The European Society for Radiotherapy and Oncology (ESTRO) developed a “Minimum Curriculum for the Theoretical Education in Radiation Oncology in Europe” in 1991. This Core Curriculum was a great success and played a pivotal role in establishing comparable standards for training across Europe. With the marked evolution in radiation oncology technology and methods a second edition was published in 2004. This was endorsed by thirty-five National Societies. It was integrated into legal or national guidelines in several European countries and provided a significant step towards harmonisation across Europe. The third edition published in 2011, endorsed by 28 national societies, changed the focus from theoretical to competency based education defining the minimum observable abilities radiation oncologists/radiotherapists needed for optimal patient outcomes. It was based on the seven roles of a physician identified in the CanMEDS 2005 physician competency framework and was endorsed by the European Union of Medical Specialists (UEMS). Since that time:
• Radiotherapy technology and techniques have continued to develop and to be more widely adopted.
• Survival rates for many cancers have increased increasing the importance of managing survivorship.
• The CanMEDS framework was revised in 2015. The role of “Manager” was changed to “Leader” and there were changes in all the roles emphasising the patient’s perspective and patient safety [1].
• The CanMEDS 2015 framework contained the concept of Entrustable Professional Activities (EPAs), “A key task of a discipline that can be entrusted to an individual who possesses the appropriate level of competence” [1]
• A Delphi survey by the Global Radiation Oncology Collaboration in Education (GRaCE) group defined a leader role curriculum for radiation oncology [2].
• The European Commission Expert Group on Cancer Control established a European Union Implementation Group tasked with exploring the training of clinical cancer specialists with particular emphasis on the interdisciplinary training of doctors in the clinical cancer specialties. They proposed competences in, radiation oncology, systemic therapy and surgery that should be acquired by all cancer specialists regardless of discipline.
The decision was therefore made to revise the core curriculum and this process was started in 2017 with a meeting of representatives of 20 European National Societies, a senior radiation oncology educationalist from Canada, representatives of yESTRO including trainees and RTTs. Radiobiologists and physicists have also contributed to the revision and multiple iterations have been developed with the advice of representatives of 27 European Countries. The final draft has been reviewed by senior radiation oncology educationalists from Australia and Canada.
The curriculum defines the EPAs and competences that trainees need to develop, the characteristics of Training Programs that will enable the trainees to develop these and the characteristics of assessment systems that will provide assurance that the trainees have developed them.
Radiotherapy (Radiation Oncology) is the branch of clinical medicine that uses ionising radiation, either alone or in combination with other therapeutic modalities, for the treatment of patients with malignant or benign diseases. It may be practiced as an independent oncological specialty or may be integrated in the broader practice of clinical oncology.
Radiotherapy (Radiation Oncology) includes responsibility for the prevention, diagnosis, treatment, follow up and supportive care of the cancer patient with a responsibility to manage their care pathway across multiple disciplines and forms an integral part of their multidisciplinary management and investigation.
This specialised area of medicine is recognised under the term ‘radiation oncology’. In this document, however, the double terminology ‘radiation oncology/radiotherapy’ will sometimes be used since, as defined by the European Union of Medical Specialists (UEMS), radiation oncology excludes non-oncological treatment for benign disease whereas radiotherapy may also be used for the treatment of non-malignant conditions. In the present document “external beam radiotherapy” will encompass the various forms of delivery (2D, 3D, IMRT, stereotactic RT) and types of beams (photons, electrons and various particles).
The aim of this curriculum is to describe the minimum competences necessary to deliver ionising radiation therapy including when this forms part of combined modality treatment with systemic therapies. It is recommended that all radiation oncologists should have sufficient knowledge of systemic therapies to be able to take clinical responsibility for the integration of care of the cancer patient.
The objective of the training programme is to educate and train physicians in the medical specialty of Radiation Oncology/Radiotherapy to the level of competency allowing them to practice as an independent specialist
The training period should be sufficient to obtain the competences to become an independent specialist. In general, the training programme should be at least five years full time or an equivalent period part-time. At least 80% of the programme should be spent in clinical work including time in education.
Responsibility for licensing doctors to practice in Radiation Oncology varies between European countries. Licensing should be based on objective assessment of completion of a training programme that fulfils the national guidelines.
