In This Issue
From Resident to Brachytherapist
Incorporating Social Media into
Patient Safety Educational Resources from the International Atomic Energy Agency
Board of Directors
Catheryn Yashar, MD, FACRO, FACR
Peter F. Orio, III, DO, MS
Daniel G. Petereit, MD
Ann Klopp, MD, PhD
Firas Mourtada, PhD
Steven J. Frank, MD
Chairman of the Board
David K. Gaffney, MD, PhD
Past Chairman of the Board
ushil Beriwal, MD
Zoubir Ouhib, MS, DABR
Christopher L. Deufel, PhD
Peter J. Rossi, MD
Journal may now be accessed online through the Elsevier Science website via the members-only portion of the ABS website. Members can access the journal articles quickly by clicking on the link below and logging in using your ABS username and password.
Reimbursement and Coding
The Socioeconomic Committee has created a
by posting relevant brachytherapy coding and reimbursement information on the ABS website. Currently, ABS members can review the 2017 Medicare proposed rule summaries and payments to physicians, hospital outpatient departments and ambulatory surgical centers. In the coming months, the Committee will post new and revised procedure codes effective in 2017 and frequently asked questions and answers.
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Welcome to the monthly communication of the American Brachytherapy Society called BrachyBlast. The BrachyBlast is somewhat informal and we welcome your feedback on issues relevant to your practice. This month's topics are,
From Resident to Brachytherapist and Incorporating Social Media into Radiation Oncology and Patient Safety Educational Resources from the International Atomic Energy Agency
Catheryn Yashar, MD, FACRO, FACR
Daniel G. Petereit, MD
Dr. Scott Glaser is our guest editor for the ABS Blast. His editorial on transitioning from resident to brachytherapist is timely and incredibly relevant - especially for newly trained radiation oncologists beginning a brachytherapy practice. He has several "pearls" for us all to consider -whether as a recently trained brachytherapist or a seasoned one implementing new techniques. For those of us who have been in practice for some time, Dr. Glaser discusses the importance of being available to assist the next generation of brachytherapists as well as for each other. This is obviously critical for the ongoing viability of our field. His mentor Dr. Sushil Beriwal took the time to discuss a very complex GYN interstitial case with me after 9 PM EST last fall while we were in the middle of treatment planning. So, thank you Sushil!
Scott Glaser, M.D., is an assistant clinical professor of radiation oncology at City of Hope National Medical Center (Duarte, California) where is clinical and research interests revolve around brachytherapy for gynecological, prostate, and breast cancer. He grew-up in Michigan, received an undergraduate degree from Hope College in Holland, Michigan, and a medical degree from the Loyola University Stritch School of Medicine in Chicago. This past summer, he completed a residency in radiation oncology at the University of Pittsburgh
We have additional "slots" open for 2018 for anyone who is inspired to write a section for our monthly communication.
Daniel G Petereit, MD, FASTRO
Catheryn Yashar, MD,
From Resident to Brachytherapist
Scott Glaser, MD
Assistant Clinical Professor at
City of Hope National Medical Center
Recently, I made the transition from residency to being an attending. During the job search process, I prioritized opportunities to be involved with brachytherapy and ended up taking a job focused primarily on brachytherapy. Now, eight months in, I wanted to take this opportunity to reflect on the transition from training to independent practice.
My interest in brachytherapy grew throughout my time in residency. Many aspects of brachytherapy drew me in, including the diversity of cases, the technical aspect, the high precision of treatment, the ability to offer definitive curative treatment, and the ability to collaborate with others. Also, I was fortunate to train in a program with a high volume of brachytherapy and with exceptional mentorship. This helped solidify my desire to pursue a career in brachytherapy. Still, there is no way to be 100% prepared for everything. There were a myriad of things I sought guidance on throughout the transition to being an attending. Some of the things that I have relied heavily upon my mentors for include planning for complex procedures, troubleshooting flawed cases, selection of new applicators for purchase, and academic networking.
The ACGME sets a minimum number of brachytherapy cases to graduate. For radiation oncology residents the minimum is 5 interstitial and 15 intracavitary cases. I finished residency with 66 interstitial and 294 intracavitary cases. My point in bringing this up is two-fold. First, even with this number there have been numerous instances when I have felt the need to reach out to my mentors (primarily Dr. Sushil Beriwal and Dr. Ryan Smith at the University of Pittsburgh Medical Center) to ask for their help or input. I am fortunate that both are willing to take my call or text at any time and provide guidance. Second, it is easily conceivable that a resident could graduate without ever doing a template-based interstitial brachytherapy procedure (or conversely without ever doing a prostate brachytherapy case). While less likely, it is even possible one could graduate by doing 15 cylinder placements for adjuvant vaginal cuff brachytherapy and never have treated a single intact cervix patient.
