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Practice Simulations of Image-Guided Radiation Therapy to

Prepare Students before Clinical Rotations

Morgan Jostpille


Since the last decade, radiation therapy has completely overhauled its methods and continues
to better its oncology treatment. Rapidly evolving technology has prompted students with
overwhelming amounts of new skills and information to be acquired. Imaging with x-rays for
radiation treatments have prevailed due to its strategic treatment methods. Clinical rotations are
the prime learning tool for students to acquire these skills. Prior to a bachelor degree in radiation
therapy, students were required to first complete a degree in radiology and continue schooling if
one wanted to pursue radiation therapy. Radiology has taught their students how to take x-ray
images. Students eventually become conformable looking at the images and can distinguish
discrepancies on abnormal radiographs. With no prior experience in the field, radiation therapy
students struggle with determining anatomy structures with these non-diagnostic images.
Aligning images using image-guided radiation therapy has been a consistent struggle for students
to master. In clinical sites, we see a trend of therapists rarely letting their amateur students run
the machine due to an extended duration of the patient’s treatment. Students feel pressure
resulting in a slower learning rate due to rarely running the console. This is a result because
students do not get adequate exposure to training before their clinical rotations. Hands-on-
learning using simulations of image-guided radiation therapy are proven to help benefit the
student while accelerating their learning process. These simulations would provide a realistic
aspect as if we were treating a real patient. They would provide pre-professionals with the
knowledge and skills while protecting the patients due to errors before being competent. A
plethora of similar studies have been proven as a successful learning tool for students in all
different majors especially high-risk procedures in the medical field. Following their example,
we could better train our students to be more prepared when entering the world as a therapist.
The subjects for this study will include junior and senior radiation therapy students. The juniors
will be exposed to the new training system, while the seniors will provide a baseline for the
research. With extra exposure and repetition, we will expect the students to perform better with
aligning images earlier compared to those with no prior training.
Research Question/Hypothesis:

If practice IGRT simulations benefits radiation therapy students prior to their clinical
rotations, then the students’ knowledge and understanding of aligning anatomy will boost their
confidence and accuracy in clinical. Due to the evidence in the literature, this study design
should be correct because similar studies have been proven to be successful. With rapidly
evolving technology, students are overwhelmed with the amounts of new skills and information
to be acquired in radiation therapy. This hypothesis needs to be tested because IGRT is the area
students struggle with most within the program.

Literature Review:

Radiation therapy techniques have advanced rapidly in the past decade because of more
strategic treatment plans.1, 3, 6 The new technology requires additional knowledge to learn in the
same four-year bachelor degree. Radiation therapists are the most affected by the new
development of IGRT technologies.3 Working in technology results in new innovations,
therefore, therapists will need to adapt to new methods and cope with ways to master the skill.

A sample of 601 surveys respond to the e-mail pertaining to IGRT modality/frequency.6 The
majority (92%) used volumetric imaging (CBCT) in their practices.6 Only 41% of radiation
oncologists have trained using the IGRT verification process.6 These statistics validate that more
education regarding IGRT is needed.

In 2015 Canadians developed a boot camp for radiation oncology residents to learn how to
contour anatomy on a CT scan. 4 The results stated the camp was effective to improve the
residents’ knowledge and understanding of anatomy and radiology, boosting their confidence
and accuracy.4 Matching more x-ray images will expose the therapists to learn the anatomy of
radiographs and how to handle discrepancies aligning images.

For years now, simulations have been applied to many different disciplines and trainees
including in the military and hospital procedures.5 It is beneficial because it creates realistic
scenarios that replicate treating at the machine until the students can master the skill. The end
goal is to reduce unnecessary risks that are potentially harmful to the patient.
In 2014 another study was conducted using a 3D gaming environment with realistic models.1
Using this gaming method students could compare their performance and practice their problem-
solving skills. The students will be able to compare how they aligned x-ray images to how the
therapists treated the patient.

It is important to train the students with the same software used during the simulation and at
the treatment machines to achieve consistency. Queensland University of Technology provided
the same imaging technics used in clinical locations including 2D portal images, orthogs, and
CBCT using MOSAIQ.2 This allowed the students to learn in a safe-positive environment
without the time pressures in the clinic.2, 5

A 6-month pilot study of 33 treatment planning system simulations was conducted for
students in Australia to complete.7 Eleven of the thirteen participates agreed they were more
knowledgeable and confident after completing the simulations.7 The mentor’s statements also
coincided. These survey scores are listed in Figure 1 for both the students and the mentors.7 This
literature is like the model I want to administer in our radiation department. Training was divided
based on location of disease using Varian Eclipse software.7 Both mentors and students
determined the simulations as successful.
Figure 1

