Int. J. Radiation Oncology Biol. Phys., Vol. 79, No. 3, pp.

853–859, 2011
Copyright Ó 2011 Elsevier Inc.
Printed in the USA. All rights reserved
0360-3016/$–see front matter

doi:10.1016/j.ijrobp.2009.10.054

CLINICAL INVESTIGATION Education

TEACHING THE ANATOMY OF ONCOLOGY: EVALUATING THE IMPACT OF

A DEDICATED ONCOANATOMY COURSE

JUNZO P. CHINO, M.D.,* W. ROBERT LEE, M.D., M.S., M.A., ED.,* RICHARD MADDEN, PH.D.,y
ERSHELA L. SIMS, PH.D.,y TRACY L. KIVELL, PH.D.,y SARA K. DOYLE, PH.D.,y TERRY L. MITCHELL, PH.D.,y
E. JANE HOPPENWORTH, M.A.,* AND LAWRENCE B. MARKS, M.D.z
From the *Department of Radiation Oncology, Duke University Medical Center, Durham, NC; yDepartment of Evolutionary
Anthropology, Duke University, Durham, NC; and zDepartment of Radiation Oncology, University of North Carolina, Chapel Hill, NC

Purpose: Anatomic considerations are often critical in multidisciplinary cancer care. We developed an anatomy-
focused educational program for radiation oncology residents integrating cadaver dissection into the didactic
review of diagnostic, surgical, radiologic, and treatment planning, and herein assess its efficacy.
Methods and Materials: Monthly, anatomic-site based educational modules were designed and implemented
during the 2008–2009 academic year at Duke University Medical Center. Ten radiation oncology residents partic-
ipated in these modules consisting of a 1-hour didactic introduction followed by a 1-hour session in the gross
anatomy lab with cadavers prepared by trained anatomists. Pretests and posttests were given for six modules,
and post-module feedback surveys were distributed. Additional review questions testing knowledge from prior
sessions were integrated into the later testing to evaluate knowledge retention. Paired analyses of pretests and
postests were performed by Wilcoxon signed-rank test.
Results: Ninety tests were collected and scored with 35 evaluable pretest and posttest pairs for six site-specific
sessions. Posttests had significantly higher scores (median percentage correct 66% vs. 85%, p < 0.001). Of 47 evalu-
able paired pretest and review questions given 1–3 months after the intervention, correct responses rates were
significantly higher for the later (59% vs. 86%, p = 0.008). Resident course satisfaction was high, with a median
rating of 9 of 10 (IQR 8-9); with 1 being ‘‘less effective than most educational interventions’’ and 10 being
‘‘more effective than most educational interventions.’’
Conclusions: An integrated oncoanatomy course is associated with improved scores on post-intervention tests,
sustained knowledge retention, and high resident satisfaction. Ó 2011 Elsevier Inc.

Oncology, Anatomy, Resident education, Radiation.

INTRODUCTION Council for Graduate Medical Education for all otolaryngol-

Gross anatomy has been part of a long-standing tradition in
medical education. However, hours devoted to teaching anat-
omy have been declining (1–3). Up to 71% of residency
directors report that incoming residents either require a re-
fresher anatomy course or are ‘‘seriously lacking in anatomic
knowledge’’ (1).
Radiation oncologists require an intimate understanding of
anatomy, in the diagnosis and staging of disease via physical,
radiologic, and pathologic examinations, and in the appropri-
ate selection of therapies (4). An intimate knowledge of anat-
omy must be cultivated to further one’s expertise in the field.
However, reviewing gross anatomy via cadaver prosections
is not a traditional part of the radiation oncology residency.
This is in contrast to many surgical subspecialties; for exam-
ple, cadaver lab experience is a required by the Accreditation
ogy residency programs (5–9).
The ‘‘oncoanatomy’’ course at the Duke University Med-
ical Center was designed in 2005 to address this need (10).
The course goal was to reintegrate the often-forgotten gross
anatomic relationships (usually learned in the first year of
medical school) with relevant oncologic problems. We herein
assess the educational impact of this initiative.
METHODS AND MATERIALS
Course description
The ‘‘oncoanatomy’’ course at Duke is based on monthly mod-
ules addressing a specific body region or tumor site where anatomic
relationships are particularly pertinent to radiation oncologists (10).
This analysis is limited to the 2008–2009 academic year for modules
listed in Table 1. Module subjects were determined by the chief

