CORE CURRICULUM FOR MEDICAL PHYSICISTS IN

RADIOTHERAPY

Revised edition June 2010

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 CORE CURRICULUM FOR MEDICAL PHYSICISTS IN
RADIOTHERAPY
9 June 2010

I. INTRODUCTION 3

II. DEFINITIONS 6

III GENERAL COMPETENCIES 9

1. ORGANIZATION 9
2. PROFESSIONALISM 10
3. COMMUNICATION 11
4. COLLABORATION 12
5. SOCIAL ACTION 13

IV RADIOTHERAPY PHYSICS KNOWLEDGE, SKILLS AND COMPETENCIES 14

Fundamental knowledge 15

1. Fundamentals of human anatomy and physiology 15

2. Fundamentals of oncology 16
3. Principles and applications of radiobiology and molecular biology 17
4. Overview of radiation physics 19
5. Principles of quality management 21
6. Statistical methods 22
7. Organisation, management and ethical issues in health care 23
8. Quality management in radiotherapy 25
9. General safety principles in the medical environment 27
10. Health technology assessment 28
11. Information and communication technology 29

Applied knowledge, skills and competencies 30

12. Dosimetry 30
13. Principles of medical imaging and image handling 32
14. External beam radiotherapy 34
15. Brachytherapy 41
16. Particle therapy 44
17. Unsealed source therapy 46
18. Radiation protection for ionising radiation 48
19. Mathematical modeling of treatment outcomes 50
20. Uncertainty in radiotherapy 51

Research Project 52

V. ASSESMENT METHODS TO EVALUATE COMPETENCIES 55

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 I. Introduction

To assist clarity, in this document we refer to Medical Physicists working (or training for a career) in
radiotherapy as radiotherapy physicists. For the same reason, given the wide variety of professional
titles in use throughout Europe, we will use the title RTT to refer to the staff delivering the
radiotherapy to patients.

Radiotherapy physicists are members of the multi-disciplinary clinical teams responsible for
radiotherapy of cancer patients. Their role is to provide critical scientific input on the physical
processes and technology that underpin the whole radiotherapy pathway. Generally, the
radiotherapy physicists design and develop the framework of radiation dosimetry, treatment
planning, quality assurance of individual patient‘s treatments, of the radiation therapy equipment
and other aspects of the treatment process including the radiation safety of the patient.
Specifically, the radiotherapy physicist provides expert advice on the development, implementation
and improvement of treatment techniques and processes. They also provide expert input during the
treatment for individual patients.
This includes having a leading role in the strategical planning, commissioning, safe utilisation and
optimisation of advances of radiotherapy technologies and techniques. In summary the radiotherapy
physicist‘s role is key for the enabling of the practice of safe, state-of-the-art radiotherapy.

In order to acquire and maintain sufficient knowledge and an appropriate level of competence, both
initial and continuing education and training are necessary.
European legislation has challenged many professional organisations to propose harmonised
professional standards of high quality. The European Union‘s Directives concerning basic safety
standards [1] and medical exposures [2] have given a statutory requirement for physicists to be
involved in the medical uses of ionising radiation; and have given impetus to the discussions of
education and training requirements in medical physics. In 2004 the Federation of Organisations
for Medical Physics (EFOMP) and the European Society for Therapeutic Radiology and Oncology
(ESTRO) issued jointly guidelines for the education and training of medical physicist within
radiation oncology. These guidelines are now updated jointly by the two organisations to
accommodate the contemporary requirements for the knowledge/ competency needs in this
rapidly evolving field of medicine.

The two organisations have a longstanding commitment to improved clinical practise, science
and development and education and training. EFOMP is an umbrella organisation for national
medical physics organisations, with one of its main objectives to harmonise and promote the
best practice of medical physics within Europe. To accomplish its goals, EFOMP has presented
various recommendations and guidelines in a number of Policy Statements, which have been
unanimously adopted by EFOMP Member Organisations. Policy Statement No 9, ―Radiation
Protection of the Patient in Europe: The Training of the Medical Physics Expert in Radiation
Physics or Radiation Technology‖ [3], is the EFOMP response to the Medical Exposure Directive,
97/43/Euratom [2]. Here EFOMP presents its recommendations on the role and the competence
requirements of the Medical Physics Expert (MPE), as defined in this Directive, together with
recommendations on education, training and Continuing Professional Development (CPD).
General criteria for structured CPD have been laid down by EFOMP in Policy Statement No 8,
―Continuing Professional Development for the Medical Physicist‖ [4]. CPD is the planned
acquisition of knowledge, experience and skills, both technical and personal, required for
professional practice throughout one‘s working life. EFOMP recommends that all medical
physicists who have completed their basic education and training should be actively involved in
CPD to maintain and increase competence and expertise after qualification. The EFOMP
approach to achieve harmonisation is to encourage the establishment of national education and

