Experience from a hypofractionation curriculum pilot: Overcoming education as a barrier to implement hypofractionation

Abstract

<h3>Background</h3> Hypofractionation has equivalent oncologic outcomes to conventional fractionation, with the advantage of shortening treatment time. This is beneficial for health systems in low-to-middle income countries (LMICs); however, little is known about how to promote its adoption globally. <h3>Methods</h3> The non-profit Rayos Contra Cancer developed a hypofractionation e-learning program to pilot in Colombia, free of charge, and shared through the Colombian Association of Radiation Oncology. Two electronic surveys were distributed, one before and one after the completion of the course. Physicians were asked questions regarding their attitudes to hypofractionation. Different sections focused on clinical scenarios related to breast, prostate, rectal, and CNS gliomas, asking current practices regarding conventional fractionation, hypofractionation (15-20 fractions), and ultra-hypofractionation (5 fractions). To measure the impact of the curriculum, we categorized physicians' use of hypofractionation with a numerical score from 0 to 12 (12 = More conventional, 0=more hypofractionation). <h3>Results</h3> Across 19 cities in Colombia, 149 participants enrolled: 61 radiation oncologists, 59 medical physicists, 7 radiation oncology residents, 18 physics residents, 1 technologist, and 1 dosimetrist. 33 physicians responded both surveys. More respondents chose hypofractionation after the curriculum for all scenarios (mean "pre-curriculum" score=5.9, vs. "post-curriculum" score = 4.15, p=0.03). For breast cancer, hypofractionation use after N0 lumpectomy increased by 24.2% for older patients (51% to 75%, p=0.766) and 18.2% for younger patients (42% to 60%, p=0.00), and for locally advanced postmastectomy increased by 12.1% (76% to 85%, p=0.435). For prostate cancer, use for unfavorable intermediate-risk patients increased by 15% (67% to 82%, p=0.176), for favorable intermediate-risk by 12.1% (76% to 85%, p=0.00), and for high-risk by 12.1% (42% to 54%, p=0.52). For rectal cancer, the increase in hypofractionation for T3N1 and T4N1 mid-rectal patients was 24.2% and 21.2%, respectively. In CNS high-grade gliomas respondents increased the use of hypofractionation in older patients with poor performance status (18.2%). At baseline, education was perceived as a barrier for the use of breast (ultra-hypo/hypo), prostate (ultra-hypo/hypo), rectal, and CNS hypofractionation in 69.7%, 45.5%, 78.8%, 63.6%, respectively. These percentages decreased by 24.2%, 9.1%, 18.2% and 12.1%. When asked if the course had increased their confidence and knowledge towards hypofractionation 100% of respondents said yes. <h3>Discussion</h3> Education is a perceived barrier for the use of ultra-hypofractionation schedules in a LMIC with a bundled payment system. An E-learning approach appears to be feasible and effective at reducing the educational barrier and increasing the use of hypofractionation.