Reprint requests to: Junzo Chino M.D., DUMC Box 3085, Dur- Conflict of interest: none.
ham, NC 27710. Tel: 919-668-7336; Fax: 919-668-7345; E-mail: Received Aug 4, 2009, and in revised form Oct 28, 2009.
junzo.chino@duke.edu Accepted for publication Oct 29, 2009.
Supported in part by an Innovations Grant from the Duke Univer-
sity School of Medicine office of Graduate Medical Education.
853
854 I. J. Radiation Oncology d Biology d Physics Volume 79, Number 3, 2011

Table 1. Oncoanatomy modules 2008-2009 in gross anatomy). Appropriate resources for the anatomic lab
session are then obtained and organized by the anatomists.
Pancreatic cancer
Existing cadavers and anatomic models from the medical school
Gastric cancer
Cancer in the mediastinum (including nodal metastases, thymoma, gross anatomy course are used in the current phase of the project.
lymphoma, and germ cell tumors) The individual modules have been opened to residents and faculty
Nasopharyngeal cancer from other disciplines as relevant to their interest, but the radiation
Lymph node drainage patterns for cancers of the head and neck oncology department is the primary instigator and beneficiary of the
Prostate cancer course. Costs for 50% full-time equivalent of an anatomist and 60%
Cervical cancer full-time equivalent of the residency coordinator are provided by an
Base of skull tumors Innovations Grant from the Duke University School of Medicine
Laryngeal cancer department of Graduate Medical Education (W.R.L., P.I.).
Retroperitoneal sarcoma Each module consists of two 1-hour sessions. The first hour is
Pancoast (superior sulcus) tumors
a clinically oriented presentation by our residents and faculty that
is similar to our conventional educational conferences. This typi-
resident (J.C.) in conjunction with the residency program director cally includes reviewing a patient case and the relevant radiographic
(W.R.L.) for each semester. This is submitted to the primary anato- anatomy. Time is devoted to defining critical normal tissues on the
mist for the project (R.M.), and the subjects of interest in each treatment planning images (i.e., image segmentation), an important
module are discussed (i.e., nodal patterns of drainage from head- factor during radiation treatment field design. The second session
and-neck site), along with defining a common vocabulary (i.e., the begins with a brief, 10-min introduction by the anatomists that in-
‘‘internal mammary artery’’ is termed the ‘‘internal thoracic artery’’ cludes review of anatomic diagrams and an orientation to up to