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training schemes at all levels in line with EFOMP recommendations. Guidelines for formal
EFOMP recognition of National Registration Schemes for Radiotherapy Physicists were
established in 1995 [5]. EFOMP approval requires inter alia clear statements of theoretical and
practical competencies, as well as training programmes consistent with the EFOMP policy on
training, and a regular renewal mechanism. CPD is now being recommended as the best way to
meet the requirement for a renewal mechanism, and Policy Statement No. 10 ―Recommended
Guidelines on National Schemes for Continuing Professional Development of Medical Physicists‖
[6], and Policy Statement No. 12 ―The present status of Medical Physics Education and Training
in Europe. New perspectives and EFOMP recommendations‖ [7], recommend National Member
Organisations to set up their own detailed CPD Scheme. In Policy Statement No.12 additional
recommendations on education and training of Medical physicists within the context of the
current developments in the European Higher Education Area arising from ‗‗The Bologna
Declaration‘‘, and with a view to facilitate the free movement of professionals within Europe,
are given.

The European Society for Therapeutic Radiology and Oncology (ESTRO) is a multidisciplinary
society of individual radiation oncologists, radiotherapy physicists,
radiobiologists and RTTs. It is a partner member in the umbrella organization, ECCO the
European Cancer Organization. ESTRO has developed, among other roles, a remit for improving
standards and practice, for providing teaching and training tools and resources and for fostering
research and development in radiotherapy in Europe. It actively co-operates with other
international and national radiation oncology societies, medical physics organisations, etc. in
these aims and activities. ESTRO has taken a multi-national European lead in developing and
delivering guidance frameworks in various areas of radiation oncology, eg. in education [8] and
quality assurance [9,10,11]. In these areas it has a record of producing consensus documents
which have been endorsed by a wide range of relevant national societies. It has provided
support for the development of guideline curricula recommendations for all the main
specialities working directly in radiation oncology [12,13]. Recently ESTRO has established
European School of Radiotherapy and Oncology which offers a large number of courses for
medical physicists within the field of radiation oncology. Moreover, a Masterclass in
radiotherapy physics for radiation oncology is under development. ESTRO has previously worked
in conjunction and cooperation successfully with EFOMP on educational issues [14,15]; both
organisations have recognised that there is a common interest. ESTRO has participated in or
contributed to many EU initiatives, for example to the ‗Guidelines on education and training in
radiation protection for medical exposures‘ [16]. The revised curriculum for medical physicists
in radiation oncology arises from an ESTRO initiative to update the education and training
requirements to accommodate todays‘ competency needs in modern radiation oncology.

The previous guidelines for education and training jointly developed by EFOMP and ESTRO [15]
focused on skills and knowledge required to safely act as a medical physicist in a radiation
oncology team. The current revision includes also other competency areas as organizational
competency, professionalism, communication, collaboration, social actions, in addition to
radiotherapy physics skills and knowledge. This structure is in accordance with the revised
guidelines for education and training of the radiation oncologists and RTT‘s developed by ESTRO.

[1] Council Directive 96/29/ Euratom of 13 May 1996, laying down basic safety standards for the
protection of the health of workers and the general public against the dangers arising from
ionising radiation. Official Journal 29.06.1996 No. L-159, page 1
[2] Directive 97/43/Euratom of 30 June 1997 on health protection of individuals against the
dangers of ionising radiation in relation to medical exposure. Official Journal of the European
Communities; 9 July 1977:22. No. L 190

