Low-Cost, Multi-Center, Longitudinal Remote Training Improves Confidence in Head and Neck Contouring

Abstract

<h3>Purpose/Objective(s)</h3> Remote training programs have been shown as a cost-effective way to bridge education and training gaps for radiation oncology providers in low- and middle-income countries (LMICs) and could be used to improve contouring skill. Given the expansion of 3D and intensity-modulated radiotherapy and high interest in contouring training in the Philippines, we seek to measure and report the efficacy of a pilot head and neck contouring curriculum. <h3>Materials/Methods</h3> A 13-week, 13-session remote training program on head and neck contouring and plan evaluation was provided at no cost to 8 participating radiation oncology residency programs in the Philippines. The program consisted of weekly 1-hour live video conferencing sessions with interactive didactics and case-based learning through a cloud-based contouring platform. Resident participants were assigned a pre-curriculum and a post-curriculum stage T3N2M0 oropharynx cancer case with 27 OARs. The cases were respectively rated as 2.67/5 and 3.83/5 in difficulty by 6 U.S. educator head and neck radiation oncologists involved in the curriculum. Participants self-rated their confidence in their performance according to a 1-5 Likert scale at the time of each submission regarding three categories: organs at risk (OARs), nodal contouring, and primary target contouring. A team of 4 educators later independently graded contours, according to a 1-5 grading rubric for the same three categories. Cases received 1-2 grades total, which were averaged for analysis. Contour submission was required for a certificate of participation, however no incentives for higher scores were provided. <h3>Results</h3> 41 residents in the Philippines (10 R1, 12 R2, 11 R3, and 9 R4) participated in the curriculum. Average participation per session was 26 (range 12-39, SD = 7.2). 26 (63.4%) participants completed pre-contours for evaluation and 17 (41.5%) post-contours for evaluation. Of these, 14 participants were eligible for paired pre- vs. post-curriculum analysis. Paired pre- and post-curriculum confidence scores (out of 5) were 3.0 and 3.77 for OARs (<i>P</i> = 0.003), 3.08 and 3.54 for nodal stations (<i>P</i> = 0.056), and 2.85 and 3.31 for primary target contouring (<i>P</i> = 0.027), respectively. Overall confidence in contouring the assigned case rose from 2.85 to 3.54 (<i>P</i> < 0.001). Paired pre- and post-curriculum educator grades were 2.96 and 3.38 for OARs (<i>P</i> = 0.135), 2.61 and 1.96 for nodal coverage (<i>P</i> = 0.019), and 2.54 and 2.73 for primary target contours (<i>P</i> = 0.292), respectively. Qualitative observations included greater participant uniformity of left and right parotid glands. <h3>Conclusion</h3> Longitudinal telehealth training integrating cloud-based tools for radiation oncology professionals is a viable and scalable method for providing head and neck contouring education in a LMIC setting. Our findings suggest that work remains to assess the concordance of confidence with performance, especially in challenging cases, and that further contouring education is needed in LMIC regions.