Fig. 1. Selected stations for the base of skull oncoanatomy module. (A) Prosection of the base of base of skull, posteroin-
ferior view. (B) Dry skull floor, superior view. (C) Prosection of the cranial fossae, superior view. (D) Prosection of the
cranial fossae with partial brain and brainstem intact, superolateral view. (E) Intact brain and brainstem, inferior view.
(F) Dry skull with mandible removed, inferolateral view.
 A dedicated course for anatomy of oncology d J. P. CHINO et al.
Fig. 2. Example questions for multiple choice ‘‘boards-style’’ questions, segmenting exercises, and field design questions
for various modules of the Duke Oncoanatomy course.
four prosection stations. The large group is then divided into smaller
groups of five to six attendees each. These small groups proceed to
rotate through each prosection station, for a 10- to 15-min informal
discussion and exploration of the prosected cadaver, guided by the
anatomist who prepared the specimen. Station topics are site specific
and vary with the module. For example, for the Base of Skull mod-
ule, stations included views of a dry skull, the cranial fossae from
a superior view, and an inferiolateral view of the jugular foramen
(Fig. 1). Radiologic imaging is available at the stations via computer
monitors to assist in the synthesis of the gross anatomy with the
radiographs. For each session, the anatomists and the radiation
oncology residents and attendings coordinate their presentations to
define the key issues to be discussed.
To assess the utility of this educational intervention, the following
aims and assessment tools were defined.
A. Aim #1: To assess the immediate educational impact of the
modules. Short, 10–15 question tests were administered within 24
h before a module, and within 24 h after module completion. The
pretest and posttest covered the same material, with small alterations
to the question subject and answer selection. Questions included
‘‘boards-style’’ multiple choice questions, segmentation of radio-
graphic images of critical tissues, and radiation field design.
Multiple choice questions had one best answer each, and one
point was awarded for each correct answer. Unanswered questions
were scored as no points. Image segmentation and field design ques-
tions were graded with reference to a ‘‘standard’’ defined with input
from at least two radiation oncologists. A three-point scale was used,
and points were awarded for both completeness of coverage of the
subject, and exclusion of neighboring structures (Fig. 2).
It was explicitly communicated to the residents that performance
on these tests would only be used for evaluation of the course, not
855
for evaluation of their performance within the residency program.
Pretests and posttests for each module were scored by one investiga-
tor (J.C.) at the same sitting to maximize scoring consistency.
B. Aim #2: to assess knowledge retention. After the first two
modules, the pretests and posttests for the latter modules were mod-
ified to include review questions addressing material presented in
prior modules completed 1–3 months earlier. The format of these
questions was identical to that described under Aim #1.
C. Aim #3: to assess the resident satisfaction with the course.
Anonymous web-based surveys were distributed to the residents
at the time of the posttest for the skull base module, which occurred
eighth in the series of 11 modules for the academic year. Participants
were asked to rate the oncoanatomy course as a whole in comparison
to other educational interventions in the Duke residency training
program. A scale of 1–10 was used, with 10 being superior to
most interventions, 5 being equivalent to the average intervention,
1 being inferior to most interventions. Participants were also asked
to rate the educational effectiveness of each portion of the oncoanat-
omy module, differentiating between the clinical didactic compo-
nent, the radiology review component, and the anatomy lab
component. A 1–10 rating scale was used; 10 being highest educa-
tional utility, 5 being of moderate utility, and 1 being of no utility.
Statistics
Paired sample analysis compared pretest versus posttest perfor-
mance (aim #1), as well as pretest versus review question perfor-
mance (aim #2) using the Wilcoxon signed-rank test (11). Tests
were paired by resident (e.g., posttest from resident 1 was compared
with pretest from resident 1). Tests that did not have a corresponding
pair were excluded from the analysis (e.g., if resident 2 completed
856 I. J. Radiation Oncology d Biology d Physics
a pretest but not a posttest for a given module, that pretest was
excluded). All p values are given for two-tailed tests. All statistical
analyses were performed in SPSS v17.0 (Chicago, IL).
RESULTS
Aim #1: to assess the immediate educational impact of the
modules
Ninety pretests and posttests were evaluable from ten res-
idents from six completed modules. Of the residents, six were
postgraduate year (PGY)-2, two were PGY-3, one was PGY-
4, and one was PGY-5. The median number of tests per res-
ident was 10 (interquartile range [IQR] 8–10). Thirty-nine
paired pretests and posttests were evaluable, with a median
of four test pairs per resident (IQR 4–4). The median pretest
score was 66% (IQR 53–82%) vs. a posttest median of 85%
(IQR 71–94%), p < 0.001 for difference by paired analysis
(Fig. 3). For the ‘‘boards style’’ multiple choice questions,
the pretest median was 71% (IQR 41–100%) vs. the posttest
median of 84% (71–100%), p < 0.001. For the image seg-
mentation and field design questions, the pretest median
score was 62% (IQR 38–77%) vs. the posttest median of
