Abstract
PURPOSE
To provide educational support to brachytherapy users during the COVID-19 pandemic, online workshops were developed and implemented by BrachyAcademy, non-profit peer-to-peer educational initiative in Elekta.
METHODS AND MATERIALS
In 2021–2022 two online workshops were organized. Participating teams had to send a clinical case of locally advanced cervical cancer (LACC) including brachytherapy Digital Imaging and Communications in Medicine (DICOM) files and questions to the faculty. During the workshop, feedback was given to each clinical case by five faculty members (two Radiation Oncologists, one Radiologist, two Medical Physicists). Participants competed a post-workshop questionnaire which included combination of qualitative and quantitative questions via yes/no responses, Likert scale, and 1 to 10 scale.
RESULTS
Twenty-one teams from eight countries (Europe, Asia, Latin America) participated in two online workshops. The total number of participants was 49. The clinical cases represented LACC with The International Federation of Gynecology and Obstetrics (FIGO) stages from IB3 to IVA. During both, Workshop1 (W1) and Workshop 2 (W2) the following areas of improvement were identified: familiarity with the GEC ESTRO and The International Commission on Radiation Units & Measurements, Report 89 (ICRU 89) recommendations for contouring and planning based on clinical drawings and MRI sequencing choice; appropriate applicator selection; experience with interstitial needles; appropriate applicator reconstruction; dose optimization. The participants rated both workshops with overall scores 8,3 for W1, and 8,5 for W2. In 82% participants the training course fully met expectations for W1, and in 76% in W2.
CONCLUSIONS
We successfully implemented the online workshops on image-guided adaptive brachytherapy (IGABT) in LACC. Main performance issues and areas for improvement were identified based on multidisciplinary discussion of participant's clinical cases through all steps of the brachytherapy procedure. We encourage teams to consider online workshops in addition to hands-on training.
Keywords
Introduction
Brachytherapy (BT), also known as interventional radiotherapy, plays a fundamental role in the management of locally advanced cervical cancer (LACC). Magnetic resonance imaging (MRI)-based image-guided adaptive brachytherapy (IGABT) is the established gold standard for brachytherapy in LACC. The clinical outcome of the prospective EMBRACE-I study was published in Lancet Oncology (
[1]
). Chemoradiotherapy and MRI-based IGABT resulted in 5-year local control 92% across all stages of LACC, with a limited grade 3–5 morbidity.Implementation of IGABT in cervical cancer is critically dependent on effective multidisciplinary education of all healthcare professionals involved in the brachytherapy treatment process (
[2]
). The current options for postgraduate education in brachytherapy are varied: teaching courses (e.g., ESTRO, ABS) (2
, 3
, 4
), simulation trainings based on mannequins or cadavers ([2]
,5
, 6
, 7
), contouring workshops ([2]
), dedicated on-site schools (8
, 9
), on-site teaching when observing and performing brachytherapy procedures (- Tagliaferri L
- Vavassori A
- Lancellotta V
- et al.
INTERACTS (INTErventional Radiotherapy ACtive Teaching School) consensus conference on sarcoma interventional radiotherapy (brachytherapy) endorsed by AIRO (Italian Association of Radiotherapy and Clinical Oncology).
