- Email: [email protected]
Training in radiation oncology in the United Kingdom
Im J. Rndmrron Oncoloyv EM>/ Phys Vol. Pnnted in the US A. All rights reserved.
24, pp.
0360.3016/92 $5.00 + .oO Copyright cc)I992 Pergamon Press Ltd.
825-831
??Special Feature
TRAINING IN RADIATION ONCOLOGY IN THE UNITED KINGDOM RICHARD G. B. EVANS, M.B.,
FRCR
Faculty of Clinical Oncology, The Royal College of Radiologists
postgraduate medical and dental education, taking into account both the standards promulgated by professional bodies, and the potential difficulties of reconciling service and training needs.
INTRODUCIION Background
The current arrangements for postgraduate and continuing medical education* in the UK were developed as a result of the Christchurch Conference convened in 196 1 by the Nuffield Provincial Hospitals Trust, chaired by Sir George Pickering. The key principle of that conference was that postgraduate education should supplement undergraduate education and continue after appointment to a career post. This principle was stressed further in the Report of the Royal Commission on Medical Education in 1968 (the Todd Report) which recognized that medical education was a continuum which did not end on acquiring a registrable qualification.
Regional organization In each region in England there is a regional postgraduate education committee (RPEC). Regional Health Authorities (RHAs), universities, Royal Colleges and Faculties, and the profession are represented on these committees although there is no uniform pattern of membership throughout the country. Among the committees’ main functions are:
To promote and keep under review postgraduate medical education and training throughout their territory; To advise the RHA and university on training and education facilities, study leave, rotations of doctors between posts, and secondment; To promote and co-ordinate the training schemes and teaching facilities, advise on content and quality of training posts, taking into account the recommendations of relevant Colleges, Faculties and Joint Higher Training Committees (see paragraph 10); To provide information on medical training facilities and give career guidance; To supervise arrangements of assessment and progress reports in connection with specialist training; To select educationally approved posts in accordance with the vocational training regulations for general practice.
National organization
The provision of postgraduate and continuing medical education depends on co-operation between the Royal Colleges and Faculties, the Joint Higher Training Committees, the universities, and the National Health Service. The content of postgraduate medical education has always been and will remain, a matter for the medical profession. The role of the Health Departments is to support and facilitate its effective provision and development, and to relate postgraduate training to the Government’s general policies for health services. Traditionally, the General Medical Council had powers (deriving from the Medical Act 1858) in relation to undergraduate medical education only. The Medical Acts 1978 and 1983, however, provided for an education committee of the GMC having the general function of promoting high standards in, and co-ordinating all stages of, medical education. The Standing Committee on Postgraduate Medical Education (SCOPME) was established in August 1988 to advise the Secretary of State for Health on the delivery of
A regional postgraduate dean (or director) is normally the chief officer or chairman of the regional postgraduate education committee. The appointment of postgraduate dean is made by the university and is usually full-time. The dean is usually responsible for the regional organi-
Reprint requests to: R. G. B. Evans, “Treetops” 67 Moorside North, Fenham, New Castle Upon Tyne, NE4 9DU, UK.
tinction is often made between training and education, the former referring to the practical acquisition of clinical skills and the latter to a predominantly formal academic process. Both are necessary for all doctors at all stages in their careers.
Accepted for publication 15 June 1992. * In this paper postgraduate education applies to the training grades and continuing education to the career grades. A dis825
826
I. J. Radiation Oncology 0 Biology 0 Physics
zation of postgraduate medical education for health authority doctors and for general practitioners. The supervision and planning of postgraduate education at local level is the responsibility of clinical tutors under the general aegis of the postgraduate dean. There are now some 385 clinical tutors in Great Britain who are consultants appointed by the university in consultation with the RHA (or in Scotland by the regional committee in consultation with the university). They receive an honorarium which is reimbursed by the RHA. Royal colleges and faculties All the hospital specialities, general practice and public health medicine are covered by the 11 Royal Colleges and Faculties. As far as postgraduate training is concerned they are responsible in their own specialties for formulating systematic programs of professional training, for devising arrangements for inspection of training posts, and for arranging formal examinations for higher qualifications. Joint higher training committees JHTCs, and their equivalents, are non-statutory bodies which have evolved primarily as a mechanism to ensure that the views of Colleges and Faculties on higher specialist training are turned into practice. Generalization is difficult because the nature, composition, and method of working adopted by each such body vary. Common functions are to agree standards and programs of higher specialist training+ and to approve posts at senior registrar level which provide this training. In connection with the approval of posts, visits may be undertaken on the JHTCs’ behalf by specialist advisory committees (SACS) for each sub-specialty and the JHTCs decisions on approval will be informed by the SACS. JHTCs’ include representatives of the relevant Royal Colleges and Faculties in the United Kingdom, the university departments, observers from health departments and, where appropriate, members of the specialist association(s) and the regional postgraduate deans. The Colleges and Faculties provide secretarial support for the JHTCs. The health departments make grants towards the costs of inspecting posts and other educational activities. In addition, health authorities meet the cost of travel and subsistence involved in particular inspections. Some of these bodies issue certificates of accreditation to those who have successfully completed a recognized program of higher specialist training. Such a program requires doctors to spend time in training posts which have educational approval from the relevant education body (which may be the College or Faculty or the JHTC). The General Medical Council has made a number of
+ Follows basic specialist training, normally intended to last 3 to 5 years, at the end of which a doctor is regarded as having completed specialist training and as being ready to accept consultant responsibilities.
Volume 24, Number 5, 1992
recommendations on the training of specialist$ including the following attributes: . The ability to solve clinical and other problems in med-
ical practice; Possession of adequate knowledge and understanding of the general structure and function of the human body and workings of the mind, in health and disease, of their interaction between man and his physical and social environment; . Possession of consultation skills; b Acquisition of a high standard of knowledge and skills in the doctor’s specialty; ?? Willingness and ability to deal with common medical emergencies and with other illness in an emergency; . The ability to contribute appropriately to the prevention of illness and the promotion of health; . The ability to recognize and analyse ethical problems so as to enable patients, their families, society, and the doctor to have proper regard to such problems in reaching decisions; 0 The maintenance of attitudes and conduct appropriate to a high level of professional practice; . Mastery of the skills required to work within a team and, where appropriate, assume the responsibilities of team leader; . Acquisition of experience in administration and planning; . Recognition of the opportunities and acceptance of the duty to contribute, when possible, to the advancement of medical knowledge and skill; . Recognition of the obligation to teach others, particularly doctors in training. a
TRAINING IN RADIATION ONCOLOGY IN THE UK History of the Royal College of Radiologists In 1934 the need for a radiological society whose membership was composed only of medical practitioners began to be felt, and in December 1934, the British Association of Radiologists was founded. Its aims were to promote the interests of radiology in relation to medicine with special reference to the clinical, ethical, educational, and medico-political aspects. One of the first matters dealt with by the British Association of Radiologists was the establishment of a higher radiological qualification, and in 1935 a special class of members, to be known as Fellows, and controlled by a Fellowship Board was created. The Society of Radiotherapists of Great Britain and Ireland was founded in November 1935 for the advancement of radiotherapy in all its aspects. Membership was confined
*Recommendations on the Training of Specialists, General Medical Council: Education Committee.