At the beginning of the training, the trainee should be presented with the curriculum and a written individual training programme. The training programme should describe the goals of the training, the time frame of each module and how the responsibilities for the training are distributed among the staff at the training institutions.
The training programme should correspond to the requirements outlined in the European core curriculum and to specific national requirements.
During the training the trainee should become gradually more responsible for patient care, with increasing autonomy and less dependent on supervision. A record clearly documenting the clinical competencies and activities of the trainee is advised as a tool to define the clinical responsibilities the trainee is authorised to undertake during different phases of their training.
Training institutions
If the minimum requirements for training institutions recommended in the core curriculum cannot be met by a single institution, several training institutions should combine and offer an integrated programme that meets these minimal requirements. Licensing for training institutions or integrated programmes should depend on fulfilment of their national guidelines.
Training institutions must be accredited in accordance with their national regulations. The training institutions, either alone, or in cooperation with other regional departments, should be adequately equipped to support both the workload and range of radiation oncology/radiation services required for training including new technologies and novel techniques.
There should be:
• Mega voltage machines available, at least one with high-energy electrons, equipped with IGRT and able to deliver IMRT
• Access to a dedicated CT-scanner
• Computerised treatment planning and technical support. This should include appropriate dosimetry
• Radiotherapy protection equipment
• Appropriate patient treatment aids
• The opportunity to become at least familiar with brachytherapy and stereotactic RT. This can be organised by collaboration with institutions in which these treatments are concentrated
• Beds for inpatients or at least sufficient access to them in other department
• Facilities for systemic therapies
• Facilities for supportive and palliative care
• Quality control programmes for patient care, treatment decisions, follow-up and outcome in a range of cancer sites,
• Access to regular Multidisciplinary Tumour Boards (MDTs)
To ensure there are an adequate number of patients and a varied case-mix, a minimum of 500 oncology patients should be irradiated annually in the parent institution or the integrated programme. An adequate case mix for each trainee should be ensured by continuous monitoring by means of a portfolio or logbook.
Organisational aspects of patient care and practical teaching vary widely between European institutions. In some institutions the patient is followed by the trainee for the whole process from the first visit over treatment planning and applications to follow-up, whereas in other institutions trainees see patients for only part of the process. For part of their training period they will see only patients during their first presentation, during other periods they perform solely treatment planning, and in other periods, follow-up. For this reason the number of patients seen by a trainee is defined as the equivalent to a patient undergoing the complete process (full case equivalent) and must be sufficient to acquire the required competences. The recommended number of full case equivalents seen by each trainee should be at least 450 during the entire clinical radiation oncology/radiotherapy training. A trainee should not treat more than 250 full case equivalents per year to ensure a good equilibrium between work experience and the time for more formal training.
Programme director
Each training institution or integrated programme should appoint a single programme director responsible for trainee education. It is considered preferable that the roles of programme director and chairman of the department are held by different people. The programme director is responsible for the general administration, the structure and the content of the programme. The programme director ensures that the programme fulfils the criteria in the core curriculum and the national requirements. They must be a highly qualified radiation oncologist with considerable experience in trainee education and in organisational activities. The programme director should organise regular documented meetings with the teaching staff to review the goals, the effectiveness and proposals for future developments of the programme. At least one trainee representative should participate in the meetings.
Adequate staffing levels in the radiation oncology/radiotherapy departments are essential for training. Several radiation oncologists with responsibility for training should be appointed. These teaching staff members need to devote dedicated professional time to the teaching programme. It is recommended that the number of trainees does not exceed the number of full time equivalent staff radiation oncologists/radiotherapists. Sufficient supervision of the trainees should be guaranteed.
ESTRO has, in cooperation with the European Federation of Physics in Medicine (EFOMP), made recommendations previously on the minimal staffing levels for the safe provision of a routine radiation oncology/radiotherapy physics service (REF). Full time medical physics support must be available in teaching institutions. Medical physics staff members responsible for teaching should be appointed. Medical trainees should be taught dosimetry and the dosimetric aspects of treatment planning under the supervision of an accredited medical physicist working in the field of radiation oncology/radiotherapy. The general principles of treatment planning should be learned under the clinical supervision of experienced radiation oncologists. The trainees should also be familiar with the safety procedures and quality assurance in the training institution and the national regulations pertaining to these.
