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Resident experience in brachytherapy: An analysis of Accreditation Council for Graduate Medical Education case logs for intracavitary and interstitial brachytherapy from 2007 to 2018
Brachytherapy
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(2019)
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Resident experience in brachytherapy: An analysis of Accreditation Council for Graduate Medical Education case logs for intracavitary and interstitial brachytherapy from 2007 to 2018 Ashwin Shinde1, Richard Li1, Arya Amini1, Neha Vapiwala2, Peter Orio III3, John A. Vargo4, Catheryn Yashar5, Yi-Jen Chen1, Sushil Beriwal4, Scott Glaser1,* 1
Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 2 Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA 3 Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, MA 4 Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA 5 Department of Radiation Oncology, University of California San Diego, La Jolla, CA
ABSTRACT
PURPOSE: We sought to characterize temporal trends of radiation oncology residentereported case experience with intracavitary brachytherapy (ICBT) and interstitial brachytherapy (ISBT). METHODS AND MATERIALS: Summarized, deidentified case logs for graduating radiation oncology residents (GRORs) between 2007 and 2018 were obtained from the Accreditation Council for Graduate Medical Education national summary data report. Cases were subdivided based on the site of treatment. Analysis of variance was used to determine differences, and strength of association was evaluated using the Pearson correlation. RESULTS: The number of GRORs increased by 66% from 114 in 2007 to 189 in 2018 ( p ! 0.001). Average number of gynecologic ICBT cases per GROR increased, from 39.6 in 2007 to 48.7 in 2018 ( p ! 0.005). Average number of ISBT cases per GROR decreased, from 34.5 to 20.6 ( p ! 0.001), due to decreasing prostate volume, from 21.5 to 12 ( p ! 0.001). Experience with gynecologic ISBT cases remained low at an average of 4.5 cases per year. CONCLUSIONS: The average number of ICBT cases per GROR has increased, although this does not differentiate between cylinder and tandem-based insertions currently. There has been a steady decline in ISBT experience. These findings may have implications for the development of Accreditation Council for Graduate Medical Education case minimums for residency programs. Ó 2019 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.
Keywords:
Brachytherapy; Resident; ACGME; Prostate; Gynecologic; Case logs; Exposure; Interstitial; Intracavitary
Introduction The use of brachytherapy (BT) in the management of multiple malignancies, especially for prostate and gynecologic cancers, is well established (1e3). Current radiation oncology residency minimum case requirements, set by
Received 1 August 2019; received in revised form 20 October 2019; accepted 23 October 2019. Disclosures: No funding was provided for this study. The authors report no conflicts of interest. * Corresponding author. Department of Radiation Oncology, City of Hope National Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010. Tel.: þ1 626-218-2247; fax: þ1 626-218-5334. E-mail address: [email protected] (S. Glaser).
the Accreditation Council for Graduate Medical Education (ACGME), specify that graduating radiation oncology residents (GRORs) must perform 15 intracavitary brachytherapy (ICBT) and five interstitial brachytherapy (ISBT) procedures to be eligible for graduation (4). As of April 2019, these minimums are being re-evaluated by the ACGME (5). Clinical use of BT is declining, with a reduced volume of both prostate and gynecologic BT use in more recent years (6e9). In cervical cancer, omission of BT leads to worse oncologic outcomes (8e10). In prostate cancer, adding prostate ISBT to external beam radiation therapy significantly increases biochemical progression-free survival in a randomized clinical trial (11) and may improve survival based on multiple retrospective series (12,13).
1538-4721/$ - see front matter Ó 2019 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.brachy.2019.10.006
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Recently, a survey of radiation oncology residents across the United States demonstrated concerns about sufficient caseload and confidence in GRORs to offer BT as part of their practice, especially ISBT (14). A previous publication demonstrated a 25% decrease in the average number of interstitial ISBT procedures between 2007 and 2011 (15). We conducted an analysis of resident case experience in ICBT and ISBT from 2007 to 2018. We sought to characterize temporal trends of GROR experience with both techniques with respect to various disease sites.
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survey, residents who performed 5 cases had either low or somewhat low confidence in starting a BT practice, whereas those with 15 or more cases had somewhat high or high confidence (14). For the purposes of prostate ISBT, low volume was defined as GRORs performing at least 5 cases, whereas high volume was defined as at least 15 cases performed. All statistical analyses were performed using SPSS statistical software (version 23.0; IBM Corporation, Armonk, NY). Given multiple comparisons were evaluated, a threshold alpha of 0.01 or less was chosen to determine statistical significance.
