Pilot Study Demonstrating the Value of Interdisciplinary Education on the Integration of Radiation Therapy in Lung Cancer Management.

This study aimed to understand baseline knowledge of basic principles of radiation therapy for lung cancer among medical oncology, thoracic surgery, and pulmonology trainees and practicing physicians and also assess whether a didactic lecture will improve objective knowledge and perceived comfort level in making appropriate referrals to radiation oncology (RO). Radiation oncologists at 8 academic institutions offered a presentation covering indications, logistics, efficacy, and toxicity of thoracic radiation. Participants completed a survey to assess their prior exposures to RO and perceived value of the lecture, and objective knowledge gained based on pre/post-lecture questions. Among 121 attendees, 76 completed the pre-test, and 25 the post-test (response rates 62.8% and 20.7%, respectively). Fifty-seven (75.0%) had never previously experienced a RO didactic about lung cancer, 62 (81.6%) had never seen a linear accelerator, and 65 (85.5%) had never rotated in a RO department. The mean pre-test score was 53.5% (SD 17.6%), with a trend (p = 0.066) towards thoracic surgeons (61.5%) performing better than medical oncologists (55.5%) or pulmonologists (48.3%). Level of training (p = 0.130), and prior RO exposures (p = 0.240), did not significantly impact pre-test scores. The mean post-test score of 75.1% (SD 3.6%) was significantly higher than mean pre-test score (p < 0.001). After the lecture, 25 participants (100%) felt more knowledgeable about RO, and 24 (96%) felt more comfortable making appropriate referrals to RO. A didactic lecture about RO for trainees and physicians who treat lung cancer at 8 academic institutions was feasible, filled a gap in exposure, and improved knowledge.

Introduction

Lung cancer is the second most common cancer, and most common cause of cancer death in the USA and the world [1]. The treatment of lung cancer has become increasingly complex with the introduction of new surgical and radiation technologies and systemic therapy options [2]. While national guidelines recommend multidisciplinary evaluation and discussion in order to optimize patient care [3, 4], it is also important that each physician in the care team understand fundamental principles of the relevant treatment modalities outside of those they specialize in themselves [5]. In this way, all physician stakeholders can contribute towards a cohesive team that provides effective, patient-centered care.

Most US physicians in medical specialties that are involved in lung cancer management unfortunately have little to no formal training in radiation oncology (RO) during their undergraduate or graduate medical education [6-9]. For instance, there are currently no RO-related American College of Graduate Medical Education (ACGME) requirements in training for thoracic surgery, pulmonology, radiology, and pathology, while mere availability of RO faculty is required for adult hematology/oncology fellowship programs [10]. As a result, it is possible that many of the lung cancer specialists may have particularly limited prior exposure to RO, knowledge regarding RO, or bias against it due to commonly held misconceptions regarding the treatment’s efficacy and side effects [9-13]. Cumulatively, this can have a dramatic impact on patients being referred to RO in a timely or appropriate fashion [11]. While assessment by a multidisciplinary care team is more likely to result in guideline-concordant care, this may not always occur if the treating physicians are unaware of the proper indications to refer to the appropriate specialists [12, 13].

The above concerns may be ameliorated through patient discussion in multidisciplinary tumor boards where RO input is readily available [14, 15]. However, such conferences are not available in the majority of practice settings [16] nor does tumor board discussion necessarily ensure that patients learn about radiation therapy as a treatment option from a radiation oncologist. Furthermore, the education offered in a working meeting like a tumor board is more informal and offered in shorter segments related to issues that come up for the individual patients discussed. Providing more formal and comprehensive interdisciplinary education (IDE) to trainees and practicing physicians in other specialties on a regular basis could help facilitate greater knowledge and guideline concordant care, but this has not been evaluated in the context of RO, or multidisciplinary lung cancer management.

Most scholarship in RO education to date has centered around teaching medical students [17, 18], but the feasibility and value of IDE for other cancer specialists in principles of RO are not well described. The hypotheses of this study are that (1) medical oncology, thoracic surgery, and pulmonology trainees and practicing physicians will have minimal prior exposures to RO and a relatively low baseline understanding of how to integrate radiation therapy into multidisciplinary lung cancer management; and (2) that a didactic lecture will improve their objective knowledge, and perceived comfort level in making appropriate referrals to radiation oncologists.