1987,
Radiation oncology training in the UK 0 R. G. B. EVANS
to medical practitioners whose main interest and occupation was in the practice of radiotherapy. A decision to amalgamate the two societies was agreed in 1939 and in 1940, they came together under the name of the Faculty of Radiologists. On 27th May 1953, the Faculty was granted a Royal Charter. Initial steps towards achieving Collegiate status were taken in 1969, and in 1975 with the granting of a Supplemental Charter the Faculty became the Royal College of Radiologists. Aims of the Royal College of‘Radiologists These are described in the Supplemental Charter. The word “radiologist” means a medically qualified person (as defined in the By-Laws) professionally engaged in the use of radiations (both ionizing and non-ionizing) in the investigation, diagnosis, and treatment of disease. The word “radiology” shall be construed accordingly. Among the objects of the College are: (a) To advance the science and practice of radiology; (b) To further public education therein; and (c) To promote study and research work in radiology and related subjects and publish the results of such study and research. For the purpose of attaining the aforesaid objects but not further or otherwise the College may exercise the following powers: (a) To further instruction and training in radiology; (b) To conduct examinations and award certificates and diplomas; (c) To diffuse information on all matters affecting medical science and in particular radiology; and (d) To develop the application of radiology in relation to medicine with a view to maintaining the highest possible standards of professional competence and practice and act as an authoritative body for the purpose of consultation in matters of public and professional interest concerning radiology. Structure qfthe Royal College of Radiologists Prior to 1990, the College was governed by seven elected officers and a council of twelve elected members; section interests were served by the Faculty Boards of Radiodiagnosis and of Radiotherapy and Oncology, and academic interests by the Education Board. Council had also formed several advisory committees to serve the interests of those working in specialized branches of radiology such as nuclear medicine and ultrasound. By 1987 it had become clear that the two specialties now had less in common than had been the case when the Faculty was formed or indeed when the College was given its charter. The common link, ionizing radiations, was still there to keep the Faculty Boards together in a College of Radiologists, but each of the specialties was diversifying, diagnostic radiologists undertaking forms of imaging which did not use ionizing radiations such as ultrasound and magnetic resonance as well as interven-
5 Clinical Oncology is the name used by Radiation Oncologists in the UK to take account of the wider role they have assumed.
827
tional radiology, radiation oncologists becoming involved more and more in the use of other forms of non-surgical treatment of malignant disease. In 1990 the College was granted a further supplemental charter, which would allow each of the Faculties more independence. Under this new structure, there are two separate Faculties, called Clinical Radiology and Clinical Oncology,” each with its own committee, the Board of the Faculty chaired by a Dean, and each with its own Education Board, chaired by a Warden. COUNCIL President Treasurer
I
FACULTY OF CLINICAL ONCOLOGY Dean Registrar
FACULTY OF CLINICAL RADIOLOGY Dean Registrar
I Education Board (Warden)
I
I
Editorial Board Editor, Clinical Radiology
Education Board (Warden)
I
Editorial Board Editor, Clinical Oncology
Functions of the education boards The education boards are concerned with all aspects of education and training in clinical radiology and clinical oncology. This includes the organization of teaching courses; visiting and approval of training departments; conducting examinations, and the appointment of examiners; the appointment of regional postgraduate education advisers; an overseas committee; an overseas doctors training scheme; the awarding of scholarships and prizes; accreditation; supervision of post FRCR training; and the overseeing of continuing medical education. Each education board consists of eight members elected from the Fellowship of each Faculty; the chairmen of the two examining boards; observers from the Royal College of Physicians, the Conference of Postgraduate Deans, and the Junior Radiologists Forum; and ex-officio the president, the treasurer, and the dean, registrar and editor of the Faculty. WARDEN EDUCATION OF TRAINEES
VISITING OF TRAINING DEPARTMENTS
EXAMINING OF TRAINEES
REGIONAL ADVISORS
CHAIRMAN OF VISITING PANEL
CHAIRMEN OF EXAMINING BOARDS
I CHAIRMAN OF REGIONAL EDUCATION COMMIlTEE
I VISITING PANEL (or specialist advisory committee)
I EXAMINERS
I TUTOR OR SUPERVISOR
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The warden chairs four meetings of education board each year and also attends and reports to the four meetings of the board of the Faculty and the four meetings of council. He chairs a meeting of Regional Advisers twice each year, attends all meetings of the visiting panel, and the meetings of the editorial board. In addition, as an officer of the College, he attends all officers meetings, and the meetings that the College has on a regular basis with the department of health, the British Institute of Radiology and the College of Radiographers. In addition he may have ad hoc meetings when necessary with examiners, with education chairmen of other Royal Colleges, with postgraduate deans, with education committees concerning radiation oncology in Europe and more recently, the United States. Examination offellowship of the Royal College of Radiologists in clinical oncology The First Examination comprises the following subjects: (a) The application of physical principles and methods in clinical radiotherapy. Physical basis of the therapeutic uses of radioactive isotopes. Radiation hazards and protection. (b) Medical statistics with special reference to clinical trials and assessment of results. (c) Pathology of neoplastic disorders and (d) Principles of cancer basic sciences including radiobiology. Candidates are permitted to sit the First Examination after 12 months’ preparation in an approved post. Examinations are held twice each year in March and September. The examination consists of: (a) A written paper in physics and medical statistics. (b) A written paper in the pathology of neoplastic disorders and cancer basic sciences including radiobiology. (c) A multiple choice question paper covering the above subjects. (d) An oral examination in physics and medical statistics, in which special attention may be paid to practical aspects of physics applied to radiotherapy. (e) An oral examination in the pathology of neoplastic disorders and cancer basic sciences including radiobiology. Candidates who obtain an insufficient mark in the multiple choice question paper will not proceed to the oral examination. Each candidate proceeding to the oral is examined by two sets of examiners, one set consists of a clinical oncologist, a physicist and a medical statistician; and the second set consists of a clinical oncologist, a pathoiogist and a radiation biologist. It is intended that these subjects should be orientated towards their clinical application in clinical oncology, and the examiners will be persons involved in clinical work. Candidates are allowed only four attempts at the first examination for the fellowship. Candidates who have passed the first examination are permitted to sit the final examination not less than three years after commencing training, having held approved posts throughout the 3 year period. Examinations are held twice each year in April and October.