Methods and materials Analysis of ACGME case logs Summarized, deidentified case logs for all GRORs between the academic years of 2007 and 2018 were obtained from the ACGME. All data were obtained from the annual National Data Report prepared by the Department of Applications and Data Analysis at the ACGME. Residency programs can access these data through the ACGME case log website (https://apps.acgme.org/connect/), and we obtained approval to perform this analysis. Each report summarizes case log numbers per each graduating resident, aggregated in a cumulative fashion over the total duration of their residency training. Values are primarily reported as mean and standard deviations. In addition, the 10th, 30th, 50th, 70th, and 90th percentile values are reported for each variable collected. All reports are deidentified and aggregated, meaning that no individual resident or training program can be identified. The present analysis focuses on resident BT experience, including both ICBT and ISBT. ICBT within the case logs was split into cervix/uterus, intraluminal, and other; categories were stratified by low-dose rate (LDR) or highdose rate (HDR). For the purposes of this study, the gynecologic subsite for ICBT was of primary interest, as most ICBT is gynecologic in nature, either as cylinder or tandem-based insertions. The case logs report on a variety of subsites for ISBT, including breast, soft tissue sarcoma, head and neck, prostate, gynecologic/pelvis, and other, including stratification for LDR or HDR. For the purposes of this study, subcategories of ISBT for prostate, gynecologic, and other (encompassing all other body sites) were evaluated. Statistical analysis Our primary analysis was the mean number of cases per graduating resident by academic year, evaluated for the entire population and subgroups. Logistic regression was used to determine statistical significance, and strength of association was evaluated using Pearson correlation coefficient. Additional supplementary analyses were performed analyzing the 10th, 30th, 50th, 70th, and 90th percentile of case numbers among GRORs. In a previous resident
Results There was an increase in the number of GRORs per year, from 114 in 2007 to 189 in 2018 (r 5 0.88; p ! 0.001). Similarly, there was an increase in the total number of residency programs, from 64 in 2007 to 87 in 2018 (r 5 0.92; p ! 0.001). There was a global increase in the total number of ICBT procedures with resident participation increasing from 5278 in 2007 to 9904 in 2018 (r 5 0.87; p ! 0.001). The average number of ICBT procedures per GROR increased nonsignificantly from 46.3 in 2007 to 52.4 in 2018 (r 5 0.62; p 5 0.038; Fig. 1), driven by a statistically significant increase in gynecologic ICBT from 39.6 in 2007 to 48.7 in 2018 (r 5 0.75; p 5 0.005; Fig. 1). ISBT experience The total number of ISBT procedures in which residents participated nationwide did not significantly change over this period, from 3933 in 2007 to 3893 in 2018 (r 5 0.53; p 5 0.077). The average number of ISBT cases per resident, across all disease sites, significantly decreased from 34.5 in 2007 to 20.6 in 2018 (r 5 0.92; p ! 0.001; Fig. 2). When evaluating only prostate ISBT, there was a decrease from an average of 21.5 cases per GROR in 2007 to 12 in 2018 (r 5 0.94; p 5 0.001; Fig. 3). During this time, LDR prostate ISBT experience decreased from an average of 19.4 cases per GROR in 2007 to 7.4 in 2018 (r 5 0.97; p 5 0.001; Fig. 3), whereas HDR prostate ISBT experience slightly increased from an average of 2.1 cases per GROR in 2007 to 4.6 in 2018 (r 5 0.72; p 5 0.009; Fig. 3). When evaluating only gynecologic ISBT, there was no significant change in cases per GROR, from 4.7 in 2007 to 4.5 in 2018 (r 5 0.11; p 5 0.724). When evaluating only ISBT in other (nongynecologic and nonprostate) locations, there was a slight decrease from an average of 1.1 cases per GROR in 2007 to 0.5 cases per GROR in 2018 (r 5 0.90; p ! 0.001). For all ISBT procedures, the lowest 10th percentile of GRORs had 10 cases in 2007. By 2018, this number had
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Fig. 1. Average case volume per graduating radiation oncology resident in intracavitary brachytherapy.
decreased to 6 cases. Similar decreases in experience by percentile were seen in the 30th (17 in 2007 to 10 in 2018), 50th (25 in 2007 to 15 in 2018), 70th (39 in 2007 to 24 in 2018), and 90th (79 in 2007 to 44 in 2018) percentile (Fig. 4A). When evaluating solely prostate ISBT, similar decreases in cases required for a certain percentile over the study period were identified: 10th (2 in 2007 to 0 in 2018), 30th (9 in 2007 to two in 2018), 50th (14 in 2007 to four in 2018), 70th (21 in 2007 to 11 in 2018), 90th (43 in
2007 to 32 in 2018; Fig. 4B). At least 70% of GRORs achieved a low volume of cases ($5) between 2007 and 2011. However, from 2015 to 2018, only 50% of GRORs met low-volume requirements. High volume ($15) was achieved by nearly 50% of GRORs in 2007 but decreased to 30% by 2011 and roughly 20% in 2018. For gynecologic ISBT, the median number of cases per GROR has remained stably low from 2007 to 2018, with 0e2 cases per GROR representing the 50th percentile. The lower 30th percentile of GRORs had no gynecologic interstitial cases performed from 2007 to 2018. The 70th percentile has ranged from 2 to 6 cases, whereas the 90th percentile ranged from 5 to 11 cases. Excepting 2007 and 2016, the 90th percentile of GRORs graduated with !10 gynecologic ISBT cases.
Discussion
Fig. 2. Average case volume per graduating radiation oncology resident in interstitial brachytherapy.
This study shows the temporal trends in BT experience for GRORs over the past 12 years and is the first to evaluate ICBT experience per GROR, showing primarily an increase in gynecologic ICBT. This is supported by a registry study showing stable volumes of cervical cancer at academic institutions (16). The increase in GROR ICBT volume may be driven by randomized trial results demonstrating oncologic safety and improved toxicity of replacing pelvic external beam radiation therapy with vaginal BT for early
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Fig. 3. Average case volume per graduating radiation oncology resident in prostate interstitial brachytherapy.
stage, high intermediate-risk endometrial cancer, leading to an increase of ICBT utilization (17e19). However, another more likely reason for an increase in the number of cases could be because of a transition from LDR ICBT, where one implant is common, to HDR ICBT, where four to five fractions is common for tandem-based insertions, and two to five insertions for cylinder-based insertions. Although this does allow for greater experience with the technical aspect of physically placing a tandem or cylinder, it likely means that the number of unique patients being treated has gone down, potentially negatively affecting a GROR’s ability for individual patient evaluation, case selection, and experience with unique or difficult anatomy. A significant point of uncertainty within these data is the lack of distinction between tandem-based ICBT, which is required for the definitive management of cervical cancer, and cylinder-based treatment frequently used as adjuvant therapy for endometrial cancer. Currently, ICBT includes both cylinder- and tandem-based insertion, and it is conceivable that GRORs could meet current requirements without ever performing tandem-based BT. A recent ACGME proposal plans to address this concern, with requirement of at least five tandem placements, across 2 patients, toward the count of 15 ICBT procedures. In addition, ACGME will mandate that no more than five of the required 15 ICBT procedures should be cylinder insertions (5). Assuming that no other forms of ICBT besides cylinder and tandem-based ICBT are performed by GRORs, this seems to mandate at least 10 tandem insertions for every GROR going forward. Theoretically, this mandates that a resident treat at least 2 patients, assuming a common cervical HDR BT fractionation scheme of 6 Gy 5, before graduating residency.