Methods

From June to September 2019, the American Society for Radiation Oncology (ASTRO) communications committee developed a slide deck titled Radiation Therapy as a Component of Multidisciplinary Lung Cancer Management, which was intended to be used by radiation oncologists to teach trainees and faculty in other specialties at their home institution. An accompanying electronic pre-test and post-test was created using REDCaP, with weblinks to each made available on the first page of the slide deck along with instructions for their use. The full slide deck (including the test questions) was originally written by a single radiation oncologist, then peer reviewed independently by an additional seven members of the ASTRO communications committee, and then approved by a member of the ASTRO lung resource panel, with edits made to the slides as needed during each step of review. The slide deck was then posted on the ASTRO website so that anyone could access it at any time (https://www.astro.org/Patient-Care-and-Research/Provider-Resources). The slide deck and questions were developed with the intention of highlighting critical points that radiation oncologists would want other specialty physicians to know about radiation therapy for lung cancer that are relevant to effective multidisciplinary care. The content covered topics such as indications, logistics, efficacy, toxicity, and recent developments that have led to new or expanded indications for radiation therapy.

The 13 knowledge-based multiple choice questions in each test were identical. Within each electronic questionnaire, demographic information was also requested in order to correlate the test scores with participants’ specialty, level of training, and exposure to RO. The post-test had two additional questions (not on the pre-test) about knowledge gained from the lecture, and comfort level in making appropriate referrals to RO after the lecture. Upon completing either the pre- or post-lecture electronic questionnaire, participants were shown the answers to each of the questions so that they could learn from them as a supplement to their learning from the lecture itself.

Radiation oncologists from the Radiation Oncology Education Collaborative Study Group (ROECSG) were invited to formally use the lecture at their institutions and attempt to collect data on its use. Seven radiation oncologists, including the principal investigator, chose to participate. After obtaining institutional review board exemption, the lecture was offered to pulmonology, hematology/oncology, and thoracic surgery program directors or department chairs at each institution, and a lecture was scheduled for those groups who agreed to participate. Due to the coronavirus disease (COVID) pandemic, some of these lectures were given in-person and others virtually. Each radiation oncologist was permitted to make subtle changes to the lecture materials to fit their style, as long as all of the material evaluated in the pre- and post-test questions was covered. The pre-test and post-test questionnaire links were emailed by a department administrator to all persons invited to the lecture within 14 days before it took place, and within 2 days after it took place, respectively. Participants had the option of completing the pre-test, or post-test, or both. Pre- and post-test responses were not linked for any individual. Only those who attended the lecture were asked to complete the post-test.

Statistical analysis was performed using SPSS. Frequency tables were used to present the demographic characteristics of those completing the pre-test and post-test. The chi-square test was used to compare the demographic features of each group. For the entire cohort, mean and standard deviation (SD) test scores are reported for the pre-test and post-test, and compared using the Student’s T-test. The pre-test and post-test responses were not paired for individual participants, and the impact of the lecture on the average participant was evaluated. The Student’s T-test and ANOVA test were used to compare the baseline knowledge (mean pre-test score) of subgroups of participants; a similar subgroup analysis was not done based on the post-test due to the smaller sample size of participants who completed it. A p-value less than 0.05 was considered statistically significant.

Results

Between November 2019 and May 2021, a total of 7 radiation oncologists from 8 institutions offered lectures as part of this study. Eleven lectures were given to various combinations of pulmonologists, thoracic surgeons, and medical oncologists. Eight of these lectures were given in-person, and three were given virtually. The total attendance at all lectures combined was 121 physicians, and the median attendance at each lecture was 8.0 physicians (interquartile range 7–15.5). Seventy-six participants completed the pre-test (response rate 62.8%), and 25 participants completed the post-test (response rate 20.7%).

The demographics of those who completed the pre-test and post-test are shown in Table 1. There were no statistically significant differences in the percentage of participants who took the pre-test and post-test in any demographic category. Table 2 also shows that there were no significant differences in baseline knowledge (based on the pre-test score) based on any participant demographics, though there was a trend based on medical specialty.

