam energies. o Isodose distributions for irradiation of intact breast, including use of wedge

compensators.

Patient Care

• Gather and organize essential important information about a breast cancer patient, including

taking an accurate history of present illness, past medical/surgical history, allergies, social/family history, particularly as they pertain to the current illness.

• Complete a full physical examination and be able to interpret all hematological, biochemical,

and radiologic studies (eg, mammograms, bone scans, CT scans, ultrasound) used to assess the breast cancer patient.


medical/scientific information, using clinical judgment. • Complete chart appropriately, including timely completion of staging sheets, consultation

notes, treatment notes, and summaries. • Develop and implement patient management plans for breast cancer patients with early stage,

locally advanced and metastatic disease, including determination of intent of treatment (palliative/definitive).

• Perform radiation therapy techniques (including 3-D conformal radiation therapy [3-D CRT]

and intensity-modulated radiation therapy [IMRT] as they become integrated into the therapy of these patients), and evaluate treatment plans and dosimetry for:

o Irradiation of the intact breast, including: Determination of treatment volume clinically and on CT scans; Alignment of tangential beam with chest wall contour, including determination

and calculation of isocenter point; Boost field techniques (electron-field set-up and dose determination), assistance

and performance of interstitial brachytherapy (as this becomes available); Determination of appropriate doses and fractionation, depending on

clinical/pathologic circumstances; Irradiation technique of regional lymphatics, including supraclavicular, axillary

and internal mammary lymph nodes; o Irradiation of chest wall, including:

Determination of treatment volumes clinically and on CT scan; Field arrangements and matchline techniques, and doses, including use of electron

fields vs. tangential fields; Set-up of supraclavicular/posterior axillary and internal mammary fields;

o A variety of palliative situations (CNS metastasis – brain, bone/spinal metastasis). • Determine basic critical organ dose parameters and begin to integrate this information into

the patient’s radiation therapy treatment plan. Particular attention should be paid to skin; breast; lung/heart tolerances.

• Identify and manage side effects of patients under treatment and in follow-up, and counsel

breast cancer patients on appropriate follow-up measures (eg, mammograms, self breast exam) aimed at maintaining health.

• Demonstrate caring behavior and communicate effectively with breast cancer patients and families; and work effectively with other health care providers, including nurses, therapists, and social workers.



Professionalism


The PGY 2-3 resident is expected to begin acquiring experience in those skills associated with practice-based learning & improvement, interpersonal & communication skills, professionalism, and systems-based practice, as may be appropriate for patients with breast cancer.


• Begin to locate, evaluate and assimilate evidence from scientific studies related to breast

cancer patients and which support patient care decisions, ie, become familiar with scientific evidence as may be presented in a standard textbook.


studies and other information on diagnostic and therapeutic effectiveness: describe study design of major randomized studies and non-randomized studies that support the use of breast conservation therapy vs. mastectomy; post-mastectomy irradiation; radiation therapy for DCIS.


support own education. • Begin to assist the learning of students and other health care providers, including nurses,



• Begin developing and sustaining a therapeutic and ethically sound relationship with breast

cancer patients. This is begun during consultation, continues during simulation and develops during the course of treatment.


elicit and provide information to and about breast cancer patients. This occurs during patient interactions and in discussion with attendings, nurses, therapists, and administrative personnel.

• Work effectively with others as a member of the health care team, eg, attendance and

participation at radiation therapy and multidisciplinary team meetings.

Professionalism

• Demonstrate respect, compassion, integrity, and responsiveness to the needs of the breast

cancer patient. • Begin to be able to obtain informed consent from breast cancer patients, including those who

may be entering protocols. • Begin to demonstrate commitment to ethical principles pertaining to permission/withholding

of clinical care to breast cancer patients, especially those treated for palliative purposes. • Begin, under the guidance of the attending, to gain experience in billing issues. • Demonstrate sensitivity/responsiveness to the breast cancer patients’ background, culture,

and age.


• Begin to identify how his/her patient care and other professional practices affect other health

care providers (eg, nurses and therapists). • Begin to practice health care that is cost-effective, and begin to learn how to allocate

resources, while not compromising quality of care. • Begin to help patients deal with health system complexities, eg, scheduling issues relating to

radiation therapy.


Marilyn N Ling MD

2nd

Rotation (PGY4-5)

In addition to gaining proficiency/expertise in the skills associated with each of the competencies outlined in the Goals and Objectives for the PGY2-3 rotation, the PGY4-5 resident is expected to acquire knowledge and gain additional proficiency in the following areas, as they pertain to the breast cancer patient population.

Medical Knowledge

• Classify and integrate the pertinent scientific literature and studies related to the role of

radiation therapy and associated oncologic disciplines for early stage breast cancer (invasive/non-invasive), locally advanced and inflammatory breast cancer, and post-mastectomy radiation therapy, and the results/outcomes of treatment for each of the disease categories and/or stages (evidence-based medicine).

• Proficiency in identifying breast cancer prognostic and predictive factors. • Discuss controversies in the treatment of breast cancer patients, including:

o Sentinel lymph node surgery vs. axillary lymph node dissection; o Role/rationale of tumor bed boost; o Rationale of radiation to lymph node regions, including internal mammary nodes; o Sequencing of radiation treatment and chemotherapy; o Local/regional recurrence after breast conservation and after mastectomy: risk factors

for patients receiving radiation; o Breast conservation for locally advanced and inflammatory breast cancer; o Salvage of isolated locoregional recurrence after mastectomy.

• Differentiate the need for the use of hormonal therapy, systemic chemotherapy,

radioprotectors, gene therapy and other new modalities as they are applicable to breast cancer.

• Differentiate unusual breast neoplasms, including their presentation and management,

including: o Lobular carcinoma in-situ; o Bilateral carcinoma; o Cystosarcoma phyllodes; o Axillary adenocarcinoma without detectable breast cancer primary; o Inflammatory breast cancer; o Breast cancer in males.

Patient Care

• Undertake all aspects of patient care related to breast cancer patients, including initial

assessment, formulation and implementation of treatment plans, discussion with patients and family, and with the referring physicians, treatment prescription and planning and integration with other treatment modalities. This includes early stage, advanced stage, recurrent and metastatic patients.

• Maturation of written consultation is expected, with emphasis on delineation of plan of

management and, when appropriate, reference to pertinent literature to substantiate recommendation.

• Identify critical organ dose parameters, including DVH analysis, effect of chemotherapy and



and their families on issues related to breast cancer, and its treatment and side effects/complications of treatment.





suggestions for improving the service and rotation). • Obtain information from the larger population from which the breast cancer patients are

drawn.


• Fully sustain a therapeutic and ethically sound relationship with breast cancer patients. • Use effective listening, non-verbal, explanatory, questioning and writing skills to elicit and

provide information to and about breast cancer patients. This includes more active participation/discussion in multidisciplinary conferences.

• Work effectively with other health care providers as a member and leader of the health care

team. The PGY4-5 resident is expected to ‘lead’ the weekly patient-under-treatment rounds.

Professionalism





care, and describe how these activities affect system performance. This includes partnering with administrative personnel or nurses to coordinate a patient’s ongoing multidisciplinary care.



PURPLE SERVICE

Learning Objectives: See attached (Please see Education Calendar for other weekly conferences)

Weekly Service Schedule: MON TUES WED THURS FRI Weekends

Didactic

Education




8.15-9.00 am Brain Tumor Conference

Clinical

Education

SIMs

OTV(8:00-8:45)

Suite A (Neuro Clinic)

OTV

FU

Didactic

Education

12.00-1.30 pm Thoracic Pre-Clinic Conference

Clinical

Education

OTV

Suite A (Thoracic Clinic)

Consults Team Meeting 2.30 pm

Didactic

Education




4:00-5:00 Thoracic Tumor Board


End of day

unscheduled

activities


Evenings












• 1,3,4 • 1,2 • 5 • 1,2,3,6 • 2,3,6 • 2,3,6 • 1,4,5,6









PURPLE/ SERVICE – OBJECTIVES

Michael Milano MD PhD

All PGY levels

Residents will evaluate adult patients with lung/thoracic malignancies and brain neoplasia, benign and malignant, as well as gain competence in the assessment of treatment of metastatic lesions to lung and liver. Patients are seen in a multidisciplinary context, with surgeons (thoracic and neurosurgeons), medical oncologists and other support personnel. The rotation provides the resident with opportunities to enhance his/her multidisciplinary knowledge, management abilities and specific skills for patients with these conditions. While on Purple Service, residents are expected to attend the weekly multidisciplinary Brain Tumor Case Conferences, and weekly Thoracic Pre-Clinic Conferences. These conferences are also attended by Radiology, Surgery, and Medical Oncology faculty, as well as basic researchers, neurologists, residents and fellows in these specialties. In addition, the resident gains training experience and eventual proficiency in the management of CNS and thoracic oncology patients during consultation of patients outside the multidisciplinary clinic, weekly patient-under-treatment visits, and follow-up clinics. The resident is expected to see each patient under treatment on a weekly basis and a majority of the follow-up patients, under the supervision of the attending. The resident is expected to gain training experience and eventual proficiency in the simulation and treatment planning of patients with brain tumors and thoracic malignancies using external beam techniques, including 3-D conformal therapy (3-D CRT) and intensity-modulated radiation therapy (IMRT), body radiosurgery and cranial stereotactic radiosurgery, in addition to experience in brachytherapy techniques as applicable to this population of patients. While the resident will not likely gain direct experience in every site and/or stage of disease, it is expected that enough experience will have been gained during the rotation for the resident to be able to apply the knowledge and experience to the unique situation when it presents itself.


• Treatment of meningioma • Treatment of low grade astrocytoma • Treatment of glioblastoma • Treatment of arteriovenous malformation • Treatment of metastatic lung disease • Treatment of hepatoma • Treatment of extremity sarcoma • Locally advanced non-small cell lung cancer • Role of post-operative radiation for non-small cell lung cancer • Limited stage small cell lung cancer • Inoperable Stage I and II non-small cell lung cancer

PURPLE SERVICE – OBJECTIVES



For each of the disease sites/categories listed below, the resident is expected to acquire the appropriate knowledge/skills, as outlined: Adult CNS

o Astrocytomas and other neuro-epithelial tumors o Oligodendrogliomas and mixed tumors, including pilocytic, ependymomas, PNET, and

pineal tumors o Meningiomas o Arteriovenous malformations o Acoustic neuromas Miscellaneous o Metastatic lesions to liver/lung and other sites o Skin cancer:

• Basal cell carcinoma • Squamous cell carcinoma • Melanoma

Thoracic Malignancies o Non-small cell lung cancer o Small cell carcinoma

Medical Knowledge

• Describe the anatomic features and relevant regional anatomic structures (draining lymphatics).

• Describe the pathologic characteristics, prognostic factors and grading system as appropriate

to each of the disease categories, especially astrocytomas and oligodendroglial tumors. • Explain tolerance doses, both fractionated and single fraction for critical brain structures, and

organs of interest for body radiosurgery (liver, kidney, lung, spinal cord, intestines, cardiac, etc).

• Explain the radiation effects and response on organ of interest and surrounding normal tissue:

acute and chronic radiation effects; complications. • Identify epidemiologic and etiologic risk factors and tumor markers/molecular

genetics/structures, potential preventative and screening methods for the specific disease category.

• Discuss the natural history, typical clinical presentations, diagnostic workup (including role

of broncoscopy and mediastinoscopy) and staging, and clinicopathologic manifestations. • Describe principles of multidisciplinary management and treatment, and role(s) of radiation

therapy (including brachytherapy, altered fractionation 3-D CRT and IMRT, radiosurgery, if appropriate) for each of the disease categories, for each stage of disease, and according to the clinical situation: o Astrocytoma:

• Low grade glioma – role of RT/SRS; • High grade glioma – role of RT/SRS;

o Oligodendroglioma: • Low grade/mixed; • Anaplastic;

o Meningioma: • Radiation therapy role – fractionated vs. stereotactic;

o Acoustic neuroma: • Role of SRS;

o Differential diagnosis of intraparenchymal and meningeal lesions; o Liver metastasis; role of respiratory gated stereotactic radiosurgery; o Lung metastasis; role of respiratory gated stereotactic radiosurgery; o Non-small cell lung cancer:

• Resectable tumor • Role of pre-operative (chemo-) radiation • Role of post-operation radiation • Role of post-operation chemotherapy or chemoradiation;

• Unresectable tumors • Definitive and palliative radiation and chemoradiation options, including

altered fractionation, hypofractionation and split course; • Surgery: types of surgery appropriate for lung cancer;

o Small cell lung cancer: • Use of chemoradiation for limited stage disease, sequencing of irradiation and

chemotherapy (sequential vs. concurrent); • Elective cranial radiation (pros and cons);

o Skin cancers: • Appropriate role of definitive radiation therapy vs. surgery for different disease

locations. • Discuss the principles of treatment of primary site, local-regional areas and lymph node

regions for each of the disease sites and stage of disease; indications for treatment for each site and stage of disease.

• Determine and apply the principles of radiological physics and radiobiology appropriate to

the radiation treatment of each of the disease categories, including: o Altered fractionation – both hypofractionation and hyperfractionation; o Importance of time-dose factors; o Repopulation; o Principle of chemoradiation sensitization;

o Principles of hyperfractionation/altered fractionation; o Principles of field alignment; use of electron fields.

• Acquire basic knowledge of controversial areas or unusual situations for each of the disease

categories, including: o Astrocytoma: • Use of hyperfractionation and tumor volume; • Role of chemotherapy; • Role of radiation vs. observation in low grade glioma; o Metastatic: • Role of stereotactic radiosurgery for brain metastasis and for metastatic lesions to the

liver/lung; o Lung:

• Superior sulcus lung carcinoma; • Superior vena cava syndrome;

• Other: identify risk of nodal disease for each disease site and stage. Patient Care

• Gather and organize essential important information about a patient with the specific disease

entity, including taking an accurate history of present illness, past medical/surgical history, allergies, social/family history, particularly as they pertain to the current illness.


and radiologic studies (eg, CXR, CT scans, PET scans) used to assess the patient with the specific disease entity.



notes, treatment notes, and summaries. • Differentiate tumor from edema, identify meningiomas vs. acoustic neuromas, and

distinguish high-grade from low-grade tumor. • Develop and implement patient management plans for patients with:

o astrocytomas; o Meningioma; o AVM; o Metastatic brain tumors; o Other metastatic lesions lesions (eg, those to liver and lung); o Non-small cell lung cancer patients receiving definitive or palliative radiation or

chemoradiotherapy or (chemo) radiation in combination with surgery either pre-operatively or post-operatively;

o Small cell lung cancer patients receiving definitive radiation and/or palliative chemotherapy.

• Perform radiation therapy (including brachytherapy, as applicable) techniques and

prescriptions, formulate and evaluate treatment plans and dosimetry according to accepted guidelines for each of the disease categories/sites according to stage of disease and the clinical situation. This includes determination of volumes, treatment portals, and doses for both the initial phase and boost treatments, in addition to beginning knowledge of possible alternative treatment-field arrangements:

o Malignant brain tumors:

• Identification of tumor/edema on MRI/CT scan, and use of MRI/MRS to determine tumor volumes for radiation therapy;

• Distinguish tumor from surgical bed and from edema; • Choose and evaluate additional studies like spectroscopy and PET to help evaluate

patients’ MRIs and CTs; • Identify meningiomas, acoustic neuromas, and metastasis, and distinguish high from

low-grade tumors; • Identify critical structures (eg, the optic nerve, the optic chiasm, the pituitary, the

brain stem, corpus callosum, the trigeminal nerve, etc) and their tolerances as a function of fraction size;

o Metastatic lesions (liver/lung): • Identify the major structures on a thoracic CT scan, including the aorta, the

pulmonary veins, the vena cava, the left and right atria, the left and right ventricles, the upper and lower left lung lobes, the lingular lobe and the upper middle and lower right lung lobes;

• Develop skills for assessing atelectasis vs. metastatic tumor; • Describe what tests are required to help in that decision-making process; • Identify and distinguish normal anatomy of the liver from metastasis in the liver; • Read and evaluate different dose volume histograms of the lung and liver and

determine whether they are safe for patients with different intrinsic disease (eg, cirrhosis, emphysema) and whether they are appropriate for delivery in combination with chemotherapy;

• Identify which patients should not be treated with extracranial radiosurgery of the lung or liver;

• Identify various tolerance organs in the thorax and abdomen and develop modifications to the radiosurgical plan to safely incorporate those tolerances;

• Use these same skills to design dose intensity modulated treatments. o Lung cancer:

• Conventional radiation therapy techniques: determination of treatment volume portals and learn managements for primary treatment and boost;

• 3-D conformal radiation therapy: determination of volumes, portals and beam arrangement, including use of Novalis-focused beam radiation;

• Brachytherapy for endobronchial tumors; o Other, as appropriate:

• Metastatic disease to bone, brain, etc.

• Gain experience in the use of the Novalis 3-D CRT and IMRT in the treatment of brain metastasis and metastatic lesions to liver/lung, and determine which patients are appropriate for the various radiosurgery protocols.

• Demonstrate caring behaviors and communicate effectively with patients with brain tumors

and metastatic lesions, and with their families, and work effectively with other health care providers, including nurses, therapists and social workers.

• Determine basic critical organ tolerance dose parameters and begin to integrate this

information into the patient’s radiation therapy treatment plan. Particular attention should be paid to lung, heart, spinal cord and esophagus tolerances.

• Identify and learn to manage acute, subacute and chronic side effects of patients under

treatment and in follow-up, and to counsel/advise patients of appropriate pre-evaluation, treatment and follow-up measures for each of the disease categories, including:

o Fatigue; o Cytopenia; o Skin: reaction/dermatitis; o Esophagitis/xerostermia/nutritional problems; o Pneumonitis/fibrosis; o Screening for second malignancies; o Other necrosis/dental problems.

• Demonstrate caring behaviors; • Counsel and communicate effectively with the thoracic/head & neck cancer patient

population and their families and with other health care providers, including nutritional and dental professionals;

• Acknowledge and act upon the recognition of the opportunity to assist patients, family

members and society in dealing with smoking, and provide appropriate resources to achieve smoking cessation in patients and family members.

• Present consent forms for standard therapy and appropriately present consent forms for experimental clinical studies, including proper presentation of Phase I, II, III studies, explain the sacrifices and mutual responsibilities of doctors and patients, as well as the rights.



Professionalism




• Begin to locate, appraise and assimilate evidence from scientific studies related to brain

tumor patients or patients with metastatic cancer, ie, become familiar with scientific evidence as may be presented in a standard textbook.


studies and other information on diagnostic and therapeutic effectiveness. • Use information technology to manage information, access online medical information and





brain tumors or metastatic lesions. • Begin using effective listening, non-verbal, explanatory, questioning, and writing skills to

elicit and provide information to and about patients with brain tumors or metastatic lesions. • Work effectively with others as a member of, or leader of a health care team.

Professionalism

• Demonstrate respect, compassion, integrity, and responsiveness to the needs of the patient

with brain tumors or metastatic lesions. • Begin to be able to obtain informed consent from patients with brain tumors or metastatic

lesions, including those entering protocols. • Begin to demonstrate commitment to ethical principles pertaining to permission/withholding

of clinical care to patients with brain tumors or metastatic lesions.

• Begin to gain experience in billing issues. • Demonstrate sensitivity/responsiveness to the patients’ background, culture, and age.





PURPLE SERVICE – OBJECTIVES


2nd

Rotation (PGY4-5)

In addition to developing proficiency in the skills associated with each of the competencies outlined in the Goals and Objectives for the PGY2-3 rotation, the PGY4-5 resident is expected to acquire knowledge and gain proficiency in the following areas associated with each of the competencies. Adult CNS

o Astrocytomas and other neuro-epithelial tumors o Oligodendrogliomas and mixed tumors, including pilocytic, ependymomas, PNET, and

pineal tumors o Meningiomas o Arteriovenous malformations o Acoustic neuromas Miscellaneous o Metastatic lesions to liver/lung and other sites o Skin cancer:

• Basal cell carcinoma • Squamous cell carcinoma • Melanoma

Thoracic Malignancies o Non-small cell lung cancer o Small cell carcinoma

Medical Knowledge

• Classify the pertinent literature and scientific studies related to the role of radiation therapy

and associated oncologic disciplines and the results/outcome of treatment for each of the disease categories and sites by stage.

• Proficiency in identifying the prognostic factors for thoracic malignancies, and patients with

brain tumors or metastatic lesions to the liver and thoracic region. • Discuss the utility and application of other modalities of treatment:

o Gamma-knife: The technical differences between the x-knife approach and Novalis; Specific differences in dose distribution and prescription.

o Protons: How the Bragg Peak influences the dosimetry and how the dosimetry from

proton beams differs from that of x-rays and how the biological effect is modified for a given physical radiation dose;

List diseases for which proton beams have proven advantageous over x-rays. o Neutrons:

List diseases for which neutron beams have proven advantageous over x-rays. o Hyperthermia:

How heat dose is measured and what heat doses are sufficient for cell kill; The biology of heat tolerance; List the diseases for which hyperthermia is of proven value.

• Differentiate unusual thoracic malignancies, including their presentation and management,

and the role of radiation therapy: o Tracheal malignancies; o Mesothelioma; o Thymoma; o Angiofibroma.

• Differentiate unusual CNS tumors, including their presentation and management, including

the role of radiation therapy: o Hemangioblastoma/hemangiopericytoma; o Spinal cord tumors; o Von-Hippel Lindau and neurofibromatosis.

• Thoroughly describe controversial areas in the treatment of thoracic malignancies:

o Role of surgery in superior sulcus carcinoma; o Role(s) of surgery and chemoradiation in Stage III A/B lung cancer; o Sequence of chemotherapy and radiation, altered fractionation and appropriate

treatment volume for small cell lung carcinoma. • Thoroughly describe controversial areas in the treatment of CNS tumors. • Differentiate the need for the use of systemic chemotherapy, gene therapy and other new and

developing modalities as they are applicable to thoracic malignancies, including opportunities for chemoprevention and for clinical and translational research in this area. This includes radiation sensitizers and hyperfractionation/altered fractionation trials in non-small cell and small cell lung cancer.

• Differentiate the need for the use of systemic therapies and other new modalities, as

applicable. Patient Care

• Undertake all aspects of patient care related to thoracic/lung cancer patients, and patients

with brain tumors or metastatic lesions to the liver and thoracic region, including initial assessment, formulation and implementation of treatment plans, discussion with family

members and referring physicians, treatment prescription and interpretation with other treatment modalities.






and their families on issues related to thoracic malignancies and CNS tumors, and their treatment and side effects/complications of treatment.

• Perform full work-up, evaluation and technical delivery of at least two patients for lung

metastasis and two patients for liver metastasis. • Gain proficiency in performing techniques and prescriptions (including alternative treatment




suggestions for improving the service and rotation). • Obtain information from the larger population from which the brain tumor patients or

patients with metastatic cancer are drawn.


• Fully sustain a therapeutic and ethically sound relationship with thoracic/lung cancer

patients. • Use effective listening, non-verbal, explanatory, questioning and writing skills to elicit and

provide information to and about brain tumor patients or patients with metastatic cancer. • Work effectively with other health care providers as a member and leader of the health care


Professionalism



• Identify how his/her health care practices affect health care providers and the larger society, and how elements of the system affect his/her own practice.


care, and explain how these activities affect system performance.



ORANGE SERVICE


Weekly Service Schedule: MON TUES WED THURS FRI Weekends

Didactic

Education




7:30 Brain Tumor Conference

Clinical

Education *

SIMs 8:00, 8:30

OTV

SIM 8:00, 8:30 Consults 8:30 Team Meeting

Didactic

Education


Clinical

Education *

OTV FU

Didactic

Education





End of day

unscheduled

activities

• Dictations, including treatment summaries • Treatment planning •

Evenings

In addition, at the end of each week, the residents should check the SRS schedule for the upcoming week and decide on their clinical priorities. This includes working with physics and their attending to appropriately schedule time frames for the SRS planning and delivery. Assessments/Evaluations:











• 1,3,4 • 1,2 • 5 • 1,2,3,6 • 2,3,6 • 2,3,6 • 1,4,5,6









ORANGE SERVICE – OBJECTIVES

Paul Okunieff MD

All PGY levels

Residents will evaluate adult patients with brain neoplasia, benign and malignant, as well as gain competence in the assessment of treatment of metastatic lesions to lung and liver. Patients are seen in a multidisciplinary context, with neurosurgeons, medical oncologists and other support personnel. The rotation provides the resident with opportunities to enhance his/her multidisciplinary knowledge, management abilities and specific skills for patients with these conditions. While on Orange Service, residents are expected to attend the weekly multidisciplinary Brain Tumor Case Conferences. These conferences are also attended by Radiology, Surgery, and Medical Oncology faculty, as well as basic researchers, neurologists, residents and fellows in these specialties. In addition, the resident gains training experience and eventual proficiency in the management of CNS oncology patients during consultation of patients outside the multidisciplinary clinic, weekly patient-under-treatment visits, and follow-up clinics. The resident is expected to see each patient under treatment on a weekly basis and a majority of the follow-up patients, under the supervision of the attending. The resident is expected to gain training experience and eventual proficiency in the simulation and treatment planning of patients with brain tumors and thoracic and head and neck malignancies using external beam techniques, including 3-D conformal therapy (3-D CRT) and intensity-modulated radiation therapy (IMRT), body radiosurgery and cranial stereotactic radiosurgery. While the resident will not likely gain direct experience in every site and/or stage of disease, it is expected that enough experience will have been gained during the rotation for the resident to be able to apply the knowledge and experience to the unique situation when it presents itself.


• Treatment of meningioma • Treatment of low grade astrocytoma • Treatment of glioblastoma • Treatment of arteriovenous malformation • Treatment of metastatic disease • Treatment of hepatoma


Paul Okunieff MD


For each of the disease sites/categories listed below, the resident is expected to acquire the appropriate knowledge/skills, as outlined:

o Adult CNS Astrocytomas and other neuro-epithelial tumors

o Oligodendrogliomas and mixed tumors, including pilocytic, ependymomas, PNET, and pineal tumors

o Meningiomas o Arteriovenous malformations o Acoustic neuromas o Miscellaneous o Metastatic lesions to liver/lung and other sites

Medical Knowledge

• Describe the neuro-anatomy and relevant regional anatomic structures. • Describe the pathologic characteristics, prognostic factors and grading system as appropriate

to each of the disease categories, especially astrocytomas and oligodendroglial tumors. • Explain tolerance doses, both fractionated and single fraction for critical brain structures, and

organs of interest for body radiosurgery (liver, kidney, lung, spinal cord, intestines, cardiac, etc).

• Identify epidemiologic and etiologic risk factors and tumor markers/molecular structures for

the specific disease category. • Discuss the natural history, clinical presentation, diagnostic workup and staging. • Describe the principles of multidisciplinary management treatment and, specifically, the role

of radiation therapy or radiosurgery for each of the disease categories and according to the clinical situation:

o Astrocytoma: Low grade glioma – role of RT/SRS; High grade glioma – role of RT/SRS;

o Oligodendroglioma: Low grade/mixed; Anaplastic;

o Meningioma: Radiation therapy role – fractionated vs. stereotactic;

o Acoustic neuroma: Role of SRS;

o Differential diagnosis of intraparenchymal and meningeal lesions; o Liver metastasis; role of respiratory gated stereotactic radiosurgery; o Lung metastasis; role of respiratory gated stereotactic radiosurgery; o Intravascular brachytherapy for prevention of restenosis.

• Discuss the principles of treatment of local-regional areas for each of the disease categories

and clinical situation. • Determine and to apply the principles of radiological physics and radiobiology appropriate to

the radiation treatment of each of the disease categories, including: o Altered fractionation – both hypofractionation and hyperfractionation.

• Acquire basic knowledge of controversial areas or unusual situations for each of the disease

categories: o Astrocytoma:

Use of hyperfractionation and tumor volume; Role of chemotherapy; Role of radiation vs. observation in low grade glioma;

o Metastatic: Role of stereotactic radiosurgery for brain metastasis and for metastatic

lesions to the liver/lung. Patient Care

• Gather and organize essential important information about a patient with the specific disease

entity, including taking an accurate history of present illness, past medical/surgical history, allergies, social/family history, particularly as they pertain to the current illness.


and radiologic studies used to assess the patient with the specific disease entity. • Determine whether radiation is appropriate, based on diagnostic information and


notes, treatment notes, and summaries. • Differentiate tumor from edema, identify meningiomas vs. acoustic neuromas, and

distinguish high-grade from low-grade tumor. • Develop and implement patient management plans for patients with astrocytomas,

meningioma, AVM, metastatic brain tumors, and other metastatic lesions (eg, those to liver and lung).

• Perform radiation therapy techniques and evaluate treatment plans and dosimetry for: o Malignant brain tumors:

• Identification of tumor/edema on MRI/CT scan, and use of MRI/MRS to determine tumor volumes for radiation therapy;

• Distinguish tumor from surgical bed and from edema; • Choose and evaluate additional studies like spectroscopy and PET to help

evaluate patients’ MRIs and CTs; • Identify meningiomas, acoustic neuromas, and metastasis, and distinguish

high from low-grade tumors; • Identify critical structures (eg, the optic nerve, the optic chiasm, the pituitary,

the brain stem, corpus callosum, the trigeminal nerve, etc) and describe their tolerances as a function of fraction size;

o Metastatic lesions (liver/lung): • Identify the major structures on a thoracic CT scan, including the aorta, the

pulmonary veins, the vena cava, the left and right atria, the left and right ventricles, the upper and lower left lung lobes, the lingular lobe and the upper middle and lower right lung lobes;

• Develop skills for assessing atelectasis vs. metastatic tumor; • What tests are required to help in that decision-making process; • Identify and distinguish normal anatomy of the liver from metastasis in the

liver; • Read and evaluate different dose volume histograms of the lung and liver and

determine whether they are safe for patients with different intrinsic disease (eg, cirrhosis, emphysema) and whether they are appropriate for delivery in combination with chemotherapy;

• Identify which patients should not be treated with extracranial radiosurgery of the lung or liver;

• Identify various tolerance organs in the thorax and abdomen and develop modifications to the radiosurgical plan to safely incorporate those tolerances;

• Use these same skills to design dose intensity modulated treatments. • Gain experience in the use of the Novalis 3-D CRT and IMRT in the treatment of brain

metastasis and metastatic lesions to liver/lung, and determine which patients are appropriate for the various radiosurgery protocols.

• Demonstrate caring behaviors and communicate effectively with patients with brain tumors

and metastatic lesions, and with their families, and work effectively with other health care providers, including nurses, therapists and social workers.

• Identify and manage side-effects of patients under treatment and in follow-up and counsel

patients on appropriate follow-up measures. • Present consent forms for standard therapy and the appropriately present consent forms for

experimental clinical studies, including proper presentation of Phase I, II, III studies, explain the sacrifices and mutual responsibilities of doctors and patients, as well as the rights.



Professionalism




• Begin to locate, appraise and assimilate evidence from scientific studies related to brain

tumor patients or patients with metastatic cancer, ie, become familiar with scientific evidence as may be presented in a standard textbook.


studies and other information on diagnostic and therapeutic effectiveness. • Use information technology to manage information, access on-line medical information and





brain tumors or metastatic lesions. • Begin using effective listening, non-verbal, explanatory, questioning, and writing skills to

elicit and provide information to and about patients with brain tumors or metastatic lesions. • Work effectively with others as a member of, or leader of a health care team.

Professionalism


with brain tumors or metastatic lesions. • Begin to be able to obtain informed consent from patients with brain tumors or metastatic

lesions, including those entering protocols. • Begin to demonstrate commitment to ethical principles pertaining to permission/withholding

of clinical care to patients with brain tumors or metastatic lesions. • Begin to gain experience in billing issues.

• Demonstrate sensitivity/responsiveness to the patients’ background, culture, and age.






Paul Okunieff MD

2nd

Rotation (PGY4-5)

In addition to developing proficiency in the skills associated with each of the competencies outlined in the Goals and Objectives for the PGY2-3 rotation, the PGY4-5 resident is expected to acquire knowledge and gain proficiency in the following areas associated with each of the competencies.

Medical Knowledge

• Classify the pertinent literature and scientific studies related to the role of radiation therapy in

patients with brain tumors or metastatic lesions. • Proficiency in identifying the prognostic factors for patients with brain tumors or metastatic

lesions to the liver and thoracic region. • Determine the utility and application of other modalities of treatment:

o Gamma-knife: The technical differences between the x-knife approach and Novalis; Have a specific understanding of the differences in dose distribution and

prescription. o Protons:

How the Bragg Peak influences the dosimetry and how the dosimetry from proton beams differs from that of x-rays and how the biological effect is modified for a given physical radiation dose;

List diseases for which proton beams have proven advantageous over x-rays. o Neutrons:

List diseases for which neutron beams have proven advantageous over x-rays. o Hyperthermia:

How heat dose is measured and what heat doses are sufficient for cell kill; The biology of heat tolerance; List the diseases for which hyperthermia is of proven value.

• Differentiate unusual tumors, including their presentation and management, including the

role of radiation therapy: o Hemangioblastoma/hemangiopericytoma; o Spinal cord tumors; o Von-Hippel Lindau and neurofibromatosis.

• Thoroughly discuss controversial areas in the treatment of CNS tumors. • Differentiate the need for the use of systemic therapies and other new modalities, as

applicable.

Patient Care

• Undertake all aspects of patient care related to patients with brain tumors or metastatic

lesions to the liver and thoracic region, including initial assessment, formulation and implementation of treatment plans, discussion with family members and referring physicians, treatment prescription and interpretation with other treatment modalities.





• Gain proficiency in managing side effects during and after therapy’

communication/counseling with patients and families. • Perform full work-up, evaluation and technical delivery of at least two patients for lung

metastasis and two patients for liver metastasis. • Gain proficiency in performing techniques and prescriptions (including alternative treatment




suggestions for improving the service and rotation). • Obtain information from the larger population from which the brain tumor patients or

patients with metastatic cancer are drawn.


• Fully sustain a therapeutic and ethically sound relationship with head and neck cancer and

thoracic/lung cancer patients. • Use effective listening, non-verbal, explanatory, questioning and writing skills to elicit and

provide information to and about brain tumor patients or patients with metastatic cancer. • Work effectively with other health care providers as a member and leader of the health care


Professionalism








WHITE SERVICE

Learning Objectives: See attached (See Education Calendar for other weekly conferences) Weekly Service Schedule:


Didactic

Education




Clinical

Education

DPS: SIM 9.30,11 OTV

YC: OTV YC/HZ: Suite C (H & N)

DPS: SIM 8.30,9 YC: Suite A (Thoracic)

11 Team Mtg

Didactic

Education

12.00-1.30 pm Thoracic Pre-Clinic Conference

Clinical

Education

DPS: OTV YC: SIM 1,1.30,2 OTV

DPS/HZ: Suite A (H & N) 2:30 Team Meeting

1: HZ: SIM/OTV 2: DPS: Suite A (Thoracic)

Didactic

Education



4.00-5.00 pm Head & Neck Tumor Board 4.30-6.00 pm Conference

4:00-5:00 Thoracic Tumor Board


End of day

unscheduled

activities


Evenings







Service Responsibilities/Assignments: Responsibility: Competency: • Complete four service presentations (2 head & neck cancer cases, 2 lung cancer

cases) during the three-month rotation, as described in the attached objectives. • Completion of weekly patient-on-treatment service list, staging sheets and treatment





• 1,2,3,4,5,6 • 1,3,4 • 1,2 • 5 • 1,2,3,6 • 2,3,6 • 2,3,6 • 1,4,5,6









WHITE SERVICE - OBJECTIVES

Hong Zhang MD PhD & Yuhchyau Chen MD PhD

All PGY Levels

Residents will evaluate adult patients with head and neck and lung/thoracic malignancies. These patients are seen primarily in the multidisciplinary Thoracic-Oncology Clinic and Head & Neck Oncology Clinic (once established), together with surgeons (thoracic and otolaryngologists) and medical oncologists. The rotation therefore provides opportunities for enhancing the resident’s multidisciplinary knowledge and management abilities for patients with these conditions. In addition, the resident gains training experience and eventual proficiency in the management of head and neck and thoracic oncology patients during consultation of patients outside the multidisciplinary clinic, weekly patient-under-treatment visits, and follow-up clinics. The resident is expected to see each patient under treatment on a weekly basis and a majority of the follow-up patients, under the supervision of the attending. The resident is expected to gain training experience and eventual proficiency in the simulation and treatment planning of patients with thoracic and head and neck malignancies using external beam techniques, including 3-D conformal therapy (3-D CRT) and intensity-modulated radiation therapy (IMRT), in addition to experience in brachytherapy techniques as applicable to this population of patients. While the resident will not likely gain direct experience in every site and/or stage of disease, it is expected that enough experience will have been gained during the rotations for the resident to be able to apply the knowledge and experience to the unique situation when it presents itself. During each three-month rotation, the resident on White Service will need to complete four conferences/presentations on subjects related to lung cancer and head & neck tumors. The literature on cancer therapy is becoming more and more complex. There are many key articles related to each subject for the residents to learn in order to become competent radiation oncologists. To master the medical literature, it is necessary that residents learn these key articles during the time of rotation to relate to the clinical experience during the rotation. Given the large volume of publication, it will be very difficult and counter-productive if residents try to compress medical literature learning right before the board examination. There are 8-10 major subjects for lung and head & neck tumors. By doing four on each rotation, one can expect at least eight subjects will be covered before graduation. This practice will prepare our residents well for the written board examination, patient care, and oral board examination. All White Service presentations must be completed within the confines of the rotation. Failure to do so will result in a lower grade for this portion of the rotation evaluation.