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[3] EFOMP Policy Statement No. 9: Radiation Protection of the Patient in Europe: The Training of
the Medical Physics Expert in Radiation Physics or Radiation Technology. Physica Medica 1999;
XV (3): 149-153
[4] EFOMP Policy Statement No. 8: Continuing Professional Development for the Medical Physicist.
Physica Medica 1998; XIV (2): 81-83
[5] EFOMP Policy Statement No. 6: Recommended guidelines of National Registration Schemes for
Medical Physicists. Physica Medica 1995; XI (4): 157-159
[6] EFOMP Policy Statement No. 10: Recommended Guidelines on National Schemes for Continuing
Professional Development of Medical Physicists. Physica Medica 2001; XVII (2) 97-101.
[7] EFOMP Policy Statement No. 12: The present status of Medical Physics Education and Training
in Europe. New perspectives and EFOMP recommendations. Physica Medica 2010; (26) 1-5.
[8] Leer JWH, Overgaard J, Heeren G. The European core curriculum on radiotherpy. Radiother
Oncol 1991;22:153–5. EC Erasmus Programme (Grant agreements STV88-B-0193, STV 89-B-0209
and ICP 90-B-0170). Leer JWH, Overgaard J, Heeren G. The European core curriculum on
radiotherpy. Int J Radiat Oncol Biol Phys 1991;24: 813–4. also p. 153–155. EC Erasmus
Programme (Grant agreements STV88-B-0193, STV 89-B-0209 and ICP 90-B-0170). Leer JWH,
Davelaar J, Overgaard J, Heeren G. Education in radiation oncology in Europe. Int J Radiat
Oncol Biol Phys 24:819–23. EC Erasmus Programme (Grant agreements STV88-B-0193, STV 89-B-
0209 and ICP 90-B-0170).
[9] Europe Against Cancer Projects: EDRO-Education for Radition Oncology (Grant agreements.
200054 05F02 and S12300039); The development of an education network for radiotherapy
technologists (Grant agreement 201535; MORQA (Reduction of Radiation Morbidity through QA
of Dosimetry and Evaluation of Morbidity) Projects 1 and 2 (Grant agreements CAN 99CVF2-030
and 2000/CAN/210).
[10] Thwaites DI, Scalliet P, Leer JWH, Overgaard J. Quality assurance in radiotherapy (ESTRO
advisory report to the Commission of the European Union for the Europe against cancer
programme, Grant agreement Soc 95202083). Radiother Oncol 1995;35:61–73.
[11] Leer JWH, McKenzie A, Scalliet P, Thwaites DI. Practical guidelines for the implementation of
a quality system in radiotherapy ESTRO physics for clinical radiotherapy booklet 4. Brussels:
ESTRO; 1998.
[12] M. Baumann, J.W.H. Leer, O. Dahl, W. De Neve, R. Hunter, R. Rampling, C. Verfaillie, on
behalf of European Core Curriculum for Radiotherapists Working Party of the European Society
for Therapeutic Radiology and Oncology and the European Board of Radiotherapy. Updated
European core curriculum for radiotherapists (radiation oncologists). Recommended curriculum
for the specialist training of medical practitioners in radiotherapy (radiation oncology) within
Europe. Radiother Oncol 2004; 70: 107-113.
[13] Mary Coffey, Jan Degerfält, Andreas Osztavics, Judocus van Hedel, Guy Vandevelde. Revised
European core curriculum for RTs. Radiother Oncol 2004; 70: 137-158.
[14] Belletti S, Dutreix A, Garavaglia G, et al. Quality assurance in radiotherapy: the importance of
medical physics staffing levels, recommendations from a joint ESTRO/EFOMP task group.
Radiother Oncol 1996;41:89–94.
[15] Eudaldo T, Huizenga H, Lamm IL, McKenzie A, Milano F, Schlegel W, Thwaites D.I, Heeren G..
Guidelines for education and training of medical physicists in radiotherapy. Recommendations
from an ESTRO/EFOMP working group. Radiother Oncol 2004;70:125-135.
[16] European Commission. Radiation Protection 116. Guidelines on education and training in
radiation protection for medical exposures. Directorate General Environment, Nuclear Safety
and Civil Protection. Luxembourg; 2000.

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 II. DEFINITIONS

1. Medical Physics.

There is a wide and unanimous acceptance of the definition of Medical Physics. Internationally
respected organizations such as: AAPM (American Association of Physicists in Medicine), IOMP
(International Organization for Medical Physics) and EFOMP (European Federation of Organisations in
Medical Physics), have adopted similar definitions:

―Medical Physics is an applied branch of physics concerned with the application of the
concepts and methods of physics to the diagnosis and treatment of human disease‖.
Or:
―Medical Physics can be described as the scientific discipline which is concerned with the
application of the concepts and methods of physics in medicine‖.

2. Medical Physicist (MP)

Acording to the IOMP:

―A medical physicist is a professional who is qualified with a university degree or equivalent
(level corresponding to masters degree) majoring in physical or engineering science with
specialist education and training in the concepts and techniques of applying physics in
Medicine‖.

Fom the International Atomic Energy Agency (IAEA):

―A medical physicist is a healthcare professional who specialises in the application of physics
in medicine and has the knowledge and responsibility for the radiation protection of
patients, staff and the public‖.