Table 1

Demographics of participants

	Pre-test (n = 76)	Post-test (n = 25)	p-value
Specialty
Pulmonology	32 (42.1%)	7 (28.0%)	0.203
Medical oncology   Thoracic surgery   Other/unknown	28 (36.8%) 10 (13.2%) 6 (7.9%)	13 (52.0%) 5 (20.0%) 0 (0%)
Training level
Faculty/attending	9 (11.8%)	2 (8.0%)	0.132
Resident/fellow	54 (71.1%)	23 (92.0%)
Other/unknown	6 (7.9%)	0 (0%)
Prior radiation oncology didactic about lung cancer
No	57 (75.0%)	n/a	n/a
Yes	17 (22.4%)
Unknown	2 (2.6%)
Previously seen a linear accelerator
No	62 (81.6%)	18 (72.0%)	0.433
Yes   Unknown	13 (17.1%) 1 (1.3%)	7 (28.0%) 0 (0%)
Prior Radiation Oncology Rotation
No	65 (85.5%)	18 (72.0%)	0.201
Yes   Unknown	10 (13.2%) 1 (1.3%)	7 (28.0%) 0 (0%)
Had opportunity to take pre-test
No	n/a	6 (24.0%)	n/a
Yes		19 (76.0%)
Unknown		0 (0%)

Table 2

Baseline knowledge of different subgroups of participants based on their pre-test score

	Pre-test scoreMean (SD)	p-value
Specialty
Pulmonology	48.3% (18.3%)	0.066
Medical oncology	55.5% (15.3%)
Thoracic surgery	61.5% (15.7%)
Training level
Faculty/attending	60.7% (15.1%)	0.130
Resident/fellow	51.5% (17.6%)
Prior radiation oncology didactic about lung cancer
No	52.2% (17.1%)	0.240
Yes	57.9% (18.0%)
Prior radiation oncology rotation
No	52.5% (17.3%)	0.390
Yes	57.7% (18.9%)

For the entire cohort of participants, the mean pre-test score was 53.5% (SD 17.6%), and the mean post-test score was 75.1% (SD 3.6%). This difference was statistically significant (p < 0.001). All participants (100%) felt more knowledgeable about the role of radiation therapy in lung cancer treatment after this lecture, among which 12 (48.0%) felt much more knowledgeable and 13 (52.0%) felt a little more knowledgeable. Twenty-four participants (96.0%) felt more comfortable making appropriate referrals to RO, among which 9 (36.0%) felt much more comfortable, 15 (60.0%) felt a little more comfortable, and 1 (4.0%) felt not any more comfortable.

Discussion

This pilot study has demonstrated the feasibility of radiation oncologists delivering educational content to a multidisciplinary cohort of attending physicians and advanced trainees who work together in the management of lung cancer at their institution. The collected data demonstrate the importance of this type of education, given how uncommon it was for most participants to have any exposure to formal RO education previously, and their low scores at baseline prior to the lecture. The sample size completing the post-test limits the conclusions that can be drawn from our analysis of the efficacy of the lecture; however, the objective finding of a statistically significant 25% absolute increase in the average score of participants compared to the pre-test, coupled with the subjective finding of a vast majority of participants perceiving an improvement in their knowledge of RO and how to make appropriate referrals, suggests a benefit. Altogether, the data supports further investigation of IDE initiatives in RO like this at more institutions, for other disease sites, or on a broader scale in partnership with other national specialty societies or as continuing medical education (CME) activities.