• Locally advanced non-small cell lung cancer • Role of post-operative radiation for non-small cell lung cancer • Limited stage small cell lung cancer • Inoperable Stage I and II non-small cell lung cancer • Cancer of larynx (T1 and T2) • Cancer of larynx (T3 and T4) • Cancer of oropharynx • Cancer of tongue, tongue base, and oral cavity • Cancer of nasopharynx • Cancer of salivary gland and paranasal sinuses


Yuhchyau Chen MD PhD & Hong Zhang MD PhD


For each of the disease sites/categories listed below, the resident is expected to acquire the appropriate knowledge/skills, as outlined:

o Non-small cell lung cancer o Small cell carcinoma o Nasopharynx o Nasal cavity, paranasal sinuses:

Nasal vestibule, nasal cavity Ethmoid, maxillary, sphenoid sinuses

o Salivary glands: Parotid gland Submandibular gland

o Oral cavity: Lip and buccal mucosa Oral tongue Gingiva of mouth

o Tonsillar fossa, faucial arch o Oropharynx, including base of tongue soft palate o Hypopharynx:

Pyriform sinuses Pharyngeal wall Post-cricoid

o Larynx: Supraglottic Glottic Subglottic

o Thyroid cancer: Differentiated (papillary/follical) Medullary Anaplastic

o Skin cancer: Basal cell carcinoma Squamous cell carcinoma Melanoma

Medical Knowledge


lymphatics).

• Explain the radiation effects and response on organ of interest and surrounding normal tissue: acute and chronic radiation effects; complications.

• Identify epidemiologic and etiologic risk factors, tumor markers/molecular genetics, potential

preventative and screening methods. • Discuss the natural history, typical clinical presentations, diagnostic workup (including role

of broncoscopy and mediastinoscopy) and staging, and clinicopathologic manifestations. • Discuss principles of multidisciplinary management and treatment, and role(s) of radiation

therapy (including brachytherapy, altered fractionation 3-D CRT and IMRT, if appropriate) for the following sites, for each stage of disease: o Non-small cell lung cancer:

Resectable tumor • Role of pre-operative (chemo-) radiation • Role of post-operation radiation • Role of post-operation chemotherapy or chemoradiation;

• Unresectable tumors • Definitive and palliative radiation and chemoradiation options, including

altered fractionation, hypofractionation and split course; • Surgery: types of surgery appropriate for lung cancer;

o Small cell lung cancer: • Use of chemoradiation for limited stage disease, sequencing of irradiation and

chemotherapy (sequential vs. concurrent); • Elective cranial radiation (pros and cons);

o Nasopharynx: • Role of chemotherapy and radiation; altered vs. standard fractionation;

o Nasal cavity/paranasal sinuses: • Role of surgery and radiation, including altered fractionation; role of brachytherapy;

o Salivary glands: • Role of surgery and indications for treatment with post-operative radiation;

o Oral cavity: • Indications for treatment with radiation and application of brachytherapy techniques;

o Tonsillar fossa and faucial arch, oropharynx, including base of tongue: • Pre-operative/post-operative and definitive radiation therapy (including

hyperfractionation) and use of chemotherapy; o Hypopharynx:

• Use of surgery and/or radiation therapy for each sub-site by stage; o Larynx:

• Use of definitive radiation therapy including altered fractionation and post-operative radiation for each sub-site and stage;

• Chemoradiotherapy for laryngeal preservation; o Skin cancers:

• Appropriate role of definitive radiation therapy vs. surgery for different disease locations.

• Explain the principles of treatment of primary site and lymph node regions for each of the

disease sites and stage of disease; indications for treatment for each site and stage of disease.

• Determine and apply principles of radiological physics and radiobiology appropriate to

radiation therapy for each of the disease categories: o Importance of time-dose factors; o Repopulation; o Principle of chemoradiation sensitization; o Principles of hyperfractionation/altered fractionation; o Principles of field alignment; use of electron fields.

• Acquire basic knowledge of controversial areas or unusual situations in each of the disease

categories, including: o Lung:

• Superior sulcus lung carcinoma; • Superior vena cava syndrome;

o Head & Neck: • Re-treatment of recurrent nasopharyngeal carcinoma; • Esthesioneuroblastoma; • Adenoid optic carcinoma and pleomorphic adenoma; • Management of unknown primary; • Management of the neck: clinically negative or positive; definitive or combined with

surgery. • Other: describe risk of nodal disease for each disease site and stage.

Patient Care

• Gather and organize essential important information about a thoracic/head & neck cancer

patient, including taking an accurate history of present illness, past medical/surgical history, allergies, social/family history, particularly as they pertain to the current illness.


and radiologic studies (eg, CXR, CT scans, PET scans) used to assess the thoracic/head & neck cancer patients.



notes, treatment notes, and summaries.

• Develop and implement patient management plans for: o Head and neck cancer patients who will receive pre-operative or post-operative

radiation therapy +/- chemotherapy, including determination of intent of treatment (definitive/palliative);

o Non-small cell lung cancer patients receiving definitive or palliative radiation or chemoradiotherapy or (chemo) radiation in combination with surgery either pre-operatively or post-operatively;

o Small cell lung cancer patients receiving definitive radiation and/or palliative chemotherapy.

• Perform radiation therapy (including brachytherapy, as applicable) techniques and

prescriptions, formulate and evaluate treatment plans and dosimetry according to accepted guidelines for each of the disease categories/sites according to stage of disease and the clinical situation. This includes determination of volumes, treatment portals, and doses for both the initial phase and boost treatments, in addition to beginning knowledge of possible alternative treatment-field arrangements:

o Lung cancer: • Conventional radiation therapy techniques: determination of treatment volume

portals and learn managements for primary treatment and boost; • 3-D conformal radiation therapy: determination of volumes, portals and beam

arrangement, including use of Novalis-focused beam radiation; • Brachytherapy for endobronchial tumors;

o Nasopharynx: • Volumes/portals/doses of irradiation and boost; conformal radiation therapy;

o Nasal cavity/sinuses: • Radiation therapy, including 3-D radiation therapy, techniques, including

determination of treatment role; o Salivary gland:

• Radiation therapy techniques, including determination of appropriate treatment volume;

• Use of wedge pair; combination photon/electron fields; o Oral cavity:


o Tonsillar fossa/faucial arch: • Radiation techniques, including determination of appropriate treatment

volume, iuse of intensity-modulated radiation therapy and altered fractionation;

o Base of tongue/oropharynx, including soft palate: • Radiation therapy techniques, including determination of appropriate

treatment volume; o Hypopharynx:


o Larynx: • Radiation therapy techniques, including determination of treatment volumes,

including altered fractionation and importance of fraction size in glottic cancer; clinical determination of field sizes;

o Other, as appropriate: • Metastatic disease to bone, brain, etc.

• Determine basic critical organ tolerance dose parameters and begin to integrate this

information into the patient’s radiation therapy treatment plan. Particular attention should be paid to lung, heart, spinal cord and esophagus tolerances.

• Identify and learn to manage acute, subacute and chronic side-effects of patients under

treatment and in follow-up, and to counsel/advise patients of appropriate pre-evaluation, treatment and follow-up measures for each of the disease categories, including:

o Fatigue; o Cytopenia; o Skin: reaction/dermatitis; o Esophagitis/xerostermia/nutritional problems; o Pneumonitis/fibrosis; o Screening for second malignancies; o Other necrosis/dental problems.

• Demonstrate caring behaviors; • Counsel and communicate effectively with the thoracic/head & neck cancer patient

population and their families and with other health care providers, including nutritional and dental professionals;

• Acknowledge and act upon the recognition of the opportunity to assist patients, family

members and society in dealing with smoking, and provide appropriate resources to achieve smoking cessation in patients and family members.



Professionalism


The PGY 2-3 resident is expected to begin acquiring experience in those skills associated with practice-based learning & improvement, interpersonal & communication skills, professionalism, and systems-based practice, as may be appropriate for patients with these cancers.


• Begin to locate, appraise and assimilate evidence from scientific studies related to head &

neck/thoracic cancer patients, ie, become familiar with scientific evidence as may be presented in a standard textbook.


studies and other information on diagnostic and therapeutic effectiveness: describe study design of major randomized studies and non-randomized studies that support the use of radiation, including those employing altered fractionation and chemoradiation.





• Begin developing and sustaining a therapeutic and ethically sound relationship with head &

neck/thoracic cancer patients. This is begun during consultation, continues during simulation, and develops during the course of treatment.


elicit and provide information to and about head & neck/thoracic cancer patients. This occurs during patient interactions and in discussion with attendings, nurses, therapists, and administrative personnel.

• Work effectively with others as a member of, or leader of a health care team, eg, attendance

and participation at radiation therapy and multidisciplinary team meetings.

Professionalism

• Demonstrate respect, compassion, integrity, and responsiveness to the needs of the head &

neck/thoracic cancer patient. • Begin to be able to obtain informed consent from head & neck/thoracic cancer patients,

including those entering protocols. • Begin to demonstrate commitment to ethical principles pertaining to permission/withholding

of clinical care to head & neck/thoracic cancer patients, especially those treated for palliative purposes.

• Begin, under the guidance of the attending, to gain experience in billing issues.

• Demonstrate sensitivity/responsiveness to the head and neck cancer and thoracic/lung cancer patients’ background, culture, and age.




resources, while not compromising quality of care. • Begin to help patients deal with health system complexities, eg, scheduling issues relating to

radiation, chemotherapy, dental appointments, etc.


Yuhchyau Chen MD PhD & Hong Zhang MD PhD

2nd

Rotation (PGY4-5)

In addition to developing proficiency in the skills associated with each of the competencies outlined in the Goals and Objectives for the PGY2-3 rotation, the PGY4-5 resident is expected to acquire knowledge and gain proficiency in the following areas associated with each of the competencies. In addition, residents on White Service for their 2nd rotation are required to pass 10 independent simulations for head and neck patients, and 10 simulations for lung patients (including tumor volume, prescription, and treatment planning) during the 2nd rotation.

Medical Knowledge

• Classify the pertinent supportive literature and studies related to the role of radiation therapy

and associated oncologic disciplines and the results/outcome of treatment for each of the disease categories and sites by stage.

• Proficiency in identifying the prognostic factors for head and neck cancer and thoracic

malignancies. • Thoroughly discuss controversial areas in the treatment of head and neck cancer and thoracic

malignancies: o Role of surgery in superior sulcus carcinoma; o Role(s) of surgery and chemoradiation in Stage III A/B lung cancer; o Sequence of chemotherapy and radiation, altered fractionation and appropriate

treatment volume for small cell lung carcinoma; o Use of neutrons or accelerated fractionation for salivary gland cancer; o Retreatment of recurrent nasopharyngeal carcinoma.

• Differentiate unusual head and neck cancers and thoracic malignancies, including their

presentation and management, and the role of radiation therapy: o Thyroid cancer: differentiated (papillary/follicular; medullary/Hurthle cell;

anaplastic); o Tracheal malignancies; o Mesothelioma; o Thymoma; o Adnexal carcinomas; o Pleomorphic adenoma; adenoid cystic carcinoma; o Merkel cell carcinoma; o Glomus tumors/chemodectomas; o Angiofibroma; o Estherioneuroblastoma.

• Differentiate the need for the use of systemic chemotherapy, gene therapy and other new and developing modalities as they are applicable to head and neck cancers and thoracic malignancies, including opportunities for chemoprevention and for clinical and translational research in this area. This includes radiation sensitizers and hyperfractionation/altered fractionation trials in non-small cell and small cell lung cancer, and head and neck cancers.

Patient Care

• Undertake all aspects of patient care related to head and neck cancer and thoracic/lung cancer

patients, including initial assessment, formulation and implementation of treatment plans, discussion with family members and referring physicians, treatment prescription and interpretation with other treatment modalities.






and their families on issues related to head and neck cancers and thoracic malignancies, and its treatment and side effects/complications of treatment.





suggestions for improving the service and rotation). • Obtain information from the larger population from which the head and neck cancer and

thoracic/lung cancer patients are drawn.


• Fully sustain a therapeutic and ethically sound relationship with head and neck cancer and

thoracic/lung cancer patients. • Use effective listening, non-verbal, explanatory, questioning and writing skills to elicit and

provide information to and about head and neck cancer and thoracic/lung cancer patients. This includes more active participation/discussion in multidisciplinary conferences.

• Work effectively with other health care providers as a member and leader of the health care team. The PGY4-5 resident is expected to lead the weekly patient-under-treatment rounds.

Professionalism





care, and describe these activities affect system performance. This includes partnering with administrative personnel or nurses to coordinate a patient’s ongoing multidisciplinary care.



BLUE SERVICE

Learning Objectives: See attached (Please see Education Calendar for other weekly conference information) Weekly Service Schedule:


Didactic

Education




Clinical

Education

SIMS Team Meeting 11:00-12:00

Suite A (Lymphoma Clinic)

OTV FU

SIM 10:30,11:00

Didactic

Education

12.00-1.00 pm Pediatric Brain Tumor Conference/ 12.30-1.30 pm Lymphoma Tumor Board


Clinical

Education

OTV Consults Consults

Consults

Didactic

Education





End of day

unscheduled

activities


Evenings







Service Responsibilities/Assignments: Responsibility: Competency: • Complete three pediatric case presentations during the three-month rotation, as

described in the attached objectives. • Complete two service presentations (1 lymphoma – HD or NHL case, 1 sarcoma

case) during the three-month rotation, as described in the attached objectives. • Completion of weekly patient-on-treatment service list, staging sheets and treatment





• 1,2,3,4,5,6 • 1,2,3,4,5,6 • 1,3,4 • 1,2 • 5 • 1,2,3,6 • 2,3,6 • 2,3,6 • 1,4,5,6









BLUE SERVICE – OBJECTIVES

Louis S Constine MD

All PGY Levels

Residents will evaluate adult patients with sarcomas and lymphoid malignancies and pediatric patients with solid tumors, lymphoid malignancies and central nervous system tumors. These patients are discussed and evaluated in a multidisciplinary setting in the multidisciplinary lymphoma clinic and the pediatric oncology conference. The rotation provides the resident the opportunity to work closely with pediatric surgical oncologists, orthopedic oncology, and pediatric and adult medical oncologists, in a multidisciplinary fashion. In addition, the resident gains training, experience, and eventual proficiency in the management of these groups of adult and pediatric patients during consultations of patients in the radiation oncology department, weekly patient under treatment, and follow-up clinics. The resident is expected to see each patient under treatment on a weekly basis and a majority of the follow-up patients, under the direction of the attending. The resident is expected to gain training experience and eventual proficiency in the treatment planning of patients with pediatric malignancies and adult lymphoid and soft tissue malignancies using external beam technique and 3D-CRT and brachytherapy as appropriate. While the resident will not likely gain direct experience in every site and/or stage of disease, it is expected that enough experience will have been gained during the rotation for the resident to be able to apply the knowledge and experience to the unique situation when it presents itself. During each three-month rotation, the resident on Blue Service must prepare one pediatric case presentation per month. These presentations will take place on the 2nd Friday of each month at 4.00 pm in the Pediatric Oncology Multidisciplinary Conference. The format will be a rapid case presentation, including radiology and pathology (10 mins), followed by an in-depth problem-oriented case discussion (approx 20 mins) to decide on difficult patient decisions. In addition, during each three-month rotation, the resident on Blue Service must prepare one lymphoma (Hodgkin’s Disease or non-Hodgkin’s Lymphoma) and one sarcoma case presentation. These presentations will be held on the first Thursday of the 2nd and 3rd months at 4.00 pm. Each case presentation will preferably be on a patient whose treatment approach is still under consideration. However, in an effort to attack a spectrum of topics, a patient can be presented who has previously been seen. The resident on service will review 3-5 journal articles central to decision-making, and present a synopsis. PowerPoint presentations are not required. Dr Constine will then assume the role of an ABR board examiner and quiz the resident. All other residents will be invited and all attending will be quizzed. We will keep an ongoing record of relevant reports, which will thus be updated and enlarged.


• Hodgkin’s Disease • Non-Hodgkin’s lymphoma • Wilm’s Tumor • Neuroblastoma • Rhabdomyosarcoma/soft tissue sarcoma • Pediatric CNS tumors • Soft tissue tumor


Louis S Constine MD

1st Rotation (PGY 2-3)

For each of the different sites/categories listed below, the resident is expected to acquire the appropriate knowledge and skills outlined below. • Pediatric solid and CNS

o Retinoblastoma o Wilm’s Tumor o Neuroblastoma o Rhabdomyosarcoma/soft tissue sarcoma o Lymphoma: Hodgkin’s disease/non-Hodgkin’s disease o Leukemia o Pediatric CNS tumors: PNET, medulloblastoma, ependymoma,

craniopharyngioma o Ewings’ sarcoma and other bone tumor

• Adult lymphoma/leukemia

o Hodgkin’s Disease o Non-Hodgkin’s lymphoma including extranodal sites o Leukemia o Multiple myeloma/plasmacytoma

• Bone/soft tissue

o Osteosarcoma o Soft tissue tumor (extremity/retroperitoneal) o Kaposi’s sarcoma o Desmoid

Medical Knowledge


lymphatics). • Explain radiation effects on organs of interest and surrounding normal tissue, with

particular attention to late effects in the pediatric population. • Identify epidemiologic and etiologic risk factors, tumor markers/molecular genetics. • Discuss the principles of multidisciplinary management and treatment and,

specifically, the role of radiation therapy for each of the disease sites and according to disease stage:

o Pediatric Tumors: Childhood CNS: • Medulloblastoma (PNET): role of craniospinal irradiation; • Ependymoma: role of involved field radiation therapy; • Glioma: low grade or high grade intact brain stem; • Craniopharyngioma: role of post-operative radiation therapy;

• Childhood solid tumors: • Wilms: radiation therapy treatment by stage; • Neuroblastoma; • Rhabdomyosarcoma: known usual radiation treatment approach by

site and disease extent; • Lymphoma: use of radiation for non-Hodgkin’s lymphoma and

Hodgkin’s Disease; o Adult Lymphoma/Leukemia:

• Hodgkin’s Disease: appropriate use of irradiation +/- chemotherapy by stage of disease;

• Non-Hodgkin’s Lymphoma: use of radiation by stage/extent of disease +/- chemotherapy;

• Multiple myeloma/leukemia: role of radiation therapy for bone marrow transplant or SC transplant;

o Bone/Soft tissue sarcoma: • Use of radiation therapy for soft tissue sarcoma of extremeties and

retroperitoneum; o Adult CNS:

• Including pituitary, CNS lymphomas. • Describe the principles of treatment of the lymph node region for each of the disease

categories by stage of disease. • Determine and apply principles of radiological physics and radiobiology appropriate

to radiation therapy for each of the disease categories. • Acquire basic knowledge of controversial areas or unusual situations in each of the

disease categories, including those regarding: • Craniospinal vs. local field radiation for pediatric brain tumors; • Alternative fractionation schemes for pediatric brain tumors; • Principle of management of brain tumors in young children/infants; • Radiation fields and doses for neuroblastomas, Wilms, Rhabdomyosarcomas,

depending on site of disease, stage and age; • Hodgkin’s Disease/Non-Hodgkin’s Disease: doses and treatment fields according

to each stage of disease; • CNS lymphoma.

Patient Care

• Gather and organize essential important information about a patient with pediatric

malignancies, lymphoreticular or soft tissue malignancies, including taking an accurate history of present illness, past medical/surgical history, allergies, social/family history, particularly as they pertain to the current illness.

• Complete a full physical examination and be able to evaluate all hematological,

biochemical, and radiologic studies used to assess the patient. • Determine whether radiation is appropriate, based on diagnostic information and

medical/scientific information, using clinical judgment. • Complete chart appropriately, including timely completion of staging sheets,

consultation notes, treatment notes, and summaries. • Develop and implement patient management plans for each of the different categories

listed, according to stage of disease and the clinical clinical situation. • Perform radiation therapy techniques and evaluate treatment plans and dosimetry for:

o PNET/medulloblastoma: craniospinal irradiation including volume and dose determination, field gaps and local field (boost) radiation;

o Other childhood brain tumors: determination of field volumes and fractionation;

o Childhood solid tumors: determine treatment volumes and doses for a variety of solid tumors;

o Hodgkin’s Disease/Non-Hodgkin’s Lymphoma: determine volume and doses for typical presentation of patients with Hodgkin’s disease, including mantle field, para-aotic field, inverted-Y fields; learn principles of field gapping;

o Soft tissue sarcoma: determine fields/volume and doses in pre-operation vs. post-operative situation.

• Identify basic critical organ dose parameters including pediatric dose guidelines, and

begin to integrate this information into the patient’s radiation therapy treatment plan. • Gain experience in the use of 3D treatment planning and IMRT as these modalities

become integrated into the therapy of pediatric malignancies and adult lymphoid and soft tissue tumors.

• Demonstrate caring behavior, communicate effectively with this population of

patients, particularly the pediatric population, and their parents and families, and work effectively with other health care providers, including nurses, therapists, and social workers.

• Identify and manage the side-effects of patients under treatment and seen in follow-up, including counseling of pediatric patients and survivors of appropriate follow-up measures (eg, cardiac screening, mammograms, etc).



Professionalism


The PGY 2-3 resident is expected to begin acquiring experience in those aspects of practice-based learning & improvement, interpersonal & communication skills, professionalism, and systems-based practice, as may be appropriate for patients with these cancers:


• Begin to locate, appraise and assimilate evidence from scientific studies related to

pediatric malignancy patients or adult patients with soft tissue or lymphoid malignancies, ie, become familiar with scientific evidence as may be presented in a standard textbook.

• Begin to apply knowledge of study design and statistical methods in order to appraise

clinical studies and other information on diagnostic and therapeutic effectiveness. • Use information technology to manage information, access on-line medical

information and support own education. • Assist/facilitate the learning of students and other health care providers, including

nurses, therapists, and other junior residents.


• Begin developing and sustaining a therapeutic ethically sound relationship with

pediatric malignancy patients or adult patients with soft tissue or lymphoid malignancies.

• Begin using effective listening, non-verbal, explanatory, questioning, and writing

skills to elicit and provide information to and about pediatric malignancy patients or adult patients with soft tissue or lymphoid malignancies.

• Work effectively with others as a member of, or leader of a health care team.

Professionalism

• Demonstrate respect, compassion, integrity, and responsiveness to the needs of the

pediatric malignancy patients or adult patients with soft tissue or lymphoid malignancies.

• Begin to be able to obtain informed consent from pediatric malignancy patients or

adult patients with soft tissue or lymphoid malignancies, including those entering protocols.

• Begin to demonstrate commitment to ethical principles pertaining to

permission/withholding of clinical care to pediatric malignancy patients or adult patients with soft tissue or lymphoid malignancies.

• Begin to gain experience in billing issues. • Demonstrate sensitivity/responsiveness to the patients’ background, culture, and age.


• Begin to determine how his/her patient care and other professional practices affect

other health care providers (eg, therapists). • Begin to practice health care that is cost-effective, and begin to learn how to alleviate



Louis S Constine MD

2nd

Rotation (PGY4-5)

In addition to gaining proficiency/expertise in the skills associated with each of the competencies outlined above in the goals and objectives of the PGY2-3 rotation, the PGY4-5 resident is expected to acquire knowledge and gain additional proficiency in the following areas, as they pertain to pediatric malignancy patients or adult patients with soft tissue or lymphoid malignancies:

Medical Knowledge

• Classify the pertinent scientific literature and studies related to the role of radiation

therapy for this population of malignancies. Describe the principles of randomized and non-randomized trials, especially POG/COG trials that support radiation therapy.

• Proficiency in identifying controversies in the treatment of this population

malignancies, including: o Hodgkin’s Disease:

Treatment of bulky mediastinal disease; Treatment of Hodgkin’s Disease during pregnancy or associated with

HIV; o Non-Hodgkin’s Lymphoma:

Treatment appropriate for extranodal lymphoma. • Differentiate the need for the use of systemic therapy, gene therapy and other new

modalities as they are applicable to this group of patients, and the integration of these modalities with radiation therapy.

• Differentiate unusual neoplasms, including their presentation and management:

o Bilateral Wilm’s tumor; o Radiation of benign disease, including keloid, macular degeneration, desmoid.

Patient Care

• Undertake all aspects of patient care related to pediatric malignancy patients or adult

patients with soft tissue or lymphoid malignancies, including initial assessment, formulation and implementation of treatment plans, discussion with family members and referring physicians, treatment prescription and interpretation with other treatment modalities.

• Maturation of written consultations is expected, with emphasis on delineation of plan of management and, when appropriate, reference to pertinent literature to substantiate recommendations.

• Identify critical organ dose parameters, including DVH analysis, affect of

chemotherapy and other factors, and fully integrate this information into patients’ radiation therapy treatment plans.

• Gain proficiency in managing side-effects during and after therapy and in counseling

patients and their families on issues related to these cancers, and their treatment and side effects/complications of treatment.

• Gain proficiency in performing techniques and prescriptions (including alternative

treatment arrangements), formulate treatment plans and dosimetry according to accepted guidelines for each of the disease sites, according to stage of disease and the clinical situation.



suggestions for improving the service and rotation). • Obtain information from the larger population from which these patients are drawn.


• Fully sustain a therapeutic and ethically sound relationship with pediatric malignancy

patients or adult patients with soft tissue or lymphoid malignancies. • Use effective listening, non-verbal, explanatory, questioning and writing skills to

elicit and provide information to and about pediatric malignancy patients or adult patients with soft tissue or lymphoid malignancies.

• Work effectively with other health care providers as a member of the health care

team.

Professionalism



• Identify how his/her health care practices affect health care providers and the larger

society, and how elements of the system affect his/her own practice. • Partner with health care managers and providers to assess, coordinate and improve

health care, and describe how these activities affect system performance.



HH SERVICE


Weekly Service Schedule: MON TUES WED THURS FRI Wk/ends

Didactic

Education

7.30-8.30 am Breast

Conference (JA)

8.00-9.00 am Surgical

Conference (monthly)

8.00-9.00 am NP Conference/

Work Rounds (present hallmark article & brief background of new pt)

7.30-9.00 am GYN Tumor

Board

Clinical

Education

Consults (JA)

OTVs/HDRs

(JA)

Cons/FUps

(JA)

1-HDRs (JA) 2-Rectal Clinic (MT) 3-PSIs (HZ)

SIMs (JA) (overflow)

Didactic

Education

Clinical

Education

F/Ups (JA)

OTVs/HDRs (JA) End @ 4.00 pm to

return to SMH

SIMs (JA)

End @ 4.00 pm to return to

SMH

1-HDRs (JA) 2-Rectal Clinic (MT) 3-PSIs (HZ)

Chief Resident Administration

Didactic

Education

4.30-6.00 pm Dosimetry



End of day

unscheduled

activities


Evenings

1 = Primary Responsibility: A = Priority; B = Next Priority; etc 2 = Secondary Responsibility Assessments/Evaluations:











• 1,3,4 • 1,2 • 5 • 1,2,3,6 • 2,3,6 • 2,3,6 • 1,4,5,6









HH SERVICE - OBJECTIVES

Joy Anderson MD

All PGY Levels

Residents will evaluate adult patients with gynecologic, gastrointestinal, thyroid and other malignancies. These patients are seen in the Department of Radiation Oncology at Highland Hospital and, because of the close proximity of the Department of Medical Oncology, are seen in a multidisciplinary context with medical oncologists, and other support personnel. The rotation at Highland Hospital also affords the resident with the experience of training in a community hospital setting. In addition, the resident gains training experience and eventual proficiency in the management of patients with gynecologic, gastrointestinal, thyroid and other malignancies during consultation of patients outside the multidisciplinary setting, weekly patient-under-treatment visits, and follow-up clinics. The resident is expected to see each patient under treatment on a weekly basis and a majority of the follow-up patients, under the supervision of the attending. The resident is expected to gain training experience and eventual proficiency in the simulation and treatment planning of patients with gynecologic, gastrointestinal, thyroid and other malignancies using external beam techniques, and brachytherapy (including LDR and HDR intracavitary brachytherapy) techniques as appropriate. While the resident will not likely gain direct experience in every site and/or stage of disease, it is expected that enough experience will have been gained during the rotation for the resident to be able to apply the knowledge and experience to the unique situation when it presents itself.


• Treatment of cervical cancer • Treatment of endometrial cancer • Treatment of ovarian cancer • Treatment of vulval cancer • Treatment of vaginal cancer • Treatment of thyroid cancer


Joy Anderson MD


Medical Knowledge

• Describe anatomy as appropriate for patients with gynecologic, gastrointestinal, thyroid and

other malignancies, and relevant regional anatomic structures (draining lymphatics). • Explain radiation effects on organ of interest and surrounding normal organs/tissue:

acute/chronic radiation effects; complications. • Identify epidemiologic and etiologic risk factors, tumor markers/molecular genetics for

breast cancer. • Discuss the natural history, clinical presentation and diagnostic work-up, staging and

clinicopathologic manifestation of gynecologic, gastrointestinal, thyroid, and other malignancies.

• Describe the principles of multidisciplinary treatment and management for each site and

stage: o Cervical cancer o Endometrial cancer o Ovarian cancer o Vulval cancer o Vaginal cancer o A variety of other malignancies, including gastrointestinal, genitourinary, breast and

thyroid malignancies, including the use of chemotherapy and surgery, and other modalities of treatment.

• Determine and apply the principles of radiological physics and radiobiology appropriate for

radiation therapy to each of these sites: o Time dose parameters, including treatment duration for cervical cancer; o Specific medical knowledge:

• Cervix: • Time-dose parameters (treatment duration); • Use of concomitant chemoradiation; • Use of neoadjuvant chemotherapy; • Role of post-operative radiation therapy;

• Endometrial: • Indications for pre-operative/post-operative XRT (pelvis and extended

field) and brachytherapy; • Radiation therapy alone for endometrial cancer;

• Vulva: • Definitive chemoradiation, including inguinal radiation; • Indications for post-operative radiation therapy;

• Vaginal: • Use of external beam radiation and brachytherapy;

• Ovarian: • Indications for whole abdominal/pelvic radiation post-operatively; • Radiocolloid therapy;

• Gastrointestinal cancer: • Use of external beam for rectal cancer, and other gastrointestinal tract

cancers; • Endorectal brachytherapy (papilloma);

• Thyroid cancer: • Use of external beam therapy; • Use of radio-iodine treatment.

Patient Care

• Gather and organize essential important information about patients with gynecologic,

gastrointestinal, thyroid and other malignancies, including taking an accurate history of present illness, past medical/surgical history, allergies, social/family history, particularly as they pertain to the current illness.


and radiologic studies used to assess the patient with gynecologic, gastrointestinal, thyroid and other malignancies.



notes, treatment notes, and summaries. • Develop and implement patient management plans for gynecologic-oncology patients,

gastrointestinal cancer patients, thyroid malignancies, and other malignancies, including determination of context of treatment (palliative/definitive) and integration of radiation with other modalities of threatment, including surgery and/or systemic or chemotherapy for each of the sites/stages of disease.

• Perform radiation therapy technologies (including 3-D CRT, IMRT) in addition to

evaluation, treatment planning and dosimetry for irradiation of: o Gynecologic malignancies:

• Cervix: • Treatment volume/dose of EBT: pelvis or para-aortic radiation

therapy; • Brachytherapy: treatment planning/performance of HDR/LDR;

• Endometrium: • Treatment volume/dose of EBT; • Brachytherapy: HDR brachytherapy;

• Vagina: • Treatment volume/dose; • Brachytherapy techniques;

• Vulva: • Treatment volume/dose;

• Ovary: • Treatment volume;

o Gastrointestinal malignancies: • Rectal cancer:

• EBRT; • Endocavitary radiation therapy (Papillon technique);

• Thyroid malignancies: • EBRT; • Use of radioactive iodine;

• Other miscellaneous disease sites (eg, GU; Breast; Head & Neck) • EBRT techniques; • Prostate seed implants; • Brachytherapy for breast cancer;

• Determine basic critical organ dose parameters and begin to integrate this information into

the patients radiation therapy treatment planning. • Gain experience in the use of 3-D CRT as this becomes integrated into treatment. • Demonstrate caring behaviors and communicate effectively with gynecologic cancer patients

and other patients and their families, and work effectively with other health care providers, including nurses, therapists and social workers.

• Manage side-effects of patients under treatment and in follow-up, and counsel patients on

appropriate follow-up measures (eg, regular examinations).



Professionalism




• Begin to locate, appraise and assimilate evidence from scientific studies related to patients

with gynecologic, gastrointestinal, thyroid and other malignancies, ie, become familiar with scientific evidence as may be presented in a standard textbook.

• Begin to apply knowledge of study design and statistical methods in order to appraise clinical studies and other information on diagnostic and therapeutic effectiveness.






gynecologic, gastrointestinal, thyroid and other malignancies. • Begin using effective listening, non-verbal, explanatory, questioning, and writing skills to

elicit and provide information to and about patients with gynecologic, gastrointestinal, thyroid and other malignancies.

• Work effectively with others as a member of, or leader of a health care team.

Professionalism


with gynecologic, gastrointestinal, thyroid and other malignancies. • Begin to be able to obtain informed consent from patients with gynecologic, gastrointestinal,

thyroid and other malignancies, including those entering protocols. • Begin to demonstrate commitment to ethical principles pertaining to permission/withholding

of clinical care to patients with gynecologic, gastrointestinal, thyroid and other malignancies. • Begin to gain experience in billing issues. • Demonstrate sensitivity/responsiveness to the patients’ background, culture, and age.



health care providers (eg, therapists). • Begin to practice health care that is cost-effective, and begin to learn how to allocate



Joy Anderson MD

2nd

Rotation (PGY4-5)

In addition to gaining proficiency/expertise in the skills associated with each of the competencies outlined above in the goals and objectives of the PGY2-3 rotation, the PGY4-5 resident is expected to acquire knowledge and gain additional proficiency in the following areas, as they pertain to the breast cancer patient.

Medical Knowledge

• Classify the pertinent scientific literature and studies related to the role of radiation therapy

and associated oncologic disciplines for patients with gynecologic, gastrointestinal, thyroid and other malignancies.

• Proficiency in identifying prognostic factors for patients with gynecologic, gastrointestinal,

thyroid and other malignancies. • Discuss controversies in the treatment of patients with gynecologic, gastrointestinal, thyroid

and other malignancies, including: o Gynecologic malignancies:

Post-operative radiation therapy after radical hysterectomy; Treatment of incidental carcinoma of cervix after hysterectomy; Use of chemotherapy for cervical cancer; Recurrent cervical cancer; Carcinoma of the cervical stump; Adjuvant radiation therapy +/- brachytherapy for various stages of

endometrial cancer; Radiation for vaginal recurrence of endometrial cancer; Indication of radiation therapy for ovarian cancer;

o Gastrointestinal malignancies: Rectal cancer: use of radiation and endocavitary radiation therapy for

sphincter preservation. • Differentiate the need for the use of systemic therapy, gene therapy, and other new modalities

as applicable to patients with gynecologic, gastrointestinal, thyroid and other malignancies. • Differentiate unusual neoplasms, including their presentation and management, including:

o Vaginal melanoma/lymph node adenocarcinoma; o Small cell carcinoma – cervix; o Uterine sarcoma; o Carcinoma of cervix during pregnancy; o Dysgerminoma; o Granulosa cell tumor.

Patient Care

• Undertake all aspects of patient care related to patients with gynecologic, gastrointestinal,

thyroid and other malignancies, including initial assessment, formulation and implementation of treatment plan, discussion with patients and family, and with the referring physician, treatment prescription and integration with other treatment modalities.

• Maturation of written consultation is expected, with emphasis on delineation of plan of

management and, when appropriate, reference to pertinent literature to substantiate recommendation.


other factors, and fully integrate this information into patients radiation therapy treatment plan.


and their families on issues related to gynecologic, gastrointestinal, thyroid and other malignancies, and their treatment and side effects/complications of treatment.





suggestions for improving the service and rotation). • Obtain information from the larger population from which the patients with gynecologic,

gastrointestinal, thyroid and other malignancies are drawn.


• Fully sustain a therapeutic and ethically sound relationship with patients with gynecologic,

gastrointestinal, thyroid and other malignancies. • Use effective listening, non-verbal, explanatory, questioning and writing skills to elicit and

provide information to and about patients with gynecologic, gastrointestinal, thyroid and other malignancies.

• Work effectively with other health care providers as a member of the health care team.

Professionalism








Medical Oncology Rotation

Division of Hematology/Medical Oncology, Strong Memorial Hospital

Course Director: Deepak Sahasrabudhe MD

Key to Core

Competencies:


Goals: Competencies:

• Gain a broad perspective and understanding of the discipline of medical oncology in the diagnosis and management of patients with malignant disease.

• Learn about the major cancer sites in which medical oncology has a significant role (eg, GI, breast cancer, lung cancer), and learn about their role in other areas that are unique to or specific to medical oncology (eg, myeloma, leukemia).

• Understand how to work with health care professionals from other disciplines to provide patient-focused care in the medical oncology setting.

• Demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value and appropriate to this patient population.

• Understand how your patient care and other professional practices affect health care professionals, and how these elements of the system affect your own practice.

• Learn how the Medical Oncology practice differs from others. • Know how to partner with health care managers and health care providers to assess,

coordinate, and improve health care and know how these activities can affect performance in this discipline.

• 1,2 • 1,2 • 1 • 6 • 6 • 6 • 6

Description:

Each resident will rotate through the Ambulatory Care services, performing consultations and participating in clinics and conferences. Schedule of Activities: Week 1: Week 2:

Hematology/Oncology/Vascular Medicine, Ambulatory Care, SMH

Learning Objectives: Competency:

Week 1&2 – Ambulatory Care In Hematology, Medical Oncology And Vascular Medicine: • Know the signs and symptoms of common cancers, their diagnostic evaluation,

natural history, and therapy. • Know the signs and symptoms, diagnostic evaluation, natural history, and therapy of

common hematologic malignancies such as lymphoma, leukemia, myeloma etc. • Understand diagnostic evaluation and principles governing the treatment of common

coagulopathies. • Understand the principles of cancer therapy including chemo-, hormonal-, and

biologic-therapy. • Understand the management of common complications of therapy including

myelosuppression, infection, hemorrhage, nausea, vomiting, and renal and cardiac failure.

• Recognize the occurrence of oncologic emergencies; such a neutropenic fever, spinal cord compression, hypercalcemia, etc.

• Understand the management of pain and the use of narcotic analgesics and adjunctive medications.

• Understand the principles of terminal care of patients including hospice programs, ethical, and emotional issues.

• Know the long term complications of cancer and its therapy. • Understand the rationale for clinical trials in cancer and development of new

therapies. • Understand cancer prevention techniques.

Week 1&2: • 1,2 • 1,2 • 1,2,3 • 1,2,3 • 1,2,3 • 1,2,3 • 1,2,3 • 1,2,4,5 • 1,2,3,4,5 • 3,6 • 3,6

Rotation Assignments/Additional Requirements: REQUIRED READING:

• Residents receive a syllabus, prepared by Dr Deepak Sahasrabudhe, describing the principles of general management and specific cancers.