Teaching institutions or integrated programmes should aim to have guaranteed access to a cancer biology laboratory and a chance to interact with its scientific staff. A minimum requirement is to provide mandatory training in radiobiology by formal accredited national or international courses.
Access should be available to:
A sufficient variety of journals, reference books, and resource materials (or electronic equivalents) pertinent to radiation oncology/radiotherapy and associated fields in oncology, basic sciences, and general medicine must be readily accessible for the trainee. The training institution should provide ready access to a computerised search system and rapid access to databases in medicine to permit literature reviews.
The training programme must provide the trainee with in-depth knowledge in the basic and clinical sciences in the field of radiation oncology/radiotherapy and must train the trainee to be proficient in the clinical practice of radiation oncology/radiotherapy.
Training institutions or integrated programmes must schedule regular conferences, teaching rounds, case presentations and scheduled lectures. These teaching activities must include trainee participation that increases with experience.
Training institutions should facilitate access to teaching courses on a national or international level. These courses should attempt to put specific items of the European core curriculum in an international perspective. They should be sufficiently wide-ranging to offer different point of views on the same subject; facilitate interactions of trainees from different countries and promote radiation oncologists visiting different radiotherapy institutions in Europe. These recommended teaching courses should be adapted according to the national requirements and the specific needs of the individual training programme. To add a European dimension to the education, it is recommended that at least one teaching course should be at a European level. A further recommendation is that each trainee should participate in at least one international scientific meeting on radiation oncology/radiotherapy.
Teaching courses in radiation protection have to be provided according to national regulations.
Training institutions must allow the trainees sufficient protected time during their working hours for study of the literature, preparation of case presentation, etc. It is suggested that the minimum should be an average of 10% of the weekly working time. The remaining 90% of time should be mainly devoted to supervised and unsupervised clinical activities in proportions that will vary depending on the experience of the trainee.
Trainees should actively participate in tumour-boards, journal clubs and research conferences.
Trainees should be encouraged to engage in a research project or quality improvement project under the supervision of experienced staff (experimental research, clinical research or trainers with expertise in quality improvement). They should be encouraged to spend a period of training in another institution (national or international) with an accredited teaching programme, which is accepted by the trainee’s national society. These activities should also be recorded in a portfolio/logbook.
Member of the teaching staff should schedule regular practical teaching sessions with the trainees. There should be continuous feed-back to the trainees about their management of patients including their competences in radiotherapy planning. A minimum of one and preferably several practical training sessions between the teacher and the trainee should be scheduled per week to enable the trainee to reach the required levels for the EPAs.
Regular external audit of the training programme is recommended.
It is recommended that training periods undertaken by trainees in an accredited training programme in any member state should be accepted as equivalent to the same period of training in their own state.
The numbered statements under each domain may be regarded as Entrustable Professional Activities (EPAs) or just headings depending on the choice of each National Society.
1) Develop a management plan for patients with a cancer diagnosis
2) Implement a treatment strategy
3) Develop and implement a management plan for survivorship
| Contribute effectively to tumour board discussions |
Explain the pathological factors that determine treatment decisions |
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| Discuss the optimal imaging staging strategy including national or international guidelines | |
| Stage the cancer appropriately | |
| Apply national or international guidelines to the management of an individual patient | |
| Apply research evidence to the management of an individual patient | |
| Discuss the role of radiotherapy in the management of the patient. This may include patients with benign disease. | |
| Discuss the role of systemic therapy in the management of the patients. This may include, for example : Chemotherapy Hormonal therapy Monoclonal antibodies Tyrosine kinase inhibitors Immunotherapy With curative, neoadjuvant, adjuvant and palliative intent |
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| Discuss the role of chemoradiotherapy in the management of the patient Discuss the role of surgery in the management of the patient Describe when surgery is the primary curative modality in the treatment of a cancer Describe at a basic level the operations that are indicated for particular cancers including regional nodal surgery Discuss the role of surgery in enabling other treatments modalities (for example, placement of clips, pelvic spacers or omentum) to enable optimal radiotherapy treatment |