Although this change is at least a step in the right direction, the mandated minimum number is not high enough to ensure any minimum level of competence or comfort with BT as part of a GROR’s practice as an attending. This study also reinforces the conclusions of the one previous study evaluating ACGME case logs for ISBT, which reported from 2007 to 2011, showing a 25% decrease in ISBT volume (15). From 2011 to 2018, experience in ISBT has decreased by another 20%, for a total 40% decrease from 2007 compared to 2018. This decrease in ISBT is driven by a near 50% decrease in experience in prostate ISBT for an average GROR between 2007 and 2018. The total number of prostate ISBT cases with resident involvement nationally has remained stable; however, because of a 65% increase in the number of yearly GRORs between 2007 and 2018, the average case volume per GROR has decreased sharply. There has been a slight increase in the use of HDR prostate ISBT recently, but HDR increase has not been sufficient or widespread enough to offset the decrease in LDR prostate ISBT. Although the recently published ASCENDE-RT trial may generate greater prostate ISBT experience in the future, factors that may continuing to diminish prostate ISBT volume include increasing use of active surveillance for low-risk disease, radical prostatectomy for intermediate and high-risk disease, and prostate stereotactic body radiation therapy as a noninvasive modality for low- and intermediate-risk disease (20e22). Gynecologic ISBT experience has remained minimal throughout the study period, with at least 30% of GRORs never having performed a traditional gynecologic ISBT implant. However, it is unclear whether GRORs are logging hybrid intracavitary/interstitial applicators, such as the
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Fig. 4. Case requirement thresholds for various percentiles in (A) all interstitial brachytherapy and (B) prostate-only interstitial brachytherapy.
Vienna or Venezia, as ISBT procedures. Gynecologic ISBT, although an important tool, may not be necessary at every institution throughout the United States. However, appropriately selected patients derive significant benefit from this modality, and familiarity with the procedure is of importance for all GROR. The low number of gynecologic ISBT cases performed by GRORs raises concerns regarding patients receiving an optimal treatment course regardless of their extent of disease. Recently, the ACGME has proposed a change to increase the requirement of total ISBT cases from 5 to 7 (5). The issue of not having site-specific minimums in BT means that a GROR can perform seven prostate ISBT implants and have never seen an advanced
cervical cancer requiring a full interstitial implant. That GROR could then be asked to do a full Syed template as an attending. Until the case minimums are radically increased, the idea of competence being derived by those doing the current minimums is essentially impossible. The largest driving factor of the decrease in ISBT experience is dilution of the resident experiencedalthough the number of cases for which there has been resident coverage has remained similar over the study period, there has been an explosion of residency expansion over the past decade. With stable usage and more residents, average numbers are bound to drop. If ISBT is felt to be an important skill for all US GRORs to possess, a primary solution may be
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not only an immediate halting of all residency expansion but also a true contraction of the number of residency spots offered throughout the country. Residency expansion, in addition to dilution of ISBT experience, has led to concerns about an oversupply and diminished job prospects (23,24). The issue of whether new attendings are competent to practice independently is an issue in fields besides just procedural radiation oncology. There have been multiple publications in subspecialties of general surgery questioning the capabilities of newer graduates based on case logs (25e27). However, the robustness of how surgeons use case logs to evaluate competence is multitudes stronger than what radiation oncology currently has, and a valid comparison of how ACGME case logs compare to competence is premature. For example, general surgery has a long list of site-specific minimums that must be met before being eligible for residency graduation (28). The minimum requirements for procedural aspects of radiation oncology are so low that competence at completion of residency by someone who has only done the minimum number of cases is unlikely. The ideal case log minimum so as to provide a potential to reach competence has not been well established, and although there is some interest into simulation-based training (29e31), the only true way of assessing competence for GRORs would be to have simulation-based competency assessments that would be factored into assessing board certification, potentially as part of the current oral boards. However, use of BT is not common among the majority of radiation oncology attendings, and thus, oral boards would ideally be moved to immediately after residency so as to avoid significant testing on a modality that is not commonly used. Our study does have several limitations; the primary one is that case logs are self-reported and may be subject to reporting bias. Previous publications have demonstrated a 75e80% rate of accurate logging for surgical residents (32,33). Evaluation of ACGME case log accuracy in radiation oncology does not provide definitive evidence of systematic under- or over-logging of cases (34). These statistics only reflect on residents having logged the cases as performed; they do not contain any information about the quality of learning experience. Another limitation is that we may not be able to assure the assumptions required for linear regression, given we only had access to the summarized data, without the raw data. Despite these limitations, we believe this study offers value in updating previously reported trends in resident case experience in BT (15). In conclusion, we report a summary of resident-reported experience with BT. We found a slight increase in ICBT cases per GROR over time, mostly driven by an increase in gynecologic ICBT. However, this number does not differentiate between cylinder and tandem-based ICBT. We found a persistent decrease in ISBT volume per GROR, driven by decreasing experience in prostate ISBT. Gynecologic ISBT volume has been low for over the entire study