J Contemp Brachytherapy. 2020; 12: 397-404
[3]
,[10]
), didactic lectures ([3]
,[10]
), fellowships with mentorship and coaching (2
, 3
, 4
,[11]
), annual meetings (e.g., GEC-ESTRO, ABS, ESTRO, ASTRO) ([2]
,[3]
), clinical trial participation (e.g., EMBRACE) ([2]
). BT education can be established as a national training curriculum: “300 in 10 initiative” in the USA ([4]
), “Area of Focused Competence in Brachytherapy” in Canada ([10]
), second-level university Master's degree or PhD programs in brachytherapy in Italy ([12]
).Industry also plays an important role in brachytherapy education. With a rapid growth of IGABT in LACC around the globe, companies started to receive numerous requests from customers for education. Typical product trainings on brachytherapy equipment couldn't cover educational needs for IGABT. Elekta organized 28 in-person peer-to-peer workshops at the Medical University of Vienna since 2008, and Varian organized nine workshops in Aarhus/Ljubljana since 2011 (
[2]
). During the 2-day workshops, practical and hands-on learning activities were offered to radiation oncologists and medical physicists: observation of a live patient case in operation theater, practice with applicators and mannequins, contouring and treatment planning exercises, and discussion of workflow issues. To support peer-to-peer education in brachytherapy, Elekta established the BrachyAcademy in 2013 and expanded brachytherapy educational activities to low- and middle-income countries ([4]
).The idea of online training in radiation oncology is not new. Contouring workshops, lectures and teaching courses, discussion of clinical cases with experts were organized in the past by different entities (
13
, 14
, 15
, 16
). Furthermore, the COVID-19 pandemic transformed educational programs in brachytherapy, forced to change curriculums, adopt new technologies and overcome obstacles to meet students’ needs ([17]
).BrachyAcademy wanted to provide educational support to brachytherapy users during the pandemic by keeping an interactive component as much as possible. Since the online format didn't allow to apply key elements of in-person workshops like live clinical case observation, hands-on training, or live contouring and treatment planning practice on demo workstations, the workshop faculty proposed an in-depth discussion of participants’ clinical cases instead. Key lectures from in-person BrachyAcademy workshops were kept in the online format.
This paper describes preparation, execution, and evaluation of two online BrachyAcademy workshops in 2021–2022. The purpose of the paper was to share our educational experience with the brachytherapy community, discuss lessons learned and find opportunities for possible implementation of online workshops in the future.
Methods and materials
Minimum two team members were required to participate in the online workshop from each hospital: a radiation oncologist/clinical oncologist (RO/CO) and a medical physicist (MP). Participants were required to have clinical experience with combined intracavitary/interstitial (IC/IS) IGABT in LACC. Each participating team was asked to send a case including applicator choice, contours and the actual plan. Each case was assessed individually by each faculty member and discussed online in order to identify main issues and recommendations for improvement. To satisfy the needs of participating teams, we encouraged them to send questions together with the clinical case. We limited the number of participating hospitals to 11. Each hospital could send one clinical case. Registrations were accepted on a first come, first served basis. There was a long waiting list after the first workshop in November 2021, therefore BrachyAcademy organized the second workshop with the same agenda in March 2022. Participants attended the online workshops free of charge as it was a pilot program.
The participants were asked to send a presentation of the clinical case in Microsoft PowerPoint format, together with questions to the faculty. A template was sent to homogenize the case presentation, the requested information for the case presentation is summarized in Table 1. In addition, participants were requested to send DICOM brachytherapy treatment files of the same patient including MRI or/and CT images, structures, and RT doses. All patient data should be anonymized. A deadline for sending the complete clinical case was 1 month before the Workshop 1 (W1), and 2 months before the Workshop 2 (W2). The files of clinical cases were collected and forwarded to the faculty in a bundle using the online transfer service (MediaFire, Shenandoah, TX). A demo workstation of the treatment planning system Oncentra Brachy (Elekta, Sweden) was used to review the treatment plans.
Table 1Template for clinical case presentation.
| Patient & tumor | Age |
| Local stage | |
| Stage L (Lymph nodes metastases) and M (Distant metastases) | |
| Histological type | |
| Initial clinical findings | Cervix: exophytic/endophytic tumor |
| Vagina: not involved/involved (detailed description) | |
| Parametria: Right: proximal/distal/pelvic wall involvement. Left: proximal/distal/pelvic wall involvement | |
| Initial clinical drawings | Sagittal, coronal, axial, speculum views (according to the GYN GEC-ESTRO recommendations) |
| Initial MRI findings | Para-sagittal, para-coronal, axial views |
| Initial MRI findings with measurements | Ellipsoid formula applied: V = width×thickness×height×0.5 |
| EBRT | EBRT technique, total dose, dose per fraction |
| Chemotherapy | Drug name, dose, # of cycles |
| Clinical findings at brachytherapy | Cervix: exophytic/endophytic tumor |
| Vagina: not involved/involved (detailed description) | |
| Parametria: Right: proximal/distal/pelvic wall involvement. Left: proximal/distal/pelvic wall involvement | |
| Clinical drawings before brachytherapy | Sagittal, coronal, axial, speculum views (according to the GYN GEC-ESTRO recommendations) |
| MRI findings after EBRT | Para-sagittal, para-coronal, axial views: compare with initial MRI findings |
| Applicator choice | Name of the applicator, characteristics, reason for choosing |
| Questions for the faculty |
GYN GEC-ESTRO = Gynaecology working group of the GEC-ESTRO; EBRT = External Beam Radiation Therapy.