78% (IQR 67–100%), p < 0.001).
Upper level residents (PGY 3-5; years 2–4 of radiation
oncology training) performed better on pretests overall
(median score for PGY-2 residents 59% [IQR 40–74%], vs.
upper level median of 73% [IQR 58–86%], p = 0.03), but
not on posttests (median PGY-2 score 83.3% [IQR 69–
92%], vs. upper level median 84.6% [IQR 73-100%], p =
p<0.001
100
80
Test Performance (Percentile)
60
40
20
0
Pretests Posttests
(All Questions) (All Questions)
Fig. 3. Boxplots of scores from pretest and posttests. The box outlines the upper and lower quartiles, the horizontal line
inside the box is the median, and the whiskers represent the range. Outliers are noted by points outside of the whiskers.
Volume 79, Number 3, 2011
0.34). The differences were largest in the pretest board-style
questions (PGY-2 median 50% [IQR 34–81%] vs. upper
level median 81% [IQR 50–100%], p = 0.04), with smaller
differences in the pretest segmentation and field design exer-
cises (PGY-2 median 59% [IQR 28–73%] vs. upper level me-
dian 66.7% [IQR 47–92%], p = 0.15). Both higher level
residents and lower residents showed improved performance
after the oncoanatomy modules, statistically significant for
all comparisons except for boards style questions for the
higher level residents (Fig. 4).
Aim #2: to assess knowledge retention
Eight multiple choice review questions were introduced
into the testing in the latter four modules; each of these ques-
tions was identical to a question on a pretest for a prior mod-
ule. Individual resident performance on the review question
was compared to their performance on the pretest between
1 to 3 months prior. Forty-seven pretest and review question
pairs were evaluable. Thirty of the pairs were obtained 1
month after module completion, 10 pairs were 2 months after,
and 7 were 3 months after. Performance on review questions
was improved compared with pretest performance; percent
correct on all review questions was 86% vs. pretest percent
correct was 59%, p = 0.008 by paired analysis. There was
no difference between the performance on the review ques-
tions and the corresponding immediate posttest questions
(percent correct was 84% for postest, 86% for review,
p = 1.0 for paired comparisons).
p<0.001 p<0.001
Pretests Posttests Pretests Posttests
(Boards Style) (Boards Style) (Segmentation (Segmentation
& Field Design) & Field Design)
 A dedicated course for anatomy of oncology d J. P. CHINO et al.
p < 0.001 p = 0.011
PGY 2 PGY 3-5
pre post pre post
100
80
Test Performance (Percentile)
60
40
20
0
All Questions
Fig. 4. Boxplots of scores from pre- and post-module testing grouped by year of residency. The box outlines the upper and
lower quartiles, the horizontal line inside the box is the median, and the whiskers represent the range.
Though the number of evaluable tests at 3 months after inter-
vention were limited, performance remained significantly bet-
ter on review versus the matched pretest (1/7 correct in pretest,
5/7 correct in review 3 months after intervention, p = 0.046).
Aim #3: to assess the resident satisfaction with the course
Ten anonymous web surveys were distributed at the time
of the eighth module (base of skull), and all were returned
(response rate 100%). The results are collated in Fig. 5.
High resident satisfaction was seen in all module components
with a median evaluation of 10 of 10 for each of the three
components. The median evaluation for the whole course
was 9 of 10 (IQR 8–9).
DISCUSSION
This study demonstrates that integrating the gross anatomy
lab into a coherent oncoanatomy course is a useful educa-
tional intervention, as measured on objective tests. We also
demonstrate that the knowledge gained during these inter-
ventions is maintained for at least 3 months.
Oncology practice requires an in depth understanding of
anatomy, for the diagnosis and staging of disease via physi-
cal, radiologic, and pathologic examinations, and for the
appropriate selection of therapies. For the surgical and
857
p < 0.001 p = 0.099 p < 0.001 p = 0.034
PGY 2 PGY 3-5 PGY 2 PGY 3-5
pre post pre post pre post pre post
Boards Style Segementation
& Field Design
radiation oncologist, a detailed knowledge of the regional
anatomy and the patterns of spread of cancer are critical to
appropriately address both macroscopic and microscopic
extent of disease. For the surgeon, anatomy influences the
selection of dissection plane, resection extent, and either
biopsy or resection of lymph node drainage basins. For the
radiation oncologist, anatomy influences the sequence of
treatment (preoperative vs. postoperative treatment), the
selection of treatment modality (teletherapy, brachytherapy,
intraoperative therapy, and particle therapy), and the design
of treatment volumes and doses.
In addition, with increasing survivorship, particular atten-
tion must be paid to the relationship of normal tissues within
treatment fields, and the potential morbidity of treatments
(12–14). In the case of local regional treatments such as sur-
gery and radiation therapy, the normal tissue often establishes
the limit to which the macroscopic and microscopic disease
can be treated.
An elective oncologic-anatomy course for first-year medical
students was previously described by Hansen et al. at the Uni-
versity of Rochester (15). Their course was designed to intro-
duce clinical relevance to medical students during their
training in gross anatomy. In some respects, the current study
is an inverted form of the Rochester format. We return residents
in clinical oncology to the gross anatomy lab to reinforce the
858 I. J. Radiation Oncology d Biology d Physics Volume 79, Number 3, 2011

