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2. Assessing and teaching radiotherapy contouring

Author

Duke, Simon L.

Subjects
WN Radiology. Diagnostic imaging
Abstract

Advanced radiotherapy techniques such as image-guided adaptive brachytherapy for cervical cancer improve local tumour control and reduce treatment toxicity. This benefit is critically dependent on radiotherapy targeting or "contouring" by oncologists. Numerous studies have shown considerable inter-observer contouring variation across all tumour sites, often measured in centimetres, suggesting that current methods of teaching contouring are ineffective. Moreover, assessing contouring competency is currently a subjective, time-consuming and onerous process. The aim of this programme of research is to investigate the assessment and teaching of radiotherapy contouring within an educational design research framework. The thesis reviews the limitations and challenges of current strategies to improve radiotherapy contouring and how insights from the educational literature such as cognitive load theory, deliberate practice theory, and best practices in assessment and feedback can inform and improve contouring assessment and teaching. Real-world data from two studies of online assessment and education for radiotherapy contouring, within an international clinical trial of advanced radiotherapy techniques for locally advanced cervical cancer, were analysed to substantiate the limitations of current approaches within a clinical trial setting. The thesis describes a novel low-fidelity radiotherapy contouring simulation tool developed to address some of the issues identified in the clinical studies. A detailed useability study was carried out in a small group of oncologists, which also yielded interesting insights into their clinical reasoning and self-regulation processes. The simulation was then used in three pilot studies of different types of learners (trainees and experts) and programmes (one-off workshops and longitudinal programmes) to explore its acceptability, useability and effectiveness. The thesis concludes by discussing possible approaches for the next iteration of software development and educational research, which could lead to meaningful change in the teaching and assessment of radiotherapy contouring.

Published
2021

5. Implementing an online radiotherapy quality assurance programme with supporting continuous medical education – report from the EMBRACE-II evaluation of cervix cancer IMRT contouring.

Author

Duke, Simon L., Tan, Li-Tee, Jensen, Nina B.K., Rumpold, Tamara, De Leeuw, Astrid A.C., Kirisits, Christian, Lindegaard, Jacob C., Tanderup, Kari, Pötter, Richard C., Nout, Remi A., and Jürgenliemk-Schulz, Ina M.

Subjects
*RADIOTHERAPY, *CANCER education, *CERVICAL cancer, *QUALITY assurance, *MEDICAL education, *CONTINUING medical education, *STUDENT engagement
Abstract

• Online RTQA with minimal data transfer is feasible and reduces manpower burden • Expert evaluation with qualitative feedback improved contouring compliance. • The Jaccard Conformity Index was not a reliable alternative to expert assessment. • Common delineation errors were identified which form the basis for ongoing education. • Strategies to improve engagement with educational content are needed. EMBRACE-II is an international prospective study of IMRT and MRI-guided adaptive brachytherapy (IGABT) in locally advanced cervix cancer. An online radiotherapy quality assurance (RTQA) programme with minimal data transfer and supporting continuing medical education (CME) was implemented for IMRT contouring. Participant contours for six volumes-of-interest (VOIs) on one benchmark case were scored (2 = excellent, 1 = fair, 0 = revision required) against a consensus reference contour. For contours receiving a 0 or 1 score, additional qualitative comments were provided. The Jaccard conformity index (JCI) was retrospectively calculated. User interaction with CME content (pre-accreditation questionnaire, contouring atlas, practice cases, quizzes, internal target volume (ITV-T) guide) was analysed. 78 clinicians submitted contours for evaluation. 41% passed at the first attempt, 44% after one revision and 6% after two or more revisions. 9% did not re-submit after failing. The lowest mean scores were for the elective nodal CTV (CTV-E) (1.01/2) and ITV-T (1.06/2). 60 different errors across the six VOIs were identified; five potentially had high impact on loco-regional control. A JCI cut-off of 0.7 would have identified 87% contours that failed expert assessment, but also excluded 54% of passing contours. 39 clinicians responded to the pre-accreditation questionnaire – 36% anticipated difficulties with the ITV-T and 13% with the CTV-E. 35% clinicians contoured on the practice cases, 17% answered a quiz, 96% used the atlas and 38% the ITV-T guide. Expert evaluation with qualitative feedback improved contouring compliance. The JCI is not a reliable alternative to expert assessment. Moderate uptake of optional CME content limited evaluation. [ABSTRACT FROM AUTHOR]

Published
2020
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6. Assessing and teaching radiotherapy contouring

Author

Duke, Simon L.

Abstract

Advanced radiotherapy techniques such as image-guided adaptive brachytherapy for cervical cancer improve local tumour control and reduce treatment toxicity. This benefit is critically dependent on radiotherapy targeting or “contouring” by oncologists. Numerous studies have shown considerable inter-observer contouring variation across all tumour sites, often measured in centimetres, suggesting that current methods of teaching contouring are ineffective. Moreover, assessing contouring competency is currently a subjective, time-consuming and onerous process.\ud \ud The aim of this programme of research is to investigate the assessment and teaching of radiotherapy contouring within an educational design research framework. The thesis reviews the limitations and challenges of current strategies to improve radiotherapy contouring and how insights from the educational literature such as cognitive load theory, deliberate practice theory, and best practices in assessment and feedback can inform and improve contouring assessment and teaching. Real-world data from two studies of online assessment and education for radiotherapy contouring, within an international clinical trial of advanced radiotherapy techniques for locally advanced cervical cancer, were analysed to substantiate the limitations of current approaches within a clinical trial setting. \ud \ud The thesis describes a novel low-fidelity radiotherapy contouring simulation tool developed to address some of the issues identified in the clinical studies. A detailed useability study was carried out in a small group of oncologists, which also yielded interesting insights into their clinical reasoning and self-regulation processes. The simulation was then used in three pilot studies of different types of learners (trainees and experts) and programmes (one-off workshops and longitudinal programmes) to explore its acceptability, useability and effectiveness.\ud \ud The thesis concludes by discussing possible approaches for the next iteration of software development and educational research, which could lead to meaningful change in the teaching and assessment of radiotherapy contouring.

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