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| Discuss the scheduling of radiotherapy, systemic therapy or surgery in patients treated with combined modality therapy | |
| Discuss how radiotherapy, surgery, systemic therapies may interact during the therapeutic phase of treatment | |
| Discuss the implications of hereditary gene mutations on the management of a patient | |
| Discuss the management of a patient when there is therapeutic uncertainty, complexity and ambiguity | |
Undertake the initial outpatient consultation |
Identify when a patient should be offered the opportunity to enter a research trial |
| Justify a decision that radiotherapy, systemic therapy and surgery are not indicated | |
| Discuss the role of palliative care in the management of the patient | |
| Structure the consultation effectively | |
| Take a focused history, undertake a careful clinical examination and order relevant imaging and laboratory examinations | |
| Elicit and manage psychosocial factors | |
| Evaluate and discuss with the patient the possible management strategies taking into account the factors related to the cancer, the patient’s goals, their comorbidities and frailty and the adverse effects of the possible options | |
| Facilitate shared decision making with the patient | |
| Explain the implications of hereditary genetic abnormalities and refers appropriately for genetic counselling | |
| Discuss a radiotherapy treatment strategy including: Pre-treatment procedures such as dental review Goals of treatment Simulation including immobilization and the use of contrast Fractionation regimen Acute toxicities and supportive measures Late toxicities |
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| Identify when brachytherapy, SCRT, SBRT, proton therapy or IORT may be of value and outline the procedure to the patient | |
| Identify when systemic therapy alone or combined with radiotherapy may be of value and outline the process to the patient | |
| Describe the acute and long term toxicities of the commonly used systemic therapies either alone or combined with radiotherapy | |
| Identify when emergency surgery is indicated e.g. bowel obstruction or perforation or upper airways obstruction | |
| Identify when surgery may palliate symptoms or prolong life e.g., bile duct obstruction, hydronephrosis | |
| Implement the treatment strategy | Diagnose oncological emergencies including spinal cord compression SVC obstruction Neutropenic sepsis Thromboembolic disease Metabolic abnormalities such as hypercalcaemia, hyponatraemia and hyperkalaemia Manage them or collaborate with other specialties to do so Determine and outline the GTV, CTV, ITV, PTV, OAR and PRV using appropriate diagnostic scanning techniques including CT, MRI and PET/CT for external beam and brachytherapy plans, using planning atlases when indicated |
| Evaluate the dose constraints for normal tissues as defined on a DVH | |
| Evaluate the external beam/brachytherapy treatment plan in collaboration with physicists and RTTs including conformal 3D and IMRT plans Know the ICRU guidelines for prescribing, recording and reporting dose Critically evaluate the dose distribution in the tumour volume and the OAR Identify an adequate plan and suggest options for improving an inadequate plan Take overall responsibility for the treatment plan. |
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| Evaluates the risks and benefits of an external beam/brachytherapy treatment plan. Able to balance tumour control against potential damage to OAR and resulting toxicities | |
| Modify treatment plan according to individual characteristics such as comorbidities and systemic treatment | |
| Verify radiotherapy treatments, describes techniques available for real time image guidance. Assess accuracy of patient set up and recommend adjustments | |
| Know the level of tolerance accepted for set up margins in their department and how this influences PTV | |
| Discuss the indications and aims of brachytherapy. Describe the methods available Describe the principles of dose prescription Apply radiation protection principles when assessing patients |
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Manage survivorship |
Assess and manage early radiation reactions in patients receiving external beam, brachytherapy and combined modality treatment |
| Know the common acute toxicities of systemic therapies but when given as single modalities and when combined with radiotherapy | |
| Administer and take clinical responsibility for delivery of radiation therapy and systemic agents or collaborate with other specialties to do so | |
| Assess the acute toxicities of systemic therapies combined with radiotherapy and manage them or collaborate with other specialties to do so | |
| Modify treatment to adjust for gaps in treatment using the principles of radiobiology | |
| Evaluate response to treatment using RECIST and other commonly used criteria for formally evaluating response | |
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| Discuss the role of exercise or diet and smoking cessation and alcohol as appropriate | |
| Construct a plan for patient specific rehabilitation | |
| Take a focused history to diagnose the common psychological sequelae following a cancer diagnosis and treatment for cancer, manage them or refer appropriately to other specialties | |