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period. These findings may have implications for the development of significantly ACGME case minimums for residency programs in the future. References [1] NCCN. NCCN Guidelines: Prostate Cancer 2018. Available at: https://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf. Accessed March 4, 2019. [2] NCCN. Uterine Neoplasms. Pract Guidel Oncol 2018;1e48. [3] Bradley K, Crispens MA, Frederick P. NCCN Guidelines: Cervical Cancer 2018. Available at: https://www.nccn.org/professionals/ physician_gls/pdf/cervical.pdf. Accessed March 4, 2019. [4] Common Program Requirements, Radiation Oncology. Effective July 1. Chicago, IL: Accreditation Council for Graduate Medical Education; 2017.. Accessed April 3, 2019. [5] ACGME Program Requirements for Graduate Medical Education in Radiation Oncology. Summary and impact of focused requirement revisions 2019. Available at: https://www.acgme.org/Portals/ 0/PFAssets/ProgramResources/RadiationOncology_Summary_PRChanges2019.pdf?ver52019-08-26-120824-023. Accessed March 4, 2019. [6] Orio PF, Nguyen PL, Buzurovic I, et al. The decreased use of brachytherapy boost for intermediate and high-risk prostate cancer despite evidence supporting its effectiveness. Brachytherapy 2016; 15:701e706. [7] Orio PF, Nguyen PL, Buzurovic I, et al. Prostate brachytherapy case volumes by academic and nonacademic practices: implications for future residency training. Int J Radiat Oncol 2016;96:624e628. [8] Gill BS, Lin JF, Krivak TC, et al. National cancer data base analysis of radiation therapy consolidation modality for cervical cancer: the impact of new technological advancements. Int J Radiat Oncol 2014;90:1083e1090. [9] Mayadev J, Klapheke A, Yashar C, et al. Underutilization of brachytherapy and disparities in survival for patients with cervical cancer in California. Gynecol Oncol 2018;150:73e78. [10] Robin TP, Amini A, Schefter TE, et al. Disparities in standard of care treatment and associated survival decrement in patients with locally advanced cervical cancer. Gynecol Oncol 2016;143:319e 325. [11] Morris WJ, Tyldesley S, Rodda S, et al. Androgen Suppression Combined with Elective Nodal and dose Escalated Radiation Therapy (the ASCENDE-RT trial): an analysis of survival endpoints for a randomized trial comparing a low-dose-rate brachytherapy boost to a dose-escalated external beam boost for high- and intermediate-risk prostate cancer. Int J Radiat Oncol 2017;98: 275e285. [12] Kishan AU, Cook RR, Ciezki JP, et al. Radical prostatectomy, external beam radiotherapy, or external beam radiotherapy with brachytherapy boost and disease progression and mortality in patients with Gleason score 9-10 prostate cancer. JAMA 2018;319:896. [13] Johnson SB, Lester-Coll NH, Kelly JR, et al. Brachytherapy boost utilization and survival in unfavorable-risk prostate cancer. Eur Urol 2017;72:738e744. [14] Marcrom SR, Kahn JM, Colbert LE, et al. Brachytherapy training survey of radiation oncology residents. Int J Radiat Oncol 2019; 103:557e560. [15] Compton JJ, Gaspar LE, Shrieve DC, et al. Resident-reported brachytherapy experience in ACGME-accredited radiation oncology training programs. Brachytherapy 2013;12:622e627. [16] Trifiletti DM, Grover S, Libby B, et al. Trends in cervical cancer brachytherapy volume suggest case volume is not the primary driver of poor compliance rates with brachytherapy delivery for locally advanced cervical cancer. Brachytherapy 2017;16:547e551. [17] Nout RA, Putter H, J€urgenliemk-Schulz IM, et al. Quality of life after pelvic radiotherapy or vaginal brachytherapy for endometrial
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[18]
[19]
[20]
[21] [22]
[23]
[24]
[25]
cancer: first results of the randomized PORTEC-2 trial. J Clin Oncol 2009;27:3547e3556. Nout R, Smit V, Putter H, et al. Vaginal brachytherapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high-intermediate risk (PORTEC-2): an open-label, non-inferiority, randomised trial. Lancet 2010;375:816e823. Zavitsanos PJ, Leonard KL. Patterns of care in women with highintermediate risk endometrioid adenocarcinoma in the PORTEC-2 era: a SEER database analysis. Brachytherapy 2017;16:109e115. Weiner J P, Schwartz D, Shao M, et al. Stereotactic radiotherapy of the prostate: fractionation and utilization in the United States. Radiat Oncol J 2017;35:137e143. Chung BH. The role of radical prostatectomy in high-risk prostate cancer. Prostate Int 2013;1:95. Kinsella N, Helleman J, Bruinsma S, et al. Active surveillance for prostate cancer: a systematic review of contemporary worldwide practices. Transl Androl Urol 2018;7:83e97. Sura K, Lischalk JW, Grills IS, et al. Modern perspectives on radiation oncology residency expansion, fellowship evolution, and employment satisfaction. J Am Coll Radiol 2019;16:749e753. Pan HY, Haffty BG, Falit BP, et al. Supply and demand for radiation oncology in the United States: updated projections for 2015 to 2025. Int J Radiat Oncol Biol Phys 2016;96:493e500. Larson KE, Grobmyer SR, Reschke MAB, et al. Fifteen-year decrease in general surgery resident breast operative experience: are we training proficient breast surgeons? J Surg Educ 2018;75: 247e253.
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[26] Potts JR, Valentine RJ. Declining resident experience in open vascular operations threatens the status of vascular surgery as an essential content area of general surgery training. Ann Surg 2018; 268:665e673. [27] Park CJ, Armenia SJ, Cowles RA. Trends in routine and complex hepatobiliary surgery among general and pediatric surgical residents: what is the next generation learning and is it enough? J Surg Educ 2019;76:1005e1014. [28] ACGME. Defined category minimum numbers for general surgery residents and credit role 2018. [29] Singer L, Damast S, Lin L, et al. Development of a MultiInstitutional simulation-based gynecologic brachytherapy Curriculum. Int J Radiat Oncol Biol Phys 2019;104:1175e1176. [30] Zhao S, Francis L, Todor D, Fields EC. Proficiency-based cervical cancer brachytherapy training. Brachytherapy 2018;17:653e659. [31] Thaker NG, Kudchadker RJ, Swanson DA, et al. Establishing highquality prostate brachytherapy using a phantom simulator training program. Int J Radiat Oncol Biol Phys 2014;90:579e586. [32] McPheeters MJ, Talcott RD, Hubbard ME, et al. Assessing the accuracy of neurological surgery resident case logs at a single institution. Surg Neurol Int 2017;8:206. [33] Nygaard RM, Daly SR, Van Camp JM. General surgery resident case logs: do they accurately reflect resident experience? J Surg Educ 2015;72:e178ee183. [34] Cordero F, Cardan RA, Popple RA, et al. Single institution analysis of case-logging accuracy and compliance by residents. Int J Radiat Oncol 2017;99:E121eE122.