Highly More Effective

Effective Than Most
10 10 Educational
Component
Interventions

Resident Evaluations 8 8

6 6
Moderately As Effective as
Effective an Average
Component Educational
Intervention
4 4

2 2
Less Effective
Ineffective
Than Most
Component
Educational
Clinical Radiology Anatomy Overall Course Interventions

Lecture Review Lab Evaluation

Fig. 5. Participant survey results. The box outlines the upper and lower quartiles, the horizontal line inside the box is the
median, and the whiskers represent the range. Outliers are noted by points outside of the whiskers.

three-dimensional relationships learned 5–9 years previously,
now particularly relevant to their postgraduate training.
A randomized trial of the integration of cadaver dissection
into the obstetrics and gynecology residency program was
reported in 1995 (6). In this small trial, 13 first- and sec-
ond-year obstetrics and gynecology residents were randomly
assigned to 2- to 3-h dissection sessions with a female
cadaver or the same amount of protected self-study time
with provided anatomical references. The dissection group
performed significantly better on posttests than the control
group, with an improvement of 56.7% compared with
a 20% improvement in controls (p < 0.001).
There have been several recent studies looking at optimal
methods of improving image segmentation and field design
skills among residents in radiation oncology. A study from
Memorial Sloan-Kettering demonstrated improved head
and neck target delineation among 11 residents after a dedi-
cated seminar series in combination with a hands-on image
segmentation session (16). Investigators at Princess Margaret
Hospital conducted a small randomized trial of a single image
segmentation educational intervention in prostate and normal
anatomy delineation in 31 participants (17). The participants
receiving the image segmentation intervention became more
confident with their image segmentation skill. However, the
control group and intervention group had similar improve-
ments in pretest vs. posttest scoring. Tai et al. found a signif-
icant improvement in target delineation of the cervical
esophagus after specific training in an uncontrolled cohort
of 12 radiation oncologists (18). They were also able to
show that the uniformity achieved by training was main-
tained 1–2 months after intervention.
The development of consensus atlases and protocols has
been shown to improve consistency in image segmentation
in the setting of prostate bed treatment and gynecologic bra-
chytherapy planning (19, 20). The Radiation Therapy Oncol-
ogy Group has developed consensus contouring atlases in
anorectal, gynecologic, head-and-neck, prostate, and breast
cancer, with a goal to standardize volume delineation (21).
The challenge facing residency programs, then, is how to
optimally train residents to accurately reproduce these vol-
umes. We believe that integrating experiences in the cadaver
lab with didactic teaching methods will prove useful to this
goal, and is the subject of future research.
We acknowledge that our analysis has several potential
shortcomings. First, the importance of the anatomy lab com-
ponent of this initiative is unclear as we have not performed
similar pretests and posttests for other didactic educational
conferences. Nevertheless, comments and evaluations from
the residents suggest that the gross anatomy lab is of high
utility. Second, the number of residents involved is modest.
Even so, the findings were fairly similar across our residents.
Further, our study is a reasonable size when compared with
other studies of educational initiatives in oncology education.
Third, the follow-up remains relatively short in the evaluation
for knowledge retention at 3 months. That stated, there are
few reports of resident educational interventions with any
evaluation of retention (22–25). Moreover, we intend to pur-
sue longer follow-up of this course in the coming years.
Finally, the three-point scale used in evaluation of segmenta-
tion and field design is coarse. A more refined quantitative
method of segmentation analysis is being developed for
future research to address this.
CONCLUSION
An integrated oncoanatomy course is a useful educational
intervention based on objective testing, sustained knowledge
retention, and high attendee satisfaction.
 A dedicated course for anatomy of oncology d J. P. CHINO et al.
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