• Bethesda Handbook of Clinical Oncology • The Washington Manual of Oncology

RESIDENT EVALUATION/ SURVEY REQUIRED:


TEST/EXAM REQUIRED:

To receive a grade of Satisfactory, the resident must: • attend conferences; • complete and submit a case log of all patients seen and their

diagnosis (see attached); • present a patient case to the Department of Radiation Oncology in

which medical oncology played a critical role in the patient’s evaluation and/or treatment. The quality of these presentations will be evaluated.

• receive a satisfactory evaluation from his/her preceptors.

Weekly Didactic Schedule:

MON TUES WED THURS FRI

AM

8.00-9.00 am Clinical Case Management Conference

8.00-9.00 am Medicine Grand

Rounds

8.00-9.00 am DRO Lecture

8.00-9.00 am Fellowship Conference

8.00-9.00 am Oncology Fellows

Conference

NOON

12.30-1.30 pm

Hematopathology Conference

11.30-1.00 Breast

Conference

11.30-12.30 BMT Health Team

Rounds

12.00-1.00 pm Clinical Pathology

Conference

12.00-1.00 pm

Cancer Center Grand Rounds

PM

4.30-6.00 pm DRO Lecture


4.30-6.00 pm DRO Conference



Diagnostic Imaging Rotation

Department of Imaging Sciences, Strong Memorial Hospital

Course Director:

David Dombroski MD

Key to Core

Competencies:



• Gain an understanding of a variety of common malignancies as they manifest in various diagnostic imaging studies.

• Understand the appropriate utilization of imaging modalities in the diagnosis of malignancies, including differential diagnosis of benign versus malignant disease.

• Understand how to work with health care professionals from Radiology to provide patient-focused care

• Demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.


• Learn how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources in Radiology.

• Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect performance.

• 2 • 1,2 • 1 • 6 • 6 • 6 • 6

Description:

Each resident will rotate through the following Imaging Services: CT, MRI, Neuro-Radiology, Mammography, Ultrasound, Nuclear Medicine, and PET/CT. In addition, residents should be exposed to pediatric radiology cases during this rotation. Additional time may be spent in the following areas: General Radiology, GI/GU Radiology, and Angiography. During the course of this rotation, the resident will become acquainted with radiographic examinations and procedures, and will be exposed to radiographic appearance of common malignancies for both adult and pediatric patients, involving the following:

• Brain and spine (neuro-oncology) • Head and neck (otolaryngologic malignancies) • Chest (lung cancer, esophageal cancer, and mediastinal masses) • Abdomen (malignancies of the gastrointestinal system) • Pelvis (genitourinary and gynecologic malignancies) • Musculoskeletal, vascular, and reticuloendothelial

Schedule of Activities: Week 1: CT/MRI Head & Neck, neuro-radiology Week 2: CT/MRI Body, cross-sectional imaging Week 3: Mammography/Ultrasound/Nuclear Medicine/PET-CT Plus exposure to Pediatric Radiology cases Key to Core

Competencies:


Learning Objectives: Competencies: Week 1 – CT/MRI Head & Neck/Neuro-radiology: • Interpret CT and MRI images of the nasopharynx, oropharynx, hypopharynx, larynx,

paranasal sinuses, and salivary gland. • Identify the defined head and neck regional lymph node levels on CT and/or MRI. • Recognize typical CT and T1- and T2-weighted MRI appearances of primary brain

tumors and metastatic lesions.

Week 1: • 2,3,6 • 2,3,6 • 2,3,6

Week 2 - CT/MRI Body: • Interpret CT and MRI images of various anatomic regions, eg, thoracic, abdomen,

pelvis. • Identify the lymph node maps of the lung on CT. • Recognize lymphadenopathy in the supraclavicular fossa, axillary region,

abdominal/retroperitoneal iliac areas, inguinal area, and other defined areas. • Observe a CT-guided biopsy. • Understand the uses of contrast agents in radiologic practice.

Week 2: • 2,3,6 • 2,3,6 • 2,3,6 • 2 • 2

Week 3 – Mammography/Ultrasound/Nuclear Medicine/PET-CT: • Observe mammography, stereotactic core needle biopsy, ultrasound core needle

biopsy, wire localization and post-lumpectomy mammogram. • Be knowledgeable of the science of mammography and the mammographic

appearance of benign and malignant breast lesions. • Identify using CC and MLO views of the breast quadrant location of a lesion. • Observe an ultrasound-guided biopsy. • Become knowledgeable of the science of ultrasonography as applied to the

evaluation of gynecologic malignancies, prostate pathology (transrectal ultrasound), and gastrointestinal abnormalities (endoscopic ultrasonography).

• Observe an administration of therapeutic I-131. • Identify on PET scan areas of abnormal and normal distribution and correlate these

with abnormalities on CT scan. • Learn the appropriate use of PET imaging in the diagnosis of new and recurrent

malignancies. • Learn the differential diagnosis of PET scan findings. • Understand the biological basis for the use of PET scanning and the techniques

involved. • Identify on gallium-67 scan, indium-111 prostaScint scan, and bone scan areas of

normal and abnormal distribution.

Week 3: • 2 • 2 • 2,3 • 2 • 2,3 • 1,2,3,6 • 2,3,6 • • • • 2,3,6

Pediatric radiology cases: • Learn a logical approach to pediatric imaging studies and be able to interpret and

evaluate imaging studies of pediatric patients and provide a differential diagnosis. • Acquire an understanding of the role of the radiologist as a consultant involved in

the patient care team.

• 1,2 • 4,6


• Oncologic Imaging, 2nd Edition. Bragg, Rubin, and Hricak: - Brain, Spinal Cord, and Head and Neck Tumors (Chapters

11-15); - Thorax (Chapters 18-19); - Breast Cancer (Chapters 16-17); - Gastrointestinal System, Genitourinary and Gynecologic

Cancer and Lympho-proliferative Neoplasms – chapters of interest.

• AJCC Cancer Staging Manual, 6th Edition: - Part II: Head and Neck Sites; - Part IV: Thorax & Part XII: Lymphoid Neoplasms - Part VII: Breast.

• Review the teaching file at Highland Hospital Women’s Health Clinic.

• Nuclear Medicine: The Requisites, 2nd Edition. Thrall and Ziessman - Chapter 9: Oncology.

ADDITIONAL RESPONSIBILITIES:

Prepare one case write-up per week (see attached guidelines) to be presented to Dr Dombroski every Friday during your rotation.



TEST/EXAM REQUIRED:

To receive a grade of Satisfactory, the resident must: • attend conferences; • prepare and present one case write-up per week to Dr Dombroski; • complete and submit a case log of all patients seen and their

diagnosis (see attached); • present two imaging-based new patient presentations (1 adult and 1

pediatric pt) to the Department of Radiation Oncology. The quality of these presentations will be evaluated;




AM

8.00-9.00 am DRO New Pt Presentation

Imaging Sciences

Conference

7.30-8.30 am Neuro-Oncology

Conference 8.00-9.00 am DRO Lecture

Imaging Sciences

Conference

Imaging Sciences

Conference

NOON

Imaging Sciences Conference





PM






DRO = Department of Radiation Oncology



Palliative Care Rotation

Strong Health Palliative Care Program

Course Director: Timothy Quill MD

Key to Core

Competencies:



• Understand the principles in pain and symptom management for seriously ill patients.

• Understand psychosocial issues and provide appropriate counseling for patients and family facing serious illness.

• Understand how to work with health care professionals from other disciplines to provide patient-focused care in the palliative care setting.

• Demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value and appropriate to this patient population.


• Learn how this type of medical practice differs from others, including its impact on controlling health care costs and allocating resources.

• Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect performance.

• 1,2 • 1,2,4,6 • 1 • 3,6 • 6 • 6 • 6

Description:

Residents spend two weeks in the Strong Health Palliative Care Program, under the direction of Dr Quill, providing special care and specialized treatment for pain, discomfort and emotional distress for patients facing serious illnesses. During the course of this rotation, the resident will perform palliative care consultations and participate in weekly meetings, teaching sessions and conferences.

Learning Objectives: Competencies: • Understand the potential of palliative care to improve quality of life for all

seriously ill patients, whether or not they are continuing active treatment. • Develop basic knowledge and skill about pain management, including

equianalgesic dose conversions. • Develop basic knowledge and skill in the management of other physical

symptoms that afflict seriously ill patients, including constipation, dyspnea, depression, and delirium.

• Learn how to talk with and listen to severely ill patients and their families about non-physical suffering, including issues of loss, hope, meaning, spirituality, and religion.

• Learn how to have timely discussions with patients and families about do-not-resuscitate, advance directives, prognosis, and risks and benefits of hospice and / or experimental therapy.

• Learn about last-resort options available to address severe, unrelenting suffering.

• Learn how to function as a member of an interdisciplinary team, and utilize the members to help address the many dimensions of patient and family suffering.

• Develop self-awareness about one’s own personal responses to severely ill and dying patients.

• 1,2,4,6 • 1,2 • 1,2 • 2,4,5 • 1,2,4,5,6 • 1,2 • 4,5,6 • 4,5

Rotation Assignments/Additional Requirements: REQUIRED READING FOR WEEKLY PALLIATIVE CARE TEACHING SESSION:

Week 1: • Hospice & Palliative Care • Pain & Symptom Management Week 2: • Psychosocial & Spiritual Issues • Last-resort Options

RECOMMENDED STRUCTURE:

• Discussion of questions or answers that emerged from required readings;

• Review questions about cases seen by residents that have not been discussed on rounds, with special attention to: o Pain and symptom management (including dose

calculations, etc); o End-of-life issues raised; o Communication issues with patient and family; o Personal impact of the case;

• Review of unresolved questions to be addressed next session, and any assignments for literature review.

SUPPLEMENTAL READING:

Please see attached list

Rotation Assignments/Additional Requirements continued: RESIDENT EVALUATION/SURVEY REQUIRED:


TEST/EXAM REQUIRED:

To receive a grade of Satisfactory, the resident must: • attend conferences; • complete and submit all required reading assignments; • complete and submit a case log of all patients seen and

their diagnosis, including a description of the services offered by the Palliative Care Program;

• present a patient case to the Department of Radiation Oncology in which palliative care/medical ethics played a critical role in the patient’s evaluation and/or treatment.


Schedule of Activities:


DAILY Palliative Care Team Rounds

Palliative Care Team Rounds




AM

8.00-9.00 am DRO

Conference

8.00-9.00 am Medical Grand

Rounds

8.00-9.00 am PC Interdisciplinary

Team Mtg

NOON

12.00-1.00 pm

Noon Conference Series:

1st – Ethics Committee Mtg

2nd – Clinical Ethics Rounds

3rd Schwartz Rounds

4th – Palliative Care Rounds

PM





Oncologic Pathology Rotation

Department of Pathology, Strong Memorial Hospital

Course Directors:

Linda Schiffhauer MD

Ping Tang MD

Key to Core

Competencies:



• Learn about the gross, histologic, cytopathologic, and immunocytochemical techniques commonly employed in diagnostic pathology.

• Learn about the histologic pathology of malignant disease, for both adult and pediatric malignancies, as they are manifest in specific anatomic and organ sites, and those which are common to a variety of malignancies.

• Understand how to work with health care professionals from the discipline of Pathology to provide patient-focused care.

• Demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.

• 2 • 2 • 1 • 6

Description:

This rotation will provide residents with an understanding of the pathology of malignant disease and the role of the pathologist in diagnosis and treatment. Schedule of Activities: Week 1: 2 days – Neuropathology

3 days – Cytopathology Week 2: 2 days – Hematopathology

3 days – Surgical Pathology – adult and pediatric patients Week 3&4: Surgical Pathology – adult and pediatric patients Autopsy Pathology: In addition, residents will be provided with the opportunity to participate in

Autopsy Pathology on an ad hoc basis. Pathology residents will identify autopsy patients having previously received radiation treatment and will notify Radiation Oncology. Radiation Oncology residents will be able to observe these procedures. This experience will provide our residents with the opportunity to learn about and observe the normal tissue effects and late effects of radiation.

General Learning Objectives: Competencies:

• Become familiar with the gross, histologic, cytopathologic, and immunocytochemical techniques commonly employed in diagnostic pathology. This includes how surgical pathology specimens are processed, including orientation, sectioning, frozen sectioning, detection of surgical margin and permanent sectioning.

• Recognize and describe the histologic pathology of malignant disease for both adult and pediatric malignancies, as they are manifest in specific anatomic and organ sites and those that are common to a variety of malignancies.

• Understand the appropriate use of a variety of special techniques used to diagnose malignant disease. This includes various special stains, tumor markers, immunohistochemical and flow cytometry studies, that can be used to facilitate the determination of a histopathological diagnosis.

• Identify specific pathologic features that may be important from a diagnostic, prognostic or therapeutic standpoint in a variety of common and unusual malignancies, of both adult and pediatric populations.

• 1,2,6 • 2,6 • 2,6 • 1,2,6


• Rosai & Ackerman’s Surgical Pathology, 2 Volume set & CD • Robbins, ‘Pathological Basis of Disease’ • AFIP Atlas of Tumor Pathology, Fascicles, 2nd Series

ADDITIONAL RESPONSIBILITIES:

During the 3rd week of the rotation, residents must identify 2 suitable cases (1 adult and 1 pediatric) for preparation during their last week, for subsequent case write-up and presentation.



TEST/EXAM REQUIRED:

To receive a grade of Satisfactory, the resident must: • attend conferences; • complete and submit a case log of all patients seen and their

diagnosis (see attached); • within 2 weeks following the rotation, present 2 patient cases (1

adult & 1 pediatric) to the Department of Radiation Oncology and Department of Pathology, in which pathologic assessment played a critical role in the patient’s evaluation and/or treatment. The quality of these presentations will be evaluated.




AM

8.00-9.00 am DRO New Pt Presentation

8.00-9.00 am AP Didactic

8.00-9.00 am SP Unknown

Conference 8.00-9.00 am DRO Lecture

7.30-8.30 am

Neuroradiology Conference

NOON

12.00-1.00 pm Pathobiology, Oncology & Molecular

Medicine Seminar

12.00-1.00 pm

PM Report

12.00-1.00 pm

Clinical Pathology Conference

PM



CLINICAL INVESTIGATION AND RESEARCH

The basic working relationship between scientists and clinicians that has evolved in the Department of Radiation Oncology has become the translational research model of the James P. Wilmot Cancer Center (JPWCC) at the University of Rochester. The interactions between these investigators have led to the clinical investigation of laboratory-derived ideas. Such concepts are tested in small, high quality controlled pilot studies to determine if they should be mounted in larger clinical trials of the national cooperative groups.

It can be said that the development and conduct of pilot studies at the institutional level is the backbone of national cooperative group trials. Throughout the past several years, we have developed the resources, facilities, and support personnel to conduct Phase I and II feasibility studies while searching for efficient and effective treatment schedules and combinations. The important feature of our work has been the establishment of a mechanism for developing studies that we believe represent the leading edge in radiation oncology research. Scholarship, in its broadest definition, and participation in research is an integral component of residency training. In addition to benefiting from the extensive knowledge, skills and experience of our faculty, our residents enjoy opportunities to learn from and work with distinguished faculty mentors on a research project of their choice. Residents perform research on at least two or three levels, described below. The time devoted to research varies according to the resident’s interest. Some research time is built into the daily workload in terms of patient enrollment on clinical protocols (see below). National multi-institutional or SMH Cancer Center Protocols: Residents are closely involved in clinical research through the participation of the Department in several multi-institutional groups including SWOG, RTOG, and COG, as well as investigations organized within the Cancer Center. Patients are entered on appropriate protocols, providing the attending physician the opportunity to discuss issues relevant to clinical trials including ethical considerations. These protocols also provide the resident with current reviews of the relevant malignancy. Clinical or laboratory based investigations: All residents are required to initiate and complete a clinical or laboratory investigation during their tenure. An appropriate project must be identified and the research plan discussed with the appropriate mentor. It is expected that each resident will present their findings at departmental grand rounds. This research should result in presentation at a regional or national forum and in publication in a peer-reviewed journal. The research may take the form of a retrospective review of a patient population or involvement in a prospective study conducted by an attending physician. Optimally, the resident is involved in the design and conduction of a prospective investigation. Extensive research facilities exist within the Department of Radiation Oncology and also in the Cancer Center and Medical Center as a whole.



RESIDENT RESEARCH PROJECT

RESEARCH REQUIREMENTS:

During their training, residents shall be required to complete an investigative project under supervision of a faculty mentor. This may take the form of biological laboratory research, clinical research, translational research, medical physics research, or other research approved by the program director. The results of such projects shall be suitable for presentation at scientific meetings and publication in peer-reviewed scholarly journals. Key to Core

Competencies:


RESEARCH GOALS & OBJECTIVES: Competencies:

• Locate, appraise, and assimilate evidence from scientific studies related to your research.

• Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and to formulating the research project design.

• Use information technology to manage information and access online medical information in order to support your research project.

• Develop the ability to organize and coherently present research results in written and oral formats.

• Demonstrate the 5-step process of evidence-based healthcare: question, search, critical appraisal, application and self-evaluation.

• 2,3 • 2,3 • 3,6 • 2,3,4,5,6 • 2,3,5,6

FORMAT & DESCRIPTION:

• During the course of training residents must participate in at least one research project under faculty supervision.

• A list of research project opportunities will be distributed annually to the residents. Additional opportunities may also arise during the course of the year.

• It is expected that the results of these research projects will be suitable for presentation at a regional or national meeting. Funds will be available towards the cost of the residents’ registration and travel for these meetings, if the residents have been invited to give a poster or oral presentation. For all abstract submissions, the meeting forum must be pre-approved by the Program Director and faculty mentor as a worthwhile educational forum.

• In addition, it is expected that this research will result in subsequent submission and acceptance of a manuscript to a peer-reviewed journal.

RESEARCH RESPONSIBILITIES & TIMELINE:

End PGY-2 (ie, June): • Following discussion with the appropriate faculty mentor, residents must submit a research proposal to

the Program Director for approval. This proposal outline must include: o Name, date o Research project title o Faculty mentor o Clinical scenario o Clinical question o Start date & duration o Study design o Goals

Note: If a resident has not already taken the Clinical Biostatistics Course at the time when he/she is required to submit his/her research proposal, he/she may submit a revised proposal, if required, once he/she has completed this course. PGY-3: • Residents are then be timetabled to participate in a three-month research rotation during their second year

to commence work on the project. • Following this rotation, residents continue work on the project throughout the remainder of their

residency. PGY-4: • It is expected that the majority of research projects will be completed within 18 months (ie, by end

December of PGY-4 year). • Residents must present the findings of their projects to the Department at Grand Rounds at the beginning

of the 2nd half of this year (ie, January-February of PGY-4). • This will allow time for the residents to make any required modifications and submit an abstract of their

research to a regional or national society meeting (eg, ASTRO deadline = March). • Residents will be timetabled for an additional two-month research rotation during their 3rd year, providing

them with dedicated time to write up their research project. PGY-5: • It is anticipated that residents will be invited to present their research findings (poster or oral presentation)

at the meeting to which their abstract was submitted. • In the 4th year of residency, residents will be required to give a Grand Rounds presentation to the

Department on a topic of their choice, not necessarily related to the research project. • In addition, during the final year of residency, residents will be expected to write up their research project

and submit it to a peer-reviewed journal for subsequent publication. • They will be timetabled for an additional two-month research rotation during their 4th year, providing

them with dedicated time to prepare and submit their manuscript for publication.

PROJECT REQUIREMENTS:

• Oral/poster presentation at regional/national meeting • Publication in peer-reviewed journal

DEPARTMENT OF RADIATION ONCOLOGY RESIDENCY PROGRAM

UNIVERSITY OF ROCHESTER

POSSIBLE RESEARCH PROJECTS 2009-2010

FACULTY MENTOR: Ralph Brasacchio MD • Post-prostatectomy radiation: adjuvant vs. salvage radiotherapy: retrospectively review

experience/results/side effects of post-operative radiotherapy. • Brachytherapy: retrospective review of >400 patients treated with brachytherapy (+/- EBRT)

for prostate cancer: disease control and side effects. FACULTY MENTOR: Yuhchyau Chen MD PhD • Radiation genotoxicity marker study (bench top research): Residents will observe animal

radiation, tissue culture irradiation, culture lymphocytes, score lymphocyte based micronucleus analysis.

• Review of treatment outcome of Pancoast tumor at U of Rochester in the past 20 years. • Tumor response kinetics after chemoradiation for lung cancer. FACULTY MENTOR: Louis Constine MD Hodgkin’s disease. • Do “E” lesions connote stage IV disease? Study outcomes of patients and poll medical

oncologists, pediatric oncologists, and radiation oncologists internationally on case scenarios we devise and ask them to vote as to whether the patient is IIE or IV.

• Second malignant tumors in children: GI cancers. • Second malignant tumors in children: Thyroid. • Is there a radiation dose-response relationship for local control of bulk (mediastinal and non-

mediastinal) disease?

Non-Hodgkin’s lymphoma: • Does RT to areas of bulk disease enhance disease-free survival? • RT only for patients with Stage I/II indolent cell NHL. • What are the sites of recurrence in patients who present with extranodal lymphoma? Bone marrow transplantation: • How does pneumonitis fit into the constellation of post-BMT sequelae? How does this relate

to GVH, veno-occlusive disease of the liver, and cardiac or renal impairment?

Sarcoma:

• What other sites of metastasis (bone, liver) have been seen in our sarcoma population? Study timing of appearance (whether before or after pulmonary metastasis), and relationship to sarcoma histology.

• What is the relationship of necrosis in the resected sarcoma to local control and metastatic disease in patients treated with pre-operative RT?

Late Effects:

• Essentially all exposed organ systems are at risk for adverse effects of radiation therapy, and can be considered in the context of the specific disease or across different diseases but by the exposed organ.

FACULTY MENTOR: Bruce Fenton PhD • Preclinical testing of novel antiangiogenic strategies using murine tumor models • Antiangiogenic and radiotherapy treatment monitoring using MRI in animal models • Pathophysiological effects of antiangiogenic agents on tumor vascular structure and hypoxia,

as evaluated using immunohistochemistry and image analysis FACULTY MENTOR: Alan Katz MD MPH • Review and update of patients with liver metastases treated with stereotactic body radiation

therapy • Review of metastatic breast cancer patients treated with stereotactic body radiation therapy • Review of esophageal cancer patients treated with concurrent chemoradiation therapy over

the last 5 years FACULTY MENTOR: Peter Keng PhD • G2M checkpoints and radiation sensitivity. • Role of Actin skeletal structures in radiation sensitivity. FACULTY MENTOR: Marilyn Ling MD • Retrospective review of post-mastectomy cases at the U of R, with or without reconstruction.

Determination of locoregional recurrence, survival, impact on reconstruction. FACULTY MENTOR: Bingren Liu MD • Evaluate the risk of pelvic lymph node metastasis in uterine cancer. Since we need to work

on different stages and histology types, this could end up being several publications. There is no chart review as all data are from SEER database and we have an expert to help us.

FACULTY MENTOR: Michael T Milano MD PhD • Retrospective review of patients undergoing SRS for trigeminal neuralgia with Novalis. • Retrospective review of patients undergoing SRS for AVM with Novalis. • Retrospective review of patients with thoracic lesions from NSCLC undergoing re-irradiation

with SBRT. • Retrospective review of patients with central thoracic lesions undergoing SBRT. FACULTY MENTOR: Karen Mustian PhD • Exercise interventions to reduce fatigue and other side effects among cancer patients (several

separate studies in breast cancer, prostate cancer, metastatic disease and lymphoma). • NCI Breast Cancer Study: Efficacy of a home-based exercise program in relieving cancer-

related fatigue among breast cancer patients receiving radiation therapy. • DOD Prostate Cancer Study: Efficacy of a home-based exercise program in relieving cancer-

related fatigue among prostate cancer patients receiving radiation therapy. • Polarity Therapy to reduce fatigue and other side effects among cancer patients. This study

also assesses cytokines and salivary cortisol. • Mitochondrial study: Comparing mitochondrial gene expression profiles in skeletal muscle of

prostate cancer patients receiving radiation therapy versus prostate cancer patients receiving radiation therapy plus an exercise intervention. Also looks at whether the mitochondrial gene expression profiles correlate with changes in fatigue levels.

FACULTY MENTOR: Walter O’Dell PhD • Oligometastases: Study the rate of development of later metastases in subjects treated early

on for initial sign of metastases. • Efficacy of drugs used to moderate radiation damage to healthy lung tissue following SRT to

the lung. Do preliminary intervention using simple moderating agents, such as curcumin and celebrex, which are already approved for human use.

• Extracranial radiosurgery application to the pancreas? Study patients with metastases to the pancreas.

• Lung nodule detection and sizing. We need assistance in sizing and estimation of nodule growth and likelihood for malignancy on both real patient data sets and in realistic simulated nodules.

FACULTY MENTOR: Paul Okunieff MD • Metastatic patterns of failure for spine metastases. • Follow-up on brain tumor cytokine fatigue/anorexia study. • Develop radiation biodosimetry clinical studies. • Tumor autoimmunity research. • Clinical skin radioprotection studies.

FACULTY MENTOR: Joseph Roscoe PhD • Interventions to treat insomnia. • The role of expectations in nausea development and the use of placebos and expectations in

treating it. • Cognitive functioning problems secondary to chemotherapy. • Prevalence, predictors, and treatments for fatigue in patients receiving radiation or

chemotherapy. • Polarity Therapy to reduce fatigue. FACULTY MENTOR: Philip Rubin MD • 3-D oncologic imaging – emphasis on volumetrics of organs and neoplasms. • Clinical radiation late effect scales with application to head and neck sites. FACULTY MENTOR: Steven Swarts PhD • Novel assays as radiation dosimeter • Pharmakinetic analysis for novel anti-radiation agents FACULTY MENTOR: Sadasivan Vidyasagar MD PhD • Electrolyte and nutrient transport in small and large intestine • Functional alterations in gastrointestinal transport physiology • Epithelial barrier function in gut and skin • Intestinal stem cell biology • Nanoparticle trancytosis across epithelium • Mitigating agents for acute gastrointestinal radiation syndrom FACULTY MENTOR: Jacqueline Williams PhD • Radiation-induced cytokines during cancer radiotherapy. • Interactions between inflammatory cells and cytokines in response to chemotherapy/radiation

therapy and their role in late effect induction. • Is there a differential in patient response to radiation re their cytokine/inflammatory

responses? • Can we use the first 1 or 2 fractions of radiation therapy as a model for the low doses that

may be received as part of a terrorist attack?

FACULTY MENTOR: Hong Zhang MD PhD • Retrospective review of outcome of head and neck sarcoma using SEER database. • Retrospective review of T3N0 laryngeal cancer outcomes using various treatment options. • Treatment effect on taste in head and neck patients. FACULTY MENTOR: Lurong Zhang MD PhD • Novel anti-cancer agents. • Novel radioprotectants. • Novel anti-angiogenesis agents. • Novel anti-inflammation agents. • The therapeutic effect of combination of novel anti-cancer agents with radiation. • Apoptosis and radiation.

RESIDENT ELECTIVES

The possibilities for independent/elective study are only limited by the desires and creativity

of the resident. For example, the individual may choose to deepen his/her clinical understanding of a particular treatment technique, or a specific cancer type, or engage in clinical or laboratory research. Further expertise can be developed in any of several selected areas, including:

* pediatric radiation oncology * bone marrow transplantation oncology * * high dose rate brachytherapy * stereotactic radiosurgery *

* chronic adverse effects of cytotoxic therapy * 2D/3D treatment planning * * IMRT * radionuclide-targeted therapy *

2nd year (PGY-3) residents are scheduled to participate in a three-month research rotation to commence work on their research project. In addition, residents also complete rotations in the following ancillary disciplines: Medical Oncology, Dosimetry, Diagnostic Imaging, Palliative Care, and Oncologic Pathology. Additionally, two months are left unscheduled during the 3rd year (PGY-4) and two months during the 4th year (PGY-5) of residency training. If all competencies have been met, residents may select an area of interest, with input by appropriate faculty and the program director. External electives and fellowship opportunities are available to our residents at many institutions throughout the U.S. All electives must be pre-approved by the Program. Electives will be approved based on their educational merit; they must demonstrate the ability to promote the program’s goals, and must provide opportunities for additional experience and resources not otherwise available in the Program. Many of our residents have used this elective time to continue work on their research projects.

RESPONSIBILITIES OF THE RESIDENT

During the clinical rotations, residents are responsible for seeing all new patients referred to theirservice and will conduct complete history and physical examinations, review the pathology anddiagnostic imaging studies, obtain information from referring physicians, formulate a treatment plan,and present all of this information to the attending physicians who, in turn, review it in detail.Residents then dictate a summary of this information. The impression and recommendation must becarefully considered and supported by published data when possible. This information is thentranscribed into a consultation letter to the referring physician, which becomes part of the hospitalmedical record. A significant number of the consultations and follow-ups take place in themultidisciplinary clinics which are composed of surgical, medical, radiation and nursing oncology inseveral areas, including breast, thoracic, GU, GI and lymphoma.

Following the simulation, patients are scheduled for beam films, which are reviewed by theresidents and presented to the attending physicians. If satisfactory, treatment will then commence.The residents, with the attendings, obtain informed consents from the patients and fill out therequired treatment prescriptions as part of the treatment planning process as previously outlined. Theresidents are responsible, along with the oncology nurses and attendings, for monitoring the day-to-day progress of the patients. On a weekly basis (or more often when necessary), the residents and theattendings examine each patient and review his/her progress together. Upon completion of treatment,the residents dictate a treatment summary, which is again sent to the appropriate referring physicians.

Residents are actively involved in the follow-up clinics of their service, providing importantexposure to the natural history of various malignancies, response to treatment, normal tissue effectsand psychosocial adjustment to the disease process. Residents will often see the same patients whenthey return to a particular service in subsequent years, providing the residents with some degree ofpatient continuity during the four years in our program. In the follow-up clinics, residents presenteach patient evaluated to the attending physicians, who also see the patients. Important teachingoccurs during these follow-up clinics.

When the therapeutic strategy includesradiation therapy, patients are normallyscheduled for simulation and treatmentplanning. Residents follow through with thepatients’ management by devising the detailsof the treatment plan and its institution, withresponsibilities dependent upon their degreeof experience.

These activities are performed in conjunctionwith the attending physicians, the simulatortherapists, the dosimetrists, the physics treatmentplanning staff and nurses.

ADDITIONAL TRAINING CONTENT AND RESPONSIBILITIES

Beyond the clinical responsibilities, residents have an obligation to learn through attending conferences within our Department and the Cancer Center, as well as at national conferences through interaction with fellow residents and faculty, and by teaching medical students. Intra-departmental and Inter-departmental Classes, Tumor Boards and Conferences

Several important teaching courses, lecture series, seminars, tumor boards, and conferences occur on a weekly basis. Some are intra-departmental, whereas others are inter-departmental to complement the interdisciplinary nature of our program. These conferences are here described (* indicates conferences in which residents have substantial responsibility): *New Patient Conference (Weekly, ongoing): Residents are responsible, on a rotating basis, for presentation of new patients, including imaging studies, to the other residents and faculty. Preparation for this conference includes a background review and presentation of relevant published data. Guidance for the preparation for this conference is given by the responsible faculty. The presenting resident may prepare a handout. The presenting resident, as well as other residents, frequently participate by answering questions stimulated by the material presented in order to ‘test’ their understanding of the topic being discussed. Attendance by faculty and other residents is expected and is closely monitored. The other residents are active participants in discussion.

*DRO Chart Rounds/Dosimetry Conference (Weekly, ongoing): Each resident presents a brief clinical summation, the relevant radiologic study, treatment plans and simulation and portal films for all patients initiating therapy on his or her service during the previous week. This conference is attended by all faculty and residents, and the participation of physics/dosimetry staff and therapists is encouraged. The resident is expected to know the clinical information of the specific patients presented, and to explain and defend his/her therapeutic plans. Faculty and other residents participate by asking questions regarding the plans presented. Discussion of alternative plans, or of important clinical issues suggested by them often ensues. This meeting is also an important opportunity to discuss QA issues.

*Quality Assurance Conference (QA/M&M/PBLI/SBP Conference) (Monthly; ongoing): Each resident reviews all patients who completed therapy on their service during the previous month, directing attention to whether patients completed the prescribed therapy and whether any complications or significant side effects may have occurred. Faculty provide supervision with this review of patients. The residents prepare a short summary of the clinical events and action taken. Discussion occurs regarding the events and appropriateness of the therapy given and the intervention. All faculty and residents are required to attend. This conference also serves as a vehicle for presentation of patients seen by the resident in follow-up clinics who have experienced a long-term side effect or complication of therapy. This component will be formalized in the future. The conference is monitored at the departmental and hospital levels to assure compliance with the appropriate regulatory guidelines.

Cancer Center Grand Rounds (Weekly; ongoing): On a rotating basis, each division/department within the Cancer Center sponsors lecturers who present clinical or scientific topics of interest to medical and radiation oncologists. International and prominent scientists may be invited to give these lectures. Radiation Oncology resident attendance is mandatory when the topics to be presented are relevant to Radiation Oncology. Faculty of the Department also attend.

Radiation Oncology Grand Rounds (Occasional, ongoing): Topics of interest are presented in a didactic format to all interested members of the department by various scientists or clinicians from within the medical center, visiting professors, and by departmental faculty. The lecture is followed by a question and answer period. Each resident is expected to present a critical review of a topic or their own research project at least once during his or her residency.

*Clinical Oncology Lecture Series (Weekly, ongoing, 2-year cycle): In a 1-1 hour lecture/seminar format, the attending physician presents and discusses each malignancy so that all categories of tumor sites are presented over a 2-year cycle. Resident participation is determined by the attending physician and may include presentation of subtopics by each resident and/or actual case presentations relevant to the cancer being discussed. The seminar focuses on epidemiology, natural history, staging, evaluation, and treatment, but also is an opportunity to review the literature pertinent to radiation oncology. Faculty review clinically important anatomy, and diagnostic and therapeutic pathology and imaging studies for specific anatomic regions and diseases. Faculty also present and discuss normal tissue toxicities of radiation and chemotherapy, and late effects/pathophysiology of radiation. Format is didactic and informal. Familiarity and understanding of the scientific and clinical literature is emphasized. All residents attend this conference.

CBARMFI [Center for Bioterrorism Assessment & Risk Management Following

Irradiation] Radiation/Cancer Biology Course (Weekly; bi-annually): The CBARMFI Radiation-Cancer Biology Course for Residents includes discussion of the effects of radiation in mammalian cell systems ranging from cell culture to whole animals. Particular emphasis is placed on the application of radiobiological principles to radiotherapy practice in the clinical treatment of cancer. The course is given by the Radiobiology faculty of the Department of Radiation Oncology (Course Director: Peter C. Keng, PhD). All the radiobiology faculty and appropriate MD faculty contribute to this course. Quizzes given periodically during the lecture series and at the end of the course are used to assess the residents’ learning and to elicit feedback from the course participants. CBARMFI Training and Education Workshop Series (Bi-monthly): The main purpose of this workshop series is to critically review the field of radiation biology at all levels. For example, the observations that can be made at both the whole body (patient/terrorist victim) and tissue levels are related to what is happening at the molecular and cellular levels. Indeed, because the biological changes induced by radiation exposure are a complex subject, often fraught with misconceptions and pitfalls, this series of workshops aims to help scientists who have no previous experience with radiation or are embarking on studies related to the field of radiation biology. It is hoped that such an integrated approach stimulates the interest of scientists from all disciplines to join the efforts in developing countermeasures against radiation. The workshop series also serves as a vehicle to foster collaboration between radiation biologists/oncologists and other scientists who share the same common research subjects. Investigators in alternative

research fields actively pursue many of the same aims as in radiation biology, and may not fully appreciate the significance of their studies with respect to radiation outcomes (and vice versa). By providing our academic community with basic radiation biology information, we believe that this leads them to become more interested in radiation biology-oriented research projects since radiation can act as an important tool as well as a model in many scientific disciplines. Radiation Physics Course (Weekly; bi-annually): The Radiation Physics Course for residents incorporates all required ACGME and ABR topics, and is administered biannually. It includes didactic lectures presented by the faculty and staff of the Division of Radiation Physics, including six radiation physicists at the PhD or MS level and radiation dosimetrists. The chief of the Division (Michael C Schell PhD) is responsible for coordinating the course. The Radiation Safety Office at Strong Memorial Hospital also participates in the course. Laboratory demonstrations play a part in this course, eg, demonstration of new modalities or collection of dose delivery information. Practical Dosimetry Lecture Series (12 lectures, bi-annually): This lecture series for residents is administered biannually, on alternate years to the Radiation Physics Course. It addresses practical applications in simulation dosimetry and treatment planning and delivery of radiation, including isodose distribution, specialty calculations (eg, linear quadratic, gap calculations), total body and cranial spinal irradiation, and IMRT. Clinical Biostatistics Course (Weekly, bi-annually): This course presents broad concepts of clinical biostatistics, including descriptive statistics (univariate and bivariate analysis; tables and graphs), basic notions of probability, discrete and continuous random variables, and important distributions (binomial, gaussian). It focuses on important aspects of statistical inference, such as estimation, confidence interval and test of hypotheses, and describes a few parametric and nonparametric methods. It introduces important statistical models (analysis of variance, linear model, survival analysis and logistic regression) and some aspects of observational and experimental studies (randomized clinical trials; case-control study, case-cohort studies). It also teaches the clinical application of biostatistical concepts. *Journal Club (Monthly; ongoing): The Journal Club meets on a monthly basis with supervision by faculty and the program director. Resident attendance is required and critical analysis of scientific reports in terms of methodology, accuracy of results, data-supported conclusions, as well as clinical relevance, is emphasized. Each session is 1 -2 hours in length and each resident presents selected articles from a topic of interest or recent issues of the International Journal of Radiation Oncology, Biology and Physics, the Journal of Clinical Oncology, or the New England Journal of Medicine. Residents are also encouraged to utilize the Internet Radiation Oncology Journal Club, which also provides a basis for journal club. Alternating with journal clubs at which current articles are presented, we hold journal clubs focusing on hallmark articles for a particular disease site, on ethics topics, or palliative care.