The workshop agenda was reviewed by the faculty including 2 RO, 1 radiologist, 2 MP.
The workshop was conducted over 6 h (3 + 3 h) in two consecutive days, from 3 PM till 6 PM Central European Time zone. Each topic was led by one or two faculty members. The workshop program of the first day included: “Patient preparation, applicator choice and insertion”; “Imaging, image fusion, applicator reconstruction.” The second day was dedicated to: “Contouring and patient care”; “Treatment planning and optimization.” Duration of each of the four topics was 1.5 h. The teacher started a topic with a lecture, then analyzed each clinical case from the topic's perspective. Therefore, feedback was given to each clinical case by five faculty members. The workshop also included Q&A and discussion after each topic.
Kaltura Virtual Classroom (New York) was used as the online workshop platform. Participants received instructions for Kaltura prior to the workshop and asked to test their connection. Attendees could connect to the workshop platform individually or as a team. Kaltura features used: uploading files (Microsoft PowerPoint presentations, videos) prior to workshop and play them when needed during the workshop; desktop share function for demonstration of Oncentra Brachy and Picture Archiving and Communication System (PACS); quick polls; Q&A by chat or verbally through raising hand function; session recording (for quality assurance only; wasn't shared with participants).
Clinical cases were discussed in the presence of all workshop participants; therefore, the hospital names were anonymized. Each hospital received a number from one to 11, and only the hospital and the faculty knew the number.
Participants were asked to fill in post-course questionnaire and send it after the workshop. The questionnaire included combination of qualitative and quantitative questions which could be answered by yes/no, or ranked on a Likert scale, or 1 to 10 scale. Likert scale (very good – good – neutral – poor – very poor) was used to evaluate general impression about the workshop, course logistics, and course content. Scale 1 to 10 (where 10 is the highest score) was used to score the workshop. A copy of the post-course questionnaire is available online as a supplementary material.
Completion of the post-course questionnaire was mandatory prior to issue of course attendance certificate and workshop presentations in pdf format.
Results
In total, 21 hospitals participated in two workshops: W1–10 hospitals, W2–11 hospitals. Summed geographic distribution and corresponding number of hospitals for both workshops were: UK–9, Germany–3, Spain–3, Netherlands–2, Austria–1, Brazil 1, Guatemala–1, China–1. Total number of participants was 49: 23 RO/CO (47%), 22 MP (45%), and 4 radiation therapy technologists (8%).
Two teams from each workshop sent incomplete DICOM files (without imaging data, or structures, or RT doses), or there were technical issues (problems with anonymization of the plan file, incorrect data export or invalid links between DICOM objects). Those cases were impossible to be reviewed during the workshop, and those individuals were given feedback after the workshop.
The main characteristics of clinical cases discussed at both workshops are summarized in Table 2. The patients had LACC with FIGO stages from IB3 to IVA. All patients were treated by IGABT (MRI- or CT-based). Eight of 10 (80%) and six of 11 (55%) of clinical cases included IC/IS brachytherapy during W1 and W2, respectively; the rest intracavitary BT. Various BT applicators were used: Venezia, Geneva, Utrecht, Fletcher, Interstitial Ring CT/MR, Ring CT/MR, and three dimensional (3D) printed.