3. Qualified Medical Physicist (QMP)

EFOMP defines the QMP in its Policy Statement No.7:

―A qualified Medical Physicist is an individual who is competent to practice independently
and to register as a Medical Physicist, in one or more of the subfields of medical physics‖.

A more comprehensive definition of the QMP can be found in the EFOMP Policy Statement No. 10:
―The entry criterion to Medical Physics education and training is a basic university education
in physical sciences, engineering or equivalent.
Recognition as a Qualified Medical Physicist is achieved by a further 2 to 4 years theoretical
education and practical training in Medical Physics (depending on the national education
system) under supervision of a Qualified Medical Physicist, preferably a Specialist Medical
Physicist. At least half of the time should be spent in a clinical environment.
The Qualified Medical Physicist is competent to act independently.
The Qualified Medical Physicist should have a formal recognition from a National Competent
Authority, and should be enrolled in an EFOMP approved National Register for Medical
Physicists‖

In the EFOMP Policy Statement No. 12:

―To work as a Medical Physicist in a hospital environment, it is needed to hold a university
degree in Physics or equivalent and a university post-graduate training at the level of Master
(master in Medical Physics). To manage patients without supervision, EFOMP recommends a
second part in the post-graduate training: at least 2 years‘ training experience on-the job.

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 Only after completion of this training can a physicist be considered a Medical Physicist and
able to work independently as a Qualified Medical Physicist (QMP)‖

The AAPM also defines the Qualified Medical Physicist:

―A Qualified Medical Physicist is an individual who is competent to practice independently
one or more of the subfields of medical physics‖.

4. Specialist Medical Physicist (SPM)

From the EFOMP‘s point of view, to act as an expert further experience is required and an
involvement in a programme for Continuing Professional Development is recommended.

From the EFOMP Policy Statement No. 10:

―The Qualified Medical Physicist qualifies to become a Specialist Medical Physicist by gaining
advanced clinical experience and undergoing specialist training of at least two further years
duration, mostly in one sub-speciality, within the first period of an EFOMP approved National
CPD Scheme.
The Specialist Medical Physicist is competent to give advice on all professional matters in
their sub-speciality.
The Specialist Medical Physicist may have a formal recognition from a National Competent
Authority and should continue to be enrolled in an EFOMP approved National Register for
Medical Physicists‖.

The EFOMP Policy Statement No.12 recomends full length of one cycle time of CPD to become SMP.
(5-6 years, instead of the 2 years stated in PS No.10):
―With the rapid increase in complexity of diagnostic and therapeutic procedures and
equipment the full length of five years advanced clinical experience and specialist training
should be used to become accepted as Specialist Medical Physicist‖.

5. Medical Physics Expert

This title regarding the level of an individuals expertise arose from an european directive; The
definition was introduced in 1997 in the Council Directive 97/43/Euratom of 30 June 1997 on health
protection of individuals against the dangers of ionising radiation in relation to medical exposure. It
had to be transposed into the national legislation in all European countries, defining the medical
physics expert into national legislation. However, due to the lack of clarity or a uniformity of
criteria, the definition of the Medical Physics Expert is implemented differently across Europe.

A new directive, the Euratom Basic Safety Standards Directive (Draft Version 24 February 2010)
gives a new definition of the Medical Physics Expert. This directive will revoke both the Council
Directive 96/29/ Euratom of 13 May 1996, concerning basic safety standards for the protection of
the health of workers and the general public against the dangers arising from ionising radiation
(“the BBS”) and the Council Directive 97/43/Euratom of 30 June 1997, concerning the health
protection of individuals against the dangers of ionising radiation in relation to medical exposure
(“the MED”). This provides a clearer definition of the Medical Physics Expert:

―An individual having the knowledge, training and experience to act or give advice on
matters relating to radiation physics applied to medical exposure, whose competence to act
is recognized by the competent authorities‖.

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In the following guidelines with respect to competencies, skills and knowledge included will be
described without further referral to the above mentioned definitions as interpretation and
implementation of the various titles differs throughout Europe.
Nevertheless, the content of the curriculum is aimed to bring trainees up to the level of
competence to act and practice independently in the field of radiation therapy.

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 III. GENERAL COMPETENCIES

1. Organization

Short description

The radiotherapy physicist is a member of a multi-disciplinary team that includes radiation

oncologists, radiotherapy physicists and RTTs, computer scientists, assistant medical
technicians, nurses, administrators, hospital management and other health care
professionals, who work together to provide the radiotherapy. Therefore, the rdiotherapy
physicist must be able to participate in organising and structuring of the radiotherapy
process and associated tasks and responsibilities .