Pain Management Seminar Series (4-part Seminar Series; bi-annually): This seminar series is sponsored by Purdue Pharmaceuticals and comprises a formal lecture and discussion of the physiology, assessment, and treatment of pain, including pain in special populations, persistent non-malignant pain, and cancer pain and end-of-life care.

Medical Oncology Fellowship Conference (Weekly; ongoing): This is conducted by the Division of Hematology/Medical Oncology and involves the presentation of oncology by disease site by the Medical Oncology fellows and radiation oncology residents. It is attended by fellows and faculty of the Division of Hematology/Medical Oncology, as well as the residents in Radiation Oncology. Radiation Oncology faculty also sometimes attend. Oncology Fellows Teaching Conference (Weekly; ongoing): This is conducted by the Division of Hematology/Oncology and involves oncology presentations by Oncology Fellows and Radiation Oncology Residents, on a rotating basis. It is attended by fellows and faculty of the Division of Hematology/Medical Oncology, as well as the residents in Radiation Oncology. Radiation Oncology faculty also sometimes attend. Palliative Care Conference (Weekly, ongoing): Radiation Oncology residents participate in the weekly Palliative Care Conferences, when the topics to be presented are relevant to Radiation Oncology.

Pathology Conference (Weekly, ongoing): Radiation Oncology residents participate in the weekly pathology review conference held in conjunction with Medical Oncology. Format is instructive and interactive, and resident attendance is mandatory. Representative faculty are frequently in attendance.

Stress Management & Fatigue Awareness Seminars (Semi-annually, ongoing): We recognize the importance of balancing a sound didactic and clinical education with concerns for patient safety and resident well-being. Residents and faculty are educated on an annual basis on recognition of the signs and symptoms of fatigue. In addition, residents attend semi-annual seminars, which teach them to identify characteristics of burnout and stressors, and to help them with stress management techniques and strategies.

Tumor Boards: Integrated interdisciplinary oncology conferences, with the participation of the appropriate faculty, residents or fellows from the departments involved are held on-site at Strong Memorial Hospital. These conferences sometimes involve physicians from affiliated local or regional hospitals. Radiation Oncology residents are required to attend these conferences when they are rotating on the relevant service, and as interested as their time and schedule permits. Diagnostic radiologists and pathologists also often participate. The general format is patient presentation and discussion of treatment management. Occasionally more in depth presentation and discussion of a particular malignancy or of a relevant topic occurs. Radiation Oncology residents are sometimes asked to present a patient or topic at these conferences. The conferences held include:

Brain Tumor Pre-Clinic Conference (Weekly, ongoing) Breast Multidisciplinary Conference (Weekly, ongoing) Breast Tumor Board (Weekly, ongoing) GI Pre-Clinic Conference (Bi-weekly, ongoing) GU Pre-Clinic Conference (Bi-weekly, ongoing) Gynecologic Oncology Conference (Weekly, ongoing) [mandatory for all residents] Head & Neck Conference (Bi-weekly, ongoing) Hepatobiliary Tumor Board (Bi-weekly, ongoing) Lymphoma Tumor Board (Bi-weekly, ongoing)

Neuro-Oncology Conference (Monthly, ongoing) Pediatric Brain Tumor Pre-Clinic Conference (Bi-weekly, ongoing) Pediatric Oncology Multidisciplinary Conference (Bi-weekly, ongoing) [mandatory for

all residents]

Thoracic Pre-Clinic Conference (Weekly, ongoing) Thoracic Tumor Board (Bi-weekly, ongoing) Ad Hoc conferences (occasionally): Conferences are given on an ad Hoc basis when visiting scientists or medical experts visit the institution or department. Since these conferences often have significant educational merit, residents are excused from regular clinical activities and encouraged and expected to attend. Ad Hoc conferences recently held include: • “Development of Methods for Surveillance, Detection, Diagnosis, Treatment and Assessing

Treatment Response for Breast Metastases” – Walter O’Dell PhD • “Personalized Medicine in Breast Cancer: Oncotype Dx®” – Douglas Kingma MD • “Long-term Effects After Treatment for Testicular Cancer” – Sophie Fosså MD • “The Impact of Technology on Brain Tumor Treatment” – Philip H. Gutin, MD • “Problems from Brain Metastasis Radiosurgery: Identifying and Treating Radiation Injury

Reactions” – John C. Flickinger MD FACR • “Carbon Ion Radiotherapy” – Hitoshi Ishikawa PhD • “SBRT (Stereotactic Body Radiotherapy) Conference: Innovations and Directions for

Clinical Application”, University of Rochester • CURED Conference, University of Rochester • “How Hyperbaric Oxygen is used for Treatment of Delayed Radiation Injuries” – Terry Clark

& Kitima Boonvisudhi MD • “Human Malignant Brain Tumors: Past, Present and Future Perspectives” – James Rutka MD

PhD • “Spine Radiosurgery: A New Treatment Paradigm for Spine Tumor Therapy” – Peter

Gerszten MD • “Management Approaches for Childhood Brain Tumors” – Ian Pollack MD • “Keratinocyte Growth Factor (Palifermin) and Prevention of Mucositis/Esophagitis” –

Yuhchyau Chen MD PhD • “Advances in the Management of NSCLC and Combined Modality Therapy” – Chandra

Belani MD • “Biology Drives the Future Treatment of Lymphomas” – Richard Fisher MD • “Potential and Rationale for Reduction of Field Size” – Herman Suit MD • “Stage III non-small-cell lung cancer and new radiotherapy modalities” and “Current State of

Proton Radiation Therapy” – James Cox MD • “Center for Biophysical Assessment and Risk Management Following Irradiation” –

Yuhchyau Chen MD PhD • “”Breast Cancer” – Alice O’Connell MD • “Multiple Myeloma” – J J Ifthikharuddin MD • “Service Excellence . . . What’s in it for Physicians?” – Jay Kaplan MD FACEP • “Management of Brain Metastasis: Promising Developments for the Future” – Samuel Chao

MD • “The Role of Tarceva (Erlotinib) in the Treatment of Locally Advanced or Metastatic

NSCLC after Chemotherapy Failure” – Kishan Pandya MD • “Introduction to Molecular Imaging” – Sunil D. Pandit, PhD

• “The Tinea Capitis Saga” – Siegal Sadetzki, MD, MPH • “Mesenchymal Neoplasms of the GI Tract” – Angela D Levy MD • “Lung Cancer” – Michael Milano, MD • “Reirradiation of Patients with Non-small Cell Lung Cancer and Analysis of Clinical

Outcome and Esophageal Toxicity” – Igor Poltinnikov MD • “Wit Program – Perspectives on End-Of-Life Care – Parts 1-4” • “Developing Conscious Equanimity in the Face of Serious Suffering” – Megan Cole *Clinical Service Rounds (Weekly; ongoing): The team members involved in each of the clinical services meet on a weekly basis in order to discuss the progress of the patients under treatment. These ‘work rounds’ involve the attending, resident, nurse, dosimetrist, and secretary, and occasionally a social worker, and/or therapist. This session is led by the resident, depending on his/her level of experience, and is overseen by the attending. Each resident prepares a weekly list of patients under treatment including dose and treatment fields. Attendance at national meetings

Residents attend national conferences whenever possible. Residents who perform research and have an abstract accepted for presentation at a scientific meeting are usually approved to attend that meeting. Final year residents are also approved to attend the annual meeting of the American Society for Therapeutic Radiology and Oncology (ASTRO). Our residents have been very successful in conducting research that has led to abstracts, presentations, and published reports. Resident teaching

Residents learn teaching skills by assisting in the instruction of medical students who rotate through the Department. Many of the weekly conferences are structured in such a way as to involve residents in the teaching of other residents and faculty. Some require the preparation of a handout and active teaching by a single resident, whereas others are more interactive in terms of participation by several residents. Residents also research a topic in depth and prepare 1-2 one-hour Grand Rounds presentations during the course of the residency.

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NAME OF CONFERENCE:

Basics of Radiation Oncology Seminar Series

CONFERENCE SCHEDULE:

Mondays at 8.00 am, July-August annually

CONFERENCE FORMAT & DESCRIPTION:

Each year, the chief and senior residents provide the new and junior residents with an introductory lecture series on the basics of radiation oncology.

COURSE INSTRUCTORS:

Chief Resident/Senior Residents



Learning Objectives: Competencies:

• Summarize the anatomy, natural history, pathology, patterns of spread, work-up and staging of each disease site.

• Demonstrate an understanding of oncologic pathology, with special emphasis on neoplasia and radiation effects; and diagnostic imaging.

• Acquire knowledge of the critical literature that supports the content of each lecture.

• 1,2 • 1,2,3 • 1,2,3

Course Syllabus:

Review of disease sites, including: • Introduction to Cancer: o Clarification of terminology o Classification of tumor types o Principles of treatment and review

of treatment options: Chemotherapy Radiotherapy Surgical intervention

o Adjuvant and neoadjuvant therapy o Endpoint assessment

(response/survival) • Introduction to anti-cancer drugs • Side-effects of chemotherapy &

radiotherapy

• CNS • Head & Neck • Breast • Lung/Mediastinum • GI • GU • GYN • Lymphoreticular • Bone & soft tissue • Pediatrics • Pediatric CNS • Skin, palliation &

Metastasis

• Anatomy • Epidemiology/etiologic

agents • Natural history • Pathology • Tumor markers • Initial clinical

evaluation • Staging • Routes of local,

regional and distant spread

REQUIRED./ RECOMMENDED READING:

• Handbook of Evidence-based Radiation Oncology. Hansen E & Roach M.

• Clinical Oncology: A Multidisciplinary Approach for Physicians and Students. Rubin, (ISBN 0721674968) 2001 (8th edition)



NAME OF CONFERENCE:

Introduction to Radiology Lecture Series


Weekly lectures, July-August annually for new & junior residents

COURSE INSTRUCTORS:

Radiation Oncology & Radiology faculty


Each year, Radiation Oncology and Radiology faculty provide the new and junior residents with an introductory series of lectures and practicals on reading normal anatomy CT/MRI films.

COURSE FORMAT & DESCRIPTION: INSTRUCTORS # hours Week 1&2: Head & Neck Deepinder Singh/Hong Zhang 3 hours Week 3: Chest Deepinder Singh 1 hour Week 4: Abdomen Shweta Bhatt 1 hour Week 5: Pelvis Shweta Bhatt 1 hour Week 6: CNS Jeevak Almast 1 hour Key to Core Competencies: 1 = Patient Care


Learning Objectives: • Be able to identify the normal anatomic organs and structures • Be able to interpret CT scans and MRI films

Competencies: • 2 • 2


• Anatomy in Diagnostic Imaging, 2nd edition. Fleckenstein & Tranum- Jensen.

• Oncologic Imaging, 2nd edition. Bragg, Rubin & Hricak. • Imaging Squamous Cell Carcinomas of the Upper Aerodigestive

Tract: What Clinicians Need to Know. Mukherji, Pillsbury & Castillo. Radiology 1997, 205, 629-646.



NAME OF COURSE:

Introduction to Physics/Dosimetry Lecture Series

COURSE SCHEDULE:

Weekly lectures, July-August annually for new & junior residents

COURSE FORMAT & DESCRIPTION: INSTRUCTORS # hours Week 1: Basics of linear accelerators

Electrons, photons & calibration data Doug Rosenzweig 1 hour

Week 2: Emergency set-ups Tracey Jones 1 hour Week 3: Monitor unit calculations Mary Hare 2 hours Week 4: Contouring Mary Hare 1 hour Key to Core Competencies: 1 = Patient Care


Learning Objectives: • Define and identify the elementary components of a linear accelerator. • Describe basic linac calibration. • Compare and contrast photons and electrons in regards to their clinical use. • Perform whole brain and single-direct spine emergency set-ups. • Using the Eclipse workstation, contour anatomic structures on a treatment

planning CT scan.

Competencies: • 6 • 6 • 1, 3, 6 • 1, 3, 4, 5, 6 • 6

REQUIRED ATTENDANCE:

Attendance will be recorded as documentation of participation.


• “Treatment Planning & Dose Calculation in Radiation Oncology”, Gunilla C Bental, Charles E Nelson PhD, K Thomas Noell MD. 3rd or 4th edition.

• “The Physics of Radiation Therapy”, Faiz M Khan. 2nd or 3rd edition. RESIDENT RESPONSIBILITIES: • Complete all reading assignments • Practice relevant calculations, according to the

schedule • Plan evaluations

INSTRUCTOR RESPONSIBILITIES: • Prepare for lectures • Set up series of sample calculations and plans • Prepare lecture syllabus and reading material

RESIDENT EVALUATION/ SURVEY REQUIRED: All residents must complete an evaluation form at the end of the course.

TEST/EXAM REQUIRED: Not applicable.

Radiation Oncology Residency ProgramUniversity of Rochester

NAME OF CONFERENCE: NEW PT PRESENTATION

CONFERENCE SCHEDULE: Mondays @ 8.00-9.00 am, weekly, ongoing

CONFERENCE FORMAT &DESCRIPTION:

On a rotating basis, each resident presents 1-2 service-specific casepresentation(s), with faculty input and interactive discussion.

Key to Core Competencies: 1 = Patient Care2 = Medical Knowledge3 = Practice-Based Learning & Improvement4 = Interpersonal & Communication Skills5 = Professionalism6 = Systems-Based Practice

Learning Objectives:• Organize and defend presentation of a unique patient(s) on service.

Competencies:• 1,2,3,4,5,6

REQUIRED ATTENDANCE:• All residents must attend.• Service Faculty and Program Director must attend.Attendance will be recorded as documentation of participation.

REQUIRED READING:Key background text(s) and relevant original literature related topatient diagnosis and treatment.

RESIDENTRESPONSIBILITIES:

• Each resident must complete presentations on new or uniquepatient(s) on the resident’s current service/rotation.

• Topic(s) must be provided by the Thursday before thepresentation to allow time for advance reading on the subject(s) tobe discussed.

• Presentations should comprise:- Brief history of patient & diagnosis- Relevant pathology and imaging- Review of pertinent literature- Discussion of appropriate course of treatment

• Following the presentation, any relevant handouts discussed mustbe submitted to the Program Administrator.

ATTENDINGRESPONSIBILITIES:

• Evaluate resident’s presentation (critique).• Question residents’ knowledge of topic.


NAME OF CONFERENCE: NEW PT CHART ROUNDS

CONFERENCE SCHEDULE: Tuesdays @ 8.00-9.00 am, weekly, ongoing


Simulation films and treatment plans for all patients beginningtherapy during the previous week are presented and reviewed.


Learning Objectives:• Participate in critical analysis of new patient treatment plans;• Demonstrate ability to present a coherent, succinct overview of the patient and

treatment plan.

Competencies:• 1,2,3,4,5,6• 1,2,3,4,5,6

REQUIRED ATTENDANCE:• All residents must attend.• All attendings must attend.• Therapy, Physics and Dosimetry must be represented.Attendance will be recorded as documentation of participation.

REQUIRED READING:The list of new patients who will be presented will be provided atleast 24 hours in advance so that necessary preparation can be made.


Each resident presents:• Brief summary of each patient;• Relevant imaging studies;• Planning and simulation procedure with justification of treatment

volume, doses, and fractionation scheme prescribed;• Alternatives to the planned treatment or its delivery.

THERAPISTRESPONSIBILITIES:

• Discuss patient set-up and any associated problems.• Suggestions may be offered on how to improve on the problem in

this patient and in future patients.PHYSICS/DOSIMETRYRESPONSIBILITIES:

• Discuss treatment plan and dosimetry.• Comment on possible alternatives.

EVALUATION: Attendings will complete random evaluations of residentpresentations.

Name of Conference: Clinical Oncology Lecture Series - Schedule 2009-2011

Conference Schedule: Tuesdays @ 4.30-6.00 pm, September-June, two-year cycle

Required Attendance:

Required Reading:

Test/Exam Required:

Key to Core Competencies:

1 = Patient Care 2 = Medical Knowledge3 = Practice-Based Learning & Improvement 4 = Interpersonal & Communication Skills5 = Professionalism 6 = Systems-Based Practice


*

*

*

*

* Analyze the principles of normal tissue tolerance to radiation and tumor dose-response.

*

*

Self-Study Reading Assignment & Quick Lecture Review

Anatomy Epidemiology/etiologic agentsNatural history PathologyTumor markers Initial clinical evaluation

StagingRoutes of local, regional and distant spread

* 1,2,3

Critique the problems of recurrent and disseminated tumors and of late after-effects and complications of radiation therapy.

* 1,2,3* 1,2,3

* 1,2,3Acquire knowledge of the critical literature that supports the content of each lecture.



· All residents must attend.· Service faculty must attend.

A series incorporating reading assignments, didactic lectures, discussions and ITE and board review sessions of the subtopics of each disease site.

Conference Format &

Description:


See list of required textbooks – appropriate chapter according to disease site/subtopic.

* 1,2

* 1,2,3

Summarize the anatomy, natural history, pathology, patterns of spread, work-up and staging of each disease site.Compare and contrast clinical radiation oncology treatments, including the indications for irradiation and special therapeutic considerations unique to each site and stage of disease.

Each faculty will test the residents’ knowledge and understanding at the end of each disease site, either by written exam or oral exam.

All residents must complete an evaluation form on each faculty following completion of each disease site.

Resident Evaluation/Survey

Required:

* 1,2,3Appraise the potential value and limitations of other oncologic disciplines.Demonstrate an understanding of oncologic pathology, with special emphasis on neoplasia and radiation effects; and diagnostic imaging.

Lecture Content (comprehensive review)

1

Selection of a treatment modality 2

3Adjuvant therapies 4Treatment results (e.g., with surgery, radiation therapy, or chemotherapy) 5Patterns of failure 6Complications 7Review the critical literature that supports the content of each lecture 8Normal tissue effects & Late Effects 9

Topic review

In-Training Exam/Board Review - quiz/questionsAssessment of resident learning, incorporating self-study & lecture contentEvaluation of faculty lecture/topic review

Mock Boards

*

Tuesdays @ 4.30-6.00 pm (1 - 1.5 hours/lecture)

DATE: Anatomical Site: Fac: Sect:

Mock Oral Boards August 24,2009

9/15/09 Breast Early Stage: DCIS & LCIS MNL 2-89/22/09 Early Stage: Stage I & II 2-89/29/09 Locally Advanced, Inflammatory & Locally Recurrent 2-810/6/09 Pathology & Radiology, Normal Tissue Effects & Late Effects 1&910/13/09 ITE/Board Review & Topic Review

10/20/09 Metastasis Skeletal Metastasis & Cord Compression/Brain Metastasis DPS/KU 2-810/27/09 Vena Cava Syndrome, Other Relief of Obstruction & Hemostasis 2-811/3/09

11/10/09 ITE/Board Review & Topic Review 2-8

11/17/09 CNS Low Grade Glioma, Oligodendroglioma and Oligoastrocyt PO/MM/KU 2-8

11/24/09 Astrocytoma, Anaplastic Astrocytoma & Glioblastoma Multiforme 2-812/1/09 Meningioma, Germ Cell Tumor, Pineal Tumor, AVM & Accoustic Neurom 2-812/8/09 Pathology & Radiology, Normal Tissue Effects & Late Effects 2-812/15/09 ITE/Board Review & Topic Review 1&9

12/22/09 No Lecture Christmas

12/29/09 No Lecture New Year

Radiation therapy techniques as appropriate to the topic/site of disease - external beam (eg, SRS/SRT, IMRT, 3-D, KV, particle), brachytherapy (eg, LDR, HDR, mammosite, plaque), unsealed radioactive agents (eg, radioimmunotherapy),TBI, TSI

No Lecture - ASTRO

Oncologic imaging & pathology (Examples of slides & films, if not shown in appropriate multidisciplinary conference/tumor board)

Section:

At the end of each academic year a time period will be set aside to perform mock oral boards, based on the previous year's topics/material.

1/5/10 CNS Part II LSC 2-8

1/12/2010 - Additional session Medulloblastoma, Ependymoma, Germ Cell Tumor, Pineal Tumor 2-81/19/10 Pituitary Tumor, Parasellar Tumor & Craniopharyngioma 2-81/26/10 Pathology & Radiology, Normal Tissue Effects & Late Effects 1&92/2/10 ITE/Board Review & Topic Review

2/9/10

Lympho-

reticular Hodgkin's Disease: Early Stage (Favorable & Unfavorable) LSC 2-82/16/2010 - Additional session Hodgkin's Disease: Advanced Stage & Treatment Planning 2-82/23/10 Non-Hodgkin's Lymphoma: Aggressive 2-8

3/2/10 - Additional session Non-Hodgkin's Lymphoma: Indolent & Extranodal Sites 2-83/9/10 Leukemia, Multiple Myeloma, Plasmacytoma 2-83/16/10 Pathology & Radiology, Normal Tissue Effects & Late Effects 1&93/23/10 ITE/Board Review & Topic Review

3/30/10 H&N Introduction to H&N YC/DPS/HZ 2-84/6/10 Retreatment for Recurrent H&N Tumors 2-84/13/10 Salivary Gland & Thyroid 2-84/20/10 Oral Cavity & Oropharynx 2-84/27/10 Larynx & Supraglottic Larynx, Nasopharynx & Hypopharynx5/4/10 ITE/Board Review & Topic Review

5/11/10 GYN Cervix JA 2-85/18/10 Cervix 2-85/25/10 Endometrium & Uterus6/1/10 Ovary & Fallopian Tube, Vagina & Vulva 2-86/8/10 Pathology & Radiology, Normal Tissue Effects & Late Effects 1&96/15/10 ITE/Board Review & Topic Review

6/22/10 Special Topics, Therapies & Techniques AKIntravascular Brachytherapy & Heterotopic Bone

MOCK BOARDS

6/29/10 No lecture

7/6/10 No lecture

7/13/10 No lecture

7/20/10 No lecture

7/27/10 No lecture

8/3/10 No lecture

Astrocytoma (Juvenile, Low Grade, High Grade), Brainstem Glioma, Oligodendroglioma

8/10/10 No lecture

8/17/10 No lecture

8/24/10 No lecture

8/31/10 No lecture

9/7/10 No lecture

9/14/10 Bone & Soft

Tissue Sarcomas Part ILSC 2-8

9/21/10 Sarcomas Part II 2-89/28/10 Pathology & Radiology, Normal Tissue Effects & Late Effects 1&910/5/10 ITE/Board Review & Topic Review

10/12/10 GI Esophagus AK 2-810/19/10 Stomach & Small Bowel 2-810/26/10 Colon & Rectum 2-811/2/10 Anus 2-811/9/10 Pancreas, Biliary & Liver 2-811/16/10 Pathology & Radiology, Normal Tissue Effects & Late Effects 1&911/23/10 ITE/Board Review & Topic Review

11/30/10 Pediatrics Hodgkin's Disease & Non-Hodgkin's Lymphoma LSC 2-812/7/10 Wilm's Tumor & Neuroblastoma 2-812/14/10 Ewing's Sarcoma, Osteogenic Sarcoma 2-812/21/10 No lecture - Christmas

12/28/10 No lecture - New Year

1/4/11 Rhabdosarcoma & Soft Tissue Sarcoma 2-81/11/11 Retinoblastoma & Leukemia 2-8

Additional session Langerhan's Cell Histiocytosis, Germ Cell Tumor, Hepatic Tumor, Bone T 2-81/18/11 Pathology & Radiology, Normal Tissue Effects & Late Effects 1&91/25/11 ITE/Board Review & Topic Review

2/1/11 GU Testis: Seminoma RAB 2-8

2/8/11 Testis: Non-Seminoma; Renal Cell Carcinoma 2-8

2/15/11 Bladder, Ureter, Pelvic Kidney, Urethra & Penis - Part I 2-8

2/22/11 Bladder, Ureter, Pelvic Kidney, Urethra & Penis - Part II 2-8

3/1/11 Prostate - Early Stage Part I 2-8

3/8/11 Prostate - Early Stage Part II 2-8

3/15/11 Prostate - Intermediate/Advanced 2-8

3/22/11 Pathology & Radiology, Normal Tissue Effects & Late Effects 1&9

3/29/11 ITE/Board Review & Topic Review

4/5/11 Lung Lung - Non-Small Cell YC/MM/DPS 2-84/12/11 Lung - Small Cell 2-8

(Including Soft Tissue Sarcoma, Desmoid Tumor & Kaposi's Tumor, Osteosarcoma, Chondrosarcoma,

4/19/11 Superior Sulcus, Thymoma, Mediastinal & Mesothelioma 2-84/26/11 Pathology & Radiology, Normal Tissue Effects & Late Effects 1&95/3/11 ITE/Board Review & Topic Review

5/10/11 Skin Skin & Melanoma DPS/KU 2-85/17/11 Pathology & Radiology, Normal Tissue Effects & Late Effects 1&95/24/11 ITE/Board Review & Topic Review

5/31/11 Special Topics, Therapies & Techniques

Radioimmunotherapy & Unsealed Sources RAB/MT

MOCK BOARDS


Mock Oral Boards

This educational session was introduced at the request of the residents to provide more Board-type Review sessions and to assist the program and residents in improving their Board scores. These sessions are conducted annually, at the end of each academic year. All residents are required to participate. Topics covered during the Clinical Oncology lecture series for the previous academic year are incorporated into these ‘mock oral board’ sessions and the faculty involved in teaching these topics during the year conduct these sessions. Residents are quizzed individually, according to their level of training (junior residents are expected to have a lesser fund of knowledge than senior residents). This is meant as a learning opportunity. At the end of each session, residents will be provided with feedback on their level of knowledge and learning for that topic, to assist them in setting individual goals for improvement. This will also allow the residents to become more familiar with the Oral Board format.

Schedule

• 25 min quiz of individual residents by faculty teaching the Clinical Oncology topics for this

academic year. • 5 mins for individual feedback at end of each session. Year 1 Year 2

JA GYN RAB GU YC H&N YC Lung LSC Peds CNS/Lymphoreticular LSC Bone & Soft Tissue/Pediatrics MNL Breast AK GI PO Adult CNS MM Lung/Skin



NAME OF CONFERENCE:

Onco-Anatomy Seminars


Tuesdays @ 4.30-6.00 pm, July & August, annually

CONFERENCE FORMAT:

8-week seminar series, held in the Cooper Conference Room (WCC Rm G-0712)

COURSE DIRECTOR:

Philip Rubin MD



Learning Objectives:

• Use a uniform set of staging criteria and knowledge of the anatomy of the primary anatomic regions and their subsites to identify cancer spread patterns.

• Consider anatomic principles, concepts and facts to determine the most likely site(s) of origin of the primary location for a metastatic lesion.

Competencies:

• 1,2,6 • 1,2,6


• All residents must attend. • Service faculty are welcome to participate. Attendance will be recorded as documentation of participation.

RECOMMENDED/ REQUIRED READING:

• TNM Staging Atlas. P. Rubin and J. Hanson. Lippincott Williams and Wilkins, 2007

• B-ALERT (Biocontinuum of Adverse Late Effects Cancer Treatment)

Course Syllabus:

Week 1: Introduction: Concepts Week 2: Head and Neck:

• Paranasal Ethmoid Sinus • Maxillary Sinus • Nasopharynx • Oral Cavity • Parotid Gland • Oropharynx • Hypopharynx • Supraglottic Larynx • Glottic Larynx • Subglottic Larynx • Thyroid

Week 3: Thorax: • Pancoast Cancer • Bronchioloalveolar Cancer • Adenocarcinoma • Large Cell Anaplastic Cancer • Squamous Cell • Small Cell Anaplastic Cancer • Mesothelioma • Breast Cancer • Thoracic Esophagus

Week 4: Abdomen: • Esophagogastric

• Stomach • Liver • Gallbladder • Extrahepatic Bile Ducts • Pancreas

• Ampulla of Vater • Colon • Small Intestine • Rectum • Anus

Week 5: Male Genital: • Kidney, Renal Cancer • Renal Pelvis and Ureters • Urinary Bladder • Prostate • Penis • Testes • Urethra

Week 6: Female Genital: • Ovary • Fallopian Tube • Fundus Uteri • Gestational Trophoblastic

Tumors of the Uterus • Uterine Cervix • Vagina • Vulva

Week 7: Generalized Sites: • Skin Integumentary System • Skin Melanoma • Musculoskeletal Soft Tissue

Sarcoma • Bone • Lymphoid Neoplasms: Hodgkin

Lymphoma and Non-Hodgkin Lymphoma

Week 8: Ophthalmic Primary Sites: • Eyelid, Adnexa, and Conjunctiva • Uvea • Retina • Lacrimal Gland

RESIDENT RESPONSIBILITIES: Resident on service at the anatomic site being discussed will be expected to assist in projecting anatomy and gathering teaching materials. RESIDENT EVALUATION REQUIRED: • Residents will be asked to complete a course

evaluation at the end of the seminar series.

TEST/EXAM REQUIRED: • Self-assessment tests are administered

periodically throughout the course.



NAME OF CONFERENCE:

Introduction to Biostatistics Course Clinical Biostatistics Course

COURSE DIRECTOR:

Xing Qiu PhD DRO Faculty


Mondays @ 4.30-6.00 pm, Fall Semester, biannually

CONFERENCE FORMAT & DESCRIPTION: These courses are very beneficial to residents in preparing and submitting their research proposal and conducting their research.

Key to Core Competencies:


ADDITIONAL COURSE REQUIREMENTS: RESIDENT EVALUATION/SURVEY REQUIRED:


TEST/EXAM REQUIRED: The final grade will be derived from a final test. REQUIRED ATTENDANCE: All residents must attend.


Introduction to Biostatistics Course: Xing Qiu PhD Course Description: This course presents broad concepts of biostatistics that are useful for the health sciences. The course covers the main aspects of biostatistics and introduces very basic notions of probability. It begins with a presentation of descriptive statistics (univariate and bivariate analysis; tables and graphs). A brief introduction to probability is next given. It includes the notions of discrete and continuous random variables and presents a few important distributions (binomial, gaussian). The course focuses next on important aspects of statistical inference, such as estimation, confidence interval and test of hypotheses, and describes a few parametric and nonparametric methods. It also introduces important statistical models (analysis of variance, linear model, survival analysis and logistic regression) and some aspects of observational and experimental studies (randomized clinical trials; case-control study, case-cohort studies…). Course Objectives: Competencies: • Identify the use of biostatistics in health care research. • Differentiate between Phase I, II and III studies • Discuss the use of case control studies • Differentiate between prospective and retrospective studies • Describe randomized and non-randomized control trials • Indicate the purpose of explicit statistical terminology • Identify the mean, median and mode • Select the most appropriate measure of central tendency for a given situation • Describe the various forms of distributions (normal, Poisson, binomial) • Describe information conveyed by a probability statement and distinguish

between P values (p = .001, p= .01, p= .05, etc.) • Describe the use of T testing. • Discuss the use of Chi Square • Identify use of multivariable analyses • Differentiate between randomized and non-randomized studies

• 2,3 • 2,3 • 1,2,3 • 2,3 • 2,3 • 2,3 • 2,3 • 2,3 • 2,3 • 2,3 • 2,3 • 2,3 • 2,3 • 1,2,3

Course Syllabus: Session 1 - Introduction/Study Design: • Phase I, II and III studies • Case control studies • Prospective studies (cohort studies) • Retrospective cohort studies • Nested case control studies • Randomized and non-randomized control trials • Cross-sectional studies • Case series

Session 2 - Definition of statistical terms: • Visual display of statistical data • Measures of central tendency • Characterization of data • Basic probability • Distributions (normal, Poisson, binomial) • Others, as not covered in other sessions • General interpretation and analyses Session 3 - Sensitivity and specificity: • Positive and negative predictive value • The effect of prevalence on predictive value • Receiver operator curves • Lab tests and x-ray studies Session 4 - Tests of significance: • Alpha, beta and power • P value and confidence intervals • 1 vs 2 tail testing • Univariable analyses • Bivariable analyses

o Chi square o Z testing o T testing o Correlation o Linear regression

Session 5 - Multivariable analyses: • Logistic regression • Multiple regression • Survival analysis • Factor analysis Session 6 - Phase III Studies: • Randomized control trials • Types of sampling • Differential vs non-differential bias • Types of bias • Confounding Session 7 - Non-randomized studies: • Case control study • Nested case control study • Retrospective cohort • Selection of controls Session 8 - Met analysis: • Publication bias • Interpretation • Review session

Session 9 – Practicum Session 10 – Exam REQUIRED READING:

• Rosner, B. (2005). Fundamental of Biostatistics. Duxbury. • Motulsky, H. (1995). Intuitive Biostatistics.

Clinical Biostatistics Course: DRO Faculty Course Description: This course presents statistical concepts relative to the understanding and evaluation of clinical studies and journal articles. Course Objectives: Competencies: • Describe the steps involved in development of a study design and sample size • Distinguish between a variable and a constant • Identify the different types of measurement scales • Identify different categories or aspects of statistics and differences between them • Describe methods for dealing with random error • Distinguish between the research hypothesis and null hypothesis • Describe methods for dealing with systematic error (bias) • Perform critical analysis of literature • Discuss clinical applications related to decision making and evaluating screening

and diagnostic tests

• 2,3 • 2,3 • 2,3 • 2,3 • 2.3 • 2,3 • 2,3 • 1,2,3 • 1,2,3

Course Syllabus: Session 1 – Introduction: • Study design and sample size estimation. • Descriptive statistics and missing data.

Session 2 – Dealing with Random Error: • Effect estimation and confidence limits. • Survival analysis. • Statistical testing (hypothesis testing). Session 3 – Dealing with Systematic Error (Bias): • Multivariate analysis: confounding, interaction and risk models. • Systematic reviews and meta-analysis. • Critical appraisal of the literature. Session 4 – Clinical Applications: • Clinical decision making: evaluating screening and diagnostic tests. • Health services and outcomes research: life expectancy, QOL, cost

REQUIRED READING:

To be determined by the instructors.


NAME OF CONFERENCE: Stress-Fatigue Seminars

CONFERENCE SCHEDULE: Wednesdays at 4.30-6.00 pm, quarterly


Informal open discussion of issues related to stress and fatigue in aconfidential setting.

COURSE DIRECTOR: Joanne Dermady, Director, Employee Assistance Program


Learning Objectives:• Recognize signs and symptoms of fatigue.• Describe sleep deprivation consequences.• Identify characteristics of burnout.• Identify stressors.• Discuss stress management techniques and strategies.

Competencies:• 1,4,5 & Patient

Safety

REQUIRED ATTENDANCE:All residents must attend.Attendance will be recorded as documentation of participation.

REQUIRED/RECOMMENDEDREADING:

No prior reading assignments required, unless directed by the CourseDirector.

RESIDENT RESPONSIBILITIES:

Not applicable.

ATTENDING RESPONSIBILITIES:

Not applicable.

RESIDENT EVALUATION REQUIRED:

Not applicable.

TEST/EXAM REQUIRED:

Not applicable.


NAME OF CONFERENCE: Quality Assurance & Improvement Conference

CONFERENCE SCHEDULE: 3rd Wednesday @ 4.30-6.00 pm


Monthly review of patients completing treatment the previous month


Learning Objectives:• Discuss the importance of morbidity/mortality reviews.• Describe how QA/QI conferences are used to improve patient care, patient safety

and reduce risk.• Participate in QA/QI initiatives.

Competencies:• 1,2,3,4,5,6• 1,2,3,4,5,6

• 1,4,5

REQUIRED ATTENDANCE:• All residents must attend.• All clinical faculty must attend.Attendance will be recorded as documentation of participation.

REQUIRED READING: As assigned


• Each resident must prepare a report for the rotation to which he/she wasassigned the previous month.

• The reports must include the following:- Total # of pts completing treatment- # treated curatively- # treated palliatively- # pts on protocol- # treated as prescribed- # with complications- # not completing- # late effects seen in F/U- # pts for each disease site for that service- Presentation and discussion of any patients not completing tx.

• On a rotating basis, each resident will be asked to respond to a case-scenario patient or system problem, stating how the problem(s) mightbe resolved.

ATTENDINGRESPONSIBILITIES:

A patient previously reviewed by one of the residents will be selected by thefaculty, who will ask the residents to respond case-based scenarios.

ASSESSMENT: A summary of the case-scenario discussions will be submitted to theprogram administrator as a record of teaching in PBLI and SBP.



NAME OF CONFERENCE:

Journal Club


4th Wednesday @ 4.30-6.00 pm


Clinical (8 per year) Evidence-Based Medicine (EBM) (2 per year) Ethics (2 per year)

Month 1 Clinical Month 7 Clinical Month 2 Clinical Month 8 Clinical Month 3 EBM Month 9 EBM Month 4 Clinical Month 10 Clinical Month 5 Clinical Month 11 Clinical Month 6 Ethics Month 12 Ethics Key to Core Competencies: 1 = Patient Care


Learning Objectives: Competencies: Clinical Journal Club: • Conduct a conscientious, explicit, and judicious review of recent publications and

current literature. • Identify pertinence and importance of these articles in making decisions about the

care of individual patients.

Clinical Journal Club: • 1,2,3,4,5,6 • 1,2,3,4,5,6

EBM Journal Club: • Conduct a conscientious, explicit, and judicious review of current best evidence in

making decisions about treatment options for a specific disease. • Identify pertinence and importance of these articles in making decisions about the

care of individual patients.

EBM Journal Club: • 1,2,3,4,5,6 • 1,2,3,4,5,6

Ethics Journal Club: • Discuss the importance of ethical-based medical practice.

Ethics Journal Club: • 1, 3, 4, 5, 6

Clinical EBM Ethics

• Residents must attend all journal clubs.

• Attendings are strongly encouraged to attend all clinical journal clubs.


• Service attending and Program Director must attend EBM journal clubs.


• Program Director must attend Ethics journal clubs.


Attendance will be recorded as documentation of participation. Clinical EBM Ethics REQUIRED READING:

• 2 articles will be presented by designated resident(s).

• Articles should be chosen from the following journals: - IJROBP - JCO - NEJM


• Articles should be chosen from the following journals: - IJROBP - JCO - NEJM


• Articles will be selected by the Program Director

RESIDENT RESPONSIBILITIES: • All residents and attendings will read the articles

prior to the journal club to allow more time for discussion of the articles.