Table 2Clinical FIGO stage and characteristics of the type of brachytherapy performed on the submitted clinical cases at W1 and W2.
| Clinical cases W1 | FIGO stage | BT technique | Applicator | # of needles |
|---|---|---|---|---|
| 1 | IIB | IC | unknown | 0 |
| 2 | IB3 | IC/IS | Geneva | 6 |
| 3 | IIIA/IIIB | IC/IS | Venezia | 8 |
| 4 | IIIA | IC/IS | Interstitial Ring CT/MR | 3 |
| 5 | IIB | IC/IS | Utrecht | 6 |
| 6 | IIIC1 | IC/IS | Venezia | 4 |
| 7 | IIIC2/IVA | IC/IS | Utrecht | 3 |
| 8 | IIB | IC | Ring CT/MR | 0 |
| 9 | IIIB | IC/IS | Utrecht | 4 |
| 10 | IIB | IC/IS | Venezia | n/a |
| Clinical cases W2 | FIGO stage | BT technique | Applicator | # of needles |
| 1 | IIB | IC/IS | Venezia | 4 |
| 2 | IIIC | IC | Venezia | 0 |
| 3 | IIB | IC | Venezia | 0 |
| 4 | IIIA | IC/IS | 3D printed | n/a |
| 5 | IB3 | IC | Geneva | 0 |
| 6 | IB3 | IC/IS | Fletcher | 4–6 |
| 7 | IVA | IC/IS | Venezia, Interstitial Ring CT/MR | 4–6 |
| 8 | IIB | IC | Utrecht | 0 |
| 9 | IIB | IC | Ring CT/MR | 0 |
| 10 | IIIC1 | IC/IS | Venezia | 6–8 |
| 11 | IIIC1 | IC/IS | Venezia | 5 |
IC = intracavitary; IC/IS = combined intracavitary/interstitial; CT/MR = Computed Tomography/ Magnetic Resonance compatible; 3D = three dimensional.
We summarized the participant queries according to the workshop topics (Table 3). Most of the questions were dedicated to applicator choice and insertion, applicator reconstruction, dose optimization, and patient care. All questions were discussed during the workshops.
Table 3Most common questions of W1+W2 inquired by the participants.
| Workshop topic | Questions |
|---|---|
| Patient preparation, applicator choice and insertion |
|
| Imaging, image fusion, applicator reconstruction |
|
| Contouring and patient care |
|
| Treatment planning and optimization |
|
GTV = Gross Tumor Volume; OAR = Organ at Risk; BT = Brachytherapy.
The sections “Preparation, applicator choice and insertion” and “Contouring” featured a relatively broad spectrum of experience among the participants. In 30% of the successfully loaded cases in each workshop, the clinical drawings and the MRI sequencing choice at the time of diagnosis and prior to BT were inadequate. In terms of applicator type choice, most participants chose the correct assembly. In a couple of patients with vaginal involvement, a 3D printed applicator or an adapted Venezia was used. However, there were some recommendations for changes regarding the applicator insertion. The participants had difficulty in choosing the right length and angle of the intrauterine component and the right diameter of the intravaginal component of the applicator. In two cases in W2 an air gap between ring/ovoids and cervix was evident after insertion; this could be overcome by the right length of the tandem and diameter of the ring as such that the intravaginal component is adjacent to the cervix. The most obvious shortage in experience was related to the use of interstitial needles. 20% of the participants in W1 asked about external beam boost of the parametria as surrogate for dose escalation. In both workshops, almost half of the cases could benefit from interstitial needles, both straight and oblique in order to better cover the rest tumor extend (majority) or to spare the OARs Moreover, in two cases with parametrial involvement treated by intracavitary therapy only, interstitial needles would have been advantageous for dose coverage. The discussions during the workshop also highlighted the possibility to increase the therapeutic window between target and organ doses for cases with small CTV (<30 cm³), but unfavorable topography.
The section “Imaging, image fusion, applicator reconstruction” focused on the analysis of participants’ cases in three major aspects: reconstruction of the intracavitary applicator, reconstruction of interstitial needles, and overall image quality and applicator visibility. For the IC applicators, most centers who had already implemented the use of MRI for treatment planning used 3D applicator library models for reconstruction. Some centers with CT-only BT applied a manual reconstruction technique. Two major issues for discussion of basic concepts and caveats were encountered for both techniques in some submissions: (1) Applicator digitization on axial CT slices may lead to unrealistic shapes of the source path if not verified in 3D view after slice-by-slice reconstruction; and (2) vaginal packing may lead to wrong identification of applicator surface and consequential misplacement of the 3D applicator model. The use of CT or MR markers was also discussed. Concerning reconstruction of interstitial needles, some submissions revealed that there was a necessity to discuss about the starting point for needle digitization. The main question was to locate the external needle tip in relation to the internal first dwell position correctly on either MRI or CT. In this context, the use of individual MR sequences obtained in different orientations or 3D isotropic MR sequences was also discussed with participants. Finally, the recommendation to use as few digitization points as possible for straight needles, was demonstrated.
