RADIATION ONCOLOGY TRAINING PROGRAMME

							RADIATION ONCOLOGY TRAINING PROGRAMME

              OBJECTIVES

       GENITO-URINARY ONCOLOGY

        Version date: 20 March, 2009
GENERAL OBJECTIVES

The genitourinary oncology rotations are intended to provide the Radiation Oncology
trainee with the practical clinical experience necessary to develop the knowledge and
clinical skills required to manage patients with full spectrum of genitourinary
malignancies as well as complications of these malignancies and their treatment. The
knowledge obtained during clinical rotations should enhance that derived from self-study,
formal courses, conferences and rounds. The clinical and technical skills can only be
developed with repeated experiences, but many skills learned throughout the training
program can be applied to the management of GU malignancies. There are relatively few
site-specific skills to be mastered.

In general, the trainee should be able to:

1.     Evaluate the appropriateness of the diagnosis and management plan prior to
       referral, assess the patient and stage the disease.

2.     Develop an overall plan of management in collaboration with GU oncology
       specialists.

3.     Plan and supervise the delivery of radiation treatment.

4.     Follow the patient and deal with complications of the disease or treatment.

5.     Interact with the patient and family in sensitive yet informative manner.
SPECIFIC OBJECTIVES

Knowledge:

1.    Know the natural history of adult genitourinary malignancies including major
      (bladder, prostate and testis) and minor (kidney, penis, urethra, renal pelvis and
      ureter) sites. The natural history includes the etiological and risk factors for
      symptoms of, modes of, presentation of, functional effects and complications of
      disease in these sites.

2.    Know the methods used to obtain a tissue diagnosis in these sites, their
      specificity, sensitivity and complications.

3.    Know the pathological classification of benign neoplasia, premalignant and
      preinvasive states. Know the classification and grading systems commonly used
      in invasive malignancies, particularly in prostate cancer. Know which
      pathological technique can assist in clarifying the histopathological diagnosis in
      these sites.

4.    Understand the anatomy of the region and routes of spread of the specific
      malignancies sufficiently well to perform and interpret appropriate physical and
      radiological examinations. Know the pertinent anatomical relationships, cross
      sectional and surface anatomy in the abdomen and pelvis necessary for treatment
      planning.

5.    Use knowledge of natural history, prognostic factors and current staging systems
      to accurately stage the patients. Be able to estimate the probability of occult local,
      regional and systemic spread of invasive malignancy, the predictive value of
      selected staging tests and use this information to justify the staging work-up.

6.    Know the value of tumour markers, specifically in testicular and prostatic
      carcinoma.

7.    Be able to recognize specific syndromes associated with these sites including, but
      not exclusively:
          a) obstructive uropathy
          b) marrow failure
          c) hypercalcemia
          d) cord compression
          e) pain
          f) hematuria and clot retention
          g) acute renal failure

8.    Recognize the paraneoplastic syndromes associated with renal and prostatic
      cancer in particular.
9.    Know the psychological and social effects of the diagnosis and treatment on the
      patient and family.

10.   Know the relative role, results and complications of treatment with radiotherapy,
      hormones, surgery and/or chemotherapy in the management of primary, recurrent
      and metastatic presentations. Be familiar with modern reconstruction techniques
      and the role of salvage surgery. Know which chemotherapy combinations are
      used in this site. Know what palliative treatment is available. Discuss pros and
      cons of surveillance strategies in selected GU situations (post-operative
      seminoma, small renal cell ca, low risk prostate ca)

11.   Know the clinical manifestations of early and late radiation injury to normal
      tissues potentially irradiated in this site. Know the frequency and time course of
      such injury. Know what side effects occur during treatment at this site.

12.   Be aware of investigational treatment approaches – altered fractionation,
      radiation/drug/surgery combinations, alternative local treatment options, newer
      systemic therapies being investigated and their results.