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Resident experience in brachytherapy: An analysis of Accreditation Council for Graduate Medical Education case logs for intracavitary and interstitial brachytherapy from 2007 to 2018 Ashwin Shinde1, Richard Li1, Arya Amini1, Neha Vapiwala2, Peter Orio III3, John A. Vargo4, Catheryn Yashar5, Yi-Jen Chen1, Sushil Beriwal4, Scott Glaser1,* 1
Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 2 Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA 3 Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, MA 4 Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA 5 Department of Radiation Oncology, University of California San Diego, La Jolla, CA
ABSTRACT
PURPOSE: We sought to characterize temporal trends of radiation oncology residentereported case experience with intracavitary brachytherapy (ICBT) and interstitial brachytherapy (ISBT). METHODS AND MATERIALS: Summarized, deidentified case logs for graduating radiation oncology residents (GRORs) between 2007 and 2018 were obtained from the Accreditation Council for Graduate Medical Education national summary data report. Cases were subdivided based on the site of treatment. Analysis of variance was used to determine differences, and strength of association was evaluated using the Pearson correlation. RESULTS: The number of GRORs increased by 66% from 114 in 2007 to 189 in 2018 ( p ! 0.001). Average number of gynecologic ICBT cases per GROR increased, from 39.6 in 2007 to 48.7 in 2018 ( p ! 0.005). Average number of ISBT cases per GROR decreased, from 34.5 to 20.6 ( p ! 0.001), due to decreasing prostate volume, from 21.5 to 12 ( p ! 0.001). Experience with gynecologic ISBT cases remained low at an average of 4.5 cases per year. CONCLUSIONS: The average number of ICBT cases per GROR has increased, although this does not differentiate between cylinder and tandem-based insertions currently. There has been a steady decline in ISBT experience. These findings may have implications for the development of Accreditation Council for Graduate Medical Education case minimums for residency programs. Ó 2019 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.
Keywords:
Brachytherapy; Resident; ACGME; Prostate; Gynecologic; Case logs; Exposure; Interstitial; Intracavitary
Introduction The use of brachytherapy (BT) in the management of multiple malignancies, especially for prostate and gynecologic cancers, is well established (1e3). Current radiation oncology residency minimum case requirements, set by
Received 1 August 2019; received in revised form 20 October 2019; accepted 23 October 2019. Disclosures: No funding was provided for this study. The authors report no conflicts of interest. * Corresponding author. Department of Radiation Oncology, City of Hope National Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010. Tel.: þ1 626-218-2247; fax: þ1 626-218-5334. E-mail address: [email protected] (S. Glaser).
the Accreditation Council for Graduate Medical Education (ACGME), specify that graduating radiation oncology residents (GRORs) must perform 15 intracavitary brachytherapy (ICBT) and five interstitial brachytherapy (ISBT) procedures to be eligible for graduation (4). As of April 2019, these minimums are being re-evaluated by the ACGME (5). Clinical use of BT is declining, with a reduced volume of both prostate and gynecologic BT use in more recent years (6e9). In cervical cancer, omission of BT leads to worse oncologic outcomes (8e10). In prostate cancer, adding prostate ISBT to external beam radiation therapy significantly increases biochemical progression-free survival in a randomized clinical trial (11) and may improve survival based on multiple retrospective series (12,13).
1538-4721/$ - see front matter Ó 2019 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.brachy.2019.10.006
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Recently, a survey of radiation oncology residents across the United States demonstrated concerns about sufficient caseload and confidence in GRORs to offer BT as part of their practice, especially ISBT (14). A previous publication demonstrated a 25% decrease in the average number of interstitial ISBT procedures between 2007 and 2011 (15). We conducted an analysis of resident case experience in ICBT and ISBT from 2007 to 2018. We sought to characterize temporal trends of GROR experience with both techniques with respect to various disease sites.
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survey, residents who performed 5 cases had either low or somewhat low confidence in starting a BT practice, whereas those with 15 or more cases had somewhat high or high confidence (14). For the purposes of prostate ISBT, low volume was defined as GRORs performing at least 5 cases, whereas high volume was defined as at least 15 cases performed. All statistical analyses were performed using SPSS statistical software (version 23.0; IBM Corporation, Armonk, NY). Given multiple comparisons were evaluated, a threshold alpha of 0.01 or less was chosen to determine statistical significance.