The section “Contouring and patient care” featured the scarcity of contouring in both workshops (W1 and W2), in which 60% of participants used CT imaging for planning. Both high-risk clinical target volume (HRCTV) and intermediate-risk clinical target volume (IRCTV) were contoured from seven of 10 participants in W1. Three of 4 participants using CT imaging for brachytherapy planning contoured a single volume, corresponding to HRCTV. In 6 of 11 cases (55%) a single tumor volume (HRCTV) was contoured also in W2 group. Many centers excluded the IRCTV; some using interstitial needles contoured the target according to the position of the needles and not based on the imaging and clinical examination at the time of BT.
The section “Treatment planning and optimization” highlighted two main recommendations for changes. First, issues in the definition of dose points, which resulted in deviations for the reported dose (e.g., point A dose reported as 7 Gy instead of 5 Gy). However, most issues were in the second step, which are optimization methods and their resulting loading patterns. In lack of a well-established published standard (“Treatment planning recommendations of GEC-ESTRO/IBS/ABS” are currently in preparation) it is difficult to report quantitative results. One important parameter was the distribution of total reference air-kerma (TRAK) between vaginal applicators (ring or ovoids), intrauterine applicators (tandem) and needles. Ratios of those values could be compared to larger cohorts (unpublished data from the EMBRACE studies) to identify outliers. For example, the use of >50% of the overall dwell time (TRAK) in needles for HRCTVs of <30 cm³ was discussed regarding the resulting spatial dose distribution. Spatial loading close to the vaginal mucosa or only few dwell positions with relative high dwell time in ovoids or needles resulting in hot spots were matter of discussion. A major issue was also the compromise between target dose and dose to organs at risk (OAR) based on presented dose and volume parameters.
The discussion of the individual cases didn't result in a binary good or bad result but triggered the need to discuss the issues of each case by the faculty.
The post-course questionnaire response rate was 88%: 22 of 25 for participants of W1, and 21 of 24 for W2. Table 4 shows responses of the workshops participants to quantitative questions using Likert scale.
Table 4Responses of W1 and W2 participants to quantitative questions in post-course questionnaire.
| Question group | Quantitative question | % of participants responded “very good” and “good” | |
|---|---|---|---|
| W1 | W2 | ||
| General impression | Scope of the topics covered | 90 | 100 |
| Presentation content is clear | 91 | 85 | |
| Length of the training | 91 | 86 | |
| Realization of learning objectives | 82 | 100 | |
| Logistics | Required information received on time | 100 | 95 |
| Organization of the course | 95 | 95 | |
| Course content | Patient preparation, applicator selection & insertion | 86 | 86 |
| Imaging, image fusion, applicator reconstruction | 91 | 90 | |
| Contouring, patient care | 55 | 81 | |
| Treatment planning and optimization | 100 | 86 | |
Relatively low rating of “Contouring and patient care” topic of W1 (55% of “very good” and “good” answers; other 45% responded “neutral,” no “poor” or “very poor” answers) can be explained by the workflow of this part of the training. With the intent to offer an interactive session, the teachers implemented an “on-line PACS view,” discussing each case with “live” contouring approach. Moreover, the teachers switched between PACS and Microsoft PowerPoint presentation when discussing each clinical case and provided remarks. The switching was distracting; therefore, we didn't use PACS and “live contouring” during the W2, where the rating of the same topic was much higher–81% versus 55%, and in line with evaluation of other sessions.
Overall, only one question for both workshops (“Patient preparation, applicator selection & insertion” at W2) received one answer “poor” (5%). This participant commented: “Too many cases presented leaving no time for meaningful discussion, maybe for virtual meeting it would work better selecting fewer cases.” There were no answers “very poor” to any quantitative questions for both workshops.