• Each resident will present a brief overview of the content of one of the articles, followed by a critical appraisal (approximately 15 mins per article), including: - the strengths and weaknesses - clinical merits and applicability of

recommendations - consideration of financial impact and cost-

effectiveness of study

ATTENDING RESPONSIBILITIES: • All residents and attendings will read the articles

prior to the journal club to allow more time for discussion of the articles.


NAME OF CONFERENCE: Pain Management Seminar Series

CONFERENCE SCHEDULE: Wednesdays @ 4.30 pm – 4 sessions, biannually


4-part series on pain management, sponsored by Purdue-Pharma:Session 1 – Overview of physiology, assessment, and treatmentSession 2 – Assessing and treating pain in special populationsSession 3 – Management of persistent nonmalignant painSession 4 – Cancer pain and end-of-life care

COURSE INSTRUCTORS:Ralph A Brasacchio MD, Residency Program DirectorNora Holtz, Purdue Pharmaceuticals


Learning Objectives: Competencies:Session 1 – Overview of physiology, assessment, and treatment:• Understand the pathophysiology of pain and the underlying mechanisms.• Understand the critical elements of the pain history, and evaluate characteristics of pain

relevant to diagnosis and management.• Understand the distinction between acute and chronic pain.• Describe tools used to assist in the assessment of pain to guide management options.• Compare and contrast pharmacologic and nonpharmacologic options for the management

of pain.• Understand the approach for rational selection, administration, and titration of analgesics

used in the treatment of pain.• Understand the appropriate use of nonopioid and opioid analgesics in pain management,

as well as managing side effects.• Recognize both real and perceived barriers to effective pain management and set

priorities for establishing pain management practices that equate pain relief with diseasetreatment.

Session 1:• 2• 1,2

• 1,2• 1,2• 1,2

• 1,2,3

• 1,2

• 1,2,3

Session 2 – Assessing and treating pain in special populations:• Understand the racial and ethnic disparities in pain management and strategies to

overcome barriers to treatment in this population.• Understand principles and strategies for assessing and managing pain in patients with

addictive disorders or a history of substance abuse.• Recognize age-related physiologic changes in older adults, and how age-related changes

affect pain management.• Describe specific pharmacologic (eg, opioids, nonopioids, adjuvant agents) and

nonpharmacologic strategies (eg, exercise, cognitive-behavioral therapies) for managingpain, and age-related considerations in the older patient.

• Describe developmentally appropriate strategies and tools for assessing pain in children.• List pharmacologic and nonpharmacologic treatments for pain in children.

Session 2:• 1,2,4,5

• 1,2,4,5

• 1,2,4,5

• 1,2

• 1,2• 1,2,3

Session 3 – Management of persistent nonmalignant pain:• Understand the basic approach to the evaluation and assessment of the patient with

persistent nonmalignant pain.• Understand the basic nonpharmacological approaches to the management of persistent

pain syndromes.• Understand the appropriate use of different pharmacological interventions to treat

persistent pain syndromes.• Appropriately use opioid therapy for the treatment of persistent pain syndromes.• Describe the assessment and management approaches to common persistent pain

syndromes seen in primary care.• Describe the assessment and management of nonmalignant neuropathic pain syndromes.

Session 3:• 1,2,4

• 1,2

• 1,2

• 1,2• 1,2

• 1,2Session 4 – Cancer pain and end-of-life care:• Understand the critical elements in the assessment of cancer-related pain.• Understand the approach for rational selection, administration and titration of analgesics

used in the treatment of cancer-related pain.• Understand the use of nonopioid, opioid, and adjuvant analgesics in cancer pain

management.• Understand other approaches to the management of persistent cancer pain, including

interventional, neurostimulatory, neuroablative, physical and psychological.• Understand the issues of cancer pain management at the end of life.

Session 4:• 1,2• 1,2

• 1,2

• 1,2

• 1,2

REQUIRED ATTENDANCE: • All residents must participate.• Program Director must participateAttendance will be recorded as documentation of participation..

REQUIRED READING: American Medical Association Pain Management Program

RESIDENT RESPONSIBILITIES:• Mandatory attendance at all sessions• Each resident must read appropriate section of course

prior to the scheduled educational session.• Each resident must complete self-assessment prior to

scheduled educational session.• At time of each session, the residents will exchange

assessment forms with each other for peer evaluationof their responses.

• At the end of each session, each resident will submithis/her self-assessment as documentation ofcompletion of the session.

INSTRUCTOR RESPONSIBILITIES:• The Program Director will present an overview

for each module of the course.• The Program Director will review the correct

responses for the self-assessments with theresidents.

• The Program Director will facilitate appropriatefurther discussion on the topic.

RESIDENT EVALUATION REQUIRED:• Each resident must submit an evaluation of the

program at the end of each session.

TEST/EXAM REQUIRED:• Resident self-assessments must be submitted at

the end of each session.



NAME OF CONFERENCE:

Radiation-Cancer Biology Course CBARMFI Training & Education Workshop Series


Wednesdays @ 8.00-9.00 am, September-June, biannually Intervening period, bimonthly workshops


A series of didactic lectures, presentations, interactive discussions, and laboratory demonstrations on all aspects of radiation and cancer biology.

COURSE INSTRUCTORS:

Peter Keng PhD Bruce Fenton PhD Jacqueline Williams PhD



Learning Objectives: Competencies: • Describe principles of cellular biology and apply to principles of radiation

biology. • Apply laws and principles of radiation biology to the clinical practice of

radiation therapy. • Apply principles of electromagnetic and particulate radiations to cellular

interactions. • Distinguish between units of radiation quantities and radiobiologic measures and

demonstrate correct usage. • Compare and contrast somatic and genetic effects of radiation. • Evaluate factors influencing radiobiologic/biophysical events at the cellular and

subcellular level. • Describe radiation induced chemical reactions and analyze biologic damage. • Describe factors influencing radiation response of cells and tissues. • Apply the Laws of Bergonnie and Tribondeau to radiation biology and clinical

radiation therapy. • Construct and evaluate charts, graphs and survival curves related to radiation

biology principles. • Evaluate the relationship of radiation quality and dose to systemic responses. • Apply the principles of radiobiology to tumor cell biology and evaluate radiation

effects anticipated in the clinical practice of radiation therapy. • Describe the relationship of time, dose, fractionation, volume and site to

radiation effects.

• 1,2 • 1,2 • 1,2 • 1,2 • 1,2 • 1,2 • 1,2 • 1,2 • 1,2 • 1,2 • 1,2 • 1,2 • 1,2

• Describe the use of radiation response modifiers in the clinical practice of

radiation therapy. • Describe the principles of chemotherapy and hyperthermia and their influence on

biologic effects in combination with radiation therapy.

• 1,2 • 1,2

Course Syllabus:

Radiation-Cancer Biology Course • Interaction of Radiation with Biological

Systems • Molecular Mechanisms of DNA Damage • Molecular Mechanisms of DNA Repair • Chromosome and Chromatid Damage • Mechanisms of Cell Death • Cell and Tissue Survival Assays • Models of Cell Survival • Modifiers of Cell Survival: Linear Energy

Transfer • Modifiers of Cell Survival: Oxygen Effect • Modifiers of Cell Survival: Repair • Solid Tumor Assay Systems • Tumor Hypoxia and Therapeutic Resistance • Angiogenesis and Angiangiogenic Strategies • Cell and Tissue Kinetics • Molecular Signaling • Cancer • Total Body Irradiation • Clinically Relevant Normal Tissue Responses

to Radiation • Mechanisms of Normal Tissue Radiation

Responses (I) • Mechanisms of Normal Tissue Radiation

Responses (II)

• Therapeutic Ratio • Time, Dose, Fractionation (1) • Time, Dose, Fractionation (2) • Brachytherapy • In-Training Exam/Board Question Review • In-Training Exam/Board Question Review • Radiobiological Aspects of Alternative Dose

Delivery Systems • Chemotherapeutic Agents and Radiation

Therapy • Photodynamic Therapy • Radiosensitizers, Bioreductive Drugs,

Radioprotectors • Hyperthermia • Radiation Carcinogenesis • Heritable Effects of Radiation • Radiation Effects in the Develolping Embryo • Radiation Protection • In-Training Exam/Board Question Review • In-Training Exam/Board Question Review • In-Training Exam/Board Question Review • In-Training Exam/Board Question Review

CBARMFI Training & Education Workshop Series

• Radiation Cell Survival Curves • Radiation-induced Cell Cycle Delay • Radiation-induced Apoptosis • In-vivo Radiation Studies

• Chromosome Damage and Repair • Micronuclei Detection by Flow Cytometer • Hypoxia Measurements by Image Analysis • DNA Damage and Repair by Comet Assay

REQUIRED ATTENDANCE: All residents must attend. Attendance will be recorded as documentation of participation.

REQUIRED READING:

Appropriate chapter(s) of the following textbooks: • The Basic Science of Oncology, 4th edition: Tannock, Hill,

Bristow & Harrington • Radiobiology for the Radiologist, 5th edition: Hall

RESIDENT RESPONSIBILITIES: • Mandatory attendance at all sessions • Each resident must read the appropriate chapters

from the recommended textbooks prior to the scheduled educational session.

INSTRUCTOR RESPONSIBILITIES: • The Instructor will present an overview for each

module of the course. • The Instructor will facilitate appropriate further

discussion on each topic. RESIDENT EVALUATION REQUIRED: All residents must complete an evaluation form at the end of the course.

TEST/EXAM REQUIRED: The faculty will test the residents’ knowledge and understanding, either by written exam or oral exam.



NAME OF CONFERENCE: Practical Dosimetry Lecture Series

CONFERENCE SCHEDULE: 0.5-1 hour lectures held weekly, September-January biannually


A series of practical demonstrations and interactive discussions on all aspects of radiation physics dosimetry.

COURSE INSTRUCTORS: Certified Medical Dosimetry Staff Key to Core Competencies: 1 = Patient Care



• Become knowledgeable and proficient in all technical aspects of radiation therapy treatment planning, delivery, and documentation.

• Understand all technical availabilities and limitations with regard to patient set-up and beam delivery.

Competencies:

• 2,6 • 2,6

Course Syllabus:

• Radiotherapy Prescription Writing • Basic Emergency Calculations • Simulations

• Isodose Distributions I & II • Specialty Calculations • Technical Devices & Applications


REQUIRED READING:

• “Treatment Planning & Dose Calculation in Radiation Oncology”, Gunilla C Bental, Charles E Nelson PhD, K Thomas Noell MD. 3rd or 4th edition.

• “The Physics of Radiation Therapy”, Faiz M Khan. 2nd or 3rd edition. • “Radiation Oncology Physics: A Handbook for Teachers and

Students”, Podgorsak (http://www-pub.iaea.org/MTCD/publications/PDF/Pub1196_web.pdf)

RESIDENT RESPONSIBILITIES: • Complete all reading assignments • Practice relevant calculations, according to the

schedule • Plan evaluations

INSTRUCTOR RESPONSIBILITIES: • Prepare for lectures • Set up series of sample calculations and plans • Prepare lecture syllabus and reading material

RESIDENT EVALUATION/ SURVEY REQUIRED: All residents must complete an evaluation form at the end of the course.

TEST/EXAM REQUIRED: Not applicable.



NAME OF CONFERENCE:

Radiation Physics Course


Wednesdays @ 8.00-9.00 am, September-June, biannually Intervening period, quarterly physics labs/workshops


A series of didactic lectures, presentations, interactive discussions and laboratory demonstrations on all aspects of radiation physics.

COURSE DIRECTOR:

Michael Schell PhD




• Understand the principles of physics, particularly as they apply to radiation therapy.

• Understand the technological advances in radiation therapy treatment delivery. • Understand the role of physics in the delivery of radiation therapy.

Competencies:

• 1,2 • 1,2 • 1,2

Course Syllabus:

Radiation Physics Course

• Atomic & Nuclear Structure • Radioactive Decay • Properties & Production of Particulate &

Electromagnetic Radiation • Characteristics of Photon Beams

• Interactions of Electromagnetic Radiation with Matter

• Radiation Therapy Units

• Interactions of Particulate Radiation with Matter

• Quantification & Measurement of Dose

• Calibration of X-Ray & Electron Beams • Dosimetry of Photon Beams in a Homogeneous Water Phantom

• Dosimetry of Photon Beams in a Patient • A System of Dosimetric Calculations • Dosimetry of Radiation Fields • Treatment Planning I: Isodose Distributions • Treatment Planning II: Patient Data • Treatment Planning III: Field Shaping • Electron Beam Therapy • 3D Conformal & IMRT Treatment Planning • Brachytherapy • Diagnostic Imaging & Applications to

Radiation Therapy • Radiation Protection & Safety • Quality Assurance & Quality Management

Program

Physics Labs & Workshops

• Construction of treatment aids • Calibration of radiation therapy machines • Quality control procedures • Brachytherapy (LDR, HDR, gyn, prostate)


REQUIRED READING:

Appropriate chapter(s) of the following textbooks: • Radiation Therapy Physics. Hendee, 2004 • The Physics Of Radiation Therapy. Faiz Khan. Publisher:

Williams and Wilkins. Baltimore, 2003 (3rd edition) RESIDENT RESPONSIBILITIES: • Mandatory attendance at all sessions • Each resident must read the appropriate

chapter(s) from the recommended textbooks prior to the scheduled educational session.

• Homework assignments and examinations must be completed on time.

INSTRUCTOR RESPONSIBILITIES: • The Instructor will present an overview for

each module of the course. • The Instructor will facilitate appropriate further

discussion on each topic.

RESIDENT EVALUATION REQUIRED: All residents must complete an evaluation form at the end of the course.

TEST/EXAM REQUIRED: The faculty will test the residents’ knowledge and understanding, either by written exam or oral exam.



NAME OF CONFERENCE:

Palliative Care Modules


Six modules are completed during the course of residency

COURSE DIRECTOR: Timothy E Quill MD, Director, Center of Palliative Care and Clinical Ethics

CONFERENCE FORMAT & DESCRIPTION: • Module 1 – Pain management • Module 2 – Communicating bad news • Module 3 – Inf Informed Consent and capacity • Module 4 – Conducting a family meeting to

discuss CPR/DNR • Module 5 – Motivation and health behavior • Module 6 – Disclosing adverse outcomes ormed

Consent and capacity

Each module has 4 components: • Online self-study • Pretest, slide presentation and skill-building

session • Performance evaluation in practice (computer

or paper-based) • Standardized evaluation session and

certification Key to Core Competencies: 1 = Patient Care



Module 1 – Pain management: • List at least 3 barriers to adequate pain management (including one that is most

relevant to your clinical practice). • Define and illustrate the clinical differences between physical dependence,

tolerance, addiction, and pseudo-addiction. • Understand the 3-Step WHO Guidelines to mild, moderate and severe pain, and

give examples of starting doses of medications for each step. • Calculate and prescribe proper doses of around-the-clock opioids for chronic pain,

and select proper doses and intervals for breakthrough doses; be able perform dose conversions between different opioids and different routes using an equianalgesic table.

• Name two common side effects of opioids, and illustrate how to anticipate and counteract them.

• Name two adjuvant treatments recommended for neuropathic pain and two adjuvant treatments recommended for bone pain.

Module 1: • 2 • 2 • 1,2 • 1,2 • 1,2 • 1,2

Module 2 – Communicating bad news: • Describe the physical setting where bad news should be delivered • Understand the six basic steps used to initially deliver bad news • Understand key elements in discussing prognosis • Understand key elements of telephone notification of death • Understand basic ways to therapeutically respond to patient/family emotion • Describe two main difficulties that you personally have in delivering bad news • Demonstrate the ability to deliver bad news with compassion and honesty using

this six-step approach

Module 2: • 1,4 • 1,4 • 1,4 • 1,4 • 1,4 • 1,4 • 1,4

Module 3 – Informed consent & capacity: • Recognize the elements of a valid informed consent • Describe the process of obtaining informed consent, including disclosing relevant

information and answering questions • Recognize the components of decision-making capacity • Describe the process of assessing decision-making capacity • Understand the interaction between decision making capacity and the informed

consent process • Demonstrate the process of assessing decision making capacity and obtaining

informed consent

Module 3: • 1,2,4,5 • 4,5 • 1,2,4 • 1,2 • 3,4 • 3,4

Module 4 – Conducting a Family Meeting to Discuss CPR/DNR: • Describe CPR facts and statistics • Demonstrate the 6-step process to facilitate family decision-making • Illustrate challenges in the use of language • Demonstrate techniques to manage family conflict • Summarize key features of an effective family meeting

Module 4: • 1,2 • 4,5 • 4 • 4,5 • 4,5,6

Module 5 – Motivation and Health Behavior: • To promote the broader appreciation of behavioral counseling in clinical care • To understand the U.S. Preventive Services 5A’s model for health behavior

counseling • Understand the impact of lifestyle-related behaviors on health • To understand fundamental aspects of motivating patient health behavior • Understand the potential impact of long-term behavior change for physical

activity, tobacco, alcohol, and healthy diet • To demonstrate how to promote health behavior change using the 5A’s brief

intervention

Module 5: • 1,2,6 • 2,4,6 • 1 • 1,4 • 1,2 • 4

Module 6 – Disclosing Adverse Outcomes: • Describe the physical setting where an adverse outcome should be disclosed • Describe the process of disclosing an adverse outcome, including assessing

patient/family understanding • Recognize the need for unambiguous, clear communication • Recognize the importance of expressing regret • Recognize the importance of discussing the institutional response to the adverse

outcome • Demonstrate the process of disclosing an adverse outcome

Module 6: • 4,5 • 4,5 • 4 • 4,5 • 3,4,5 • 4

TEST/EXAM REQUIRED:

Completion of all four components of each module is required to be certified as having demonstrated basic competency in the skill area.



NAME OF COURSE:

Advanced Practice Strategies (APS) e-learning Patient Safety Course

COURSE SCHEDULE:

A series of five course units, which must be completed during the course of residency

COURSE FORMAT:

A series of educational programs intended to expand the residents’ knowledge of patient safety and reduce the risk of professional liability.

COURSE DESCRIPTION: This web-based, risk management education program will educate

residents on the following topics: Course 1 – The Nature and Causes of Errors and Injuries in Health Care:

An introduction to the systems approach to error prevention and some of the methods that are being used successfully in hospitals and offices throughout the country to make patient care safer. This course looks at medical injury and what is known about why people make mistakes. The focus is on medication errors specifically because of their potential morbidity, frequency, and preventability.

Course 2 – Preventing Errors and Injuries in Health Care Using Systems Theory

Provides information about how to use systems theory and human factors engineering to improve medical care. Participants will learn how human factors experts analyze failures and how they redesign systems to prevent them.

Course 3 – Responding to Adverse Events and Errors in Health Care

This course aims to provide a basic understanding of what is involved with system analysis of medical injuries and provide participants with a deeper understanding of what it really means when we talk about a nonpunitive environment. This course uses a root cause analysis to look at a serious adverse event and look at its effects on the patient - as well as on the clinicians involved, the “second victims.” To make health care safe, we must learn from our mistakes.

Course 4 – Changing Systems Safety experts may agree that most errors and accidental injuries result from systems defects, but, identifying systems defects is a complicated business. No significant adverse event has a single cause, a single systems defect, and few system defects can be easily corrected. However, unless systems are changed, the same problems will predictably recur. This coarse helps answer the question, “How do you change systems?”

Course 5 – Using Systems Theory to Understand Errors and Injuries in Healthcare

This course aims to provide a deeper understanding of the concept of system, some principles of how complex systems work, and how systems theory can be applied to health care. Participants will learn how systems theory changes the concept of individual responsibility for patient safety.



Learning Objectives: Competencies: Course 1 – The Nature and Causes of Errors and Injuries in Health Care: • Use the appropriate terminology to describe medical errors and injuries. • Describe the extent of adverse events in health care and characterize the risk

factors among inpatients and outpatients. • Understand the basic principles of human factors that contribute to error. • Appreciate how the culture of blame has prevented health care from addressing

medical error.

Course 1: • 2,4 • 1,,2,3,6 • 1,3,6 • 3,4,6

Course 2 – Preventing Errors and Injuries in Health Care Using Systems Theory: • Discuss the evolution of the concept of medical error from a problem of flawed

clinicians to one of poorly designed systems. • Explain basic concepts of systems theory and their application to health care. • Understand how human factors scientists analyze system failures. • Apply human factors principles to the re-design clinical systems and the

development of patient safety best practices.

Course 2: • 4,6 • 6 • 6 • 6

Course 3 – Responding to Adverse Events and Errors in Health Care: • Discuss appropriate responses in the aftermath of an adverse event—unlike

punitive responses, which are counterproductive, and even harmful, over the long term.

• Define root cause analysis and failure modes and effects analysis. • Understand how to perform a root cause analysis. • List events that must be reported to the hospital and the states. • Explain how to support the second victims of adverse events: the clinicians who

make the errors. • Explain the importance of disclosing adverse events to the patient or the patient's

family.

Course 3: • 1,2,3,6 • 6 • 6 • 4,5,6 • 5,6 • 5,6

Course 4 – Changing Systems: • Identify targets for change. • List the steps involved in the Plan-Do-Study-Act (PDSA) approach to changing

systems. • Explain how PDSA cycles can be used to address systems defects. • Describe how to evaluate the effect of changes in order to design further tests. • Explain the challenges of implementing and spreading change.

Course 4: • 6 • 6 • 6 • 6 • 6

Course 5 – Using Systems Theory to Understand Errors and Injuries in Healthcare: • Describe at least three types of active failures at the "sharp end" of medical

practice. • Identify the concept of system, basic principles of complex systems, and the

application of systems theory to health care. • Describe and analyze latent errors that create opportunities for errors and injuries

in health care • Discuss how systems theory changes the concept of individual responsibility for

patient safety.

Course 5: • 1,3,6 • 1,3,6 • 1,3,6 • 6

COURSE REQUIREMENTS: To receive credit, you must complete the pre-test, all four course

sections, the post-test and the evaluation. Pre-Test: The pre-test will quickly assess your current understanding of key

issues; you will receive feedback on your answers as a useful starting point for the rest of the course. You should complete the pre-test before you start one of the main sections of the course.

Overview: This section provides an overview of the nature and causes of errors and injuries in health care. Here you are introduced to useful terminology that describes different types of medical error, and you will explore the causes of error and relevant aspects both of human performance and of the medical environment in which such errors commonly occur.

Application: This section is comprised of a number of short interactive tasks that will help you to apply your knowledge of the key areas. The activities will encourage you to put the theory into practice as you answer questions about the nature and causes of errors and injuries, medical errors in particular.

Clinical Stories: Here you can access clinical stories that illustrate important points about how and why errors and injuries can occur. Each clinical story is described and analyzed in terms of the relevant issues.

Risk Management Review: This section draws out the most important learning points related to the risk management issues of this course. The main issues are described and each is complemented by a list of strategies you can take in order to mitigate the risks.

Post-Test: This will test your understanding after you have completed the course, and is a required element if you wish to receive credit. It is recommended that you work through the main sections of the course and the risk management review before taking the post-test. You must complete all the questions and you have only one opportunity to submit your answers.

Evaluation This evaluation provides valuable feedback on the course modules. TEST/EXAM REQUIRED: Completion of the units will be discussed at each resident’s semi-

annual reviews as a professionalism issue.


NAME OFCONFERENCE:

Advanced Cardiac Life Support (ACLS) CoursePediatric Advanced Life Support (PALS) Course

CONFERENCESCHEDULE:

Provider Course to be completed during 1st year of residencyRecertification Course to be completed during 3rd year of residency

CONFERENCEFORMAT &DESCRIPTION:

ACLS Certification:• The goal is to integrate knowledge and motor skills and proficiency in the

techniques of emergency cardiovascular care.PALS Certification:• The goal is to teach the knowledge and skills necessary to identify and

provide initial management to the seriously ill or injured child.

COURSEINSTRUCTORS:

ACLS Certification:• J Russell Norton MD• Carol Ann Diachun MD

PALS Certification:• Elise van der Jagt MD MPH• Sharon Chiumento BSN EMT-P


Learning Objectives: Competencies:ACLS Certification:• Manage the first 10 minutes of a witnessed VF/pulseless VT arrest.• Utilize basic and advanced airway management skills.• Identify the indications for and apply the use of electrical therapy.• Assess and apply ACLS cardiovascular pharmacology.• Provide a concise summary of the recommended assessment and

management actions.• Demonstrate leadership and participation in resuscitation situations.

ACLS Certification:• 1,2• 1,2• 1,2• 1,2• 1,2

• 1,2PALS Certification:• Recognize impending respiratory failure and shock in pediatric patients.• Initiate treatment based on the patient’s physiologic status as identified by

rapid cardiopulmonary assessment.• Identify and treat common pediatric cardiac (unstable) arrhythmias.• Evaluate and stabilize the pediatric trauma victim.• Initiate the first 10 minutes of pediatric cardiopulmonary resuscitation

(BLS and ALS).• Provide support to families and providers in coping with a child’s death.

PALS Certification:• 1,2• 1,2

• 1,2• 1,2• 1,2

• 1,2

ACLS Certification:• 1-day Provider Course• 1-day Recertification Course

PALS Certification:• 2-day Provider Course• 1-day Recertification Course

REQUIREDATTENDANCE:

Certification will be proof of attendance

REQUIREDREADING:

ACLS Certification:• AAP/AHA ACLS Provider

Manual provided at ProviderCourse

• Resident to bring above manualto Recertification Course

PALS Certification:• AAP/AHA PALS Provider

Manual provided at ProviderCourse

• Resident to bring above manualto Recertification Course

Additional Resident Responsibilities:ACLS Certification: PALS Certification:

• Each resident must attend 3 of the followingspecial module case scenarios:_ Trauma/Spine Immobilization_ Coping with Death_ Children with Special Health Care Needs_ Newly Born

• Each resident must complete the appropriatepost-tests.

Test/Exam Required:ACLS Certification:• Each resident must complete the course and

the appropriate post-test(s) to receivecertification.

PALS Certification:• Each resident must complete the course and

the appropriate post-test(s) to receivecertification.

Certification will be proof of attendance



SYSTEMS-BASED PRACTICE IMPROVEMENT PROJECT


During their training, residents are required to identify, participate in, and complete at least one collaborative interdisciplinary/intradisciplinary systems-based practice quality improvement project. This may take the form of an analysis of a clinical, systems-based problem. It is expected that such projects will demonstrate an improvement in the quality of a patient care issue. Key to Core

Competencies:


GOALS & OBJECTIVES: Competencies:

• Analyze practice experience and perform practice-based improvement activities using a systematic methodology.

• Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance.

• 3, 6 • 1, 4, 5


• Each resident must analyze a systems-based problem and identify a quality improvement activity or project, including providing data, a solution and implementation. He/she must demonstrate an ability to analyze, improve and change practice or patient care. He/she must work collaboratively with other health care professionals on this project.

• Upon completion of the project, the resident must submit a report, providing a written description of the

quality issue and the improvement project, and the actions necessary to correct the problem, including faculty support, coaching, and supervision that guided the process, planning, implementation, and evaluation, and the outcome of this project and incorporation into practice, if improvement occurred. The resident should also describe what the next steps were, if there was no improvement with the original plan/project.



Resident Booklist

Required Reading: A copy of each of the following core curriculum textbooks will be provided to each resident. We will try to provide you with the most current edition. If a newer edition is expected to be released soon, we may delay the purchase of this book. If a newer edition is released after the text has been purchased, it is the residents’ responsibility to update their personal library if they wish. Core Rotations:

• Handbook of Evidence-based Radiation Oncology. Springer-Verlag, 2006. • AJCC Cancer Staging Manual. Lippincott Williams and Wilkins, 2002 (6th edition) • Clinical Radiation Oncology. Leonard Gunderson, Joel Tepper. Churchill Livingstone, 2006 (2nd edition) • Principles & Practice of Radiation Oncology. Carlos A. Perez, Luther W. Brady. Lippincott Williams and

Wilkins, 2007 (5th edition) • Textbook Of Radiation Oncology. Steven A. Leibel, Theodore L. Phillips, W.B. Saunders, 2004 (2nd edition) • TNM Staging Atlas. P. Rubin and J. Hanson. Lippincott Williams and Wilkins, 2007 Site-Specific Texts:

• Pediatric Radiation Oncology. Edward C. Halperin, Louis S. Constine, Nancy J. Tarbell, Larry E. Kun.

Lippincott Williams and Wilkins, 2004 (4th edition) Radiation-Cancer Biology:

• Radiobiology For The Radiologist. Eric Hall. Publisher: Lippincott-Raven, Philadelphia, 2005 (6th edition) • Basic Science of Oncology. Tannock & Hill, 2005 (4th edition) Radiation Physics:

• Radiation Therapy Physics. Hendee, 2004 (3rd edition) • The Physics of Radiation Therapy. Faiz Khan. Publisher: Williams and Wilkins. Baltimore, 2003 (3rd edition) Treatment Planning:

• Treatment Planning in Radiation Oncology. Faiz Khan, Roger Potish. Publisher: Williams and Wilkins,

Baltimore (2nd edition), 2006 (2nd edition)



Resident Booklist

Supplemental Reading: The following textbooks are recommended for supplemental reading. Reference copies are available in the Residents’ Library, the Attendings’ Offices, or the Miner Library. These textbooks must remain in the library. Residents may also choose to purchase a personal copy. Core Rotations:

• Clinical Oncology: A Multidisciplinary Approach for Physicians and Students. Rubin, 2001 (8th edition) • Clinical Radiation Oncology: Indications, Techniques, and Results. C C Wang MD, 2000 (2nd edition) • Cancer - Principles And Practice Of Oncology & Review Manual (Govindan). Vincent T. DeVita, Jr., MD,

Samuel Hellman, MD, Steven A. Rosenberg, MD, PhD. Lippincott Williams and Wilkins, 2004 (7th edition) • Radiation Oncology – Management Decisions. K.S. Clifford Chao, Carlos A. Perez, Luther W. Brady.

Lippincott Williams and Wilkins, 2001 (2nd edition) • Radiation Oncology For Cure And Palliation. Robert Parker. Springer Verlag, Inc. 2003 (1st edition) • Cancer Medicine. Holland, Frei (6th edition) • Radiation Oncology: Rationale, Techniques, Results. James Cox, Kian Ang, 2002 (8th edition) Site-Specific Texts:

• Stereotactic Body Radiation Therapy. Kavanagh, Timmerman, 2005

• Brain Tumors: An Encyclopedic Approach. Kaye, Laws, 2001 • Cancer in the Nervous System. Levin, 2002 • Management Of Head And Neck Cancer: A Multidisciplinary Approach. Rodney Million, Nicholas Cassisi.

Lippincott Williams and Wilkins, 1993 (2nd edition) • Radiation Therapy For Head And Neck Neoplasms. C.C. Wang. John Wiley and Sons, 1997 (3rd edition) • Head and Neck Cancer: A Multidisciplinary Approach. Harrison, 2004 (2nd edition) • Diseases Of The Breast. Jay Harris, Marc Lippman, Monica Morrow, Samuel Hellman. Lippincott Williams and

Wilkins, 2000. (2nd edition) • Lung Cancer: Principles And Practice. Harvey Pass, James Mitchell, David Johnson, Andrew Turrisi, John

Minna. Lippincott Williams and Wilkins, 2000. (2nd edition) • Comprehensive Textbook of Thoracic Oncology. Aisler, Arriagada, Green, et al, 1996 • Gastrointestinal Oncology: Principles and Practice. Kelsen, et al, 2002. • Prostate Cancer: Principles & Practice. Kantoff, Carroll, D’Amico, 2002 • Comprehensive Textbook of Genitourinary Oncology. Vogelzang, et al, 1996 (1st edition) • Principles And Practice Of Gynecologic Oncology. William Hoskins, Carlos Perez, Robert Young. Lippincott

Williams and Wilkins, 2000. (third edition) • Clinical Gynecologic Oncology & Review. DiSaia, Creasman, 1997 (5th edition) • Hodgkin’s Disease. Mauch, Armitage, Diehl, Hoppe, Weiss, 1999 • Non-Hodgkin’s Lymphoma: Mauch, Armitage, Coiffier, Dalla-Favera, Harris, 2004 Radiation-Cancer Biology:

• Radiobiology Practice Examinations. Advanced Medical Publishing. Also available online at

http://www.advmedpub.com/resident.htm

• A Compilation of Radiobiology Practice Examinations. J Donald Chapman, S Shahabi, and B A Chapman. Advance Medical Publishing Inc, 2000.

Radiation Physics:

• The Physics Of Radiology. Harold Johns and John Cunningham. Publisher: Charles Thomas Publishers,

Springfield, IL (4th edition), 1983 • Radiological Physics (RAPHEX) Examinations. Advanced Medical Publishing. Also available online at

http://www.advmedpub.com/resident.htm Treatment Planning:

• A Practical Guide to Intensity-Modulated Radiation Therapy. Ling, Leibel, Fuks, 2003 • Levitt and Tapley’s Technological Basis of Radiation Therapy: Clinical Applications. Seymour Levitt, 1998

(2nd edition) • Treatment Planning And Dose Calculation In Radiation Oncology. Gunilla Bentel, Charles Nelson, K. Noell.

Publisher: McGraw-Hill, Ohio (4th edition), 1991 (1-800-262-4729) • Radiation Therapy Planning. Gunilla Bentel. Publisher: McGraw-Hill, Ohio (2nd edition), 1995 • Intensity Modulated Radiation Therapy for Head & Neck Cancer. Chao, Ozyigit, 2003 Statistics:

• Introductory Medical Statistics. Richard Mould. Publisher: Institute of Physics Publishing, Philadelphia (3rd

edition), 1998 Oncologic Imaging Rotation, Department of Imaging Sciences:

• Oncologic Imaging. Berman, 1998

• Oncologic Imaging. Bragg, Rubin, Hricak, 2002 (2nd edition) Oncologic Pathology Rotation, Department of Pathology:

• Radiation Pathology. Fajardo, 2002 (2nd edition) • AFIP Atlas of Tumor Pathology. Fascicles, 2nd Series Medical Oncology Rotation, Department of Hematology/Medical Oncology:

• Clinical Oncology. Abeloff, 2004 (3rd edition) • Cancer Medicine. Holland, Frei (6th edition)

Journals:

• The Lancet Oncology. Elsevier • Seminars in Oncology. W B Saunders • Cancer – Interdisciplinary International Journal of the American Cancer Society • Journal of Clinical Oncology – Official Journal of the American Society of Clinical Oncology Pediatric Oncology Rotation:

• Principles and Practice of Pediatric Oncology. Pizzo, Poplack, 2002 (4th edition) Palliative Care Rotation:

• Oxford Textbook of Palliative Medicine. Doyle, Hanks, MacDonald, 1998 (2nd edition) • Physician’s Guide to End-of-Life Care. Snyder, Quill, 2001 • Physician’s Guide to Pain and Symptom Management in Cancer Patients. Abrahm, 2000 • A Midwife through the Dying Process: Stories of Healing and Hard Choices at the End of Life. Quill, 1996

• Caring for Patients at the End of Life: Facing an Uncertain Future Together., Quill, 2001 Other Didactic Courses/Conferences:

Onco-Anatomy:

• 3D Oncoanatomy Text and Atlas, Rubin (10th edition)

RESIDENT EVALUATIONS

At the beginning of each rotation, the head of service meets with the resident to explain their expectations during the rotation, and the goals and objectives of the rotation. During each rotation, residents complete the following assessments with their Attending-on-Service: 2 Patient Encounters and 3 Simulations. These evaluations provide the attending physicians with a means to directly observe the residents’ performance and skills, particularly in communications with patients. In addition, residents are evaluated during each rotation by the attending physicians, who also consider input from nursing oncology and the radiation therapy staff in these assessments. Moreover, evaluation of the trainees is an ongoing topic among faculty members. At the end of the rotation, the attending physicians of each service complete written evaluations. These evaluations are then reviewed personally with the residents. These evaluations are reviewed by the Program Director on an ongoing basis and discussed with the residents on a semi-annual basis.

Confidential evaluations are also completed by the residents for each rotation and the appropriate attending at the end of each rotation. The Program Administrator compiles a summary of these evaluations and feedback is given to the appropriate attending on an annual basis. Completion of these evaluations gives the residents the opportunity to provide feedback on the attending physicians in terms of teaching, patient care and scholarship, and the Program in general. The quality of the presentation, as well as the quality of critical thought that went into its preparation is also assessed on an ongoing basis at New Pt Presentations, Chart Rounds, Oncology Teaching Conferences, and departmental Grand Rounds by all attending physicians. Beyond this, residents are required to complete semi-annual self-assessments, which are reviewed with the Program Director at the semi-annual review and are used to help develop individual learning plans. In addition, at the end of each academic year, the other non-MD professional groups within the department are asked to evaluate the residents. Annual evaluations are also completed by the residents on the faculty and other group members of the Department, as well as various aspects of the Program. Each year a formal in-training examination is given on clinical radiation oncology, radiation physics and radiation biology. In addition, at the end of each academic year, the faculty involved in teaching clinical oncology for that year ‘quiz’ the residents individually during our ‘mock oral board’ sessions.

SUMMARY OF INTENT FOR RESIDENCY TRAINING The Cancer Center, by virtue of its commitment to multidisciplinary care and its shared facilities, provides an environment in which residents are constantly exposed to the interdisciplinary management of cancer. The Radiation Oncology residency program here is designed to foster both clinical and academic excellence, providing a sophisticated understanding of our field. We believe that residents who complete our program are well-rounded radiation oncologists who are not only competent in their own field but also knowledgeable about all aspects of oncology. The structure of the Department as disease-oriented treatment teams with the resident rotating on each service assures exposure to the wide range of clinical material seen within the Department. This also allows the resident to have repetitive intensive exposures to a specific group of neoplastic diseases and to focus clinical activity and literature research in this particular area. As a resident matures, his/her responsibilities increase and more opportunities are available for therapeutic decision making and creativity in developing optimal treatment strategies. As initially stated, the basic objectives of the residency program are to develop in the trainee a commitment to patient care and clinical proficiency in radiation oncology while engendering a love for this field, thereby stimulating attitudes of continual self-improvement and to produce graduates who have been proven competent in each of the six core competencies to practice as an independent physician. Beyond this, the resident ideally becomes at least acquainted with clinical investigation, biostatistics, epidemiology, computer data management and analysis, ethical considerations in investigation, biomedical writing, and the development of new technologies. Recognizing that the complexity of our field demands training that is more comprehensive and rigorous than in the past, in accomplishing our training goals within the four year time frame, the program allows for greater exposure to special modalities, thereby enhancing the resident’s capacity to use leading edge technologies (e.g. stereotactic radiosurgery, HDR/LDR brachytherapy, newly developed radioisotopes, 3D treatment planning and 3D oncologic imaging, and total body irradiation for bone marrow transplantation) that are considered to be future practice areas. These procedures are both complex and labor intensive, but most importantly provide the opportunity for multi- and interdisciplinary interactions with other clinicians and scientists of other specialties. An additional fellowship year(s) could be devoted to providing an in-depth experience in laboratory or clinical research or in one of the many investigational therapeutic modalities under study in our Department.