Volume 24, Number 5, 1992
The final examination consists of: (a) Two written papers, one an essay paper, the other a “case orientated” short answer paper. (b) A multiple choice question paper. (c) An oral examination. (d) A clinical examination. and (e) A practical examination in radiation treatment planning. No candidate will be approved who does not satisfy the examiners in the clinical examination. Each candidate is examined by pairs of examiners who are consultants in clinical oncology. Candidates who obtain an insufficient mark in the multiple choice question paper will not proceed to the clinical, oral and treatment planning part of the examination. From April 1990 candidates are allowed only five attempts at the final examination in clinical oncology. The Royal College of Radiologists reserves the right to refer for 12 months any candidate who performs badly in either the first or final fellowship examination as a whole, or fails in one or more sections of the examination. Any candidate who withdraws from part of any examination will be deemed have failed the examination as a whole. Successful candidates in the final fellowship examination are required to become members of the College if they have not already done so, and to pay a fellowship fee. This is paid once only and should not be confused with the annual membership subscription. Before being allowed to use the title of Fellow of the Royal College of Radiologists, successful candidates must be admitted formally as such, and the admission ceremony is held twice each year, normally on the third Friday in May and November. Syllabus, first examination The syllabus is intended to ensure that candidates for the first examination for the fellowship have acquired a broad knowledge of those subjects which relate to the investigation and management of patients with cancer. The syllabus for each section is stated in general terms. Notes for guidance, setting out more precisely the subjects to be taught, are provided for teachers and candidates in order to indicate the extent to which each subject is to be covered. These notes for guidance are not intended to be exhaustive, since topics are continually advancing and candidates should be aware of relevant new developments. Candidates are required to attend formal courses designed to meet the specific objective of the syllabus. It is suggested that students should attend at least 130 hr of formal instruction and it is recommended that this time should be apportioned in the following manner: (a) Pathology = 35 hr; (b) Cell biology = 35 hr; (c) Medical statistics = 15 hr; and (d) Physics = 45 hr. “In-post” tuition by clinical oncologists, in order to consolidate the theoretical aspect of each subject to its application in clinical practice, is essential. The list of literature relevant to the syllabus is given for guidance
Radiation oncology training in the UK 0 R. G. B. EVANS
and is not to be regarded as complete or exclusive. There is considerable overlap between subjects, and particularly between cell biology and pathology. The inclusion of an item under a particular heading does not necessarily mean that it can or should be taught only by a specific department. A sound knowledge of relevant anatomy and physiology is essential, although there is no formal examination in these subjects. Pathology There is considerable overlap in the teaching of this subject and that of cell biology. General puthology 1. Definitions of and distinctions between different types of growth disorder. 2. Classification of neoplasms. 3. Aetiology, mechanisms of carcinogenesis, known types of carcinogen and their effect upon the cell. The relative importance of different factors in the causation of human cancer. multifocal; 4. Mode of origin of tumors-monoclonal, structure, differentiation and retention of function; tumor marker substances; pre-malignant and pre-invasive states. 5. Rate of growth, methods of measurement; factors affecting growth rate; mechanisms of spread; local effects of tumors; local and systemic reactions to tumors; effects of therapy on tumors and normal tissues. 6. Investigative techniques: uses and value of biopsy material. Systemic pathology. Candidates should be familiar with the origin, classification, natural history and histopathology of tumours in all systems, including: 1. 2. 3. 4. 5. 6.
Incidence, frequency, age and sex distribution. Histogenesis, aetiological factors, and epidemiology. Macroscopic and microscopic appearances. Classifications, staging, grading, and methods of spread. Prognostic indicators, including response to treatment. Screening and early detection.
The biology qf cells in relation to cancer and its treatment A basic knowledge of cytology, histology, and physiology of normal cells and tissues is assumed. This will include: 1. (a) Cell structure and function; principles of DNA, RNA, and protein synthesis. Nuclear organization, cytoplasmic organelles including the cytoskeleton, their role in mitosis and the cell cycle; (b) An introduction to the principles of Cellular chemistry and the concept of molecular biology; DNA strand breakage and repair; ionization, free radical production, and interaction
829
with biological molecules in aqueous systems; (c) Cellular injury: damage to cell organelles, for example, chromatids, chromosomes; biochemical pathways of injury and their roles in leading to division delay, mitotic and interphase cell death; (d) Cell survival curves: the concepts of cellular reproductive integrity and clonogenecity, methods for their determination with irradiated normal or neoplastic cell populations. The description of derivation of current formulae applied to cell survival curves; (e) Biological and chemical modifiers of cell survival; recovery from sublethal injury and the repair of potentially lethal damage. The effect of sensitizers, for example, oxygen, electron affinic agents. Protective agents. Dose modifying factors and their determination. Variation of response with growth and the progression of cells through the phases of the cell cycle; (f) Physical factors influencing cell survival; Relative Biological Effectiveness; its definition and determination, dependence upon linear energy transfer, dose, dose-rate, and fractionation. Hyperthermia; (g) Cytogenetics: description of changes in chromosomes in human malignant neoplasia; evidence that human cancer is caused by chromosomal abnormalities; methods available for showing human chromosome abnormalities-the use of quinacrine mustard and giemsa staining to produce banding: typical chromosomal abnormalities in human malignancies; translocations; deletions; oncogenes. The radiobiology of tissues should include: (a) A consideration, using the principles of cellular biology and dynamic histology, of the acute responses of normal renewal tissues, for example, bone marrow, epithelia and testis. The response of tumors to irradiation. (b) The injury of tissues and organs at long term risk. (c) The concepts of normal tissue tolerance, fractionation formulae and their radiobiological rationale. The therapeutic ratio and the potential influence of changes in dose, dose-rate, number of fractions, overall time quality of irradiation, oxygenation, and cell proliferation kinetics. (d) The biological hazards of irradiation; dose protraction and LET; whole body syndromes: effects on the embryo and the foetus; life shortening, leukaemogenesis and carcinogenesis, genetic and somatic hazards for exposed individuals and populations. Biological basis of radiological protection. The basic principles underlying the use of chemotherapeutic drugs: (a) Classification of anticancer drugs. The principles of cell kill by chemotherapeutic agents. Definition of phase specific and cycle specific action. (b) Principles of administration of drugs. The general principles of pharmacokinetics; factors affecting drug concentration “in viva;” for example, route and timing of administration, drug activation, plasma concentration, metabolism, and clearance. Principles of combination therapy, the use of dose response curves, adjuvant chemotherapy, problems of sanctuary sites,
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I. J. Radiation Oncology 0
Biology0 Physics
principles of high-dose chemotherapy. (c) Toxicity of drugs. Early, intermediate and late genetic and somatic effects of common classes of anticancer drugs. (d) Concept of drug resistance. (e) Introduction of new drugs. Principles of Phase I, Phase II and Phase III studies. (f) Interaction of cytotoxic drugs and irradiation. (g) Principles and practice of protection in the use of cytotoxic drugs.