It is no secret that brachytherapy utilization is declining, despite superior outcomes[1,2]. My belief is that in combination with the resource requirements and the comparatively lower RVU to effort ratio, inadequate training or confortability with the procedures may be part of the reason for this decline. This is something that hopefully could be revisited by the ACGME with encouragement from the radiation oncology societies. A welcomed secondary effect of increasing the brachytherapy case requirements may be to help curtail the spurious expansion of residency positions.
There have been numerous clinical questions for which I have called upon my mentors in Pittsburgh to provide direction. Topics of conversation have ranged from simple things like "do you think this needle is into the bowel wall and needs to be pulled back", to more complex scenarios such as "would you offer this patient with synchronous uterine and vaginal cancers with peri-urethral extension brachytherapy and if so, how would you perform it?" Other conversations have been more about the procedural aspects, like "how do you coordinate with the urologist who places the hydrogel spacer", or "what software upgrades would be necessary to allow us to have real-time seed placement captured during our prostate seed implants, and is it worth the upgrade?"
There are also things that I overlooked as a resident that I have learned the value of through trial and error on my own. For example, the necessity for a centralized brachytherapy schedule accessible to all key members of the team became apparent. Other workflow issues such as which physicist is assigned to a case and how they would be notified likely never really are an issue for most residents, but as a new attending these details become very important, very quickly. Luckily for me, one of my current partners who did the bulk of the brachytherapy before I joined has been exceedingly instructive and supportive. He has helped me understand the processes in place before my arrival and has helped identify areas for potential improvement. Indeed, I imagine it would be much more difficult to start a brachytherapy program from the ground up, than it has been for me to join a practice with a framework in place, augmenting and building upon what was already there.
One of the challenges I faced when transitioning to do brachytherapy at a new institution came from my desire to bring facets of my training to my new position. More specifically, I sought to implement MRI-based planning for each fraction of brachytherapy for intact cervix and incorporate hybrid (Vienna) applicators when necessary. As part of the hiring process I described this goal to my chairman, who has been tremendously supportive and agreed to invest in new applicators. Prior to my arrival, all cases were done with tandem and ovoids. While I comfortable with tandem and ovoids, I had more experience with, and preferred the tandem and ring (including Vienna) applicators due primarily to the fixed geometry and ease of placement. What I was not aware of during my training was all the different applicators on the market and compatibility issues with various remote afterloaders. My current institution has an "older" afterloader, and thus I came to learn that many of the "newer" applicators (which I had trained with) had a smaller internal diameter and were not compatible with our afterloader. After visiting booths at ABS and ASTRO and communicating with our brachytherapy rep we found a ring and tandem set, hybrid build up caps, and interstitial needles which were all MRI-compatible and worked with our remote afterloader. This process required purchase orders from multiple different companies. There is no doubt that having the desired applicators available, and being familiar with the equipment at one's institution will be a challenge for any resident accepting a position with a brachytherapy component. Having assistance from those more experienced in the field is paramount to achieving success.
In conclusion, there have been multiple hurdles to overcome during the move from resident to attending. Thanks to dedicated instruction and continued support from passionate mentors, it has thus far been a fun and rewarding transition. While I hope to continue to build my career as a brachytherapist through collaboration, networking, and research, an equally important goal is to pass on the skills I have learned to the residents whom I have the privilege of mentoring.
1. Gill B, Lin J, Krivak T, 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 Biol Phys. 2014;90:1083-1090.
2. Glaser S, Dohopolski M, Balasubramani G, et al. Brachytherapy boost for prostate cancer: Trends in care and survival outcomes. Brachytherapy. 2017;16:330-341.
3. Bauer-Nilsen K, Hill C, Trifiletti D, et al. Evaluation of Delivery Costs for External Beam Radiation Therapy and Brachytherapy for Locally Advanced Cervical Cancer Using Time-Driven Activity-Based Costing. Int J Radiat Oncol Biol Phys. 2018;100:88-94.