Radiation Oncology 1

ACGME Program Requirements for Graduate Medical Education

in Radiation Oncology

Common Program Requirements are in BOLD

Effective: January 1, 2009

Introduction

A. Definition

1. Radiation oncology is that branch of clinical medicine concerned with the causes, prevention, and treatment of cancer and certain nonneoplastic conditions utilizing ionizing radiation. Radiation oncologists are an integral part of the multidisciplinary management of the cancer patient, and must collaborate closely with physicians in related disciplines in the management of the patient.

2. The objective of the residency program is to educate and train

physicians to be skillful in the practice of radiation oncology, and to be caring and compassionate in the treatment of patients. To accomplish this goal, adequate structure, facilities, faculty, patient resources, and an educational environment must be provided.

B. Duration and Scope of Training

1. Resident education in radiation oncology must include five years of

accredited, clinically-oriented graduate medical education. The first year of postgraduate clinical training must be spent in internal medicine, family medicine, obstetrics/gynecology, surgery or surgical specialties, pediatrics, or a transitional-year program. This PGY-1 year must include at least nine months of direct patient care in medical and/or surgical specialties other than radiation oncology. This clinical experience must then be followed by four years focused in radiation oncology.

2. No fewer than 36 months of the four-year program must be spent in

clinical radiation oncology. (Residents enrolled in the Holman Pathway, a research track designed by the American Board of Radiology to promote a commitment to basic science or clinical research, must complete 27 months in clinical radiation oncology). In addition, the program must provide a two-month rotation in medical oncology to include adult and pediatric patients, as well as a one-month rotation in both oncologic pathology and diagnostic imaging. The medical oncology requirement may be met by documented attendance at regularly-scheduled multidisciplinary conferences (at least four hours per month during the clinical


rotations). The pathology and diagnostic imaging requirements may be satisfied through multidisciplinary conferences if pathology and imaging material for both pediatric and adult patients are shown and discussed (at least one hour per month during the clinical rotations for each discipline). The remaining months must allow for in-depth experience in individually-selected areas applicable to clinical radiation oncology, as described in Section IV.A.5.

I. Institutions

A. Sponsoring Institution

One sponsoring institution must assume ultimate responsibility for

the program, as described in the Institutional Requirements, and this

responsibility extends to resident assignments at all participating

sites.

The sponsoring institution and the program must ensure that the

program director has sufficient protected time and financial support

for his or her educational and administrative responsibilities to the

program.

1. The program director’s minimum administrative time commitment during the work week should be 10%.

2. The administration of the institution sponsoring the program in radiation oncology must provide funding for space, equipment, staff, nonprofessional personnel, and residents.

3. Education in radiation oncology must occur in an environment that

encourages the exchange of knowledge and experience among residents both in the program and in other oncology specialties within the sponsoring institution. There should be other relevant oncology-related graduate medical education programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) in the institution. These programs should include residencies or fellowships in surgical, medical, gynecological, and/or pediatric oncology.

4. A minimum number of faculty and residents is essential to provide

an opportunity for meaningful interaction throughout the program. Each program must be structured to include a minimum of four full-time-equivalent clinical faculty assigned to the primary clinical site. Other participating sites may have smaller numbers of faculty and staff.


B. Participating Sites

1. There must be a program letter of agreement (PLA) between

the program and each participating site providing a required

assignment. The PLA must be renewed at least every five

years.

The PLA should:

a) identify the faculty who will assume both educational

and supervisory responsibilities for residents;

b) specify their responsibilities for teaching, supervision,

and formal evaluation of residents, as specified later in

this document;

c) specify the duration and content of the educational

experience; and,

d) state the policies and procedures that will govern

resident education during the assignment.

2. The program director must submit any additions or deletions

of participating sites routinely providing an educational

experience, required for all residents, of one month full time

equivalent (FTE) or more through the Accreditation Council for

Graduate Medical Education (ACGME) Accreditation Data

System (ADS).

3. Assignment to a participating site must be based on a clear educational rationale, integral to the program curriculum, with clearly-stated activities and objectives, and should provide resources not otherwise available to the program. The preponderance of the educational experience should take place in the primary clinical site. When multiple participating sites are used, there should be assurance of the continuity of the educational experience.

a) The number and types of patients and procedures available

to the residents should be specified.

4. Integrated Sites

a) A site is considered integrated when the program director determines all rotations and assignments of residents, and is


responsible for the overall conduct of the educational program in the integrated site.

b) Teaching clinical faculty at the integrated site should have faculty appointments from the sponsoring institution or primary clinical site.

c) Integrated sites must provide a means for direct participation

in joint conferences; such participation may be by attendance when institutions are in geographic proximity to the primary clinical site, or by electronic transmission.

d) Rotations to integrated sites are not limited in duration,

though it is expected that the preponderance of education should be at the primary clinical site.

e) Prior approval must be obtained by the Review Committee

for an integrated participating site, regardless of the duration of rotations.

5. Participating sites that do not meet the requirements for integrated

sites must meet the following requirements:

a) Sites that are not considered a primary clinical site or integrated site may be used to complement the residents’ educational experience and/or for elective rotations.

b) Elective rotations, which are outside the primary clinical site

or integrated sites, must not exceed a total of six months during the residency.

c) Participating sites do not require prior Review Committee

approval. A program letter of agreement, however, must be developed (Section I.B.1).

II. Program Personnel and Resources

A. Program Director

1. There must be a single program director with authority and

accountability for the operation of the program. The

sponsoring institution’s GMEC must approve a change in

program director. After approval, the program director must

submit this change to the ACGME via the ADS.


a) The program director should be a member of the staff of the sponsoring institution or integrated site.

2. The program director should continue in his or her position for

a length of time adequate to maintain continuity of leadership

and program stability.

a) A minimum of three years is desirable. 3. Qualifications of the program director must include:

a) requisite specialty expertise and documented

educational and administrative experience acceptable to

the Review Committee;

b) current certification in the specialty by the American

Board of Radiology, or specialty qualifications that are

acceptable to the Review Committee; and,

c) current medical licensure and appropriate medical staff

appointment.

4. The program director must administer and maintain an

educational environment conducive to educating the residents

in each of the ACGME competency areas. The program

director must:

a) oversee and ensure the quality of didactic and clinical

education in all sites that participate in the program;

b) approve a local director at each participating site who is

accountable for resident education;

c) approve the selection of program faculty as appropriate;

d) evaluate program faculty and approve the continued

participation of program faculty based on evaluation;

e) monitor resident supervision at all participating sites;

f) prepare and submit all information required and

requested by the ACGME, including but not limited to

the program information forms and annual program

resident updates to the ADS, and ensure that the

information submitted is accurate and complete;


g) provide each resident with documented semiannual

evaluation of performance with feedback;

h) ensure compliance with grievance and due process

procedures as set forth in the Institutional Requirements

and implemented by the sponsoring institution;

i) provide verification of residency education for all

residents, including those who leave the program prior

to completion;

j) implement policies and procedures consistent with the

institutional and program requirements for resident duty

hours and the working environment, including

moonlighting, and, to that end, must:

(1) distribute these policies and procedures to the

residents and faculty;

(2) monitor resident duty hours, according to

sponsoring institutional policies, with a frequency

sufficient to ensure compliance with ACGME

requirements;

(3) adjust schedules as necessary to mitigate

excessive service demands and/or fatigue; and,

(4) if applicable, monitor the demands of at-home call

and adjust schedules as necessary to mitigate

excessive service demands and/or fatigue.

k) monitor the need for and ensure the provision of back

up support systems when patient care responsibilities

are unusually difficult or prolonged;

l) comply with the sponsoring institution’s written policies

and procedures, including those specified in the

Institutional Requirements, for selection, evaluation and

promotion of residents, disciplinary action, and

supervision of residents;

m) be familiar with and comply with ACGME and Review

Committee policies and procedures as outlined in the

ACGME Manual of Policies and Procedures;


n) obtain review and approval of the sponsoring

institution’s GMEC/DIO before submitting to the ACGME

information or requests for the following:

(1) all applications for ACGME accreditation of new

programs;

(2) changes in resident complement;

(3) major changes in program structure or length of

training;

(4) progress reports requested by the Review

Committee;

(5) responses to all proposed adverse actions;

(6) requests for increases or any change to resident

duty hours;

(7) voluntary withdrawals of ACGME-accredited

programs;

(8) requests for appeal of an adverse action;

(9) appeal presentations to a Board of Appeal or the

ACGME; and,

(10) proposals to ACGME for approval of innovative

educational approaches.

o) obtain DIO review and co-signature on all program

information forms, as well as any correspondence or

document submitted to the ACGME that addresses:

(1) program citations, and/or

(2) request for changes in the program that would

have significant impact, including financial, on the

program or institution.

p) ensure that conferences and teaching rounds provide for progressive participation of residents. There must be adequate frequency of conferences, with attendance by residents, radiation oncologists, and other staff;


q) ensure that there are intradepartmental clinical oncology conferences, including new patient conferences, weekly chart reviews, problem case conferences, continuous quality improvement, morbidity and mortality, physics, dosimetry, radiation and cancer biology, and/or journal review;

r) ensure that the resident keep a detailed, well-organized, and

accurate electronic log of those procedures noted in section IV.A.5.a. below. The log should include patients simulated, procedures performed, and modalities used, for semiannual review by the program director;

s) review the logs with all residents at least semiannually to

ensure accuracy and to verify that the case distribution meets the standards specified;

t) provide documentation of these discussions for the

resident’s record maintained by the institution; and,

u) submit the cumulative experience of graduating residents to the Review Committee office annually in accordance with the format and the due date specified by the Review Committee.

B. Faculty

1. At each participating site, there must be a sufficient number of

faculty with documented qualifications to instruct and

supervise all residents at that location.

The faculty must:

a) devote sufficient time to the educational program to

fulfill their supervisory and teaching responsibilities;

and to demonstrate a strong interest in the education of

residents, and

b) administer and maintain an educational environment

conducive to educating residents in each of the ACGME

competency areas.

c) support the goals and objectives of the educational program.

2. The physician faculty must have current certification in the

specialty by the American Board of Radiology, or possess

qualifications acceptable to the Review Committee.


a) The department chair must demonstrate an interest in and support for the training of residents in Radiation Oncology.

b) The program must provide a minimum of four full-time-

equivalent faculty radiation oncologists who devote their professional time to the program for the teaching of clinical radiation oncology. For programs with multiple sites, there must be at least four full-time equivalent clinical faculty members at the primary clinical site.

c) The faculty must include at least one full-time radiation

biologist or cancer biologist (PhD level or equivalent) who is on site to provide a scholarly environment of research, and to participate in the teaching of radiation and cancer biology.

d) The faculty must include at least one full-time faculty medical

physicist (PhD level or equivalent), who is on site to provide a scholarly environment of research, and to participate in the teaching of radiation physics.

3. The physician faculty must possess current medical licensure

and appropriate medical staff appointment.

4. The nonphysician faculty must have appropriate qualifications

in their field and hold appropriate institutional appointments.

5. The faculty must establish and maintain an environment of

inquiry and scholarship with an active research component.

a) The faculty must regularly participate in organized

clinical discussions, rounds, journal clubs, and

conferences.

b) Some members of the faculty should also demonstrate

scholarship by one or more of the following:

(1) peer-reviewed funding;

(2) publication of original research or review articles

in peer-reviewed journals, or chapters in

textbooks;

(3) publication or presentation of case reports or

clinical series at local, regional, or national

professional and scientific society meetings; or,


(4) participation in national committees or

educational organizations.

c) Faculty should encourage and support residents in

scholarly activities.

d) The majority of both physician and PhD faculty should demonstrate scholarship as defined above.

C. Other Program Personnel

The institution and the program must jointly ensure the availability of

all necessary professional, technical, and clerical personnel for the

effective administration of the program.

D. Resources

The institution and the program must jointly ensure the availability of

adequate resources for resident education, as defined in the

specialty program requirements.

1. Facilities

a) A training program in radiation oncology must have adequate space and equipment to train residents in state-of-the-art radiation oncology. At the primary clinical site there must be two or more megavoltage machines, a machine with a broad range of electron beam capabilities, CT-simulation capability, three-dimensional conformal computerized treatment planning, including IMRT, a system for the construction of treatment aids, and equipment to perform interstitial and intracavitary brachytherapy and radiosurgery.

b) Adequate conference room and audiovisual facilities must be

provided.

2. Other Services Adequate medical services must be available in the specialties of medical oncology, surgical oncology and its subspecialties, gynecologic oncology, and pediatric oncology. There must be access to current imaging techniques, nuclear medicine, pathology, a clinical laboratory, and a tumor registry.


3. The institution must assist the program director in teaching and in recruiting faculty, as well as in selecting, evaluating, and dismissing residents whose performance is unsatisfactory.

E. Medical Information Access

Residents must have ready access to specialty-specific and other

appropriate reference material in print or electronic format.

Electronic medical literature databases with search capabilities

should be available.

III. Resident Appointments

A. Eligibility Criteria

The program director must comply with the criteria for resident

eligibility as specified in the Institutional Requirements.

B. Number of Residents

The program director may not appoint more residents than approved

by the Review Committee, unless otherwise stated in the specialty-

specific requirements. The program’s educational resources must be

adequate to support the number of residents appointed to the

program.

1. The Review Committee recognizes the importance of peer interaction among residents, as well as the importance of interactions between faculty and residents in the context of conferences and patient care. A minimum number of residents is essential to provide an opportunity for meaningful interaction throughout the training period. Each program must be structured to have a minimum of four residents.

2. The faculty (full-time equivalent staff radiation oncologist) to

resident ratio must be a minimum of one faculty member for every one and a half residents during training in clinical radiation oncology.

3. Prior approval must be obtained from the Review Committee to

increase the number of resident positions. Such an increase must be based on educational considerations, not the fulfillment of service requirements.


C. Resident Transfers

1. Before accepting a resident who is transferring from another

program, the program director must obtain written or

electronic verification of previous educational experiences and

a summative competency-based performance evaluation of the

transferring resident.

2. A program director must provide timely verification of

residency education and summative performance evaluations

for residents who leave the program prior to completion.

D. Appointment of Fellows and Other Learners

The presence of other learners (including, but not limited to,

residents from other specialties, subspecialty fellows, PhD students,

and nurse practitioners) in the program must not interfere with the

appointed residents’ education. The program director must report

the presence of other learners to the DIO and GMEC in accordance

with sponsoring institution guidelines.

IV. Educational Program

A. The curriculum must contain the following educational components:

1. Overall educational goals for the program, which the program

must distribute to residents and faculty annually;

2. Competency-based goals and objectives for each assignment

at each educational level, which the program must distribute

to residents and faculty annually, in either written or electronic

form. These should be reviewed by the resident at the start of

each rotation;

3. Regularly scheduled didactic sessions;

4. Delineation of resident responsibilities for patient care,

progressive responsibility for patient management, and

supervision of residents over the continuum of the program;

and,

5. ACGME Competencies

The program must integrate the following ACGME

competencies into the curriculum:


a) Patient Care

Residents must be able to provide patient care that is

compassionate, appropriate, and effective for the

treatment of health problems and the promotion of

health. Residents:

(1) must have adequate numbers and variety of patients for resident training. At least 600 patients must receive external beam irradiation yearly, including stereotactic radiosurgery procedures, in the primary clinical and integrated sites. The number of patients treated with external beam irradiation by each resident should approximate 150 per year (determined by the number of patients simulated) with an absolute minimum of 450 over the four years of residency. A resident should not treat more than 250 patients with external beam irradiation in any one year. Only cases for which the resident has primary responsibility performing the simulation may be counted.

(a) In certain circumstances, the procedures in

radiation therapy and patient availabilities justify counting a patient twice for purposes of resident logs.

(b) External beam patients may be counted twice

when either of the following circumstances are met:

(i) a second resident participates actively in

the simulation of a separate anatomic site or substantial volume reduction for a given course of therapy, requiring a separate simulation with a different isocenter that represents sequential, non-concurrent therapy (e.g., a posterior fossa boost planned by a second resident following the planning and initial treatment by another resident; or a boost to the primary tumor site in the pelvis when the initial whole pelvic treatment was planned by another resident.)


(ii) a second course of therapy to a different site, treated sequentially for a new indication, may be counted a second time if the new area is simulated by the same resident or by a different resident (e.g., a lung cancer patient treated with chest radiotherapy who subsequently develops brain metastases and is treated with cranial radiotherapy.)

(2) must perform no fewer than five interstitial implants

and 15 intracavitary implants. Resident involvement should include planning, review of dosimetry, and hands-on participation in a significant portion of the implantation procedure. Separate applications of an implant in a given patient (such as two separate intracavitary applications) may be counted as two separate procedures. However, multiple fractions of a single application (such as multiple fractions of an intersitital implant) may be counted only once. Only one resident may count a specific application;

(3) must participate in the administration of no fewer than

six procedures using radioimmunotherapy, other targeted therapeutic radiopharmecuticals, or unsealed radioactive sources;

(4) must treat at least 12 pediatric patients of whom a

minimum of nine have solid tumors; (5) must follow-up with irradiated patients, including

pediatric patients, on an inpatient or outpatient basis as a required part of resident training; and, this must be demonstrated by the program to ensure that residents have the opportunity to learn about the problems of recurrent and disseminated tumors and of late aftereffects and complications of radiation therapy;

(6) must participate in the treatment planning and

administration of stereotactic radiosurgery in at least 10 patients. Stereotactic radiosurgery may be delivered by a variety of available technologies using image guided stereotactic localization procedures and may be either intracranial or extracranial. As defined, radiosurgery may be administered in a single fraction


or extended to a maximum of five fractions. More protracted courses of stereotactic radiation should be classified as external beam radiation cases.

(7) must have experience with lymphomas and

leukemias; gastrointestinal, gynecologic, genitourinary, breast, soft tissue and bone, skin, head and neck, lung, pediatric, and central nervous system tumors; and treatment of benign diseases for which radiation is utilized. In addition, the training program must provide instruction in the physics, radiation and cancer biology, and clinical applicability of the following areas: radiosurgery, intraoperative radiation therapy, three-dimensional conformal treatment planning and delivery, radioimmunotherapy, unsealed sources, total body irradiation as used in stem-cell transplantation, total skin irradiation, high- and low-dose rate brachytherapy, hyperthermia, kilovoltage irradiation, plaque therapy, particle therapy, and any other components that may be developed as they apply to the core curriculum.

b) Medical Knowledge

Residents must demonstrate knowledge of established

and evolving biomedical, clinical, epidemiological and

social-behavioral sciences, as well as the application of

this knowledge to patient care. Residents:

(1) must have instruction in the basic sciences essential

to radiation oncology, including medical physics and radiation and cancer biology;

(2) must have a curriculum in medical physics that

includes instruction and practical demonstrations of radiation safety procedures, calibration of radiation therapy machines, the use of state-of-the-art treatment planning systems, the construction of treatment aids, and the safe handling of sealed and unsealed radionuclides. Safe handling of unsealed sources should address quality control procedures for instruments used to determine the activity of radiopharmaceuticals for human administration and procedures used to perform checks for proper operation of survey meters. The radiation and cancer biology curriculum must include instruction in classical


and molecular effects of ionizing radiation, radiation effects on normal and neoplastic tissues, as well as the fundamental biology of the causes, prevention, and treatment of cancer;

(3) must have instruction in medical statistics;

(4) must have instruction in the potential value and

limitations of other oncologic disciplines such as medical oncology (both adult and pediatric), and surgical oncology and the various surgical specialties, which play a role in the management of the patient. This may be accomplished by attendance at multidisciplinary and departmental conferences or by clinical rotations;

(5) will gain in-depth knowledge of clinical radiation

oncology, including the indications for irradiation and special therapeutic considerations unique to each site and stage of disease. The resident must be educated in standard radiation techniques, as well as the use of treatment aids and treatment planning to optimize the distribution of the radiation dose. Residents must be taught the principles of normal tissue tolerance to radiation and tumor dose-response. The use of combined modality therapy and altered fractionation schemes should also be part of the clinical curriculum. Education in pain management and palliative care should be provided;

(6) must be educated in the use of external beam

modalities including megavoltage irradiation, electron beam, simulation using conventional and CT simulators to localize anatomy, and computerized treatment planning. The faculty must ensure that the resident personally performs technical procedures, including treatment setups as well as intracavitary and interstitial placement of radiation sources.

c) Practice-based Learning and Improvement

Residents must demonstrate the ability to investigate

and evaluate their care of patients, to appraise and

assimilate scientific evidence, and to continuously

improve patient care based on constant self-evaluation

and life-long learning. Residents are expected to


develop skills and habits to be able to meet the

following goals:

(1) identify strengths, deficiencies, and limits in one’s

knowledge and expertise;

(2) set learning and improvement goals;

(3) identify and perform appropriate learning

activities;

(4) systematically analyze practice using quality

improvement methods, and implement changes

with the goal of practice improvement;

(5) incorporate formative evaluation feedback into

daily practice;

(6) locate, appraise, and assimilate evidence from

scientific studies related to their patients’ health

problems;

(7) use information technology to optimize learning;

and,

(8) participate in the education of patients, families,

students, residents and other health

professionals.

d) Interpersonal and Communication Skills

Residents must demonstrate interpersonal and

communication skills that result in the effective

exchange of information and collaboration with patients,

their families, and health professionals. Residents are

expected to:

(1) communicate effectively with patients, families,

and the public, as appropriate, across a broad

range of socioeconomic and cultural

backgrounds;

(2) communicate effectively with physicians, other

health professionals, and health related agencies;

(3) work effectively as a member or leader of a health


care team or other professional group;

(4) act in a consultative role to other physicians and

health professionals; and,

(5) maintain comprehensive, timely, and legible

medical records, if applicable.

e) Professionalism

Residents must demonstrate a commitment to carrying

out professional responsibilities and an adherence to

ethical principles. Residents are expected to

demonstrate:

(1) compassion, integrity, and respect for others;

(2) responsiveness to patient needs that supersedes

self-interest;

(3) respect for patient privacy and autonomy;

(4) accountability to patients, society and the

profession; and,

(5) sensitivity and responsiveness to a diverse

patient population, including but not limited to

diversity in gender, age, culture, race, religion,

disabilities, and sexual orientation.

f) Systems-based Practice

Residents must demonstrate an awareness of and

responsiveness to the larger context and system of

health care, as well as the ability to call effectively on

other resources in the system to provide optimal health

care. Residents are expected to:

(1) work effectively in various health care delivery

settings and systems relevant to their clinical

specialty;

(2) coordinate patient care within the health care

system relevant to their clinical specialty;

(3) incorporate considerations of cost awareness and


risk-benefit analysis in patient and/or population-

based care as appropriate;

(4) advocate for quality patient care and optimal

patient care systems;

(5) work in interprofessional teams to enhance

patient safety and improve patient care quality;

and,

(6) participate in identifying system errors and

implementing potential systems solutions.

B. Residents’ Scholarly Activities

1. The curriculum must advance residents’ knowledge of the

basic principles of research, including how research is

conducted, evaluated, explained to patients, and applied to

patient care.

2. Residents should participate in scholarly activity.

a) During their training, residents shall be required to complete an investigative project under faculty supervision. This may take the form of biological laboratory research, clinical research, translational research, medical physics research, or other research approved by the program director. The results of such projects shall be suitable for publication in peer-reviewed scholarly journals or presentation at scientific meetings.

3. The sponsoring institution and program should allocate

adequate educational resources to facilitate resident

involvement in scholarly activities.

V. Evaluation

A. Resident Evaluation

1. Formative Evaluation

a) The faculty must evaluate resident performance in a

timely manner during each rotation or similar

educational assignment, and document this evaluation

at completion of the assignment.


b) The program must:

(1) provide objective assessments of competence in

patient care, medical knowledge, practice-based

learning and improvement, interpersonal and

communication skills, professionalism, and

systems-based practice;

(2) use multiple evaluators (e.g., faculty, peers,

patients, self, and other professional staff);

(3) document progressive resident performance

improvement appropriate to educational level;

and,

(4) provide each resident with documented

semiannual evaluation of performance with

feedback.

c) The evaluations of resident performance must be

accessible for review by the resident, in accordance

with institutional policy.

2. Summative Evaluation

The program director must provide a summative evaluation for

each resident upon completion of the program. This evaluation

must become part of the resident’s permanent record

maintained by the institution, and must be accessible for

review by the resident in accordance with institutional policy.

This evaluation must:

a) document the resident’s performance during the final

period of education, and

b) verify that the resident has demonstrated sufficient

competence to enter practice without direct supervision.

B. Faculty Evaluation

1. At least annually, the program must evaluate faculty

performance as it relates to the educational program.

2. These evaluations should include a review of the faculty’s

clinical teaching abilities, commitment to the educational

program, clinical knowledge, professionalism, and scholarly


activities.

3. This evaluation must include at least annual written

confidential evaluations by the residents.

C. Program Evaluation and Improvement

1. The program must document formal, systematic evaluation of

the curriculum at least annually. The program must monitor

and track each of the following areas:

a) resident performance;

b) faculty development;

c) graduate performance, including performance of

program graduates on the certification examination;

and,

d) program quality. Specifically:

(1) Residents and faculty must have the opportunity

to evaluate the program confidentially and in

writing at least annually, and

(2) The program must use the results of residents’

assessments of the program together with other

program evaluation results to improve the

program.

e) The Review Committee will use graduate performance data

for the most recent five- and ten-year periods in its assessments, and will take into consideration notable improvements or declines during the period considered. Poor performance will be cited if the proportion of candidates passing both the written and oral board examinations on the first opportunity is consistently low.

2. If deficiencies are found, the program should prepare a written

plan of action to document initiatives to improve performance

in the areas listed in section V.C.1. The action plan should be

reviewed and approved by the teaching faculty and

documented in meeting minutes.


VI. Resident Duty Hours in the Learning and Working Environment

A. Principles

1. The program must be committed to and be responsible for

promoting patient safety and resident well-being and to

providing a supportive educational environment.

2. The learning objectives of the program must not be

compromised by excessive reliance on residents to fulfill

service obligations.

3. Didactic and clinical education must have priority in the

allotment of residents’ time and energy.

4. Duty hour assignments must recognize that faculty and

residents collectively have responsibility for the safety and

welfare of patients.

B. Supervision of Residents

The program must ensure that qualified faculty provide appropriate

supervision of residents in patient care activities.

C. Fatigue

Faculty and residents must be educated to recognize the signs of

fatigue and sleep deprivation and must adopt and apply policies to

prevent and counteract its potential negative effects on patient care

and learning.

D. Duty Hours (the terms in this section are defined in the ACGME

Glossary and apply to all programs)

Duty hours are defined as all clinical and academic activities related

to the program; i.e., patient care (both inpatient and outpatient),

administrative duties relative to patient care, the provision for

transfer of patient care, time spent in-house during call activities,

and scheduled activities, such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.

1. Duty hours must be limited to 80 hours per week, averaged

over a four-week period, inclusive of all in-house call activities.

2. Residents must be provided with one day in seven free from

all educational and clinical responsibilities, averaged over a


four-week period, inclusive of call.

3. Adequate time for rest and personal activities must be

provided. This should consist of a 10-hour time period

provided between all daily duty periods and after in-house call.

E. On-call Activities

1. In-house call must occur no more frequently than every third

night, averaged over a four-week period.

2. Continuous on-site duty, including in-house call, must not

exceed 24 consecutive hours. Residents may remain on duty

for up to six additional hours to participate in didactic

activities, transfer care of patients, conduct outpatient clinics,

and maintain continuity of medical and surgical care.

3. No new patients may be accepted after 24 hours of continuous

duty.

a) A new patient is defined as any patient for whom the

resident has not previously provided care. 4. At-home call (or pager call)

a) The frequency of at-home call is not subject to the

every-third-night, or 24+6 limitation. However at-home

call must not be so frequent as to preclude rest and

reasonable personal time for each resident.

b) Residents taking at-home call must be provided with

one day in seven completely free from all educational

and clinical responsibilities, averaged over a four-week

period.

c) When residents are called into the hospital from home,

the hours residents spend in-house are counted toward

the 80-hour limit.

F. Moonlighting

1. Moonlighting must not interfere with the ability of the resident

to achieve the goals and objectives of the educational

program.


2. Internal moonlighting must be considered part of the 80-hour

weekly limit on duty hours.

G. Duty Hours Exceptions

A Review Committee may grant exceptions for up to 10% or a

maximum of 88 hours to individual programs based on a sound

educational rationale.

1. In preparing a request for an exception the program director

must follow the duty hour exception policy from the ACGME

Manual on Policies and Procedures.

2. Prior to submitting the request to the Review Committee, the

program director must obtain approval of the institution’s

GMEC and DIO.

VII. Experimentation and Innovation

Requests for experimentation or innovative projects that may deviate from

the institutional, common and/or specialty specific program requirements

must be approved in advance by the Review Committee. In preparing

requests, the program director must follow Procedures for Approving

Proposals for Experimentation or Innovative Projects located in the

ACGME Manual on Policies and Procedures. Once a Review Committee

approves a project, the sponsoring institution and program are jointly

responsible for the quality of education offered to residents for the

duration of such a project.

***

Editorial revisions: March, 2003 ACGME Approved: June, 2003 Effective: July, 2003 Editorial Revisions: March, 2004 Revised Common Program Requirements Effective: July 1, 2007 ACGME Approved: June 10, 2008 Effective: January 1, 2009

http://www.acgme.org/

http://www.acgme.org/

NRC Update To: Radiation Oncology Program Directors

From: Steven A. Leibel, M.D., FACR

President, American Board of Radiology (ABR)

RE: Residency Training in Unsealed Radionuclide Therapy Administration

Date: April 4, 2006

Dear Colleagues: In August 2005, we communicated to you information and procedures to address the changes in the Nuclear Regulatory Commission (NRC) rules that govern the training and experience required to administer the types of radioactive materials commonly used in radiation oncology and nuclear medicine for the treatment of several different malignancies.The final version of these changes was published on March 30, 2005 in the Federal Register. The NRC has in the past accepted ABR certification as evidence that a practitioner is properly trained to safely and effectively use therapeutic radioactive materials. The ABR wishes to retain this status under the new regulations, and accordingly, is requiring that resident training and experience and the materials on which the ABR examines match the new NRC regulations. These regulations pertain to training and experience in the therapeutic administration of unsealed byproduct material (10 CFR 35.390) as well as the use of manual brachytherapy sources (10 CFR 35.490) and remote after loader units, teletherapy units and gamma stereotactic radiosurgery units (10 CFR 35.690). Each of these modalities require a written directive as described in 10 CFR 35.40. The ABR and the Radiation Oncology RRC will maintain consistency with these requirements. What follows is an update that incorporates several clarifications of the requirements by the NRC for recognition of the ABR certification process.

1. Beginning with the oral examination of June 2007, the ABR will only admit, for examination, candidates who have a minimum of 700 hours of training in the topics described in 10 CFR 35.390 (b)(1)(i)(A) through 10 CFR 35.390 (b)(1)(i)(E) as well as supervised work experience as outlined in 10 CFR 35.390 (b)(1)(ii)(A) through 10 CFR 35.390 (b)(1)(ii)(G)(2) and (3) (authorized user for the oral administration of I-131 requiring a written directive in quantities greater than 1.22 Gigabecquerels (33 millicuries) and parenteral administration of any beta emitter or a photon-emitting radionuclide with photon energy of < 150 KeV, for which a written directive is required). The work experience outlined in CFR 35.390 (b)(1)(ii) must be obtained under the supervision of an authorized user who meets the requirements in 10 CFR 35.390 or equivalent Agreement State requirements. A supervising authorized user who meets the requirements in 35.390(b) must also have experience in the oral administration of sodium iodide I-131 for which a written directive is required and the parenteral administration of any beta emitter, or a photon-emitting radionuclide with a photon energy less than 150 KeV, for which a written directive is required. Instruction may take place as part of the RRC required courses in radiation physics, radiation and cancer biology and clinical radiation oncology or a rotation in nuclear medicine.

2. This training and supervised work experience must include all NRC-required items related to the safe handling, administration and quality control of the radionuclide doses used in clinical radiation oncology and nuclear medicine. The Federal Register provides a comprehensive list of these items. ABR testing will cover topics that include radiation safety, radionuclide handling, quality assurance, treatment planning, and the clinical use of unsealed byproduct material for which a written directive is required, as well as manual brachytherapy, remote after loading brachytherapy, stereotactic radiosurgery and external beam therapy. Such items will be included on both the written and oral examinations.

3. ABR Certification will include satisfying the requirements for authorized user status as specified

in 35.390(b)1(ii)(G)(2) and in 35.390(b)1(ii)(G)(3). To meet the requirements as an authorized user, residents must participate in three cases involving oral administration of > 33 mCi of I-131 and three cases involving the parenteral administration of any beta emitter, or a photon-emitting radionuclide with photon energy of < 150 KeV. Note that this category includes I-131 labeled antibodies and I-131 MIBG.

4. The specific dates on which experiences with oral I-131 and parenteral therapy occur and a case

description should be kept in a log by each resident. Because of HIPAA concerns, data that might identify a patient should not be included in the log. This log is to be submitted by the program director along with the other materials that attest to the resident´s oral exam eligibility.

To license an individual as an authorized user of radionuclides

the NRC will require that another authorized user/preceptor - typically this would be an appropriately trained radiation oncologist or nuclear medicine physician - submit a preceptor form to attest to the candidate´s satisfactory completion of the NRC requirements and attainment of competency sufficient to function as an authorized user. The attestation of the residency program director will not be accepted by the NRC unless that program director is also an appropriately-qualified authorized user, and the program director completes the NRC preceptor form.

For admittance to the ABR exam, however, residency program director attestation on an ABR

form will suffice.

The ABR recommends that all residency programs reevaluate their training in the use of these agents and add the content elements outlined in this communication and in the NRC Final Regulations at http://www.nrc.gov/reading-rm/doc-collections/cfr/part035/part035-0390.html. In this way, residents will be prepared and qualified to take the ABR oral examination.

THE AMERICAN BOARD OF RADIOLOGY

Radiation Oncology Study Guide

The computer-based and oral exams include clinical oncology and radiation treatment planning and technique, physics, and cancer and radiation biology, as these subjects relate to the clinical practice of radiation oncology.

The three computer-based examinations are administered over two days. The radiologic physics for radiation oncology exam is two hours long. The combined radiation and cancer biology exam is also two hours long. The clinical oncology exam, administered on the second day, is four hours long.

The oral exam is administered separately. It is case-based; that is, candidates are shown images and asked questions about the depicted patients and diseases. See the following areas for detailed study guides for each of the exams.