Methods and materials Analysis of ACGME case logs Summarized, deidentified case logs for all GRORs between the academic years of 2007 and 2018 were obtained from the ACGME. All data were obtained from the annual National Data Report prepared by the Department of Applications and Data Analysis at the ACGME. Residency programs can access these data through the ACGME case log website (https://apps.acgme.org/connect/), and we obtained approval to perform this analysis. Each report summarizes case log numbers per each graduating resident, aggregated in a cumulative fashion over the total duration of their residency training. Values are primarily reported as mean and standard deviations. In addition, the 10th, 30th, 50th, 70th, and 90th percentile values are reported for each variable collected. All reports are deidentified and aggregated, meaning that no individual resident or training program can be identified. The present analysis focuses on resident BT experience, including both ICBT and ISBT. ICBT within the case logs was split into cervix/uterus, intraluminal, and other; categories were stratified by low-dose rate (LDR) or highdose rate (HDR). For the purposes of this study, the gynecologic subsite for ICBT was of primary interest, as most ICBT is gynecologic in nature, either as cylinder or tandem-based insertions. The case logs report on a variety of subsites for ISBT, including breast, soft tissue sarcoma, head and neck, prostate, gynecologic/pelvis, and other, including stratification for LDR or HDR. For the purposes of this study, subcategories of ISBT for prostate, gynecologic, and other (encompassing all other body sites) were evaluated. Statistical analysis Our primary analysis was the mean number of cases per graduating resident by academic year, evaluated for the entire population and subgroups. Logistic regression was used to determine statistical significance, and strength of association was evaluated using Pearson correlation coefficient. Additional supplementary analyses were performed analyzing the 10th, 30th, 50th, 70th, and 90th percentile of case numbers among GRORs. In a previous resident
Results There was an increase in the number of GRORs per year, from 114 in 2007 to 189 in 2018 (r 5 0.88; p ! 0.001). Similarly, there was an increase in the total number of residency programs, from 64 in 2007 to 87 in 2018 (r 5 0.92; p ! 0.001). There was a global increase in the total number of ICBT procedures with resident participation increasing from 5278 in 2007 to 9904 in 2018 (r 5 0.87; p ! 0.001). The average number of ICBT procedures per GROR increased nonsignificantly from 46.3 in 2007 to 52.4 in 2018 (r 5 0.62; p 5 0.038; Fig. 1), driven by a statistically significant increase in gynecologic ICBT from 39.6 in 2007 to 48.7 in 2018 (r 5 0.75; p 5 0.005; Fig. 1). ISBT experience The total number of ISBT procedures in which residents participated nationwide did not significantly change over this period, from 3933 in 2007 to 3893 in 2018 (r 5 0.53; p 5 0.077). The average number of ISBT cases per resident, across all disease sites, significantly decreased from 34.5 in 2007 to 20.6 in 2018 (r 5 0.92; p ! 0.001; Fig. 2). When evaluating only prostate ISBT, there was a decrease from an average of 21.5 cases per GROR in 2007 to 12 in 2018 (r 5 0.94; p 5 0.001; Fig. 3). During this time, LDR prostate ISBT experience decreased from an average of 19.4 cases per GROR in 2007 to 7.4 in 2018 (r 5 0.97; p 5 0.001; Fig. 3), whereas HDR prostate ISBT experience slightly increased from an average of 2.1 cases per GROR in 2007 to 4.6 in 2018 (r 5 0.72; p 5 0.009; Fig. 3). When evaluating only gynecologic ISBT, there was no significant change in cases per GROR, from 4.7 in 2007 to 4.5 in 2018 (r 5 0.11; p 5 0.724). When evaluating only ISBT in other (nongynecologic and nonprostate) locations, there was a slight decrease from an average of 1.1 cases per GROR in 2007 to 0.5 cases per GROR in 2018 (r 5 0.90; p ! 0.001). For all ISBT procedures, the lowest 10th percentile of GRORs had 10 cases in 2007. By 2018, this number had
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Fig. 1. Average case volume per graduating radiation oncology resident in intracavitary brachytherapy.
decreased to 6 cases. Similar decreases in experience by percentile were seen in the 30th (17 in 2007 to 10 in 2018), 50th (25 in 2007 to 15 in 2018), 70th (39 in 2007 to 24 in 2018), and 90th (79 in 2007 to 44 in 2018) percentile (Fig. 4A). When evaluating solely prostate ISBT, similar decreases in cases required for a certain percentile over the study period were identified: 10th (2 in 2007 to 0 in 2018), 30th (9 in 2007 to two in 2018), 50th (14 in 2007 to four in 2018), 70th (21 in 2007 to 11 in 2018), 90th (43 in
2007 to 32 in 2018; Fig. 4B). At least 70% of GRORs achieved a low volume of cases ($5) between 2007 and 2011. However, from 2015 to 2018, only 50% of GRORs met low-volume requirements. High volume ($15) was achieved by nearly 50% of GRORs in 2007 but decreased to 30% by 2011 and roughly 20% in 2018. For gynecologic ISBT, the median number of cases per GROR has remained stably low from 2007 to 2018, with 0e2 cases per GROR representing the 50th percentile. The lower 30th percentile of GRORs had no gynecologic interstitial cases performed from 2007 to 2018. The 70th percentile has ranged from 2 to 6 cases, whereas the 90th percentile ranged from 5 to 11 cases. Excepting 2007 and 2016, the 90th percentile of GRORs graduated with !10 gynecologic ISBT cases.
Discussion
Fig. 2. Average case volume per graduating radiation oncology resident in interstitial brachytherapy.
This study shows the temporal trends in BT experience for GRORs over the past 12 years and is the first to evaluate ICBT experience per GROR, showing primarily an increase in gynecologic ICBT. This is supported by a registry study showing stable volumes of cervical cancer at academic institutions (16). The increase in GROR ICBT volume may be driven by randomized trial results demonstrating oncologic safety and improved toxicity of replacing pelvic external beam radiation therapy with vaginal BT for early
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Fig. 3. Average case volume per graduating radiation oncology resident in prostate interstitial brachytherapy.
stage, high intermediate-risk endometrial cancer, leading to an increase of ICBT utilization (17e19). However, another more likely reason for an increase in the number of cases could be because of a transition from LDR ICBT, where one implant is common, to HDR ICBT, where four to five fractions is common for tandem-based insertions, and two to five insertions for cylinder-based insertions. Although this does allow for greater experience with the technical aspect of physically placing a tandem or cylinder, it likely means that the number of unique patients being treated has gone down, potentially negatively affecting a GROR’s ability for individual patient evaluation, case selection, and experience with unique or difficult anatomy. A significant point of uncertainty within these data is the lack of distinction between tandem-based ICBT, which is required for the definitive management of cervical cancer, and cylinder-based treatment frequently used as adjuvant therapy for endometrial cancer. Currently, ICBT includes both cylinder- and tandem-based insertion, and it is conceivable that GRORs could meet current requirements without ever performing tandem-based BT. A recent ACGME proposal plans to address this concern, with requirement of at least five tandem placements, across 2 patients, toward the count of 15 ICBT procedures. In addition, ACGME will mandate that no more than five of the required 15 ICBT procedures should be cylinder insertions (5). Assuming that no other forms of ICBT besides cylinder and tandem-based ICBT are performed by GRORs, this seems to mandate at least 10 tandem insertions for every GROR going forward. Theoretically, this mandates that a resident treat at least 2 patients, assuming a common cervical HDR BT fractionation scheme of 6 Gy 5, before graduating residency.