Incorporating Social Media into Radiation Oncology
Chirag Shah, MD
Associate Staff in the Department of Radiation Oncology and Director of Clinical Research in the Department of Radiation Oncology at the
Throughout all aspects of our lives, the impact of social media continues to rise. The use of social media in Radiation Oncology started off slower than many other fields but is rising rapidly. Incorporating of social media into a radiation oncology practice can seem daunting and the question of the relevance is appropriate. It is important to realize that social media offers several unique ways to be incorporated into Radiation Oncology. The first way is simply as a source of information; each day, new data and studies are published and it is daunting to keep up with the literature. Social media can serve as a way to identify studies to review or critical updates. Physicians interested in a specific site (ex. Breast cancer) can use site specific hashtags (ex. #bcsm) to further narrow the scope of the information they receive. Additionally, information regarding major societies, policy, and meetings can easily be found through social media. A second way that social media can be utilized is to educate. Social media allows for users to promote their research, presenting key findings from their group. Also, it allows users to promote their practices and institutions, highlighting differentiating factors. Finally, social media allows users to promote data regarding key topics to the specialty. Finally, social media can be a way to engage the community; beyond physicians, social media has large numbers of patients and advocates, allowing physicians to reach communities in a unique. While social media offers promise for radiation oncologist, it is also important to remember common pitfalls. First and foremost, assume everything posted will be available forever regardless of whether you delete it. Before posting, take a deep breath, re-read your post and consider how others could interpret. Additionally, despite how others may act, remember that you are still a professional and are judged as such. Therefore, while spirited discussions are welcome remember to remain polite to others regardless of what is said. Finally, have fun! Social media may seem daunting at first but once you get used to it, should be a source of enjoyment. One of the most enjoyable things for me is to get on to a social media platform and see what colleagues are doing to advance our field and tackle the challenges we face day in and day out. For those interested in getting on social media, I invite you the Annual Meeting Social Media Session.
Patient Safety Educational Resources from the International Atomic
Tim Showalter, MD, MPH, University of Virginia
The ABS Patient Safety Committee aims to connect members with educational resources to enrich patient safety and quality in brachytherapy. ABS members may be interested in the online resources provided by the International Atomic Energy Agency (IAEA) on this topic . The IAEA offers their Safety in Radiation Oncology (SAFRON) program to improve the safety of radiation therapy throughout the world. In addition to the SAFRON incident reporting and learning system, which supports reporting of both external beam radiation therapy and brachytherapy for member institutions, the IAEA offers online training and educational reports on patient safety in radiation therapy.
On the IAEA website, there is a freely accessible electronic learning course on Safety and Quality in Radiation Therapy . The training module can be completed in 5 hours of less and a certificate of completion is available. This is a potentially valuable resource for institutions interested in offering education in patient safety for the entire brachytherapy team or for a radiation oncology residency program curriculum. At the University of Virginia, we feature this learning module in the residency curriculum to meeting program requirements for patient safety education.
The IAEA also offers educational reports based upon reports from the SAFRON incident reporting and learning system. Since the SAFRON system includes brachytherapy events, the educational reports may be of interest to ABS members. Brachytherapy events have been described in the last two issues of the SAFRON Updates on Patient Safety in Radiotherapy educational reports [3; 4]. The August 2017 report includes a description of a brachytherapy event that involved a source wire breaking during HDR brachytherapy treatment that resulted in the source remaining inside a patient. This critical incident highlights the importance of following standard safety procedures, including paying attention to radiation monitors and adhering to standard safety practices . The December 2017 reports includes description of a brachytherapy event that involved incorrect transfer tube length during treatment with a new transfer tube. The discussion emphasizes the importance of commissioning of new equipment, verifying the lengths of all brachytherapy transfer tubes and applicators, and clear communication .
The IAEA webpage  also includes links to other useful online resource. The IAEA resources complement material available elsewhere through the ABS, ASTRO, AAPM, and other organizations. Please consider using the IAEA materials to supplement educational materials available to your center. As always, the ABS Patient Safety Committee welcomes any suggestions or contributions that may be useful to the ABS membership.
 International Atomic Energy Agency, SAFRON Updates on Patient Safety in Radiotherapy, August 2017, SAFRON Updates on Patient Safety in Radiotherapy, Vienna, Austria, 2017.
 International Atomic Energy Agency, SAFRON Updates on Patient Safety in Radiotherapy, December 2017, SAFRON Updates on Patient Safety in Radiotherapy, Vienna, Austria, 2017.
Membership Committee Participation
The ABS Membership Committee is looking for volunteers for regional membership recruitment efforts - if you are interested please contact committee chair Jarek Hepel .