Volume 24, Number 5, 1992
3.
Medical statistics and epidemiology 1. Summarizing and presenting data: (a) Qualitative data: proportions, bar charts, contingency tables, relative risk. (b) Quantitative data: measurements of location and spread, histograms, transformations, the Normal distribution, scatter diagrams. 2. Sampling: concept of a source population, random sampling, sample mean as estimating the population mean, standard error of sample mean and of a proportion, confidence limits. 3. Statistical significance: (a) Concepts of null hypothesis, types I and II errors. (b) Paired and two-sample t-tests, analysis of 2 X 2 contingency tables, the ideas of extension to analysis of variance and larger tables, simple linear regression, nonparametric analogues of the ttest. 4. Survival and recurrence data: presentation of individual patient survival data, crude survival rate, age-adjusted survival rate, life-table (actuarial) calculation of survival rate, survival curves, comparison of two curves, logrank test, concept of a cured group, recurrence-free rates. 5. Clinical trials: problems of retrospective comparisons and use of historical controls, prospective randomized controlled studies, protocols, aims of study, patient eligibility, informed consent, methods of allocating treatment options, numbers required, multicentre studies, double-blind studies. Measures of response: tumor regression, quality of life, morbidity, local and regional recurrence, distant metastases, death. 6. Epidemiology: mortality rates, standardized mortality rates, cancer registration and follow-up, cancer incidence and mortality rates for major anatomical sites, trends in cancer incidence and mortality, aetiological, and diagnostic studies. Ph vsics 1. Production of x-rays. Factors controlling the quantity and quality of x-ray emission. 2. Interaction of x-rays, y-rays and other ionizing radiations with matter. The photoelectric, Compton and pair-production processes. The parameters upon which their magnitudes depend. Their relative importance in clinical practice. The range of the secondary electrons emitted, and its clinical importance. Attenuation and
4.
5.
6.
7.
8.
absorption. Coefficients and the exponential law. Half value layer and filtration. Range of charged particles and the Bragg curve. Linear Energy Transfer (LET). The measurement of x- and y-rays. Exposure, kerma, and absorbed dose; units. Ionization, photographic, thermoluminescent and other methods of measurement and detection. Simple principles of air ionization measurement. Derivation of absorbed dose from air kerma, including calibration standardization. Relationship between exposure, kerma, and absorbed dose. Absorbed dose in heterogeneous materials. Data acquisition for treatment planning. The physical basis of radiation teletherapy. The steps involved in the establishment of the absorbed dose at any point in an irradiated patient: phantoms, “output” calibration, depth dose data, TAR, and isodose curves. Features of external photon and electron beams. Beam modification-filters and tissue compensators. Principles of rotation therapy. Beam therapy apparatus: Relative merits of different types of radiotherapy equipment in routine use. (A knowledge of generator circuitry is not required). Collimation, “applicators,” moving diaphragms. Penumbra. Controls and safety interlocks. Principles of high LET radiation. The principles of treatment planning: Localization. Simulators. Dose computations and construction of isodose distributions. Principles of obliquity and inhomogeneity corrections. Applications of computers to treatment planning, including CT planning; Front and back pointers, isocentric mounting, treatment shells; Principles of treatment verification. General properties and production of radioactive material. Radioactive decay, half-life and equilibrium, units of radioactivity. Radiations from radioactive materials-with special reference to clinical usage; Specific activity; Radionuclides in treatment: (a) Sealed sources and their construction, including p-ray sources; Principles of dosage systems. (b) Unsealed sources; General principles of their use. Principles and practice of radiation protection. Radiation hazards. Protective arrangements in Radiotherapy Departments. Care and custody of sealed and unsealed sources. Monitoring. Protection of the patient and the public. Relevant aspects of the current legislation.
SylIabus:$nal examination The College advice is simple and straightforward: “A wide knowledge of malignant disease and the management of the cancer patient is required. There will be special emphasis on radiotherapy and chemotherapy but a good knowledge of general medicine, surgery, and gynaecology is expected.” The examination is intended to test: (a) Academic knowledge-written papers; (b) Application of knowl-
Radiation oncology training in the UK 0 R. G. B. EVANS
edge-written papers + practical examination; (c) Opinion-written papers + practical examination; (d) Proficiency in the specialty-practical examination (planning). Notwithstanding this simple advice, a working-party of the Education Board which was advising on appropriate training for the post-FRCR period felt compelled to establish what ought to be a minimum core training leading up to the FRCR. The following guidelines were suggested: Didactic teaching in cancer basic sciences. (Part I Syllabus). Radiotherapy practice. (a) Principles of radiotherapy, including: integration of imaging techniques including CT with treatment planning; use of computers; treatment optimization. (b) Special techniques: electrons; total body irradiation; intracavitary radiation; interstitial radiation. (c) Use of radio-isotopes for therapy. Application of radiotherapy treatment to different sites, including patient selection and supervision plus care and knowledge of the comnlications. both of disease
831
and its treatment. Knowledge should be gained in management of the following groups of cancer: head and neck, CNS, skin/soft tissue, gynecology, pediatrics, gastro-intestinal tract, thorax, lymphomas, and genitourinary. 4. Delivery of cytotoxic chemotherapy and care of the immuno-suppressed and pancytopenic patient. 5. Conduct and analysis of clinical trials. 6. Symptom control/terminal care/counselling. While hands-on experience should be available for the vast majority of the topics listed, for some there may be no experience available in training centres and theoretical knowledge only may be gained. There are likely to be considerable problems in achieving much ofthis core training in small departments where there may be one or two Registrars at most, and consideration needs to be given to secondments and rotation from smaller departments to larger ones in order to ensure a uniform level of basic training.