The goal of implementing simulations is

to provide a software system that
consists of ports, orthogs, and conebeam
images for students to acquire the skills
necessary to treat the patient before
entering clinical rotations. By having the
senior radiation therapy students
complete a survey, it will determine if
simulations would be beneficial to their
learning. They would answer questions Figure 2
concerning their learning habits, ways to improve clinical for students, and when
they felt comfortable imaging in clinic. The senior members would be the baseline for the study.
The seniors will not get the training for the simulations. The new image simulation would be
applied to the junior members in the autumn semester. Clinical supervisors will monitor the
junior students during spring semester to observe if their imaging accelerated their skills better
the seniors. At the end of spring semester, the junior students will take a survey to determine if
the simulations were educational and when they felt comfortable imaging in the clinic. Junior
students would go through a semester of matching different kinds of image methods and two
different images would be due at the end
of each week. The same software, Aria,
will be used to make the transition from
simulation to clinical transparent.
Information will still be provided, just
like clinical, concerning what structures
the doctor wants the image aligned. Using
previous-deidentified-patient’s x-rays
will create a sense of realism in the
simulations to mimic real-life situations
as seen in clinic. As the duration of the
course increases, the intensity level of the Figure 3
image will go from simple to complex. First, the students will start with a basic conformal plan.
An example could be orthogs of a whole brain seen in Figure 2. Later in the course, the students
will master images of all anatomy sites with all image methods. An example for a difficult
patient could be discrepancies in a conebeam concerning a head and neck patient seen in Figure
3. This will teach the students how important critical thinking is as a therapist and hopefully
develop this skill during this time. The students will be able to submit how they think the patient
should be treated by shifting the images. Then, they can compare to how the therapists treated on
the treatment machine. Students would have an unlimited amount of time before the weekly due
date to examine in detail to perfect the image. With unlimited time, students will process where
they think the image looks best without pressures. Students would be graded solely on a
completion grade. At the end of the week an in-class discussion with the professor would provide
time to ask questions during their matching simulations. The professor can then clarify why the
therapists went with certain structures because it does not always clear. Students would learn a
variety of skills such as, what stable alignment marks are for different treatment areas, critical
structures, how to physically adjust the patient to better the treatment area, what is clinically
acceptable tolerances for treating a patient. Students should improve in multiple areas which will
provide the confidence we see in lacking in students. Having this background training would
maximize clinical time, therefore allowing students to perform better when imaging for the first
time. Better preparing the students for the role of a therapist would be the ideal outcome when
implementing this simulation. If this study is proven to be successful, we could implicate the
simulations not just with radiation therapy students, but also with physician residents and
physicist residents. Physicians and physicists are exposed to aligning these images with no prior
experience to their specialty residency.

Possible results:

From the results, the junior radiation therapy students outperformed the senior students using
image-guidance radiation therapy. They acquired the skills significantly faster and could jump
right into their clinical rotation with ease. The transition ran smoothly because the simulations
used the same software system as the clinical sites. From the post survey, we gathered that the
students thought that the additional training was educational. They also confirmed that they felt
comfortable imaging in the clinic months before the senior students stated. The clinical
supervisors also agreed they seen accelerated improvement in aligning images. When comparing
the performance of the juniors to the seniors it was found to be significantly different. Therefore,
the department will continue to train all their students with this same exact method. After
implementing this training, we will see an improvement in skill level upon graduation. This will
hopefully lead to 100% job placement upon graduation.

If the study did not support my hypothesis, we would see the data to not be significantly
different. The juniors and seniors would perform about at the same level during clinical rotations.
The training would continue the same next year to see if there were confounding variables. One
potential confounding variable is that the senior students are more studious than the junior class.
If the following year the results are still not significant, we will resume with the previous method
before the training was introduced. This method consisted of running the console during second
semester and only practicing during clinical hours. Now, another hypothesis could be formed.
The focus is on achieving a program that prepares the students to become radiation therapy
leaders in the oncology department.

1. Bridge P, Gunn T, Kastanis L, et al. The development and evaluation of a medical

imaging training immersive environment. Journal of Medical Radiation Sciences.
2014;61(3):159-165. doi:10.1002/jmrs.60.

2. Chamunyonga, C., Rutledge, P., Caldwell, P., & Burbery, J. (2017). Implementing and
integrating a radiation oncology information system as a pedagogical tool for
undergraduate radiation therpay training. Journal of Radiotherapy in Practice, 16(2),
199-206. Doi:10.1017/S1460396916000546

3. Elizabeth White, Gabrielle Kane, Radiation Medicine Practice in the Image-Guided

Radiation Therapy Era: New Roles and New Opportunities, Seminars in Radiation
Oncology, Volume 17, Issue 4, 2007, Pages 298-305, ISSN 1053-4296,

4. Jaswal JJ. International journal of radiation oncology, biology, physics: Evaluating the
impact of a Canadian national anatomy and radiology contouring boot camp for radiation
oncology residents. Pergamon Press; 03/2015;91:701.

5. Lateef F. Simulation-based learning: Just like the real thing. Journal of Emergencies,
Trauma and Shock. 2010;3(4):348-352. doi:10.4103/0974-2700.70743.

6. Nabavizadeh, Nima et al. Image Guided Radiation Therapy (IGRT) Practice Patterns and
IGRT’s Impact on Workflow and Treatment Planning: Results From a National Survey of
American Society for Radiation Oncology Members, International Journal of Radiation
Oncology, Biology, Physics, Volume` 94, Issue 4, 2016, Pages 850-857,
7. Opie C, Elsner K. Using simulations to train students in the treatment planning. Radiation
Therapist. Spring 2010; 19(1): 18-26. Available from: CINAHL, Ipswich, MA. Accessed
July 3, 2017.