Though some radiation oncologists are surely giving presentations like this independently to colleagues in other departments already, there is very little medical literature that reports on interdisciplinary education in RO. Olson et al. reported a strong correlation between Canadian family physicians’ knowledge of palliative radiation therapy, and referral of patients for palliative radiation therapy, with their having received education after medical school in palliative care or radiotherapy [19]. While, to the best of our knowledge, no studies have demonstrated that IDE among non-RO oncology specialists can directly result in better patient outcomes, several prior studies have sought to improve communication and patient outcome among different medical professions within RO, such as physicians, nurses, dosimetrists, and physicists [20, 21], as has also been demonstrated in other healthcare fields [22]. In an attempt to improve IDE among physicians of different specialties, Bullard et al. established an interdisciplinary simulation curriculum among first year interns. Those who participated in the program demonstrated statistically significant improvements in perceived interdisciplinary collegiality, respect, attitudes, comfort level, and work interactions [23]. Another study attempted to combat “siloed medical education” by developing an interdisciplinary seminar series among a group of psychiatry, developmental medicine, neurology, and education trainees and successfully established a sense of community in learning [24]. Similarly, the current study serves as a foundation on which various educational programs can be established by teaching others in a multidisciplinary care team about RO in order to improve collegiality, communication, and collaboration, which will hopefully translate into improved patient outcomes.

Importantly, participating institutions in this study were major academic centers that have all the lung cancer specialties within the same institution. The participants have had multiple venues to learn about RO through attendance of multidisciplinary tumor boards and continuing medical education events. Yet, the vast majority of participants reported having no prior formal exposure to RO prior to participating in this study, and the clear improvement in subjective and objective measures of RO knowledge also demonstrates a gap not sufficiently addressed by the existing training program curriculum and daily interactions with RO related to patient care. The lack of familiarity with RO is only expected to be greater in the community and/or private practice settings, where multi-disciplinary conferences and opportunities to closely interact with RO are less widely available [14-16]. The results of this study underscore the importance of improving IDE in RO in disease sites in which RO plays an integral role in multidisciplinary management. Similar slide decks focused on integration of radiation therapy into the multidisciplinary management of other types of malignancies, developed for the other types of cancer providers who diagnose and treat them, are also available on the ASTRO website, and are continuing to be developed [25].

There are several limitations to this study that must be acknowledged. The primary goal of these lectures was to encourage attendance and build relationships. Less emphasis was placed on maximizing the completion rate of the pre-test and post-test, or for every participant to complete both of them. This may have led to some selection bias in terms of which attendees chose to participate in the research component of the study. Also, because individuals’ pre-test and post-test responses were not linked, we could not evaluate a change in knowledge for individual participants. It is also unclear if attendees scored higher on the post-test because of the prior experience with the pre-test questions (after which answers were provided) or the lecture itself, though ultimately, an improvement in post-test scores reflects the desired increase in knowledge from our intervention, regardless of the means by which that knowledge was gained. The lower number of post-tests completed, as compared to pre-tests, also limited the power of our findings.

Another limitation is the low number of faculty/attendings that participated. This was in part due to the fact that the trainees tended to have more regularly protected lecture times compared to the faculty/attendings. Finding additional ways to offer didactics, like for instance offering Continuing Medical Education credits, or giving lectures as part of grand rounds, may increase the rate of faculty/attending participation. There was also a mixture of in-person and virtual presentations in this study, which may have affected participant attendance, engagement, and completion of the tests. However, the study also demonstrated feasibility to deliver such lectures in a virtual format, which may be more convenient and encourages attendance. Due to the COVID pandemic, virtual conferences, lectures, and even rotations have become more common throughout medicine. It is expected that technological advances will continue to facilitate learning in the virtual environment for years to come [26]. Finally, this pilot study was not designed to measure the downstream effect of these lectures on differences in patient care or referral patterns, which is important to translate these findings into improved patient outcomes.

Conclusion

The findings of this study highlight how most medical specialists who treat lung cancer have minimal prior exposure to RO and poor knowledge of the integration of radiation therapy into lung cancer management. An introductory didactic lecture about radiation therapy in multidisciplinary lung cancer management, designed specifically for physicians in specialties that diagnose and treat lung cancer, was feasible to administer at multiple institutions, with improved participants’ knowledge and comfort level in this area. Based on the lack of exposure that medical students and physicians in most specialties have to RO, it is likely that a similar type of knowledge gap exists for many other disease sites where RO also plays an integral role in care. Further studies are needed to examine whether such efforts can help build stronger clinical collaborations between radiation oncologists and other specialist physicians, to promote guideline-concordant and patient-centered care.

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 45 KB)

Supplementary file2 (PDF 43 KB)