13.   Understand the purpose of follow-up and what types of clinical examination and
      investigations are required and their frequency.
CLINICAL SKILLS:

1.   The resident will be able to perform an appropriate history and physical
     examination, learning to perform a digital rectal examination (DRE) in men with
     prostate cancer to define the size of the gland, differentiate between benign and
     malignant nodularity and map out tumour extent; a bimanual examination in
     female patients with lower urinary tract tumours to define tumour size and extent;
     and scrotal examinations in patients with a history of testicular cancer to rule out
     recurrence.

2.   Interpret the pathology report and to extract important prognostic information,
     particularly in uro-epithelial tumours. Discuss the differential diagnosis of a
     tumour at these sites.

3.   Request appropriate laboratory, imaging and surgical staging investigations and
     interpret the results in terms of disease status and activity.

4.   Formulate and defend a management plan. Discuss the controversies having
     evaluated all options and reasonable alternatives.

5.   Demonstrate the willingness and ability to describe dispassionately the diagnosis
     and likely clinical course, the therapeutic options including benefits and side
     effects to the patient and family. Demonstrate the ability to balance the
     responsibility for providing a realistic appraisal of the clinical condition with the
     need to preserve hope. Involve the patient in treatment decision making.

6.   Provide appropriate management for the medical complications of GU
     malignancies as outlined under the section Knowledge No.7 and 8.

7.   Understand the details of the surgical options sufficiently to discuss the
     appropriateness of a given type of operation in a given situation and to judge the
     adequacy of a given resection and the risk of residual disease. This includes (but
     not exclusively) radical prostatectomy, cystectomy and retroperitoneal node
     dissection.

8.   Understand possible chemotherapy/radiation interactions to modify radiotherapy
     schedules and doses to take account of these.

9.   Anticipate, recognize and treat radiation side effects during and following
     treatment (e.g. dysuria, frequency, rectal pain, late rectal bleeding, sexual
     dysfunction)
TECHNICAL SKILLS:

1.   Procedural Skills
        a) Catherization
        b) Transrectal ultrasound (observation)
        c) Prostate seed implant (observation)

2.   Treatment planning skills
        a) Immobilization techniques to minimize movement of the pelvis for most
           major and minor sites, immobilization of the penis during radical
           treatment and ensure daily reproducibility in large field seminoma
           treatment.
        b) Simulation – define
                 - extent of disease
                 - tumour volume
                 - target/treatment volume
                 - markers for daily localization
                 - critical normal structures
                 - beam modifying devices
                 - appropriate technique – single field, multiple field, arc rotations,
                     dynamic/conformational, IMRT, implants
        c) Dosimetry
                 - optimizing isodose plan, including limiting dose of normal
                     structures to established constraints
                 - selection of appropriate isodose for prescription
                 - compensation
                 - dynamic/conformal/IMRT/implant
        d) Treatment
                 - Machine and beam energy selection
                 - Dose/fractionation/overall time

3.   Graded Responsibility : Trainee should be able to:

     Year 1 (PGY3)
        a) apply basic knowledge to perform an appropriate history and physical
            examination
        b) present the case summarizing the important factors and findings,
            recommend staging tests, discuss general principles of treatment including
            the role of radiation with approximate treatment results
        c) plan simple, radical and palliative treatments




     Year 2 (PGY4)
   a) plan and defend a staging work-up (if appropriate) and evaluate results of
      investigations
   b) propose and defend a management plan that may include surgery,
      hormones, radiation and chemotherapy for major GU malignancies
   c) communicate this plan to patient and family, answering questions
      regarding treatment outcome and toxicity
   d) communicate plan to other members of the health care team
   e) plan more complex radical and palliative treatments, including multiple
      field techniques and implants

Year 3 (PGY5) - as previous years with additional ability to
   a) formulate a management plan to ALL GU presentations
   b) discuss the controversies in the management and cite key literature in the
       area
   c) plan all radical and palliative cases