Clinical Oncology

Radiologic Physics for Radiation Oncology

Radiation and Cancer Biology

Oral Examination

Study Guide: Clinical Oncology

• This examination assesses your understanding of oncology and radiation therapy. Included

are questions related to cancers of every type, including: • the epidemiology and pathology • the requirements for their diagnosis, staging, treatment (including the utilization of

modalities other than radiation therapy) and follow-up • understanding of how radiation therapy affects normal tissues • complications resulting from radiation • ethics • statistics • anatomy • optimum beams and radiation sources for various clinical situations • tumor localization • dose distribution • selection of optimum volume, dose and fractionation • precision and errors in treatment planning • techniques involved in the treatment of the various anatomic and organ sites

• Questions in any category may relate to:

• anatomy • epidemiology/etiologic agents • natural history • pathology • tumor markers • initial clinical evaluation • staging • routes of local, regional and distant spread • selection of a treatment modality • radiation therapy techniques (including external beam, brachytherapy and treating with

unsealed radioactive agents) • treatment results (e.g., with surgery, radiation therapy, or chemotherapy) • patterns of failure • complications • normal tissue effects

Categories for Clinical Oncology

• Pediatrics

• Retinoblastoma • Wilms tumor • Neuroblastoma • Rhabdomyosarcoma and other soft tissue sarcomas • Lymphomas • Leukemias • Histocytosis X • Ewing ’s sarcoma and other bone tumors • Pediatric solid tumors • Soft-tissue sarcoma • Germ cell tumor

• Hepatic tumor • Osteosarcoma • Hodgkin's disease

• Pediatric CNS Tumors

• Medullooblastoma • Astrocytoma (glioma) low grade • Astrocytoma, high grade • Brain stem glioma • Ependymoma • Pineal/Germ cell • Craniopharyngioma • Optic tract • Other

• Gastrointestinal (GI) Tract

• Esophagus • Stomach • Small bowel • Colon/rectum • Anus • Pancreas • Biliary tract • Liver • Other

• Gynecology

• Cervix • Endometrium/uterus • Ovaries & fallopian tubes • Vagina • Vulva • Other

• Genitourinary (GU) Tract

• Prostate • Bladder • Testes/seminoma • Testes/nonseminoma • Kidneys • Ureter • Urethra • Penis • Other

• Lymphomas and Leukemias

• Hodgkin disease • Non-Hodgkin lymphoma • Leukemia • Multiple myeloma/plasmacytoma • Total body irradiation • Total skin irradiation • Radioimmunotherapy • Other

• Head, Neck and Skin

• Larynx • Oral cavity • Oropharynx • Hypopharynx • Nasopharynx • Salivary glands • Orbits • Temporal bone • Skin • Thyroid gland • Other

• Lung/Mediastinum

• Non-small cell cancer • Small cell cancer • Superior sulcus tumor • Thymomas and/or other mediastinum tumors • Other

• Breast

• Early-stage breast cancer • Locally advanced breast cancer • Inflammatory breast cancer • Carcinoma in situ, ductal and lobular • Locally recurrent breast cancer • Metastatic breast cancer • Other

• Soft Tissue

• Osteosarcoma and/or chondrosarcoma • Ewing ’s sarcoma • Other bone tumors • Soft tissue sarcomas • Desmoid tumor • Kaposi’s sarcoma • Other

• Central Nervous System (CNS)

• Astrocytoma, low grade • Astrocytoma, high grade • Medulloblastoma • Brainstem glioma • Ependymoma • Pineal • Brain • Lymphoma • Meningioma • Pituitary • Spinal cord • Craniopharyngioma • Arteriovenous malformation (AVM) • Optic tract • Oligodendroglioma • Other

• Palliation

• Skeletal metastases • Brain metastases • Cord compression • Vena cava syndrome • Hemostases • Relief of obstruction • Other

• Biostatistics

• Study design • Definitions of statistical terms • General interpretation & analysis • Survival curves • Specificity/sensitivity • Tests of significance • Phase III studies (randomized) • Retrospective trials/historical controls • Phase I & II studies (nonrandomized case control studies) • Multiple trials/metaanalysis • Lab tests/x-ray studies • Other

• Miscellaneous

• Ethics • Intravascular brachytherapy • Questions that do not relate to specific anatomical sites as listed above • Other applications of irradiation

Study Guide: Radiologic Physics for Radiation Oncology

This exam tests your knowledge of the principles of physics underlying the practice of radiation oncology. Included are questions on:

• basic physics • instruments and measurements • dosimetry • radioactivity (radionuclides and physics of therapeutically employed radionuclides) • protection and safety

Categories for Radiologic Physics for Radiation Oncology

• Atomic and Nuclear Structure

• Bohr model of the atom o Coulombic force and electron binding energy o Electron orbits (energy levels) o Electron transitions—absorption and emission of energy o Characteristic radiation and the Auger effect

• Nuclear structure o Nucleons —protons and neutrons o Nuclear force o E = mc2 and nuclear binding energy

• Factors affecting nuclear stability o Neutron-to-proton ratio o Average binding energy per nucleon o Pairing of similar nucleons in the nucleus

• Nuclear nomenclature o The four isos (isotopes, isotones, isobars, isomers) o Shorthand representation of isotopes

• Radioactive Decay

• Modes of radioactive decay o Beta (ß)

ß- (negative beta, negatron) ß+ (positive beta, positron) Electron capture

o Alpha ( ) • Other decay processes

o Gamma rays o Internal conversion

• Decay schemes o Construction and interpretation o Examples for each decay mode

• Mathematics of radioactive decay o Units (SI Units) o Exponential decay equation

Half-life Decay constant

Mean life, average life, and effective half life Simple dose calculation for implants

o Radioactive equilibrium Secular equilibrium

Radium needles

90Sr applicators Transient equilibrium

Nuclear medicine generators o Counting statistics

• Naturally occurring radioisotopes • Manmade radioisotopes

o Fission o Nuclear bombardment

• Decay schemes and properties for therapeutic isotopes

• Properties and Production of Particulate and Electromagnetic Radiation

• Particulate radiation o Mass, charge o Relativistic energy equation

• Electromagnetic radiation o Wave-particle duality o Wave equations o Electromagnetic spectrum

• Production of radiation o Principles o Radioactive decay o X-ray tube

• Linear accelerators o Operational theory of wave guides

Standing wave guides Traveling wave guides

o Bending magnet systems o Flattening filters o Electron scattering foils o Electron cones o Targets o Factors affecting

Beam energy Entrance dose Depth of maximum dose Beam uniformity Dose rate

o Monitor chamber o Collimation systems

Primary and secondary collimators Coupled and independent jaws (including virtual wedges) Multileaf collimators Other collimation systems (e.g., stereotactic systems) Radiation and light fields (including field size definition)

o Mechanical and operational features

• Cyclotron • Microtron • Cobalt units • Therapeutic x-ray (<300 kVp)

• Interactions of Electromagnetic Radiation with Matter

• Coherent scatter • Photoelectric effect • Compton effect • Pair production • Photonuclear disintegration • Relative probabilities of interactions in human tissues

o Energy dependence o Atomic number dependence o Electron density dependence

• Interactions of Particulate Radiation with Matter

• Formalism o W value o Specific ionization o Linear energy transfer o Range o Stopping power

• Types of interactions o Heavy vs light particles o Charged vs uncharged particles o Elastic collisions o Inelastic collisions

• Heavy charged particles o Inelastic collisions with electrons o Depth dose characteristics ( Bragg peak)

• Light charged particles o Elastic and inelastic collisions with electrons o Inelastic collisions with nuclei

• Neutrons o Elastic collisions with hydrogen nuclei o Depth dose characteristics vs charged particles and photons

• Biological implications of particle therapy

• Quantification and Measurement of Dose (including SI units)

• Exposure (air kerma) • Absorbed dose (kerma) • Dose equivalent • RBE dose • Calculation of absorbed dose from exposure (e.g., f factor) • Bragg-Gray cavity theory • Gas-filled detectors

o Principles of operation o Uses

• Ion chambers

o Types o Exposure measurement o As a Bragg-Gray cavity o Correction factors (e.g., temperature and pressure) o Calibration of photon and electron beams (e.g., TG 21 and TG 25)

• Thermoluminescent dosimetry • Calorimetry • Film • Chemical dosimetry • Solid state diodes • Scintillation detectors • Measurement techniques

• Characteristics of Photon Beams

• Mathematics of exponential attenuation o Half-value thickness o Attenuation coefficients (linear, mass, partial, total) o Narrow beam vs broad beam geometry o Monoenergetic vs heteroenergetic o Parallel vs diverging beams

• Beam quality for heteroenergetic beams o Energy distribution of accelerated electron beam o Filtration o Geometry o Effective energy o Energy spectra

• Dosimetry of Photon Beams in a Homogeneous Water Phantom

• Dose distributions o Central axis percent depth dose o Isodose curves o Factors affecting dose distributions and penumbra

Beam energy or quality (including patient dose from neutrons) Source size SSD and SAD Mayneord F factor Inverse square law Field size and shape Equivalent square Scatter effects Flattening filters Depth Surface dose Other

o Dose distributions for multiple unshaped beams Open beams Wedged beams

o Tissue-air ratio and backscatter factor o Tissue-maximum ratio o Tissue-phantom ratio

o Relationships between PDD, TAR, TMR, TPR o Point dose and treatment time calculation methods for single unshaped fields

Machine output factors (e.g., absolute and relative output, head scatter, patient scatter factors)

Equivalent squares SSD vs SAD setups Beam modifier factors (e.g., wedge and tray factors)

o Dose calculation at the isocenter of a rotating beam o Point dose and treatment time calculations for single shaped fields

Separation and recombination of primary and scatter radiation (e.g., Clarkson techniques)

Off-axis factors Dose under blocks Equivalent squares for shaped fields

o Isodose distributions for multiple fields, including arc therapy o Measurement of photon dose distributions

• Dosimetry of Photon Beams in a Patient

• Dose specification (eg, ICRU 50) • Corrections for patient contour

o Effective SSD method o TAR ratio method o Isodose shift method

• Corrections for tissue inhomogeneities o TAR ratio method o Power law method o Isodose shift method o Equivalent TAR

• Dose within and around an inhomogeneity • Matching of adjacent fields • Using multiple wedged fields • Parallel opposed beams

o Point of maximum dose o Uniformity, dependence upon

Energy Separation SSD

• Entrance dose and exit dose, including beam modifying devices • Isodose distributions for multiple beams, including mixed modality and arc therapy • Compensation

o Missing tissue o Dose compensation o Bolus

• Off-axis factors • Practical/simple calculation of dose • Practical/simple 2D treatment planning

• 3D conformal treatment planning 3D conformal treatment planning Advanced Treatment

Planning for EBRT, Letter G) • Dose delivery accuracy and precision

• Dosimetry of Electron Beams

• Dose distributions o Central axis percent depth dose o Isodose curves

• Factors affecting dose distributions o Beam quality o Beam spreading systems o SSD and SDD

Effective SSD techniques Inverse square

o Field size and shape o X-ray contamination o Depth o Surface dose o Inhomogeneities (e.g., CET) o Other

• Energy specification o Most probable energy o Mean energy o Energy at depth o Ranges (extrapolated, practical, R50)

• Choice of energy and field size • Air gaps and oblique incidence • Tissue inhomogeneities • Bolus, absorbers, and spoilers • Matching adjacent fields • Point dose and treatment time calculations • Field shaping techniques • Electron arc • Total skin electron therapy

• Brachytherapy

• Historical review—role of radium • Calculation of dose from a point source • Calculation of dose from a line source • Physical and dosimetric properties of commercial sealed sources and applicators • Implant instrumentation and techniques

o Low dose rate o High dose rate (including PDR) o Biological considerations of dose, dose rate, and fractionation

• Calibration and specification of sources • Disseminated (unsealed sources) • Acceptance testing and quality assurance • Dose specification, implantation dosimetry, and dosimetry systems

o Patterson-Parker o Quimby

o Paris o Other

• Dose specification and dosimetry systems of intracavitary implants

• Advanced Treatment Planning for EBRT

• Plane radiography and fluoroscopy for simulation • Portal imaging

o Film-based o Electronic

• Imaging for radiation therapy planning o CT o MRI o Ultrasound o Isotope imaging

• Image processing o Image enhancement o 2D and 3D visualization of volumetric data (DRRs, volume rendering) o Image registration

• Virtual simulation (including BEV techniques) • Treatment planning systems • 3D conformal treatment planning

o Plan evaluation (DVH, NTCP, TCP, etc) o Dose optimization techniques o Noncoplanar beams o IMRT

• Radiosurgery • Patient setup and alignment

• Quality Assurance

• Equipment-related o Regulations and recommendations o Measurement techniques

• Patient related o Misadministration

External beam Brachytherapy

• Brachytherapy source inventory

• Radiation Protection and Safety

• Principles, biological effect models, personnel dose limits, rules, regulations • Structural shielding design for external beam therapy

o Primary barriers o Secondary barriers o Machine shielding (beam stoppers and head shielding) o Neutrons

• Radiation protection for brachytherapy procedures o Source storage and transport containers o Patient room o Special considerations for high dose rate brachytherapy o Special procedures and source prep rooms

o Release of patients treated with temporary implants • Leak testing of sealed sources • Routine radiation surveys • Personnel monitoring • Protection against nonionizing radiation • Administrative requirements

o Radiation Safety Officer o Radiation Safety Committee

• Safety instructions and safety precautions o Sealed-source brachytherapy o Radiopharmaceutical therapy

• Quality Management Program

• Written directive • Identification of patient • Plan and delivery in accordance with written directive • Unintended deviation

o Recordable events o Misadministrations

• Special Topics

• Hyperthermia • Computers

Study Guide: Radiation and Cancer Biology

This exam tests your knowledge of the principles of cancer and radiation biology underlying the practice of radiation oncology. Included are questions on:

• basic cancer biology and the molecular biology of cancer • the response to radiation at the subcellular and cellular levels • the radiation responses of normal and malignant tissues • radiation carcinogenesis • hereditary effects as they relate to radiation protection

Categories for Cancer and Radiation Biology

• Interaction of Radiation with Matter

• Definition of ionizing radiation and types • Definition of LET and quality of radiation • Generation of free radicals • Direct and indirect action of radiation • Role of oxygen

• Molecular Mechanisms of DNA Damage

• Assays for DNA damage • Neutral and alkaline elution, pulsed field electrophoresis, comet, plasmid-based assays • Types of DNA lesions and numbers per cell/Gy • Multiply damaged sites • Single lethal hits and accumulated damage (inter- and intratrack)

• Molecular Mechanisms of DNA Repair

• Types of repair • Repair of base damage, single-strand and double-strand breaks • Homologous recombination • Nonhomologous end-joining

• Chromosome and Chromatid Damage

• Assays • Conventional and FISH • Dose response relationships • Use of peripheral blood lymphocytes in in vivo dosimetry • Stable and unstable chromatid and chromosome aberrations • Human genetic diseases that affect DNA repair, fragility, and radiosensitivity

• Mechanisms of Cell Death

• Apoptotic death o Developmental and stress induced o Morphological and biochemical features of apoptosis o Molecular pathways leading to apoptosis o Radiation-induced apoptosis in normal tissues and tumors

• Necrotic death o Morphological, pathological, and biochemical features of necrosis

• Mitotic death following irradiation o Catastrophic vs apoptotic death

o Cell division postradiation and time of clonogen death • Radiation-induced senescence

• Cell and Tissue Survival Assays

• In vitro clonogenic assays o Effects of dose, dose rate, cell type

• In vivo clonogenic assays o Bone marrow stem cell assays, jejunal crypt stem cell assay, skin clones, kidney

tubules

• Models of Cell Survival

• Random nature of cell killing and Poisson statistics • Comparison of survival of viruses, bacteria, and eukaryotic cells after irradiation • Single-hit, multitarget models of cell survival • Two component models • Linear quadratic model • Calculations of cell survival with dose

• Linear Energy Transfer

• RBE defined • RBE as a function of LET • Tissue type

• Oxygen Effect

• Define OER • Dose and dose per fraction effects • OER vs LET • Impact of O2 concentration • Time scale of oxygen effect • Mechanisms of oxygen effect

• Repair at the Cellular Level

• Sublethal damage repair • Potentially lethal damage repair • Half-time of repair • Dose rate effects and repair • Dose fractionation effects

• Solid Tumor Assay Systems

• Experimental models • TD50 limiting dilution assay • Tumor regrowth assay • TCD50 tumor control assay • Lung colony assay • In vitro / in vivo assay • Spheroid systems

• Tumor Microenvironment

• Tumor vasculature • Angiogenesis • Hypoxia in tumors

o Measurement of hypoxia o Transient and chronic hypoxia

• Reoxygenation following irradiation • Relevance of hypoxia in radiation therapy • Hypoxia as a factor in tumor progression • Hypoxia-induced signal transduction • Cellular composition of tumors

• Cell and Tissue Kinetics

• Cell cycle • Measurement of cell cycle parameters by 3H-thymidine • Measurement by flow cytometry, DNA staining and BrdU • Cell cycle synchronization techniques and uses • Effect of cell cycle phase on radiosensitivity • Cell cycle arrest and redistribution following irradiation • Cell cycle checkpoints, cyclins, cyclin dependent kinase inhibitors • Tissue kinetics

o Growth fraction o Cell loss factor o Volume doubling times o Tpot

• Growth kinetics of clinical and experimental tumors

• Molecular Signaling

• Receptor/ligand interactions • Phosphorylation/dephosphorylation reactions • Transcriptional activation • Gene expression profiling and radiation-induced gene expression • Radiation-induced signals

o DNA damage response o Non-DNA damage response

• Cell survival and death pathways

• Cancer

• Cancer as a genetic disease • Oncogenes • Tumor suppressor genes • Telomeric changes in cancer • Epigenetic changes in cancer (e.g., hypermethylation) • Multistep nature of carcinogenesis • Molecular profiling of cancer • Signaling abnormalities in carcinogenesis • Effects of signaling abnormalities on radiation responses • Prognostic and therapeutic significance of tumor characteristics

• Total Body Irradiation

• Prodromal radiation syndrome • Cerebrovascular syndrome • Gastrointestinal syndrome • Hematopoietic syndrome • Mean lethal dose and dose/time responses • Immunological effects • Assessment and treatment of radiation accidents • Bone marrow transplantation

• Clinically Relevant Normal Tissue Responses to Radiation

• Responses in skin, oral mucosa, oropharyngeal and esophageal mucous membranes, salivary glands, bone marrow, lymphoid tissue bone and cartilage, lung, kidney, testis, eye, central and peripheral nervous tissues

• Mechanisms of Normal Tissue Radiation Responses

• Molecular and cellular responses in slowly and rapidly proliferating tissues o Cytokines and growth factors o Regeneration o Remembered dose o Functional subunits

• Mechanisms underlying clinical symptoms o Latency o Inflammatory changes o Cell killing o Radiation fibrosis o Volume effects

• Scoring systems for tissue injury o LENT and SOMA

• Therapeutic Ratio

• Tumor control probability ( TCP) curves o Calculation of TCP o Factors affecting shape and slope of TCP curves o Influence of tumor repopulation/regeneration on TCP

• Normal tissue complication probability (NTCP) curves o Influence of normal tissue regeneration on responses o Response of subclinical disease o Causes of treatment failure o Factors determining tissue tolerance o Normal tissue volume effects o Dose-volume histogram analysis

• Effect of adjuvant or combined treatments on therapeutic rationals

• Time, Dose, Fractionation

• The 4 R’s of fractionation • The radiobiological rationalc behind dose fractionation • The effect of tissue type on the response to dose fractionation • Effect of tissue/tumor types on a/b ratios • Quantitation of multifraction survival cures • BED and isoeffect dose calculations

• Brachytherapy

• Dose rate effects ( HDR and LDR) • Choice of isotopes • Interstitial and intracavitary use • Radiolabeled antibodies

• Radiobiological aspects of alternative dose delivery systems

• Protons, high LET sources, BNCT • Stereotactic radiosurgery/radiotherapy, IMRT, IORT • Dose distributions and dose heterogeneity

• Chemotherapeutic agents and radiation therapy

• Classes of agents • Mechanisms of action • The oxygen effect for chemotherapy • Multiple drug resistance • Interactions of chemotherapeutic agents with radiation therapy • Photodynamic therapy • Gene therapy

• Radiosensitizers, Bioreductive Drugs, Radioprotectors

• Tumor radiosensensitization o Halogenated pyrimidines, nitroimidazoles

• Hypoxic cell cytotoxins o Tirapazamine

• Normal tissue radioprotection o Mechanisms of action, sulfhydryl compounds, WR series, dose reduction factor (

DRF) • Biological response modifiers

• Hyperthermia

• Cellular response to heat • Heat shock proteins • Thermotolerance • Response of tumors and normal tissues to heat • Combination with radiation therapy

• Radiation Carcinogenesis

• Initiation, promotion, progression • Dose response for radiation-induced cancers • Importance of age at exposure and time since exposure • Malignancies in prenatally exposed children • Second tumors in radiation therapy patients • Effects of chemotherapy on incidence • Risk estimates in humans • Calculations based on risk estimates

• Heritable Effects of Radiation

• Single gene mutation

• Chromosome aberrations • Relative vs absolute mutation risk • Doubling dose • Heritable effects in humans • Risk estimates for hereditable effects

• Radiation Effects in the Developing Embryo

• Intrauterine death • Congenital abnormalities and neonatal death • Microcephaly, mental retardation • Growth retardation • Dose, dose rate, and stage in gestation • Human experience of pregnant women exposed to therapeutic dose

• Radiation Protection

• General philosophy • Stochastic and deterministic effects • Relative weighting factors • Equivalent dose-tissue weighting factor • Effective dose, committed dose • Collective exposure dose • Dose limits for occupational and public exposure • ICRP and NCRP

Study Guide: Oral Exam

You will be examined by eight examiners for a period of 30 minutes with each. The subject matter is the clinical management of malignant and benign disease, and is usually presented according to the anatomical site of the primary tumor. Electronic display of images may be used in some categories of the examination. Questions in any category may relate to:

• Anatomy • Epidemiology • Pathology • Patterns of local, regional and distant involvement • Clinical evaluation, including staging and tumor markers • Selection of treatment modalities, including surgery, radiation therapy and systemic

therapy, as applicable • Radiation therapy planning and technique • Results of treatments including patterns of failure and prognostic factors • Complications of treatments with emphasis on the effects of radiation therapy on normal

tissues, and how they should be managed The anatomical sites are divided into the following eight categories:

• Gastrointestinal Tract— includes malignancies of the :

• esophagus • stomach • small bowel • colon • rectum • anus • pancreas • adrenal gland • liver • gallbladder • bile ducts

• Gynecologic Malignancies—includes malignant lesions of the:

• cervix • vagina • uterus • allopian tubes • ovaries • vulva

• Genitourinary Tract—includes malignancies of the:

• prostate • kidney • ureter • urethra • bladder

• penis • testis

• Lymphoma/Leukemia—includes:

• Hodgkin disease • non-Hodgkin lymphomas • leukemias • myeloma

• Head, Neck, and Skin—includes malignancies of the:

• oral cavity • paranasal sinuses • salivary glands • nasopharynx • hypopharynx • thyroid • larynx • oropharynx • skin

• Breast— includes:

• malignancies of the breast • in-situ carcinomas of the breast

• Central Nervous System and Pediatric Malignancies—includes benign and malignant

diseases of the:

• central nervous system • neoplasms of the pediatric age group

o histiocytoses

• Lung and Mediastinum, Soft Tissue and Bone—includes malignancies of the:

• lung and mediastinum • pleura • soft tissues • bone

RADIATION ONCOLOGY RESIDENT TRAINING

GUIDELINES FOR CANCER AND RADIATION BIOLOGY

These guidelines are meant to indicate the topics of which residents should have knowledge. They are not intended to indicate the depth of knowledge or the order in which they are taught. I Interaction of Radiation with Biological Systems (++) Definition of ionizing radiation

Types of ionizing and non-ionizing radiation Definition of LET and quality of ionizing radiation Generation of free radicals Direct and indirect action of ionizing radiation

II Molecular Mechanisms of DNA Damage (+) Assays for DNA damage

neutral and alkaline elution, pulsed field electrophoresis, comet, plasmid-based assay

Types of DNA lesions and numbers per cell/Gy Multiply damaged sites Single lethal hits and accumulated damage (inter- and intra-track)

Role of oxygen in the generation of damage Role of LET and radiation quality

III Molecular Mechanisms of DNA Repair (+++) Different types of DNA repair mechanisms

Mechanisms involved in repair of base damage and DNA single strand breaks Mechanisms involved in repair of double strand breaks

Homologous recombination Non-homologous end joining

IV Chromosome and Chromatid Damage (++) Assays

Conventional smears, banding, comparative genomic hybridization (CGH) and FISH

Dose response relationships Use of peripheral blood lymphocytes in in vivo dosimetry Stable and unstable chromatid and chromosome aberrations

Human genetic diseases that affect DNA repair, fragility, and radiosensitivity V Mechanisms of Cell Death (+++) Apoptotic death Developmental and stress induced Morphological and biochemical features of apoptosis Molecular pathways leading to apoptosis Radiation-induced apoptosis in normal tissues and tumors Necrotic death Morphological, pathological, and biochemical features of necrosis Mitotic death following irradiation Types of mitotic death - mitotic catastrophe vs. apoptosis Cell division post-radiation and time to clonogenic cell death Radiation-induced senescence VI Cell and Tissue Survival Assays (+) In vitro clonogenic assays Calculation of plating efficiency and surviving fraction

In vivo clonogenic assays Bone marrow stem cell assays, jejunal crypt stem cell assay, skin clones, kidney tubules

Functional endpoints VII Models of Cell Survival (+++)

Random nature of cell killing and Poisson statistics Doses for inactivation of viruses, bacteria, and eukaryotic cells after irradiation Single hit, multi-target models of cell survival Two component models Linear quadratic model Calculations of cell survival with dose Effects of dose, dose rate, cell type

VIII Modifiers of Cell Survival: Linear Energy Transfer (+) Definition of RBE RBE as a function of LET Effect of LET on cell survival Endpoint dependence of RBE Effects of dose, dose rate, cell type IX Modifiers of Cell Survival: Oxygen Effect (++) Definition of OER Effect of dose, dose rate, cell type OER as a function of LET

Impact of O2 concentration Time scale of oxygen effect Mechanisms of oxygen effect X Modifiers of Cell Survival: Repair (++) Sub-lethal damage repair Potentially lethal damage repair Half-time of repair Effects of dose, dose rate, and cell type Effect of dose fractionation

Effect of LET Effects of oxygen/hypoxia

XI Solid Tumor Assay Systems (+) TD50 limiting dilution assay Tumor regrowth assay TCD50 tumor control assay Lung colony assay In vitro/in vivo assay Monolayers vs. 3-D spheroid cultures XII Tumor Microenvironment (+++) Tumor vasculature Angiogenesis Hypoxia in tumors Measurement of hypoxia Transient and chronic hypoxia Reoxygenation following irradiation Relevance of hypoxia in radiation therapy Hypoxia as a factor in tumor progression Hypoxia-induced signal transduction

Cellular composition of tumors XIII Cell and Tissue Kinetics (+++) Cell cycle Measurement of cell cycle parameters by 3H-thymidine

Measurement by flow cytometry, DNA staining and BrdU Cell cycle synchronization techniques and uses Effect of cell cycle phase on radiosensitivity Cell cycle arrest and redistribution following irradiation Cell cycle checkpoints, cyclins, cyclin dependent kinase inhibitors Tissue kinetics Stem, progenitor, differentiated cells Growth fraction Cell loss factor Volume doubling times Tpot Growth kinetics of clinical and experimental tumors XIV Molecular Signaling (++) Receptor/ligand interactions Phosphorylation/dephosphorylation reactions Transcriptional activation Radiation-induced gene expression Gene expression profiling Proteomics Radiation-induced signals DNA damage response Non-DNA damage responses Cell survival and death pathways XV Cancer (+++) Cancer as a Genetic Disease Oncogenes Tumor suppressor genes Telomeric changes in cancer Epigenetic changes in cancer e.g hypermethylation

Multi-step nature of carcinogenesis Repair genes in carcinogenesis The metastatic process Molecular profiling and staging of cancer Gene expression profiling Proteomics Signaling abnormalities in cancer

Effects of signaling abnormalities on radiation responses Prognostic significance of tumor characteristics Therapeutic targets and strategies for intervention Monoclonals, small molecule inhibitors, gene therapy XVI Total Body Irradiation (++) Prodromal radiation syndrome Cerebrovascular syndrome Gastrointestinal syndrome Hematopoietic syndrome Mean lethal dose and dose/time responses Immunological effects

Assessment and treatment of radiation accidents or terrorism Bone marrow transplantation XVII Clinically Relevant Normal Tissue Responses to Radiation (+++)

Responses in skin, oral mucosa, oropharyngeal and esophageal mucous membranes, salivary glands, bone marrow, lymphoid tissues, bone and cartilage, lung, kidney, testis, ovary, eye, central and peripheral nervous tissues Scoring systems for tissue injury LENT and SOMA

XVIII Mechanisms of Normal Tissue Radiation Responses (+++)

Differences between slowly and rapidly proliferating tissues Molecular and cellular responses in slowly and rapidly proliferating tissues

Cytokines and growth factors Regeneration Remembered dose Functional subunits

Mechanisms underlying clinical symptoms Latency Inflammatory changes Cell killing

Radiation fibrosis Vascular damage

Volume effects Pharmacological modification of normal tissue responses XIX Therapeutic Ratio (+++) Tumor control probability (TCP) curves Calculation of TCP

Factors affecting shape and slope of TCP curves Influence of tumor repopulation/regeneration on TCP

Normal tissue complication probability (NTCP) curves Influence of normal tissue regeneration on responses

Response of subclinical disease Causes of treatment failure Factors determining tissue tolerance Normal tissue volume effects Dose-volume histogram analysis Effect of adjuvant or combined treatments on therapeutic ratio XX Time, Dose, Fractionation (+++) The 4 R’s of fractionation The radiobiological rationale behind dose fractionation The effect of tissue type on the response to dose fractionation Effect of tissue/tumor types on a/b ratios Quantitation of multifraction survival curves BED and isoeffect dose calculations XXI Brachytherapy (+) Dose rate effects (HDR and LDR) Choice of isotopes Interstitial and intracavitary use Radiolabeled antibodies BED and Isoeffective dose calculations

XXII Radiobiological aspects of alternative dose delivery systems (+)

Protons, high LET sources, BNCT Stereotactic radiosurgery/radiotherapy, IMRT, IORT

Dose distributions and dose heterogeneity XXIII Chemotherapeutic agents and radiation therapy (+++) Classes of agents

Mechanisms of action The oxygen effect in chemotherapy Multiple drug resistance Interactions of chemotherapeutic agents with radiation therapy (chemoradiation therapy)

Photodynamic therapy XXIV Radiosensitizers, Bioreductive drugs, Radioprotectors (++) Tumor radiosensensitization Halogenated pyrimidines, nitroimidazoles Hypoxic cell cytotoxins tirapazamine Normal tissue radioprotection

Mechanisms of action, sulfhydryl compounds, WR series, dose reduction factor (DRF)

Biological response modifiers XXV Hyperthermia (+) Delivery modalities Cellular response to heat Heat shock proteins Thermotolerance Response of tumors and normal tissues to heat Combination with radiation therapy XXVI Radiation Carcinogenesis (++) Initiation, promotion, progression Dose response for radiation-induced cancers Importance of age at exposure and time since exposure Malignancies in prenatally exposed children Second tumors in radiation therapy patients Effects of chemotherapy on incidence Risk estimates in humans Calculations based on risk estimates XXVII Heritable Effects of Radiation (+) Single gene mutation Chromosome aberrations Relative vs. absolute mutation risk Doubling dose Heritable effects in humans Risk estimates for hereditable effects XXVIII Radiation Effects in the Developing Embryo (+) Intrauterine death Congenital abnormalities and neonatal death Microcephaly, mental retardation Growth retardation Dose, dose rate, and stage in gestation Human experience of pregnant women exposed to therapeutic dose

XXIX Radiation Protection (++) General philosophy Stochastic and deterministic effects Effective dose - relative weighting factors Equivalent dose – tissue weighting factor Committed dose

Collective exposure dose Dose limits for occupational and public exposure ICRP and NCRP

Int. J. Radiation Oncology Biol. Phys., Vol. 68, No. 5, pp. 1276–1288, 2007Copyright � 2007 Elsevier Inc.

Printed in the USA. All rights reserved0360-3016/07/$–see front matter

doi:10.1016/j.ijrobp.2007.01.068

REPORT

ASTRO’S 2007 CORE PHYSICS CURRICULUM FOR RADIATIONONCOLOGY RESIDENTS

AD HOC COMMITTEE ON TEACHING PHYSICS TO RESIDENTS: ERIC E. KLEIN, PH.D.,* BRUCE J. GERBI, PH.D.,y

ROBERT A. PRICE, JR., PH.D.,z JAMES M. BALTER, PH.D.,x BHUDATT PALIWAL, PH.D.,k

LESLEY HUGHES, M.D.,{ AND EUGENE HUANG, M.D.#

*Washington University, St. Louis, MO; yUniversity of Minnesota, Minneapolis, MN; zFox Chase Cancer Center, Philadelphia, PA;xUniversity of Michigan, Ann Arbor, MI; kUniversity of Wisconsin, Madison, WI; {Saint Joseph Medical Center, Reading, PA; and

# MD Anderson Cancer Center, Houston, TX

In 2004, the American Society for Therapeutic Radiology and Oncology (ASTRO) published a curriculum forphysics education. The document described a 54-hour course. In 2006, the committee reconvened to update thecurriculum. The committee is composed of physicists and physicians from various residency program teaching in-stitutions. Simultaneously, members have associations with the American Association of Physicists in Medicine,ASTRO, Association of Residents in Radiation Oncology, American Board of Radiology, and American Collegeof Radiology. Representatives from the latter two organizations are key to provide feedback between the examin-ing organizations and ASTRO. Subjects are based on Accreditation Council for Graduate Medical Education re-quirements (particles and hyperthermia), whereas the majority of subjects and appropriated hours/subject weredeveloped by consensus. The new curriculum is 55 hours, containing new subjects, redistribution of subjects withupdates, and reorganization of core topics. For each subject, learning objectives are provided, and for each lecturehour, a detailed outline of material to be covered is provided. Some changes include a decrease in basic radiologicphysics, addition of informatics as a subject, increase in intensity-modulated radiotherapy, and migration of somebrachytherapy hours to radiopharmaceuticals. The new curriculum was approved by the ASTRO board in late2006. It is hoped that physicists will adopt the curriculum for structuring their didactic teaching program, andsimultaneously, the American Board of Radiology, for its written examination. The American College of Radiologyuses the ASTRO curriculum for their training examination topics. In addition to the curriculum, the committeeadded suggested references, a glossary, and a condensed version of lectures for a Postgraduate Year 2 residentphysics orientation. To ensure continued commitment to a current and relevant curriculum, subject matter willbe updated again in 2 years. � 2007 Elsevier Inc.

American Society for Therapeutic Radiology and Oncology (ASTRO), Radiation oncology, Physics, Education,Core curriculum.

INTRODUCTION

In 2002, the American Society for Therapeutic Radiology

and Oncology’s (ASTRO’s) Radiation Physics Committee

appropriated an ad hoc Committee on Physics Teaching to

Medical Residents. The main initiative was to develop

a core curriculum for teaching institutions to follow. Publica-

tions have pointed to a wide variation in teaching intensity

and subject matter (1–5). The publication by Klein et al.(6) on physics teaching showed that although consistencies

are seen, there are also many variations in physics instruction

to resident physicians (i.e., most residencies taught exclu-

sively to Postgraduate Year 2 residents, whereas a minority

taught different subjects [or levels] to different year resi-

dents). Radiation dosimetry, treatment planning, and brachy-

127

therapy constituted approximately half the teaching hours.

Some programs taught basic radiation physics intensely

with minimal treatment planning coursework, whereas others

had the reverse prioritization. On average, total classroom

time was 61.4 hours/year, with a startling range of 24–118

hours. The survey showed enormous differences in national

teaching efforts.

Another challenge facing teaching programs is how to

assess the physics teaching success. The ultimate goal for

teaching is to prepare the resident for a successful career

that must include a strong physics backbone. The more read-

ily available assessment comes from the pass rate for the

American Board of Radiology (ABR) written examination

and the American College of Radiology (ACR) in-training

Reprint requests to: Eric E. Klein, Ph.D., Radiation Oncology,Washington University School of Medicine, Campus Box 8224,4921 Parkview Pl, St. Louis, MO 63110-1093. Tel: (314) 747-3721; Fax: (314) 747-9557; E-mail: [email protected]

6

Conflict of interest: none.Received Dec 19, 2006, and in revised form Jan 26, 2007.

Accepted for publication Jan 31, 2007.

mailto:[email protected]

ASTRO’s 2007 physics curriculum for residents d E. E. KLEIN et al. 1277

examination scores. Both these organizations have physics

examination committees that strive to update examination

questions for relevance and accuracy. The challenge is in de-

ciding what is relevant and what level the training programs

must include. For reasons of resolving teaching disparity and

providing examination consistency with acceptable training

expectations, a physics core curriculum was recommended.

In 2005, the curriculum was published (7) and adopted by

many teaching physicists and by the ACR for its in-training

examination. At that juncture, it was made clear that the cur-

riculum would be updated every 2 years to ensure the mate-

rial was up to date. The committee reconvened in 2006 to

accomplish this task. The new curriculum was developed

and in addition to the curriculum, the committee added sug-

gested references for each subject. Along with the curricu-

lum, a recommendation for a physics orientation with

a suggested program for the incoming first-year residents

was added.

METHODS AND MATERIALS

The committee was composed of physicists and physicians from

various teaching institutions with active residency programs. Simul-

taneously, members had associations with the American Associa-

tion of Physicists in Medicine (AAPM), ASTRO, Association of

Residents in Radiation Oncology, ABR, or ACR. The latter two

organizations’ representatives were on their respective physics exam-

ination committees because one of the main agendas was to provide

a feedback loop between the examining organizations and ASTRO.

In preparation for the 2004 curriculum, a survey was sent to recent

graduates assessing the effectiveness of their physics teaching. Most

graduates believed the physics course(s) they had taken may have

prepared them for their examinations, but not necessarily for their

clinical or academic career, especially in regard to new technologies.

A large variation in physics teaching was also found among many

respondents. This survey confirmed the growing concern for a

curriculum to be developed.

Because the members came from teaching facilities of varying

sizes, the members pooled their own institutions’ curricula, which

were then combined to develop the first curriculum. Committee

members then reviewed and commented on each subject and which

intensity of teaching was used. Special consideration was made to

include subject matter relevant to fundamental understanding of

physics (radiologic physics), practice needs (treatment planning,

up-to-date intensity-modulated radiotherapy [IMRT], and imaging)

and also meet requirements of the Accreditation Council for Grad-

uate Medical Education (particles and hyperthermia). Once the cur-

riculum was completed according to subjects and hours/subject,

learning objectives were added for each subject to provide the level

of teaching intensity recommended for subjects. This was organized

hour by hour for each subject.

For the new curriculum, members were assigned subjects from

the first curriculum to review and update. Each subject had three re-

viewers contributing to the update. Once the edits were compiled,

a 1-day meeting was held to finalize the subject matter included in

the curriculum.

In addition, suggested references were compiled by the authors

according to the subject. It was also decided to add a glossary defin-

ing terms found in the curriculum. The final part was to add a recom-

mendation for a physics orientation program. This was deemed

necessary and therefore was adopted as part of the curriculum. It

is suggested that the orientation be given for a short time within

the first few weeks of the first year of residency.

RESULTS

The new curriculum resulted in a recommended 55-hour

course. The committee also decided it was necessary to com-

plement some particular subjects with hands-on experience

obtained during a physics rotation. Table 1 summarizes the

curriculum.

Some pertinent changes compared with 2004 include a

decrease in some basic radiologic physics subject hours,

the addition of an informatics subject (digital imaging and

communications in medicine [DICOM], picture archiving

and communication system [PACS], etc.), increase in

Table 1. Recommend subjects and teaching hours forphysics teaching to radiation oncology residents (2007)

Subject matterTeaching

hours/subject

Atomic and nuclear structure (including decayand radioactivity)

2

Production of X-rays, photons, and electrons 2Treatment machines and generators; simulators

(including CT)3

Radiation interactions 3Radiation beam quality and dose 3Radiation measurement and calibration 3*Photons and X-rays (including concepts,

isodoses, MU, heterogeneities, field shaping,compensation, field matching, etc.)

7*

Electrons (including concepts, isodoses, MU,heterogeneities, field shaping, fieldmatching, etc.)

2

External beam quality assurance 2Informatics (DICOM, networking, PACS, data

management)1

Radiation protection and shielding 2Imaging for radiation oncology 43D-CRT, including ICRU concepts and beam-

related biology3*

Assessment of patient setup and treatment(including EPID, immobilization, etc.)

2*

IMRT 3Special procedures (including radiosurgery,

TBI, etc.)3

Brachytherapy (including intracavitary,interstitial, HDR, etc.)