Participants provided with free-form responses to qualitative questions. Participants’ comments regarding both workshops are summarized in Table 5.
Table 5Summary of responses of workshops participants to qualitative questions in post-course questionnaire.
| Qualitative question | Comments and corresponding # of responders |
|---|---|
| Learning objectives have been met |
|
| Learning objectives haven't been met |
|
| Suggestions for improving the course content |
|
| Suggestions for improving the course organization |
|
| Subjects could be addressed in future training courses |
|
The participants rated both workshops very high. Scores for W1 and W2 were 8,3 and 8,5 on a scale from 1 to 10. We received “yes” to the question “Did the training course meet your expectations?” from 82% and 76% of participants, “partly” from 18% and 24% participants, and “no” from 0 participants for W1 and W2, respectively.
Discussion
In BT hands-on training is essential (
[3]
,5
, 6
, 7
,18
, 19
, 20
). Theoretical teaching could only partially replace on-site education ([3]
,[21]
); therefore, organization of online courses can be challenging. At the same time, virtual training has a big advantage: no travel costs. A recent survey from Poland concluded that lack of financial support was the most important factor preventing radiation oncologists from attending educational or clinical activities outside of home institution ([22]
). Other advantages of the online training are comfort to attend from home or workplace, interaction with teachers in real time ([16]
,[23]
). However, unawareness of availability of virtual training, resistance to new teaching methods prevented online courses from growing fast ([23]
). COVID pandemic facilitated this transition, and now online teaching is becoming an integral part in radiation oncology education, including brachytherapy. For instance, ESTRO teaching courses “Image-guided radiotherapy and chemotherapy in gynecological cancer” in 2020–2021 were conducted online ([24]
). Given the current travel restrictions, brachytherapy experts from the USA are developing virtual curricula for brachytherapy in cervical cancer which may prove to be a cost-effective alternative to in-person simulation-based training ([25]
).Post-course questionnaires after our workshops demonstrated high satisfaction of participants with the online course despite the lack of physical contact with the faculty. Another positive result was a large geographic spread of participating hospitals regardless of the different time zones (Latin America, Europe, Asia). These findings are in line with previously reported outcomes of online brachytherapy courses (
[24]
). Although some of participants stressed on necessity of organizing in-person workshops and hands-on training (which was precluded by the pandemic), in 82% participants the training course fully met expectations for W1, and in 76% for W2.Participants of both workshops liked to see and discuss clinical cases of other hospitals because they could get new ideas and compare their performance with others. Reports from the ESTRO GYN teaching courses confirmed a necessity of discussing challenges in the group, interaction with centers having similar issues in their clinical practice, benchmarking, and individualized systematic feedback (
[2]
,[24]
).Incorporating all steps of the brachytherapy procedure into the training program is important (
[18]
). There is an emphasis on contouring and treatment planning among current educational initiatives in IGABT, while other skills like applicator insertion, patient care and logistics get less attention. There is a misbelief that these skills will be achieved only with experience ([2]
). Taking this information into account, challenges during all steps of the brachytherapy procedure were discussed at our online workshops. Although Kaltura software allows break-out rooms, we wanted to keep RO and MP together to emphasize the necessity of the teamwork in brachytherapy. This approach was appreciated by most of the participants.Several authors reported lack of training for interstitial or hybrid gynecological brachytherapy and a need in addressing the brachytherapy training to more complicated, advanced cases (
[2]
,[5]
). A particular attention during our online workshops was given to hybrid brachytherapy in cervical cancer: 67% of all cases included IC/IS brachytherapy. Although the clinical IC/IS brachytherapy experience was a requirement to participate in the workshop, one third of teams sent IC cases for the review. We believe that participants would benefit from the online case discussion more if the level of the brachytherapy experience in the group is the same. We learned that we should make a stratification of the workshop participants into groups through a precourse questionnaire. This selection could allow to separate advanced brachytherapy users from the ones who just started gynecological brachytherapy and discuss topics and cases according to their experience. These types of webinars could benefit from a combination of pre and post course questionnaires. These could compare participants' skills, behavior, and understanding before and after the workshop, so the impact of the online learning could be quantified. We will consider implementing precourse questionnaire in future workshops.Disadvantages of online learning are: lack of physical interaction, inability to control the audience's environment, lack of kinesthetic learning, technical issues such as network interruptions, software incompatibility, and hardware malfunction (