Although this change is at least a step in the right direction, the mandated minimum number is not high enough to ensure any minimum level of competence or comfort with BT as part of a GROR’s practice as an attending. This study also reinforces the conclusions of the one previous study evaluating ACGME case logs for ISBT, which reported from 2007 to 2011, showing a 25% decrease in ISBT volume (15). From 2011 to 2018, experience in ISBT has decreased by another 20%, for a total 40% decrease from 2007 compared to 2018. This decrease in ISBT is driven by a near 50% decrease in experience in prostate ISBT for an average GROR between 2007 and 2018. The total number of prostate ISBT cases with resident involvement nationally has remained stable; however, because of a 65% increase in the number of yearly GRORs between 2007 and 2018, the average case volume per GROR has decreased sharply. There has been a slight increase in the use of HDR prostate ISBT recently, but HDR increase has not been sufficient or widespread enough to offset the decrease in LDR prostate ISBT. Although the recently published ASCENDE-RT trial may generate greater prostate ISBT experience in the future, factors that may continuing to diminish prostate ISBT volume include increasing use of active surveillance for low-risk disease, radical prostatectomy for intermediate and high-risk disease, and prostate stereotactic body radiation therapy as a noninvasive modality for low- and intermediate-risk disease (20e22). Gynecologic ISBT experience has remained minimal throughout the study period, with at least 30% of GRORs never having performed a traditional gynecologic ISBT implant. However, it is unclear whether GRORs are logging hybrid intracavitary/interstitial applicators, such as the
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Fig. 4. Case requirement thresholds for various percentiles in (A) all interstitial brachytherapy and (B) prostate-only interstitial brachytherapy.
Vienna or Venezia, as ISBT procedures. Gynecologic ISBT, although an important tool, may not be necessary at every institution throughout the United States. However, appropriately selected patients derive significant benefit from this modality, and familiarity with the procedure is of importance for all GROR. The low number of gynecologic ISBT cases performed by GRORs raises concerns regarding patients receiving an optimal treatment course regardless of their extent of disease. Recently, the ACGME has proposed a change to increase the requirement of total ISBT cases from 5 to 7 (5). The issue of not having site-specific minimums in BT means that a GROR can perform seven prostate ISBT implants and have never seen an advanced
cervical cancer requiring a full interstitial implant. That GROR could then be asked to do a full Syed template as an attending. Until the case minimums are radically increased, the idea of competence being derived by those doing the current minimums is essentially impossible. The largest driving factor of the decrease in ISBT experience is dilution of the resident experiencedalthough the number of cases for which there has been resident coverage has remained similar over the study period, there has been an explosion of residency expansion over the past decade. With stable usage and more residents, average numbers are bound to drop. If ISBT is felt to be an important skill for all US GRORs to possess, a primary solution may be
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not only an immediate halting of all residency expansion but also a true contraction of the number of residency spots offered throughout the country. Residency expansion, in addition to dilution of ISBT experience, has led to concerns about an oversupply and diminished job prospects (23,24). The issue of whether new attendings are competent to practice independently is an issue in fields besides just procedural radiation oncology. There have been multiple publications in subspecialties of general surgery questioning the capabilities of newer graduates based on case logs (25e27). However, the robustness of how surgeons use case logs to evaluate competence is multitudes stronger than what radiation oncology currently has, and a valid comparison of how ACGME case logs compare to competence is premature. For example, general surgery has a long list of site-specific minimums that must be met before being eligible for residency graduation (28). The minimum requirements for procedural aspects of radiation oncology are so low that competence at completion of residency by someone who has only done the minimum number of cases is unlikely. The ideal case log minimum so as to provide a potential to reach competence has not been well established, and although there is some interest into simulation-based training (29e31), the only true way of assessing competence for GRORs would be to have simulation-based competency assessments that would be factored into assessing board certification, potentially as part of the current oral boards. However, use of BT is not common among the majority of radiation oncology attendings, and thus, oral boards would ideally be moved to immediately after residency so as to avoid significant testing on a modality that is not commonly used. Our study does have several limitations; the primary one is that case logs are self-reported and may be subject to reporting bias. Previous publications have demonstrated a 75e80% rate of accurate logging for surgical residents (32,33). Evaluation of ACGME case log accuracy in radiation oncology does not provide definitive evidence of systematic under- or over-logging of cases (34). These statistics only reflect on residents having logged the cases as performed; they do not contain any information about the quality of learning experience. Another limitation is that we may not be able to assure the assumptions required for linear regression, given we only had access to the summarized data, without the raw data. Despite these limitations, we believe this study offers value in updating previously reported trends in resident case experience in BT (15). In conclusion, we report a summary of resident-reported experience with BT. We found a slight increase in ICBT cases per GROR over time, mostly driven by an increase in gynecologic ICBT. However, this number does not differentiate between cylinder and tandem-based ICBT. We found a persistent decrease in ISBT volume per GROR, driven by decreasing experience in prostate ISBT. Gynecologic ISBT volume has been low for over the entire study