| Take a focused history, undertake a careful clinical examination and order relevant investigations to diagnose long-term toxicities from cancer therapies including secondary malignancies and multiple cancers. Discuss the options for managing these and implement them or refer appropriately to other specialties | |
| Discuss the physical and psychological impacts of surgery. Identify patients who may benefit from surgical procedures to ameliorate these e.g., resiting of a stoma | |
| Discuss the role of surgery in improving function, ameliorating deformities and improving cosmesis including treatment for long term toxicities from radiation therapy | |
Manage patients with relapsed disease |
Take a focussed history, perform a careful clinical examination and request relevant investigations to diagnose relapsed disease |
| Evaluate the possible management strategies taking into account the factors related to the cancer including whether there is a possibility of curative treatment, the patient’s goals, their comorbidities and frailty and the adverse effects of the possible options | |
| Discuss the benefits and toxicities of radiotherapy treatment including reirradiation | |
| Describe when surgery may be curative e.g., liver metastasis | |
| Discuss the role and timing of surgery in palliative care | |
| Discuss the role of radiofrequency ablation and cryotherapy in the management of metastases | |
| Discuss the role, benefits and common toxicities of systemic therapies in palliative care. This may include, for example: Chemotherapy Hormonal therapy Monoclonal antibodies Tyrosine kinase inhibitors Immunotherapy |
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| Implement the radiotherapy treatment strategy | |
| Recognise when radiotherapy, systemic therapy and surgery are not indicated | |
| Discuss the role of palliative care in the management of the patient. Implement treatment to control symptoms or refer appropriately to other specialties |
4) Communicate appropriately and effectively with patients and their relatives
| Build a therapeutic relationship with patients and their relatives | Know the theory underpinning communication skills |
|---|---|
Elicit and synthesise accurate and relevant information from patients Develop management plans with patients and their families that reflect their health care needs and goals | Demonstrate empathy, respect and compassion |
| Provide a clear structure for and manage the flow of the consultation | |
| Demonstrate active listening | |
| Communicate clearly with patients respecting their social, political, cultural, religious and sexual standpoint | |
| React to body language and verbal cues with relevant observations and questions | |
| Give clear objective information about standard treatments, randomised trials and experimental treatments including the process, side effects and risks | |
| Ascertain if the patient and their families have understood the information and take effective measures if this is not the case | |
| Assist patients and their families to access reliable sources of information including websites | |
| Discuss their beliefs regarding alternative and complementary therapies | |
| Take informed consent from patients and know the legal position if the patient lacks capacity | |
Manage emotionally charged conversations Document accurately and share appropriately information about the consultation | Elicit the patients’ wishes regarding the information they wish to receive and break bad news in an appropriate way |
| Discuss critical issues such as life with cancer, sexual issues, acceptance and death | |
| Disclose errors and adverse safety events appropriately | |
| Document in a timely and accurate manner details of the consultation and management plan, either in a written or digital form, complying with national legislation | |
| Communicate this information clearly to the appropriate health care team | |
| Maintain patient confidentiality |
5) Work effectively with other health care professionals to provide safe care and to optimise the quality of treatment
Work effectively with physicians and other members of the health care professions Transfer care safely to another health care professional Support colleagues | Contribute to effective discussions in multidisciplinary teams (MDT). Willing to compromise to reach a consensus. Respect the views of others and the conclusions of the MDT |
|---|---|
| Understand and value the roles of physicists, RTTs, nurses and other health care professionals and encourage team working to optimise treatment | |
| Negotiate overlapping responsibilities for shared care of patients | |
| Determine when care should be transferred to another physician or health care professional | |
| Facilitate continuity of care by timely, effective communication | |
| Identify when colleagues are under pressure and offer help |
6) Discuss the context in which they work and apply the principles of change management including quality improvement methodology in this context
7) Use resources appropriately
8) Demonstrate the ability to work in, build and lead teams
Contribute to the improvement of cancer care delivery in teams and the wider health care system | Identify where quality improvements may be initiated in the work environment |
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| Demonstrate knowledge of the steps and tools that may be applied to quality improvement processes including the use of data to drive change | |
| Describe key quality indicators for monitoring service performance in radiation oncology | |
| Describe radiation oncology incident reporting and monitoring systems | |