24, pp.
0360.3016/92 $5.00 + .oO Copyright cc)I992 Pergamon Press Ltd.
825-831
??Special Feature
TRAINING IN RADIATION ONCOLOGY IN THE UNITED KINGDOM RICHARD G. B. EVANS, M.B.,
FRCR
Faculty of Clinical Oncology, The Royal College of Radiologists
postgraduate medical and dental education, taking into account both the standards promulgated by professional bodies, and the potential difficulties of reconciling service and training needs.
INTRODUCIION Background
The current arrangements for postgraduate and continuing medical education* in the UK were developed as a result of the Christchurch Conference convened in 196 1 by the Nuffield Provincial Hospitals Trust, chaired by Sir George Pickering. The key principle of that conference was that postgraduate education should supplement undergraduate education and continue after appointment to a career post. This principle was stressed further in the Report of the Royal Commission on Medical Education in 1968 (the Todd Report) which recognized that medical education was a continuum which did not end on acquiring a registrable qualification.
Regional organization In each region in England there is a regional postgraduate education committee (RPEC). Regional Health Authorities (RHAs), universities, Royal Colleges and Faculties, and the profession are represented on these committees although there is no uniform pattern of membership throughout the country. Among the committees’ main functions are:
To promote and keep under review postgraduate medical education and training throughout their territory; To advise the RHA and university on training and education facilities, study leave, rotations of doctors between posts, and secondment; To promote and co-ordinate the training schemes and teaching facilities, advise on content and quality of training posts, taking into account the recommendations of relevant Colleges, Faculties and Joint Higher Training Committees (see paragraph 10); To provide information on medical training facilities and give career guidance; To supervise arrangements of assessment and progress reports in connection with specialist training; To select educationally approved posts in accordance with the vocational training regulations for general practice.
National organization
The provision of postgraduate and continuing medical education depends on co-operation between the Royal Colleges and Faculties, the Joint Higher Training Committees, the universities, and the National Health Service. The content of postgraduate medical education has always been and will remain, a matter for the medical profession. The role of the Health Departments is to support and facilitate its effective provision and development, and to relate postgraduate training to the Government’s general policies for health services. Traditionally, the General Medical Council had powers (deriving from the Medical Act 1858) in relation to undergraduate medical education only. The Medical Acts 1978 and 1983, however, provided for an education committee of the GMC having the general function of promoting high standards in, and co-ordinating all stages of, medical education. The Standing Committee on Postgraduate Medical Education (SCOPME) was established in August 1988 to advise the Secretary of State for Health on the delivery of
A regional postgraduate dean (or director) is normally the chief officer or chairman of the regional postgraduate education committee. The appointment of postgraduate dean is made by the university and is usually full-time. The dean is usually responsible for the regional organi-
Reprint requests to: R. G. B. Evans, “Treetops” 67 Moorside North, Fenham, New Castle Upon Tyne, NE4 9DU, UK.
tinction is often made between training and education, the former referring to the practical acquisition of clinical skills and the latter to a predominantly formal academic process. Both are necessary for all doctors at all stages in their careers.
Accepted for publication 15 June 1992. * In this paper postgraduate education applies to the training grades and continuing education to the career grades. A dis825
826
I. J. Radiation Oncology 0 Biology 0 Physics
zation of postgraduate medical education for health authority doctors and for general practitioners. The supervision and planning of postgraduate education at local level is the responsibility of clinical tutors under the general aegis of the postgraduate dean. There are now some 385 clinical tutors in Great Britain who are consultants appointed by the university in consultation with the RHA (or in Scotland by the regional committee in consultation with the university). They receive an honorarium which is reimbursed by the RHA. Royal colleges and faculties All the hospital specialities, general practice and public health medicine are covered by the 11 Royal Colleges and Faculties. As far as postgraduate training is concerned they are responsible in their own specialties for formulating systematic programs of professional training, for devising arrangements for inspection of training posts, and for arranging formal examinations for higher qualifications. Joint higher training committees JHTCs, and their equivalents, are non-statutory bodies which have evolved primarily as a mechanism to ensure that the views of Colleges and Faculties on higher specialist training are turned into practice. Generalization is difficult because the nature, composition, and method of working adopted by each such body vary. Common functions are to agree standards and programs of higher specialist training+ and to approve posts at senior registrar level which provide this training. In connection with the approval of posts, visits may be undertaken on the JHTCs’ behalf by specialist advisory committees (SACS) for each sub-specialty and the JHTCs decisions on approval will be informed by the SACS. JHTCs’ include representatives of the relevant Royal Colleges and Faculties in the United Kingdom, the university departments, observers from health departments and, where appropriate, members of the specialist association(s) and the regional postgraduate deans. The Colleges and Faculties provide secretarial support for the JHTCs. The health departments make grants towards the costs of inspecting posts and other educational activities. In addition, health authorities meet the cost of travel and subsistence involved in particular inspections. Some of these bodies issue certificates of accreditation to those who have successfully completed a recognized program of higher specialist training. Such a program requires doctors to spend time in training posts which have educational approval from the relevant education body (which may be the College or Faculty or the JHTC). The General Medical Council has made a number of
+ Follows basic specialist training, normally intended to last 3 to 5 years, at the end of which a doctor is regarded as having completed specialist training and as being ready to accept consultant responsibilities.
Volume 24, Number 5, 1992
recommendations on the training of specialist$ including the following attributes: . The ability to solve clinical and other problems in med-
ical practice; Possession of adequate knowledge and understanding of the general structure and function of the human body and workings of the mind, in health and disease, of their interaction between man and his physical and social environment; . Possession of consultation skills; b Acquisition of a high standard of knowledge and skills in the doctor’s specialty; ?? Willingness and ability to deal with common medical emergencies and with other illness in an emergency; . The ability to contribute appropriately to the prevention of illness and the promotion of health; . The ability to recognize and analyse ethical problems so as to enable patients, their families, society, and the doctor to have proper regard to such problems in reaching decisions; 0 The maintenance of attitudes and conduct appropriate to a high level of professional practice; . Mastery of the skills required to work within a team and, where appropriate, assume the responsibilities of team leader; . Acquisition of experience in administration and planning; . Recognition of the opportunities and acceptance of the duty to contribute, when possible, to the advancement of medical knowledge and skill; . Recognition of the obligation to teach others, particularly doctors in training. a
TRAINING IN RADIATION ONCOLOGY IN THE UK History of the Royal College of Radiologists In 1934 the need for a radiological society whose membership was composed only of medical practitioners began to be felt, and in December 1934, the British Association of Radiologists was founded. Its aims were to promote the interests of radiology in relation to medicine with special reference to the clinical, ethical, educational, and medico-political aspects. One of the first matters dealt with by the British Association of Radiologists was the establishment of a higher radiological qualification, and in 1935 a special class of members, to be known as Fellows, and controlled by a Fellowship Board was created. The Society of Radiotherapists of Great Britain and Ireland was founded in November 1935 for the advancement of radiotherapy in all its aspects. Membership was confined
*Recommendations on the Training of Specialists, General Medical Council: Education Committee.
