Experience from a Hypofractionation Curriculum Pilot: Extending Opportunities for Education in Radiation Oncology

Abstract

<h3>Purpose/Objective(s)</h3> Hypofractionation offers equivalent treatment outcomes as conventional schedules and can optimize the utility of radiotherapy resources. This is critical in Low and Middle-Income countries (LMICs) with limited radiation therapy resources. However, its utilization is poorly developed in LMICs. We seek to understand the current hypofractionation practice patterns and hypothesize that education is perceived as a barrier for using hypofractionation in a country with a bundle payment system. <h3>Materials/Methods</h3> A non-profit developed a hypofractionation e-learning program to pilot in Colombia, a free of charge and open program shared through the Colombian Association of Radiation Oncology. Interested radiation oncologists, medical physicists and trainees were asked to complete an e-questionnaire. Physicians were asked details 42 questions regarding their clinical practice and attitudes to hypofractionation using 12 clinical scenarios. Other professionals were asked just 22 questions regarding their baseline attitudes regarding hypofractionation. <h3>Results</h3> Across 19 cities in Colombia, one hundred forty-nine (n=149) participants enrolled in the program. Ultra-hypo-, hypo-, and conventional fractionation was used by 49.3%, 44.8%, 3.0% for older patients with breast cancer and 31.8%, 65.2%, 3.0% for younger patients (< age 50), respectively. For postmastectomy, ultra-hypo-, hypo, and conventional fraction were used by 10.4%, 62.7%, and 58.2%, respectively. Prostate ultra-hypofractionation was used by 7.5% and only for favorable intermediate risk (FIR) disease. For rectal cancer; 23.5% use ultra-hypofractionation for cT3-T4 node-positive patients. This was reduced to 15% in patients with anal sphincter tone compromised. For CNS high-grade gliomas, performance status appeared to drive the use of hypofractionation (64.2% ECOG 2 vs. 26.9% for ECOG 0-1 in older patients). Out of physicians who don't regularly use hypofractionation, not being familiarized with protocols was listed as the lead reason. Lack of convincing clinical evidence was the main reason for CNS too (20.0%). Not having clinical experience was the main reason for breast cancer (ultra). Education was perceived as a barrier for the generalized use of hypofractionation along the studied clinical settings (Table 1). <h3>Conclusion</h3> Hypofractionation and ultra-hypofractionation use is heterogeneous, despite economic incentives in a bundled health system. Education is perceived as a barrier to implementing the use of ultra-hypofractionation. Targeted efforts to improve educational opportunities for LMICs may be a key for promoting the adoption of hypofractionation and greater accessibility of radiotherapy for patients.