| Participate in the development and implementation of patient safety initiatives | |
| Participate in the investigation of a radiation-related adverse event, “near miss” or system error | |
| Demonstrate knowledge of the radiation therapy utilisation rates in the region/country of practice | |
Engage in stewardship of cancer care resources Demonstrate elements of leadership in practice | Describe local and international guidelines and initiatives to promote resource stewardship |
| Discuss factors involved with resource stewardship including financial and other costs of cancer patient care | |
| Discuss funding arrangements for radiation oncology service delivery in region/country of practice | |
| Discuss prioritisation of patients on waiting lists | |
| Prioritise tasks including patient assessment and treatment | |
| Discuss the conceptual differences between the radiation oncologist as a manager and as a leader | |
| Describe leadership theories and styles and how these may apply in practice | |
| Engage in developing self-awareness – strengths, weaknesses, values, behaviours drivers and impact on others | |
| Take responsibility for effective communication around the vision for, and purpose of, change with radiation oncology team members, patients and other stakeholders | |
| Engage and support team members to bring them through a change process | |
| Demonstrate the ability to negotiate and problem-solve with other team members | |
| Demonstrate awareness of the roles and organisational structures of relevant professional societies and how radiation oncologists contribute to these |
9) Advocates for cancer patients
Advise the patient on behaviour and lifestyle Support patients to navigate the health care system | Advise the patient on relevant changes in behaviour and lifestyle prior to treatment to increase the chance of tumour response and to cope with acute toxicities e.g., smoking cessation and diet |
|---|---|
| Advise the patient on relevant changes in behaviour and lifestyle to enable them to cope optimally with late toxicities due to previous treatment and the side effects of present medication | |
| Advise the patient on relevant changes in behaviour and lifestyle to reduce the risk of them developing further cancers | |
| Enable patients to access the available resources, including information, to obtain treatment in a timely manner |
10) Plan personal learning experiences and use them to enhance patient care
11) Educate others to enhance patient care
12) Contribute to the knowledge base that underpins patient care
| Develop and follow a continuing personal development plan Deliver and enhance learning experiences Participate in research activities | Assess gaps in knowledge and identify resources to meet these |
|---|---|
| Critically review medical information | |
| Develop or revise local evidence based guidelines, integrating evidence into personal practice | |
| Assess learning needs of the audience | |
| Plan and deliver the learning activity to meet these needs | |
| Plan how to revise the learning activity in the light of evaluations | |
| Undertake workplace based assessments with more junior trainees | |
| Provide feedback to enhance learning and performance | |
| Evaluate learning experiences and programmes appropriately | |
| Discuss the scientific principles of research, the design of clinical trials and their statistical analysis | |
| Discuss the organisations that design and run trials nationally and internationally and how to access information regarding their trials | |
| Undertake accurate and timely activities for local and/or multicentre trials and research projects | |
| Evaluate the design of research projects and clinical trials | |
| Build collaborative networks through participation in local, regional, national or international societies and meetings | |
| Aware of rules for writing scientific papers and how to submit them for publication | |
| Present summary of findings of research in both written and verbal form |
13) Demonstrate that the care of their patients is their first concern
14) Manage their work life balance to maintain their own wellbeing
| Adhere to high ethical standards Aspire to excellence Maintain own wellbeing |
Identify the ethical issues in caring for patients |
|---|---|
| Discuss ethical principles and be able to apply them | |
| Demonstrate honesty, integrity, humility, commitment, respect, humility, altruism | |
| Respect diversity. Do not disadvantage a patient on grounds of their gender, race, and culture, philosophical or religious beliefs. Show understanding for patients’ ethical concerns and divergent viewpoints. | |
| Maintain patient confidentiality and be able to inform patients on the legal situation regarding information held on them in medical notes | |
| Apply codes of research ethics | |
| Provide the patient with all relevant information when taking consent | |
| Manage conflicts of interest appropriately | |
| Exhibit appropriate behaviour in the use of communication on the internet | |
| Work according to professional codes and laws | |
| Keep knowledge and skills up to date | |
| Recognise own competency limits and refer appropriately | |
| Take responsibility for actions | |
| Respond appropriately to negative feedback | |
| Work collaboratively with other health care professionals to optimise patient care | |
| Recognise and respond to unethical behaviour in other health care professionals | |
| Exhibit self-awareness and manage personal and professional demands to reduce the risk of burn out |