1987,
Radiation oncology training in the UK 0 R. G. B. EVANS
to medical practitioners whose main interest and occupation was in the practice of radiotherapy. A decision to amalgamate the two societies was agreed in 1939 and in 1940, they came together under the name of the Faculty of Radiologists. On 27th May 1953, the Faculty was granted a Royal Charter. Initial steps towards achieving Collegiate status were taken in 1969, and in 1975 with the granting of a Supplemental Charter the Faculty became the Royal College of Radiologists. Aims of the Royal College of‘Radiologists These are described in the Supplemental Charter. The word “radiologist” means a medically qualified person (as defined in the By-Laws) professionally engaged in the use of radiations (both ionizing and non-ionizing) in the investigation, diagnosis, and treatment of disease. The word “radiology” shall be construed accordingly. Among the objects of the College are: (a) To advance the science and practice of radiology; (b) To further public education therein; and (c) To promote study and research work in radiology and related subjects and publish the results of such study and research. For the purpose of attaining the aforesaid objects but not further or otherwise the College may exercise the following powers: (a) To further instruction and training in radiology; (b) To conduct examinations and award certificates and diplomas; (c) To diffuse information on all matters affecting medical science and in particular radiology; and (d) To develop the application of radiology in relation to medicine with a view to maintaining the highest possible standards of professional competence and practice and act as an authoritative body for the purpose of consultation in matters of public and professional interest concerning radiology. Structure qfthe Royal College of Radiologists Prior to 1990, the College was governed by seven elected officers and a council of twelve elected members; section interests were served by the Faculty Boards of Radiodiagnosis and of Radiotherapy and Oncology, and academic interests by the Education Board. Council had also formed several advisory committees to serve the interests of those working in specialized branches of radiology such as nuclear medicine and ultrasound. By 1987 it had become clear that the two specialties now had less in common than had been the case when the Faculty was formed or indeed when the College was given its charter. The common link, ionizing radiations, was still there to keep the Faculty Boards together in a College of Radiologists, but each of the specialties was diversifying, diagnostic radiologists undertaking forms of imaging which did not use ionizing radiations such as ultrasound and magnetic resonance as well as interven-
5 Clinical Oncology is the name used by Radiation Oncologists in the UK to take account of the wider role they have assumed.
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tional radiology, radiation oncologists becoming involved more and more in the use of other forms of non-surgical treatment of malignant disease. In 1990 the College was granted a further supplemental charter, which would allow each of the Faculties more independence. Under this new structure, there are two separate Faculties, called Clinical Radiology and Clinical Oncology,” each with its own committee, the Board of the Faculty chaired by a Dean, and each with its own Education Board, chaired by a Warden. COUNCIL President Treasurer
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FACULTY OF CLINICAL ONCOLOGY Dean Registrar
FACULTY OF CLINICAL RADIOLOGY Dean Registrar
I Education Board (Warden)
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I
Editorial Board Editor, Clinical Radiology
Education Board (Warden)
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Editorial Board Editor, Clinical Oncology
Functions of the education boards The education boards are concerned with all aspects of education and training in clinical radiology and clinical oncology. This includes the organization of teaching courses; visiting and approval of training departments; conducting examinations, and the appointment of examiners; the appointment of regional postgraduate education advisers; an overseas committee; an overseas doctors training scheme; the awarding of scholarships and prizes; accreditation; supervision of post FRCR training; and the overseeing of continuing medical education. Each education board consists of eight members elected from the Fellowship of each Faculty; the chairmen of the two examining boards; observers from the Royal College of Physicians, the Conference of Postgraduate Deans, and the Junior Radiologists Forum; and ex-officio the president, the treasurer, and the dean, registrar and editor of the Faculty. WARDEN EDUCATION OF TRAINEES
VISITING OF TRAINING DEPARTMENTS
EXAMINING OF TRAINEES
REGIONAL ADVISORS
CHAIRMAN OF VISITING PANEL
CHAIRMEN OF EXAMINING BOARDS
I CHAIRMAN OF REGIONAL EDUCATION COMMIlTEE
I VISITING PANEL (or specialist advisory committee)
I EXAMINERS
I TUTOR OR SUPERVISOR
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The warden chairs four meetings of education board each year and also attends and reports to the four meetings of the board of the Faculty and the four meetings of council. He chairs a meeting of Regional Advisers twice each year, attends all meetings of the visiting panel, and the meetings of the editorial board. In addition, as an officer of the College, he attends all officers meetings, and the meetings that the College has on a regular basis with the department of health, the British Institute of Radiology and the College of Radiographers. In addition he may have ad hoc meetings when necessary with examiners, with education chairmen of other Royal Colleges, with postgraduate deans, with education committees concerning radiation oncology in Europe and more recently, the United States. Examination offellowship of the Royal College of Radiologists in clinical oncology The First Examination comprises the following subjects: (a) The application of physical principles and methods in clinical radiotherapy. Physical basis of the therapeutic uses of radioactive isotopes. Radiation hazards and protection. (b) Medical statistics with special reference to clinical trials and assessment of results. (c) Pathology of neoplastic disorders and (d) Principles of cancer basic sciences including radiobiology. Candidates are permitted to sit the First Examination after 12 months’ preparation in an approved post. Examinations are held twice each year in March and September. The examination consists of: (a) A written paper in physics and medical statistics. (b) A written paper in the pathology of neoplastic disorders and cancer basic sciences including radiobiology. (c) A multiple choice question paper covering the above subjects. (d) An oral examination in physics and medical statistics, in which special attention may be paid to practical aspects of physics applied to radiotherapy. (e) An oral examination in the pathology of neoplastic disorders and cancer basic sciences including radiobiology. Candidates who obtain an insufficient mark in the multiple choice question paper will not proceed to the oral examination. Each candidate proceeding to the oral is examined by two sets of examiners, one set consists of a clinical oncologist, a physicist and a medical statistician; and the second set consists of a clinical oncologist, a pathoiogist and a radiation biologist. It is intended that these subjects should be orientated towards their clinical application in clinical oncology, and the examiners will be persons involved in clinical work. Candidates are allowed only four attempts at the first examination for the fellowship. Candidates who have passed the first examination are permitted to sit the final examination not less than three years after commencing training, having held approved posts throughout the 3 year period. Examinations are held twice each year in April and October.