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period. These findings may have implications for the development of significantly ACGME case minimums for residency programs in the future. References [1] NCCN. NCCN Guidelines: Prostate Cancer 2018. Available at: https://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf. Accessed March 4, 2019. [2] NCCN. Uterine Neoplasms. Pract Guidel Oncol 2018;1e48. [3] Bradley K, Crispens MA, Frederick P. NCCN Guidelines: Cervical Cancer 2018. Available at: https://www.nccn.org/professionals/ physician_gls/pdf/cervical.pdf. Accessed March 4, 2019. [4] Common Program Requirements, Radiation Oncology. Effective July 1. Chicago, IL: Accreditation Council for Graduate Medical Education; 2017.. Accessed April 3, 2019. [5] ACGME Program Requirements for Graduate Medical Education in Radiation Oncology. Summary and impact of focused requirement revisions 2019. Available at: https://www.acgme.org/Portals/ 0/PFAssets/ProgramResources/RadiationOncology_Summary_PRChanges2019.pdf?ver52019-08-26-120824-023. Accessed March 4, 2019. [6] Orio PF, Nguyen PL, Buzurovic I, et al. The decreased use of brachytherapy boost for intermediate and high-risk prostate cancer despite evidence supporting its effectiveness. Brachytherapy 2016; 15:701e706. [7] Orio PF, Nguyen PL, Buzurovic I, et al. Prostate brachytherapy case volumes by academic and nonacademic practices: implications for future residency training. Int J Radiat Oncol 2016;96:624e628. [8] Gill BS, Lin JF, Krivak TC, et al. National cancer data base analysis of radiation therapy consolidation modality for cervical cancer: the impact of new technological advancements. Int J Radiat Oncol 2014;90:1083e1090. [9] Mayadev J, Klapheke A, Yashar C, et al. Underutilization of brachytherapy and disparities in survival for patients with cervical cancer in California. Gynecol Oncol 2018;150:73e78. [10] Robin TP, Amini A, Schefter TE, et al. Disparities in standard of care treatment and associated survival decrement in patients with locally advanced cervical cancer. Gynecol Oncol 2016;143:319e 325. [11] Morris WJ, Tyldesley S, Rodda S, et al. Androgen Suppression Combined with Elective Nodal and dose Escalated Radiation Therapy (the ASCENDE-RT trial): an analysis of survival endpoints for a randomized trial comparing a low-dose-rate brachytherapy boost to a dose-escalated external beam boost for high- and intermediate-risk prostate cancer. Int J Radiat Oncol 2017;98: 275e285. [12] Kishan AU, Cook RR, Ciezki JP, et al. Radical prostatectomy, external beam radiotherapy, or external beam radiotherapy with brachytherapy boost and disease progression and mortality in patients with Gleason score 9-10 prostate cancer. JAMA 2018;319:896. [13] Johnson SB, Lester-Coll NH, Kelly JR, et al. Brachytherapy boost utilization and survival in unfavorable-risk prostate cancer. Eur Urol 2017;72:738e744. [14] Marcrom SR, Kahn JM, Colbert LE, et al. Brachytherapy training survey of radiation oncology residents. Int J Radiat Oncol 2019; 103:557e560. [15] Compton JJ, Gaspar LE, Shrieve DC, et al. Resident-reported brachytherapy experience in ACGME-accredited radiation oncology training programs. Brachytherapy 2013;12:622e627. [16] Trifiletti DM, Grover S, Libby B, et al. Trends in cervical cancer brachytherapy volume suggest case volume is not the primary driver of poor compliance rates with brachytherapy delivery for locally advanced cervical cancer. Brachytherapy 2017;16:547e551. [17] Nout RA, Putter H, J€urgenliemk-Schulz IM, et al. Quality of life after pelvic radiotherapy or vaginal brachytherapy for endometrial
A. Shinde et al. / Brachytherapy
[18]
[19]
[20]
[21] [22]
[23]
[24]
[25]
cancer: first results of the randomized PORTEC-2 trial. J Clin Oncol 2009;27:3547e3556. Nout R, Smit V, Putter H, et al. Vaginal brachytherapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high-intermediate risk (PORTEC-2): an open-label, non-inferiority, randomised trial. Lancet 2010;375:816e823. Zavitsanos PJ, Leonard KL. Patterns of care in women with highintermediate risk endometrioid adenocarcinoma in the PORTEC-2 era: a SEER database analysis. Brachytherapy 2017;16:109e115. Weiner J P, Schwartz D, Shao M, et al. Stereotactic radiotherapy of the prostate: fractionation and utilization in the United States. Radiat Oncol J 2017;35:137e143. Chung BH. The role of radical prostatectomy in high-risk prostate cancer. Prostate Int 2013;1:95. Kinsella N, Helleman J, Bruinsma S, et al. Active surveillance for prostate cancer: a systematic review of contemporary worldwide practices. Transl Androl Urol 2018;7:83e97. Sura K, Lischalk JW, Grills IS, et al. Modern perspectives on radiation oncology residency expansion, fellowship evolution, and employment satisfaction. J Am Coll Radiol 2019;16:749e753. Pan HY, Haffty BG, Falit BP, et al. Supply and demand for radiation oncology in the United States: updated projections for 2015 to 2025. Int J Radiat Oncol Biol Phys 2016;96:493e500. Larson KE, Grobmyer SR, Reschke MAB, et al. Fifteen-year decrease in general surgery resident breast operative experience: are we training proficient breast surgeons? J Surg Educ 2018;75: 247e253.
-
(2019)
-
7
[26] Potts JR, Valentine RJ. Declining resident experience in open vascular operations threatens the status of vascular surgery as an essential content area of general surgery training. Ann Surg 2018; 268:665e673. [27] Park CJ, Armenia SJ, Cowles RA. Trends in routine and complex hepatobiliary surgery among general and pediatric surgical residents: what is the next generation learning and is it enough? J Surg Educ 2019;76:1005e1014. [28] ACGME. Defined category minimum numbers for general surgery residents and credit role 2018. [29] Singer L, Damast S, Lin L, et al. Development of a MultiInstitutional simulation-based gynecologic brachytherapy Curriculum. Int J Radiat Oncol Biol Phys 2019;104:1175e1176. [30] Zhao S, Francis L, Todor D, Fields EC. Proficiency-based cervical cancer brachytherapy training. Brachytherapy 2018;17:653e659. [31] Thaker NG, Kudchadker RJ, Swanson DA, et al. Establishing highquality prostate brachytherapy using a phantom simulator training program. Int J Radiat Oncol Biol Phys 2014;90:579e586. [32] McPheeters MJ, Talcott RD, Hubbard ME, et al. Assessing the accuracy of neurological surgery resident case logs at a single institution. Surg Neurol Int 2017;8:206. [33] Nygaard RM, Daly SR, Van Camp JM. General surgery resident case logs: do they accurately reflect resident experience? J Surg Educ 2015;72:e178ee183. [34] Cordero F, Cardan RA, Popple RA, et al. Single institution analysis of case-logging accuracy and compliance by residents. Int J Radiat Oncol 2017;99:E121eE122.