6

Radiopharmaceutical physics and dosimetry 2Hyperthermia 1Particle therapy 1Total 55

Abbreviations: CT = computed tomography; MU = monitor unit;DICOM = digital imaging and communications in medicine;PACS = picture archiving and communication system; 3D-CRT =three-dimensional conformal radiotherapy; ICRU = InternationalCommission on Radiation Units and Measurements; EPID = elec-tronic portal imaging device; IMRT = intensity-modulated radio-therapy; TBI = total body irradiation; HDR = high dose-rate.

Bold/italic numbers indicate change, including total number ofhours or new author (bold only).

* Subject matter that should be complemented during a physicsrotation.

1278 I. J. Radiation Oncology d Biology d Physics Volume 68, Number 5, 2007

IMRT teaching hours, and reassignment of brachytherapy

hours to the radiopharmaceuticals section. The last reassign-

ment was mainly to accommodate the didactic requirement

for radioactive authorized-user approval (Nuclear Regulatory

Commission [NRC] 10CFR Part 35) (8). The NRC allows for

authorized-user approval on a radioactive material license for

therapeutic radiopharmaceuticals provided didactic training

has been provided in related radiation safety, dosimetry,

and radiation chemistry. Subjects were reordered after careful

review of the teaching flow. Details of the subjects, including

learning objectives for each subject, are described in the

Appendix.

The committee also recommends a minimum of a 4-hour

physics-related orientation for incoming first-year residents.

It is recommended that this orientation occur within the first

2 weeks and include the following material:

Overview of planning process from simulation to treat-

ment (1 hour)

General operation of simulation devices (30 minutes)

Overview of linear accelerator (linac) systems and opera-

tion (30 minutes)

Introduction to treatment immobilization, localization,

and verification (30 minutes)

Table 2. Suggested options for textbook chapters and references

1. Atomic and nuclear structure (including decay and radioactivity) Khan, Ch. 1; Cherry, Ch. 22. Production of X-rays, photons, and electrons Khan, Ch. 3; Hendee, Ch. 23. Treatment machines and simulators Khan, Ch. 4 & 7; Metcalfe, Ch. 1; Van Dyk, Ch. 4–74. Radiation interactions Khan, Ch. 5; Metcalfe, Ch. 2; Cherry, Ch. 6; Hendee, Ch. 35. Radiation beam quality and dose Khan, Ch. 7; Hendee, Ch. 46. Radiation measurement and calibration Khan, Ch. 8; Hendee, Ch. 5 & 67. Photons and X-rays Khan, Ch. 11–13; Metcalfe, Ch. 68. Electrons Khan, Ch. 14; AAPM TG-25/709. External beam quality assurance Khan, Ch. 17; AAPM TG-40

10. Informatics astro.org/pdf/Research/IHE-RO.pdf; DICOM Standard Protocols11. Radiation protection and shielding Khan, Ch. 16; NCRP 151; Thomadsen, Ch. 10; McGinley (entire book)12. Imaging for radiation oncology Van Dyk, Ch. 2; Curry, Ch. 10–16, 19, 20, 22–24; Sprawls (entire book)13. 3D-CRT, including ICRU Khan & Potish, Ch. 4, 10, 18–28; ICRU-6214. Assessment of patient setup and treatment

(including EPID, immobilization, etc.)Van Dyk, Ch. 7; Bentel (entire book)

15. IMRT Khan, Ch. 20; Palta/Mackie (entire book); Roeske/Mundt(entire book)16. Special procedures (including radiosurgery, TBI, etc.) Khan, Ch. 21, 18; Metcalfe, Ch. 517. Brachytherapy (including intracavitary, interstitial, HDR, etc.) Khan, Ch. 22–24; Thomadsen, Ch. 28–33, 41–4918. Radiopharmaceutical physics and dosimetry Khan, Ch. 15; Cherry, Ch. 5; Thomadsen, Ch. 1119. Hyperthermia Hall, Ch. 2820. Particle therapy Van Dyk, Ch. 20, 21

Abbreviations as in Table 1.Suggested Books for Residents.� Bentel GC. Patient positioning and immobilization oncology. New York: McGraw-Hill; 1999.� Cherry SR, Sorenson J, Phelps M. Physics in nuclear medicine. 3rd Ed. Philadelphia: Saunders; 2003.� Curran BH, Balter JM, Chetty IJ. Integrating new technologies into the clinic: Monte Carlo and image-guided radiation therapy. (Mono-

graph no. 32). Madison, WI: Medical Physics Publishing; 2006.� Curry TS, Dowdey JE, Murry RC. Christensen’s physics of diagnostic radiology. 4th Ed. Philadelphia: Lippincott Williams & Wilkins;

1990.� Ezzell GA, Galvin JM, Low D, et al. Guidance document on delivery, treatment planning, and clinical implementation of IMRT: Report

of the IMRT Subcommittee of the AAPM Radiation Therapy Committee. Med Phys 2003;30:2089–2115.� Hall EJ, Giaccia AJ. Radiobiology for the radiologist. Philadelphia: Lippincott Williams & Wilkins; 2005.� Hendee WR, Ibbott GS, Hendee EG. Radiaiton therapy physics. 3rd Ed. New York: Wiley; 2004.� Khan FM, Doppke KP, Hogstrom KR, et al. Clinical electron-beam dosimetry: Report of AAPM Radiation Therapy Committee Task

Group No. 25. Med Phys 1991;18:73–109.� Khan FM, Potish RA. Treatment planning in radiation oncology. Philadelphia: Lippincott Williams & Wilkins; 2006.� McGinley PH. Shielding techniques for radiation oncology facilities. 2nd Ed. Madison, WI: Medical Physics Pub.; 2006.� Metcalfe P, Kron T, Hoban P. The physics of radiotherapy X-rays from linear accelerators. Madison, WI: Medical Physics Pub.; 1997.� Mundt AJ, Roeske JB. Intensity modulated radiation therapy: A clinical perspective. Decker; 2005.� NCRP National Council on Radiation Protection and Measurements Report No. 151. Structural shielding design and evaluation for

megavoltage X- and gamma-ray radiotherapy facilities. Washington, DC: Institute of Physics Pub. 2005.� Palta J, Mackie TRl. Intensity-modulated radiation therapy: The state of the art (Medical Physics Monograph #29). Madison, WI: Medical

Physics Pub. 2003.� Sprawls P. Magnetic resonance imaging: Principles, methods, and techniques. Madison, WI: Medical Physics Publishing Corp.; 2007.� Thomadsen B, editor. Categorical course in brachytherapy physics. Oak Brook, IL: RSNA Publications; 1997.� Thomadsen B, Rivard M, Butler W. Brachytherapy physics. 2nd Ed. Madison, WI: Medical Physics Pub.; 2005.� Van Dyk J. The modern technology of radiation oncology. Madison, WI: Medical Physics Publishing; 2005.


Basic monitor unit (MU) calculations appropriate for

emergency patients (45 minutes)

Radiation safety, including material to be studied for insti-

tutional examination (45 minutes)

If more than 4 hours can be granted, introductory lectures

for special procedures and quality assurance (QA) should be

given.

DISCUSSION AND CONCLUSIONS

The updated curriculum was completed and approved by

the ASTRO Board of Directors in late 2006. Changes were

made to update the curriculum according to technology needs

and strengthen the flow of each teaching program. It is our

hope that teaching physicists will adopt the recommended

curriculum and the ABR may consider using the curriculum

for its written physics examination. The ACR training exam-

ination has been using the previous ASTRO curriculum as

the basis for subject matter and depth of understanding and

will adopt the new curriculum.

The committee did not make recommendations for text-

books to be used because this is left to each individual insti-

tution. However, suggested references are included (Table 2)

for instructors to evaluate for use in teaching or as recommen-

ded student reading. It is anticipated that future curricula will

be available online and will include teaching materials and

examination questions. The curriculum will again be updated

in 2 years.

REFERENCES

1. Dunscombe P. The teaching of physics and related courses toresidents in radiation oncology. Can Assoc Radiol J 1989;40:

211–212.2. Coia LR, Wilson JF, Bresch JP, et al. Results of the in-training

examination of the American College of Radiology for residents

in radiation oncology. Int J Radiat Oncol Biol Phys 1992;24:

903–905.3. Marks JE, Armbruster JS, Brady LW, et al. Special require-

ments for residency training in radiation oncology. Radiation

Oncology Subcommittee of the Residency Review Committee

for Radiotherapy. Int J Radiat Oncol Biol Phys 1992;24:

815–817.

4. Doppke KP, Morin RL, Chu W, et al. A survey of radiationoncologists regarding their radiation physics instruction. Int JRadiat Oncol Biol Phys 1993;25:345–352.

5. Smith AR. Radiation physics instruction for residents. Int JRadiat Oncol Biol Phys 1992;24:851–852.

6. Klein EE, Gerbi B, Meli J, et al. 1995 Survey of physics teachingefforts in radiation oncology residency programs. Int J RadiatOncol Biol Phys 1997;38:441–446.

7. Klein EE, Balter JM, Chaney EL, et al. ASTRO’s Core PhysicsCurriculum for Radiation Oncology Residents. Int J RadiatOncol Biol Phys 2004;60:697–705.

8. NRC (2002) Code of Federal Regulations: Part 35: Medical useof byproduct material.

GLOSSARY

AAPM - American Association of Physicists in Medi-

cine

ALARA - ‘‘as low as reasonably achievable’’

AP/PA - anterior-to-posterior/posterior-to-anterior

beam projection

BANG - Bis (N, N0-methylene-bisacrylamide), acryl-

amide, nitrogen, and gelatine

BEV - beam’s eye view60Co - cobalt 60131Cs - cesium 131

CSDA - continuous slowing down approximation

CT - computed tomography

CTV - clinical target volume

DICOM - digital imaging and communications in medi-

cine

DMLC - dynamic multileaf collimation

DRR - digitally reconstructed radiograph

DVH - dose–volume histogram

e-arc - electron arc

EPID - electronic portal imaging device

ESRT - extracranial stereotactic radiotherapy

FET - field effect transistor

FOV - field of view

GTV - gross tumor volume

HDR - high dose-rate

ICRU - International Commission on Radiation Units

and Measurements

IMRT - intensity-modulated radiotherapy

IS - information systems

IT - information technology

kerma - kinetic energy released in medium

kV - kilovoltage

kVp - kilovoltage peak

LDR - low dose-rate

mg - milligram

MIRD - Medical Internal Radiation Dose Committee

MLC - multileaf collimator

MOSFET - metal oxide semiconductor field effect tran-

sistor

MRI - magnetic resonance imaging

MU - monitor unit

MV - megavoltage

MVCT - megavoltage computed tomography

NRC - Nuclear Regulatory Commission

NCRP - National Council on Radiation Protection and

Measurements

NTCP - normal tissue complication probability

NIST - National Institute of Standards and Technol-

ogy

NaI - sodium iodide


PACS - picture archiving and communication system103Pd - palladium 103

PDD - percent depth dose

PET - positron emission tomography

PRV - planning organ at risk volume

PTV - planning target volume

QA - quality assurance

RBE - relative biologic effectiveness

SAD - source-to-axis distance

SMLC - segmental multileaf collimation

SPECT - single-photon emission computed tomogra-

phy

SRS - stereotactic radiosurgery

SRT - stereotactic radiotherapy

SSD - source-to-skin (or source-to-surface) distance

SUV - standardized uptake value

TBI - total body irradiation

TCP - tumor control probability

TE - time to echo (MRI)

TG43 - task group report number 43 (AAPM)

TG51 - task group report number 51 (AAPM)

TLD - thermoluminescent dosimeters

TMR - tissue maximum ratio

TP - treatment planning (system)

TR - time of repetition (MRI)

TSET - total skin electron therapy

T1 - longitudinal relaxation time (MRI)

T2 - transverse relaxation time (MRI)

1D - one-dimensional

2D - two-dimensional

3D-CRT - three-dimensional conformal radiotherapy

4D - four-dimensional

APPENDIX: ASTRO’S 2007 PHYSICS CURRICULUM FOR RESIDENTS

1. Atomic and Nuclear Structure (2 Lectures)

Learning ObjectivesThe resident should learn:

1. the structure of the atom, including types of nucleons, re-lation between atomic number and atomic mass, andelectron orbits and binding energy; be able to relate en-ergy to wavelength and rest mass; and understand anddescribe an energy spectrum (with respect to isotopesand/or linacs).

2. about radioactivity, including decay processes, proba-bility, half-life, parent-daughter relationships, equilib-rium, and nuclear activation.A. The atom

- Protons, neutrons, electrons (charge, rest mass)

- Atomic number and atomic mass

- Orbital electron shells (binding energy, transitions)

- Wave and quantum models of radiation

- Energy and wavelength, energy spectrum

B. Radioactivity and decay

- Decay processes (of commonly used isotopes for

imaging/therapy, as appropriate)

- Probability and decay constant

- Activity, half-life, mean life

- Radioactive series

2. Production of Photons and Electrons (2 Lectures)

Learning ObjectivesThe resident should learn:1. the means by which X-rays are produced in a linac, in

diagnostic X-ray units, and orthovoltage units.2. production of bremsstrahlung-produced X-rays and

characteristic X-rays.3. the major components of a linac and their function.4. about teletherapy treatment units (i.e., Gamma Knife)

using radioactive materials.A. Basic physics of X-ray beam production

- Bremsstrahlung production of X-rays

- Characteristic radiation

- Diagnostic X-ray tube design

- X-ray energy spectrum

B. Generation of beams

- X-ray energy spectra and filtration

- Gamma-radiation teletherapy sources (60Co)

- Linac production of X-rays and electrons

3. Treatment Machines and Generators; Simulators and

Simulation Tools (3 Lectures)


1. the mechanics and delivery of radiation with respect towave guides, magnetron vs. klystron for production sys-tems.

2. the production and delivery of electrons by the electrongun, buncher, and scattering foil vs. scanning.

3. the production and delivery of photons, including thetarget and flattening filter.

4. the benefits and limitations of multileaf collimators(MLCs) and cerrobend shielding and hand-blocking ofphotons.

5. the purpose and use of monitor chambers.6. the production and collimation of superficial photons.7. alternative to conventional linacs (i.e., X-Band).8. the production of low-energy X-rays for imaging.9. the differences in film and other imaging modalities for

simulation.10. generation of a digitally reconstructed radiograph

(DRR).A. Linacs

- Operational theory of wave guides

- Bending magnet systems

- Photon beam delivery

- Electron beam delivery

- Beam energy

- Monitor chamber


B. Linac collimation systems and other teletherapy

- Primary and secondary collimators

- MLCs

- Other collimation systems (radiosurgery)

- Radiation and light fields (including field size

definition)

- Cobalt units (Gamma Knife)

- X-Band systems (CyberKnife, Mobetron)

- Therapeutic X-ray (<300 kVp)

C. Simulators

- Mechanical and radiographic operation

- Fluoroscopy, flat panel detectors, and intensifiers

- Computed tomography (CT) simulation machinery

- CT simulation operation

- Simulators with CT capability

4. Radiation Interactions (3 Lectures)

Learning ObjectivesThe resident should learn:1. the physical description, random nature, and energy de-

pendence of the five scatter and absorption interactionsthat X-ray photons undergo with individual atoms (coher-ent scatter, photoelectric effect, Compton effect, pairproduction, and photonuclear disintegration).

2. the definitions of key terms, such as attenuation, scatter,beam geometry, linear and mass attenuation coeffi-cients, energy transfer, energy absorption, and half-value layer, and how these terms relate to radiationscatter and absorption through the exponential attenu-ation equation.

3. the physical description and energy dependence of theelastic and inelastic collision processes in matter fordirectly and indirectly ionizing particulate radiation.

4. the definitions of key terms, such as linear energy transfer,specific ionization, mass stopping power, and range, andhow these terms relate to energy deposition by particulateradiation.

A. Interactions of X- and g-rays with matter

- Scatter vs. absorption of radiation

- Coherent scatter

- Photoelectric effect

- Compton effect

- Pair production

- Photonuclear disintegration

B. Attenuation of photon beams

- Attenuation, energy transfer, and energy absorp-

tion

- Exponential attenuation equation

- Attenuation coefficients

- Half-value layer

- Beam geometry

C. Interactions of particulate radiation

- Directly and indirectly ionizing particles

- Elastic and inelastic collisions with orbital elec-

trons and the nucleus

- Linear energy transfer, specific ionization, mass

stopping power, range

- Interactions of electrons

- Interactions of heavy charged particles (i.e., protons)

- Interactions of neutrons

5. Radiation Beam Quality and Dose (2 Lectures)

Learning ObjectivesThe resident should learn:1. the physical characteristics of monoenergetic and poly-

energetic photon and particle beams and terms, such asenergy spectrum, effective energy, filtration, and homoge-neity, that are used to describe such beam.

2. the definitions and units for kinetic energy released in me-dium (kerma), exposure, absorbed dose, dose equivalent,and relative to biologic effectiveness (RBE) dose; the con-ditions under which each quantity applies; and the phys-ical basis for measuring or computing each quantity.

3. how absorbed dose can be determined from exposure, andthe historical development of this approach.

A. Monoenergetic and polyenergetic bremsstrahlung

beams

- Energy spectra for bremsstrahlung beams

- Effects of electron energy, filtration, beam geometry

- Homogeneity coefficient

- Effective energy

- Clinical indices for megavoltage beams (e.g., per-

cent depth dose [PDD] at reference depth)

B. Dose quantities and units

- Evolution of dose units

- Kerma

- Exposure

- Absorbed dose

C. Relationships of kerma, dose, and exposure

- Dose equivalent

- RBE dose

- Calculation of absorbed dose from exposure

- Bragg-Gray cavity theory

6. Radiation Measurement and Calibration (3 Lectures)

Learning ObjectivesThe resident should learn:1. Bragg-Gray cavity theory and its importance in radiation

dosimetry.2. stopping power ratios and the effective point of measure-

ment for radiation dosimetry.3. how photon and electron beams are calibrated, the dose-

calibration parameters, and the calibration protocols forperforming linac calibrations.

4. how to determine exposure and dose from radioactivesources.

5. the various methods by which to measure absorbed dose.These should include calorimetry, chemical dosimetry,solid-state detectors, and film dosimetry.

6. devices used for clinical dosimetry (film, diodes, thermo-luminescent dosimeters [TLDs], etc.).

A. Calculation of dose

- Calculation of absorbed dose from exposure: his-

torical perspective (in light of AAPM task group

report number 51 [TG51])


- Bragg-Gray cavity theory: stopping powers, effec-

tive point of measurement

B. Dose output calibration

- Ionization chambers (cylindrical, parallel plate)

- Calibration of megavoltage beams

Photon beams

Electron beams

Dose calibration parameters

TG51 (theory and overview)

- Exposure from radioactive sources

- Other methods of measuring absorbed dose

- Calorimetry

- Chemical dosimetry (Fricke solution; Bis [N, N0-methylene-bisacrylamide], acrylamide, nitrogen,

and gelatine [BANG] co-polymer gel dosimetry)

C. Clinical dosimetry

- Solid-state detectors

TLDs

Diode detectors

Field effect transistor (FET) detectors

Detector arrays (for IMRT/TomoTherapy verifica-

tion)

- Film dosimetry (IMRT verification dosimetry)

XV2 film

EDR2 film

Radiochromic film

Processors in film dosimetry

7. Photons and X-ray Characteristics and Dosimetry (7 Lec-

tures)


1. basic dosimetric concepts of photon beams.2. how these concepts relate to calculation concepts.3. basic calculation parameters.4. how these parameters relate to one another and how to

cross convert.5. how parameters depend on source-to-skin distance

(SSD) and source-to-axis distance (SAD) setups.6. how beam modifiers affect beams and calculations.7. basic treatment planning arrangements and strategies.8. how beam shaping affects isodose distributions.9. surface and exit dose characteristics.

10. the effect and use of beam modifiers, including bolus.11. interface dosimetry considerations.12. heterogeneity corrections and effects on dose distribu-

tions.13. beam-matching techniques and understanding of

peripheral dose.14. special considerations for pacemaker, pregnant pa-

tients.A. External beam dosimetry concepts (Part I)

- Dosimetric variables from calibration

Inverse square law

Backscatter factor

Electron buildup

PDD

Mayneord F-factor

Definition of area (collimator, scatter, patient)

Equivalent squares

B. External beam dosimetry concepts (Part II)

- Primary vs. scatter

- Scatter-to-primary ratio

- Tissue–phantom ratio

- Tissue–maximum ratio (TMR)

- Converting PDD to TMR

- Dose normalization and prescription

C. System of dose calculations

- MU calculations

Calibration

Collimator scatter factor and phantom scatter factor

Field size correction factors

Beam modifier factors (wedges)

Patient attenuation factors

Output factor

- Calculations in practice

SAD technique

SAD treatment and SAD calibration

SAD treatment and SSD calibration

SAD rotational treatment

SSD technique

SSD treatment same as SSD of calibration

SSD treatment different from SSD of calibra-

tion

SSD treatment and SAD calibration

Calculation of maximum dose in parallel opposed

field plans

D. Translation of computerized planning

- Beam models (i.e., convolution)

- Flatness and symmetry of beam profiles

- Isodoses

- Beam combination (2-, 3-, 4-, 6-field techniques)

- Beam weighting

- Irregular fields

- Bolus

- Arc rotation therapy

E. Computerized treatment planning (TP) strategies

- Surface and buildup dose

- Entrance and exit dose

- Penumbra

- Wedge isodose curves and techniques

Wedge angle and hinge angle

Wedge factor

- Wedge and compensator techniques

Wedge pair

Open and wedged field combination

Custom compensators

Different types of wedges (universal, dynamic,

physical, segmentation)

F. Surface corrections and heterogeneity calculations

- Effects and corrections for surface obliquities

- Corrections and limitations for inhomogeneities

Simple one- (1D) and two-dimensional (2D)

methods


Convolution and superposition methods

Monte Carlo methods

Dose perturbations at interfaces

G. Adjoining fields and special dosimetry problems

- Two-field matching

- Three-field matching

- Craniospinal field matching

- Treatment considerations for pacemaker and defi-

brillators

- Gonadal dose, measurement and minimization

- Pregnant patient, considerations and dosimetry

8. Electron Beam Characteristics and Planning (2 Lectures)

Learning ObjecivesThe resident should learn:1. the basic characteristics of electron beams for therapy, in-

cluding components of a depth–dose curve as a functionof energy, electron interactions, isodoses, oblique inci-dence, skin dose, and electron dose measurement tech-niques.

2. the nature of treatment planning with electrons, includingsimple rules for selecting energy based on treatment depthand range, effect of field size, bolus, and field shaping (es-pecially for small fields), about field matching with pho-tons and other electron fields, internal shielding,backscatter, and the effects of inhomogeneities on elec-tron isodoses.

A. Basic characteristics

- Depth–dose characteristics

- Electron interactions

- Continuous slowing down approximation (CSDA)

and range

- Dose vs. depth

- Electron skin dose

- Isodoses

- Oblique incidence

B. Treatment planning with electrons

- Selection of energy, field size

- Bolus for surface buildup

- Bolus for depth–range compensation

- Field shaping

- Electron-electron matching

- Electron-photon matching

- Electron backscatter dosimetry

- Inhomogeneities

- Internal shielding

- External shielding (i.e, eye shields, bremmstrah-

lung production, energy and shielding material

thickness)

9. External Beam QA (2 Lectures)


1. the goals of a departmental QA program, the staffing re-quired to perform these QA activities, and the duties andresponsibilities of the individuals associated with the QAprogram.

2. what is entailed in making equipment selections in radi-ation therapy and the content of equipment specification.

3. what is involved in acceptance testing of a linac and incommissioning both a linac and a TP system.

4. what linac QA is required on a daily, monthly, andyearly basis and the acceptance tolerances associatedwith these tests.

A. Overview of QA in radiation therapy

- Goals, regulations

- Continuing quality improvement vs. QA

- Staffing

Roles, training, duties, and responsibilities of indi-

viduals

- Equipment specifications

- Error analysis and prevention

B. Linac and imaging QA

- Acceptance testing; linac

- Commissioning; linac

- Data required

- TP commissioning and QA

- Routine QA and test tolerance

Daily QA

Monthly QA

Yearly QA

- QA of imaging apparatus

Portal imagers

CT simulators

Conventional simulators

Processors

10. Informatics (1 Lecture)

Learning ObjectivesThe resident should learn:1. the various information systems and how they communi-

cate with imaging, planning, and delivery systems.2. methods of data transfer, storage, and security.

A. DICOM

B. PACS

C. Network integration and integrity

D. Storage and archival

E. Information system (IS) maintenance

F. Physics and information technology (IT) staff roles

11. Radiation Protection and Shielding (2 Lectures)

Learning ObjectivesThe resident should learn:1. the general concept of shielding, including ‘‘as low as rea-

sonably achievable’’ (ALARA) and federal regulations.2. the units of personnel exposure, sources of radiation

(man-made and natural), and means of calculating andmeasuring exposure for compliance with regulations.

3. components of a safety program, including NRC defini-tions and the role of a radiation safety committee.

A. Radiation safety

- Concepts and units

Radiation protection standards

Quality factors

Definitions for radiation protection


Dose equivalent

Effective dose equivalent

- Types of radiation exposure

Natural background radiation

Man-made radiation

National Council on Radiation Protection and

Measurements (NCRP) #91 Recommendations

on Exposure Limits

- Protection regulations

NRC definitions

Medical event

Authorized user

NRC administrative requirements

Radiation safety program

Radiation safety officer

Radiation safety committee

NRC regulatory requirements (including security)

Personnel monitoring

B. Radiation shielding

- Treatment room design

Controlled/uncontrolled areas

Types of barriers

Factors in shielding calculations

Workload (W)

Use factor (U)

Occupancy factor (T)

Distance

- Shielding calculations (including IMRT)

Primary radiation barrier

Scatter radiation barrier

Leakage radiation barrier

Neutron shielding for high-energy photon and

electron beams

- Sealed source storage

- Protection equipment and surveys

Operating principles of gas-filled detectors

Operating characteristics of radiation monitoring

equipment

Ionization chambers (Cutie Pie)

Geiger–Mueller counters

Neutron detectors

- Shielding requirements for conventional simula-

tors, CT simulators

- High dose-rate (HDR) unit shielding (linac vault

vs. dedicated bunker)

- Special procedure shielding (total body irradiation

[TBI])

12. Imaging for Radiation Oncology (4 Lectures)

Learning ObjectivesThe resident should learn:1. the principles and factors influencing radiograph in the

megavoltage (MV) and kilovoltage (kV) ranges.2. commonly used in-room imaging equipment technology

and its use.3. imaging technology and related physical principles for

treatment planning (CT, positron emission tomography[PET], and magnetic resonance imaging [MRI]).

4. nuclear medicine imaging applied to radiation oncology.5. image registration methods typically used to aid in treat-

ment planning.6. QA procedures to aid in successful integration of imaging

within radiation oncology.A. Radiography fundamentals

- Diagnostic imaging physical principles

Physical principles

Impact on quality

Systems

- Port film imaging

Film types and cassettes

- Electronic portal imaging

Overview of electronic portal imaging devices

Types of portal imaging devices

Clinical applications of electronic portal imaging

device [EPID] technology in daily practice

kV flat panel detectors

Room mounted systems

Gantry mounted systems

B. CT and PET

- CT

Principles of image formation (Hounsfield num-

bers, CT numbers, etc.)

Systems (large bore, small bore, single/multidetec-

tor, conebeam, and field of view [FOV])

Factors influencing image artifacts

Image quality

Dose

- PET

Principles of image formation

Detection

Reconstruction (brief)

Quantitative use of PET (standardized uptake

value [SUV])

Artifacts

C. MRI and ultrasound

- MRI scanning

Physical principles of image formation

Signal generation

Sources of contrast

Artifacts

Longitudinal relaxation time (T1), transverse

relaxation time (T2), time to echo (TE), time of

repetition (TR), imaging characteristics

Advantages and limitations of MRI

- Ultrasound

Physical principles of image formation

Systems (endorectal, volumetric, planar)

Utility in diagnosis and patient positioning

Artifacts and image distortion

D. Use of imaging in treatment planning

- Image registration

- Contrast agents

- Image fusion

Advantages

- Challenges


- Techniques

- Limitations (deformable body)

E. Hybrid systems (including single-photon emission

CT [SPECT])

- QA

Image transfer process

Imager QA

13. Three-dimensional Conformal Radiotherapy (3D-CRT),

Including International Commission on Radiation Units

and Measurements (ICRU) Concepts and Beam-Related

Biology (3 Lectures)

Learning ObjectivesThe resident should learn:1. the intended goals and technologies needed for planning

and delivering volumetric (3D-CRT) vs. nonvolumetricplanning.

2. the concepts associated with 3D-CRT planning, includinguniform vs. nonuniform tumor dose distributions, nonbio-logic and biologic models for computing dose–volumemetric.

3. the ICRU definitions and reporting recommendationsfor tumor-related volumes, such as gross tumor(GTV), clinical target (CTV), and planning target vol-umes (PTV).

4. the magnitudes, sources, and implications of day-to-daytreatment variabilities.

A. 3D-CRT concepts, volumetric (3D-CRT) vs. non-

volumetric

- Technology and methods for planning (volume-

based planning)

- Building patient models (image reconstruction and

segmentation)

- Virtual simulation

- Implications of treatment variabilities

Systematic and random setup variability, patient

breathing

ICRU Report 62 (Supplement to ICRU Report 50)

Contouring variability

B. Volumetric beam placement

- DRR generation

- Beam’s eye view (BEV), dose–volume histogram

(DVH)

- Noncoplanar beams

- Planning tools

Biologic implications of uniform vs. nonuniform

dose delivery

Nonbiologic and biologic dose–volume metrics

(DVHs, tumor control probabilities [TCPs], nor-

mal tissue complication probabilities [NTCPs])

Margins (PTVs, planning organ at risk volumes

[PRVs])

C. Treatment planning methods

- Beam selection

- 4D imaging and planning

- Dose reporting

- Volumetric vs. point prescriptions

14. Assessment of Patient Setup and Verification (2 Lec-

tures)

Learning ObjectivesThe resident should learn:1. the principles and devices currently associated with

patient positioning and immobilization.2. imaging methods applied in the treatment position for

localization of the target and critical structures beforetreatment.

3. use of in-room measurements for post-treatment adjust-ments.

4. the use of these resultant images and localization data forpotentially modifying the initial treatment plan throughan adaptive planning strategy.

A. Positioning and immobilization methods and devices

- Table coordinates, lasers, distance indicators

- Positioning options (calibrated frames, optical and

video guidance, etc.)

- Breathing maintenance

- Immobilization methods (thermoplastic masks,

bite blocks, etc.)

B. Treatment verification

- Image based

Radiographic

Cone-beam CT

Megavoltage CT (MVCT)

Internal markers (e.g., implanted fiducials)

- Non–image based

Ultrasound

Video imaging

Electromagnetic sources

On-line correction of setup errors

- Dosimetry based

Diodes

TLDs

Metal oxide semiconductor FET (MOFSET)

- Adaptive planning concepts

15. IMRT (3 Lectures)

Learning ObjectivesThe resident should learn:1. the details of the different delivery systems, including

advantages, differences, and limitations.2. the differences for simulation and positioning compared

with conventional therapy.3. the principles of forward and inverse planning and opti-

mization algorithms.4. the issues with inverse planning.5. systematic and patient-specific QA.

A. IMRT delivery systems

- Segmental (SMLC) and dynamic MLCs (DMLC)

- Serial tomotherapy (MIMiC)

- Helical tomotherapy

- Robotic linac

- Compensators

B. Dose prescription and inverse planning

- Discuss concept of PRVs


- Forward and inverse planning components

- Key components of planning system (optimization)

- Planning evaluation

Isodoses, DVH

Deliverability

Hot spots

C. IMRT QA

- Commissioning of planning and delivery

- Systematic QA

- Patient-specific QA tools and metrics

Chambers, film, EPID, Monte Carlo calculations

- Delivery QA

Record/verify

Machine treatment delivery records

16. Special Procedures (3 Lectures)

Learning ObjectivesThe resident should learn:1. the basis of stereotactic radiation therapy (SRT) delivery

and dosimetry.2. SRT, extracranial treatments, including immobilization

and localization systems.3. dosimetry of small-field irradiation, including stereotac-

tic radiosurgery (SRS) cones and micro/mini MLCs.4. TBI techniques and large-field dosimetry.5. Logistics and dosimetric considerations for total skin

electron therapy (TSET) and electron arc (e-arc).A. Delivery and positioning

- Stereotactic systems

Linac based

Gamma Knife

Robotic linac

Extracranial

- Positioning and immobilization

Frames

Extracranial SRT (ESRT)

Frameless

B. SRS dose prescription and planning, QA

- Prescriptions

- Dosimetry

Outputs

Profiles

- TP commissioning

- Delivery options

Arc therapy

MLC based

- QA

C. Other special procedures

- Photon TBI

Simulation

Patient setup (lateral, AP/AP, multifield: advan-

tages and disadvantages)

Dosimetry

Selection of energy, field size, distance, dose-rate

considerations

MU calculations

- TSET

- Electron arc

17. Brachytherapy (6 Lectures)


1. characteristics of the individual sources: half-life, pho-ton energy, half-value layer shielding, exposure rateconstant, and typical clinical use.

2. source strength units: activity, apparent activity, airkerma strength, exposure rate, equivalent of milli-gram-hours of radium, and National Institute of Stan-dards and Technology (NIST) standards for calibration.

3. the application of HDR vs. low dose-rate (LDR) in termsof alpha/beta ratios, fractionation, and dose equivalence.

4. specification and differences of linear and point sources.5. implant systems and related dosimetry.6. implantation techniques for surface and interstitial im-

plants regarding the sources used and how they are op-timized, especially for prostate and breast treatments.

7. dose calculations for temporary vs. permanent implants.8. uterine cervix applicators: Fletcher-Suit applicators

(tandem and ovoids), HDR applicators (tandem andovoids/ring), vaginal cylinders, and TP systems foreach applicator system.

9. cervix dosimetry conventions: milligram-hours, Man-chester system, bladder and rectum dose, and theICRU system (points A, B, and P).

10. radiation detectors used for calibration and patientsafety during implantations.

11. implant-loading specifics of dose rates, delivery devices,safety concerns, emergency procedures, and shieldingfor both patients and personnel.

12. discuss NRC and state regulations regarding use, stor-age, and shipping of sources.

13. QA and safety program development.A. Radioactive sources (general information) and cali-

bration

- Radium; disadvantages of radium, effect of source

casing

- Cesium 137

- Cobalt 60

- Iridium 192

- Gold 198

- Iodine 125

- Cesium 131

- Palladium 103

- Specification of source strength

- Linear sources

- Seeds

- Exposure rate calibration

B. Calculations of dose distributions

- Biologic considerations of dose, dose rate, and

fractionation

- Calculation of dose from a point source (AAPM

task group report number 43 [TG43])

- Calculation of dose from a line source

C. Implantation techniques

- Remote and manual

- Surface molds/plaques


- Interstitial therapy

Prostate brachytherapy

HDR vs. LDR treatments

Planning techniques

Uniform vs. peripheral

Breast brachytherapy

Single-catheter vs. multiple-catheter planning

D. Gynecologic implants

- General information (advantages/disadvantages)

- Remote afterloading units

- HDR vs. LDR

Intracavitary therapy

Uterine cervix

Milligram-hours

Manchester system

Bladder and rectum dose

ICRU system

Absorbed dose at reference points

Interstitial therapy

E. Systems of implant dosimetry

- Historic (Paterson-Parker)

- Computerized TP process and calculations

- Units, decay

- Applicators

- Limitations

- Imaging

F. QA and safety

- QA

Placement verification

Treatment planning accuracy

Applicator integrity

- Safety

Detectors

Regulatory requirements

Surveys

Inventory and wipe tests

Shipping and receiving

Source handling

18. Radiopharmaceutical Physics and Dosimetry (2 Lec-

tures)

Learning ObjectivesThe resident should learn:1. methods of radiopharmaceutical production.2. clinical treatments using internally administered radio-

isotopes.3. internal dosimetry.4. safety and regulations.

A. Methods of production and clinical treatments

- Reactor-produced isotopes

- Cyclotron-based production

- Radiochemistry basics

- Clinical treatments using internally administered

radioisotopes

Iodine treatment for thyroid

Radioimmunotherapy

Emerging treatments

B. Internal dosimetry and safety

- Dosimetry systems

- Compartmental models

- Medical Internal Radiation Dose (MIRD) Commit-

tee method

- Dose estimates for embryo/fetus and breast-feed-

ing infant

- Radiation safety

Equipment

Survey meters, sodium iodide (NaI) probes,

well counters, radionuclide calibrators

Instrument quality controls and checks

Safety procedures

Radiation protection, including internal protec-

tion, spill response, and decontamination, inpa-

tient and outpatient therapy precautions,

written directive, medical event, radioactive

package receipt, and area surveys/removable

contamination wipe tests

Regulations

19. Hyperthermia (1 lecture)

Learning ObjectivesThe resident should learn:1. basic physics of hyperthermia and how this applies clini-

cally.2. hyperthermia systems.3. thermometry.

A. Physics aspects of hyperthermia

- The bioheat equation and simplified solutions

- Specific absorption rate (SAR)

- Thermal aspects of blood flow/perfusion

B. External superficial electromagnetic hyperthermia

applicators

C. Interstitial electromagnetic hyperthermia applicators

D. Ultrasound hyperthermia systems

- Electromagnetic applicators for regional hyper-

thermia

- Thermometry performance criteria, tests, and arti-

facts

20. Particle Therapy (1 lecture)

Learning ObjectivesThe resident should learn:1. basic physics and safety of neutron and proton beams.2. configurations of proton and neutron delivery systems.3. treatment planning considerations for particle therapy.

A. Cyclotrons and synchrotrons

B. Protons

- Proton beam energy deposition; RBE

- Equipment for proton beam therapy

- Clinical proton beam dosimetry

Range modulation

Spot-scanning vs. passive scattering

Beam penumbra

- Clinical proton beam therapy

Treatment planning

C. Neutrons


- Fast vs. slow neutron production

- Boron neutron capture

Accelerator requirements

Clinical beam dosimetry; basic PDD curves for

neutron beams

D. Safety and shielding for protons and neutrons

Residency Training Program in Radiation Oncology

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