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The final examination consists of: (a) Two written papers, one an essay paper, the other a “case orientated” short answer paper. (b) A multiple choice question paper. (c) An oral examination. (d) A clinical examination. and (e) A practical examination in radiation treatment planning. No candidate will be approved who does not satisfy the examiners in the clinical examination. Each candidate is examined by pairs of examiners who are consultants in clinical oncology. Candidates who obtain an insufficient mark in the multiple choice question paper will not proceed to the clinical, oral and treatment planning part of the examination. From April 1990 candidates are allowed only five attempts at the final examination in clinical oncology. The Royal College of Radiologists reserves the right to refer for 12 months any candidate who performs badly in either the first or final fellowship examination as a whole, or fails in one or more sections of the examination. Any candidate who withdraws from part of any examination will be deemed have failed the examination as a whole. Successful candidates in the final fellowship examination are required to become members of the College if they have not already done so, and to pay a fellowship fee. This is paid once only and should not be confused with the annual membership subscription. Before being allowed to use the title of Fellow of the Royal College of Radiologists, successful candidates must be admitted formally as such, and the admission ceremony is held twice each year, normally on the third Friday in May and November. Syllabus, first examination The syllabus is intended to ensure that candidates for the first examination for the fellowship have acquired a broad knowledge of those subjects which relate to the investigation and management of patients with cancer. The syllabus for each section is stated in general terms. Notes for guidance, setting out more precisely the subjects to be taught, are provided for teachers and candidates in order to indicate the extent to which each subject is to be covered. These notes for guidance are not intended to be exhaustive, since topics are continually advancing and candidates should be aware of relevant new developments. Candidates are required to attend formal courses designed to meet the specific objective of the syllabus. It is suggested that students should attend at least 130 hr of formal instruction and it is recommended that this time should be apportioned in the following manner: (a) Pathology = 35 hr; (b) Cell biology = 35 hr; (c) Medical statistics = 15 hr; and (d) Physics = 45 hr. “In-post” tuition by clinical oncologists, in order to consolidate the theoretical aspect of each subject to its application in clinical practice, is essential. The list of literature relevant to the syllabus is given for guidance
Radiation oncology training in the UK 0 R. G. B. EVANS
and is not to be regarded as complete or exclusive. There is considerable overlap between subjects, and particularly between cell biology and pathology. The inclusion of an item under a particular heading does not necessarily mean that it can or should be taught only by a specific department. A sound knowledge of relevant anatomy and physiology is essential, although there is no formal examination in these subjects. Pathology There is considerable overlap in the teaching of this subject and that of cell biology. General puthology 1. Definitions of and distinctions between different types of growth disorder. 2. Classification of neoplasms. 3. Aetiology, mechanisms of carcinogenesis, known types of carcinogen and their effect upon the cell. The relative importance of different factors in the causation of human cancer. multifocal; 4. Mode of origin of tumors-monoclonal, structure, differentiation and retention of function; tumor marker substances; pre-malignant and pre-invasive states. 5. Rate of growth, methods of measurement; factors affecting growth rate; mechanisms of spread; local effects of tumors; local and systemic reactions to tumors; effects of therapy on tumors and normal tissues. 6. Investigative techniques: uses and value of biopsy material. Systemic pathology. Candidates should be familiar with the origin, classification, natural history and histopathology of tumours in all systems, including: 1. 2. 3. 4. 5. 6.
Incidence, frequency, age and sex distribution. Histogenesis, aetiological factors, and epidemiology. Macroscopic and microscopic appearances. Classifications, staging, grading, and methods of spread. Prognostic indicators, including response to treatment. Screening and early detection.
The biology qf cells in relation to cancer and its treatment A basic knowledge of cytology, histology, and physiology of normal cells and tissues is assumed. This will include: 1. (a) Cell structure and function; principles of DNA, RNA, and protein synthesis. Nuclear organization, cytoplasmic organelles including the cytoskeleton, their role in mitosis and the cell cycle; (b) An introduction to the principles of Cellular chemistry and the concept of molecular biology; DNA strand breakage and repair; ionization, free radical production, and interaction
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with biological molecules in aqueous systems; (c) Cellular injury: damage to cell organelles, for example, chromatids, chromosomes; biochemical pathways of injury and their roles in leading to division delay, mitotic and interphase cell death; (d) Cell survival curves: the concepts of cellular reproductive integrity and clonogenecity, methods for their determination with irradiated normal or neoplastic cell populations. The description of derivation of current formulae applied to cell survival curves; (e) Biological and chemical modifiers of cell survival; recovery from sublethal injury and the repair of potentially lethal damage. The effect of sensitizers, for example, oxygen, electron affinic agents. Protective agents. Dose modifying factors and their determination. Variation of response with growth and the progression of cells through the phases of the cell cycle; (f) Physical factors influencing cell survival; Relative Biological Effectiveness; its definition and determination, dependence upon linear energy transfer, dose, dose-rate, and fractionation. Hyperthermia; (g) Cytogenetics: description of changes in chromosomes in human malignant neoplasia; evidence that human cancer is caused by chromosomal abnormalities; methods available for showing human chromosome abnormalities-the use of quinacrine mustard and giemsa staining to produce banding: typical chromosomal abnormalities in human malignancies; translocations; deletions; oncogenes. The radiobiology of tissues should include: (a) A consideration, using the principles of cellular biology and dynamic histology, of the acute responses of normal renewal tissues, for example, bone marrow, epithelia and testis. The response of tumors to irradiation. (b) The injury of tissues and organs at long term risk. (c) The concepts of normal tissue tolerance, fractionation formulae and their radiobiological rationale. The therapeutic ratio and the potential influence of changes in dose, dose-rate, number of fractions, overall time quality of irradiation, oxygenation, and cell proliferation kinetics. (d) The biological hazards of irradiation; dose protraction and LET; whole body syndromes: effects on the embryo and the foetus; life shortening, leukaemogenesis and carcinogenesis, genetic and somatic hazards for exposed individuals and populations. Biological basis of radiological protection. The basic principles underlying the use of chemotherapeutic drugs: (a) Classification of anticancer drugs. The principles of cell kill by chemotherapeutic agents. Definition of phase specific and cycle specific action. (b) Principles of administration of drugs. The general principles of pharmacokinetics; factors affecting drug concentration “in viva;” for example, route and timing of administration, drug activation, plasma concentration, metabolism, and clearance. Principles of combination therapy, the use of dose response curves, adjuvant chemotherapy, problems of sanctuary sites,
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principles of high-dose chemotherapy. (c) Toxicity of drugs. Early, intermediate and late genetic and somatic effects of common classes of anticancer drugs. (d) Concept of drug resistance. (e) Introduction of new drugs. Principles of Phase I, Phase II and Phase III studies. (f) Interaction of cytotoxic drugs and irradiation. (g) Principles and practice of protection in the use of cytotoxic drugs.