[16]
,[23]
). During our online workshops we met some technical drawbacks and couldn't control the attention of the audience. With transfer of DICOM files we experienced the same problems as other groups ([26]
): institutional firewall for file transfers, possible inability to export the data in the proper format, different versions of software, discrepancies when performing anonymization. We learned from our workshops that we should provide to the participants detailed technical instructions regarding collection, anonymization, export of DICOM files.The faculty identified main areas for improvement in clinical cases presented at both workshops: issues with clinical drawings and the MRI sequencing choice, appropriate applicator selection; experience with interstitial needles; appropriate applicator reconstruction; dose optimization. Issues with clinical drawings and the MRI sequencing choice may be solved by learning of the GEC ESTRO and ICRU 89 recommendations (
27
, 28
, 29
), and by building an effective cooperation with radiologists ([30]
).Many participants asked for EBRT boost to parametria as a surrogate for IC/IS BT dose escalation. This has proven issues, including organ movement; increase in the volume of normal tissue irradiated to 60 Gy (
[31]
), therefore prone to more side effects. With the advent of IGABT, the use of interstitial needles allows a good distribution, which results in increased therapeutic ratio ([1]
,[32]
). There is an obvious need in teaching the practice of choosing the position and the length of the interstitial needles appropriately. This training can be done successfully in person, using simulation-based modules ([6]
,[33]
).The online workshops revealed that the participants mostly used CT for BT treatment planning, and many of them didn't contour IRCTV or/and contoured the target incorrectly. Contouring uncertainties were identified as the most important protocol deviations in the EMBRACE study dummy run (
[34]
). Our experience confirmed that the contouring discrepancies remain an important issue for IGABT. We hope that due to the recently published CT-based contouring recommendations ([35]
) these deficiencies would be overpassed. In addition to the contouring, appropriate applicator reconstruction was identified as an issue in presented clinical cases which correlates with earlier publications ([34]
,[36]
).There is a misconception about education that brachytherapy workshops would result in long-term changes in competency and behavior (
[2]
). Brachytherapy requires the continuous development of the program ([37]
). We consider an opportunity for both online and in-person educational activities in brachytherapy for LACC because they can address different needs and provide flexibility. Online discussion of clinical cases by multidisciplinary teams can be useful for brachytherapy users through the learning curve and should be carried out periodically. It is highly likely that the online training only is not sufficient for physicians and physicists at the beginning of IGABT implementation. However, we believe that it could be useful after gaining a solid clinical experience in IC brachytherapy (>10 cases), soon after starting IC/IS brachytherapy (3–5 cases), and after performing >10 IC/IS cases. Since learning efforts, performance issues and questions depend on the learning curve phase, it is important to organize workshops in homogenous groups. Online training cannot replace hands-on learning but could be suggested in 6–12 months as follow-up of a hands-on workshop in order to maintain and strengthen skills gained.Conclusion
We successfully implemented the online workshops on IGABT in LACC. Main performance issues and areas for improvement were identified based on in-depth multidisciplinary discussion of participant's clinical cases through all steps of the brachytherapy procedure. We encourage teams to consider online workshops in addition to hands-on training.
Appendix. Supplementary materials
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Article info
Publication history
Published online: February 22, 2023
Accepted:
January 21,
2023
Received in revised form:
January 17,
2023
Received:
October 20,
2022
Publication stage
In Press Corrected ProofFootnotes
Disclosures: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: AS, LR, LT, CK report educational grants from Elekta for teaching at the online workshops. Medical University of Vienna receives financial support for the EMBRACE study office from Elekta and Varian Medical Systems. ED works for Elekta; BrachyAcademy is a non-profit initiative in Elekta.
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© 2023 The Authors. Published by Elsevier Inc. on behalf of American Brachytherapy Society.
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