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3.
Medical statistics and epidemiology 1. Summarizing and presenting data: (a) Qualitative data: proportions, bar charts, contingency tables, relative risk. (b) Quantitative data: measurements of location and spread, histograms, transformations, the Normal distribution, scatter diagrams. 2. Sampling: concept of a source population, random sampling, sample mean as estimating the population mean, standard error of sample mean and of a proportion, confidence limits. 3. Statistical significance: (a) Concepts of null hypothesis, types I and II errors. (b) Paired and two-sample t-tests, analysis of 2 X 2 contingency tables, the ideas of extension to analysis of variance and larger tables, simple linear regression, nonparametric analogues of the ttest. 4. Survival and recurrence data: presentation of individual patient survival data, crude survival rate, age-adjusted survival rate, life-table (actuarial) calculation of survival rate, survival curves, comparison of two curves, logrank test, concept of a cured group, recurrence-free rates. 5. Clinical trials: problems of retrospective comparisons and use of historical controls, prospective randomized controlled studies, protocols, aims of study, patient eligibility, informed consent, methods of allocating treatment options, numbers required, multicentre studies, double-blind studies. Measures of response: tumor regression, quality of life, morbidity, local and regional recurrence, distant metastases, death. 6. Epidemiology: mortality rates, standardized mortality rates, cancer registration and follow-up, cancer incidence and mortality rates for major anatomical sites, trends in cancer incidence and mortality, aetiological, and diagnostic studies. Ph vsics 1. Production of x-rays. Factors controlling the quantity and quality of x-ray emission. 2. Interaction of x-rays, y-rays and other ionizing radiations with matter. The photoelectric, Compton and pair-production processes. The parameters upon which their magnitudes depend. Their relative importance in clinical practice. The range of the secondary electrons emitted, and its clinical importance. Attenuation and
4.
5.
6.
7.
8.
absorption. Coefficients and the exponential law. Half value layer and filtration. Range of charged particles and the Bragg curve. Linear Energy Transfer (LET). The measurement of x- and y-rays. Exposure, kerma, and absorbed dose; units. Ionization, photographic, thermoluminescent and other methods of measurement and detection. Simple principles of air ionization measurement. Derivation of absorbed dose from air kerma, including calibration standardization. Relationship between exposure, kerma, and absorbed dose. Absorbed dose in heterogeneous materials. Data acquisition for treatment planning. The physical basis of radiation teletherapy. The steps involved in the establishment of the absorbed dose at any point in an irradiated patient: phantoms, “output” calibration, depth dose data, TAR, and isodose curves. Features of external photon and electron beams. Beam modification-filters and tissue compensators. Principles of rotation therapy. Beam therapy apparatus: Relative merits of different types of radiotherapy equipment in routine use. (A knowledge of generator circuitry is not required). Collimation, “applicators,” moving diaphragms. Penumbra. Controls and safety interlocks. Principles of high LET radiation. The principles of treatment planning: Localization. Simulators. Dose computations and construction of isodose distributions. Principles of obliquity and inhomogeneity corrections. Applications of computers to treatment planning, including CT planning; Front and back pointers, isocentric mounting, treatment shells; Principles of treatment verification. General properties and production of radioactive material. Radioactive decay, half-life and equilibrium, units of radioactivity. Radiations from radioactive materials-with special reference to clinical usage; Specific activity; Radionuclides in treatment: (a) Sealed sources and their construction, including p-ray sources; Principles of dosage systems. (b) Unsealed sources; General principles of their use. Principles and practice of radiation protection. Radiation hazards. Protective arrangements in Radiotherapy Departments. Care and custody of sealed and unsealed sources. Monitoring. Protection of the patient and the public. Relevant aspects of the current legislation.
SylIabus:$nal examination The College advice is simple and straightforward: “A wide knowledge of malignant disease and the management of the cancer patient is required. There will be special emphasis on radiotherapy and chemotherapy but a good knowledge of general medicine, surgery, and gynaecology is expected.” The examination is intended to test: (a) Academic knowledge-written papers; (b) Application of knowl-
Radiation oncology training in the UK 0 R. G. B. EVANS
edge-written papers + practical examination; (c) Opinion-written papers + practical examination; (d) Proficiency in the specialty-practical examination (planning). Notwithstanding this simple advice, a working-party of the Education Board which was advising on appropriate training for the post-FRCR period felt compelled to establish what ought to be a minimum core training leading up to the FRCR. The following guidelines were suggested: Didactic teaching in cancer basic sciences. (Part I Syllabus). Radiotherapy practice. (a) Principles of radiotherapy, including: integration of imaging techniques including CT with treatment planning; use of computers; treatment optimization. (b) Special techniques: electrons; total body irradiation; intracavitary radiation; interstitial radiation. (c) Use of radio-isotopes for therapy. Application of radiotherapy treatment to different sites, including patient selection and supervision plus care and knowledge of the comnlications. both of disease
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and its treatment. Knowledge should be gained in management of the following groups of cancer: head and neck, CNS, skin/soft tissue, gynecology, pediatrics, gastro-intestinal tract, thorax, lymphomas, and genitourinary. 4. Delivery of cytotoxic chemotherapy and care of the immuno-suppressed and pancytopenic patient. 5. Conduct and analysis of clinical trials. 6. Symptom control/terminal care/counselling. While hands-on experience should be available for the vast majority of the topics listed, for some there may be no experience available in training centres and theoretical knowledge only may be gained. There are likely to be considerable problems in achieving much ofthis core training in small departments where there may be one or two Registrars at most, and consideration needs to be given to secondments and rotation from smaller departments to larger ones in order to ensure a uniform level of basic training.