Competences:

 demonstrate an understanding of local and national health care organisational structures

 demonstrate an awareness of trends in health care structure development
 ability to work effectively, in terms of time and equipment and other resources as a
staff member in a radiotherapy team
 ability to manage own workload to ensure effective input to the team
 demonstrate an understanding of the required technological infrastructure for a
radiotherapy department and an awareness of how to establish the necessary
interactions with other disciplines within the hospital (e.g. diagnostic radiology and
other fields of oncology).
 ability to organise various aspects of the routine radiotherapy physics service
 ability to organise networks for research and development within the scientific
community of radiotherapy physicists.

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 2. Professionalism

Short description:

The radiotherapy physicist must have a high standard of professionalism and integrity. This
includes self-awareness and knowledge of limits, high standards of ethical and moral
behaviour, reliability and responsibility, respect for patient dignity, and autonomy.

Competences:
 able to cope with own emotions and criticism.
 displays appropriate behaviour.
 know his own limitations of knowledge and competency and to work within them,
thereby knowing when to seek advice.
 Understanding that he is responsible for his own actions.
 Understanding of relevant national professional codes and the need to work within
them.
 Understand the requirements of data protection, privacy and dignity legislation.
 Understand organisational policies and national legislation to ensure they behave
correctly towards colleagues and members of the public in carrying out their duties

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 3. Communication

Short description:
The radiotherapy physicist must be able to communicate in an efficient and unambigious
way, with a variety of healthcare professionals, to ensure the safe and accurate provision
of health care services. This includes the accurate communication of information within
the radiotherapy or oncology department and with other departments/ hospital staff.
It is also necessary to be able to give information to the patient (and their carers) or
answer their questions, in these situations it is often necessary to use non—sceintific
language, avoiding ‗technical jargon‘ whilst ensuring clear and understandable information
is given. To prepare the radiotherapy physicist for the encounter with cancer patients and
their families, the radiotherapy physicst needs to learn basic skills and strategies needed
for effective communication.

Competences:
 Demonstrate an understanding and correct use of specific terminology
 Ability to discuss technical and clinical aspects of radiotherapy with members of the
multidisciplinary team using appropriate terminology
 Ability to discuss general radiotherapy aspects with staff/ public who do not have
any knowledge of radiotherapy
 Ability to prepare written material (research and routine) in the form of notes,
resumes, reports and scientific papers to be presented at seminars, conferences or
to be submitted for publication in scientific journals
 Being able to understand the international literature in the field,
 Preferrably having the able to communicate in a language/languages other than
his/her mother tongue; in particularly english as the commonly used scientific
language.
 Ability to communicate clearly with patients and their family and provide them with
concise information about their treatment.
 Ability to recognise and respond to the emotions of patients and their family and to
deal with one‘s own emotional response to the challenges in working with cancer
patients.

Core Curicullum Items

 Impact of communication on the patient‘s wellbeing;

 Communication skills in the interaction between patients and health care
professionals.

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 4. Collaboration

Short description:
In order to secure the best possible health care for the patients, the radiotherapy physicist
must be able to collaborate with other health care professionals involved in the
radiotherapy process. Moreover, the ability to collaborate constructively also rely on a
sound understanding of one‘s own role within the clinical team and the necessary
interactions with individuals and health care professional groups.

Competences:
 demonstrate the ability to work in multidisciplinary team
 demonstrate an understanding of the role of the radiotherapy physicists within the
team
 being able to work within the framework of cross-disciplinary research collaboration
to improve the routine clinical service,
 be able to work in an international team of scientists and health care providers,
 is able to demonstrate leadership capability whenever necessary,

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 5. Social Actions

Short description:
As a heath care professional the role of the radiation physicist implies certain social actions
that has consequences for the patient, the heath care organization and society.

Competences:

 to demonstrate an understanding of, and be able to act within, relevant national

legal frameworks, regulations and guidelines
 Demonstrate the ability to act according to best use of resources in the interest of
the patient and society
 Have the ability to takes adequate action (within own competency limitations) in
response to incidents
 Show consideration for other person‘s ethical, religious, cultural or moral issues

Core Curiculum Items

 National and European heath care legislation

 Ethical guidelines
 National and European regulations on the use of ionizing radiation in medicine
 National and international guidelines

Recommended literature for the general competencies

 Maintenance of certification for radiation oncology. Larry E. Kun, Kian Ang, Beth
Erickson, et al. Int. J. Radiation Oncology Biol. Phys., Vol. 62, No. 2, pp. 303–308, 2005.
 The American Board of Radiology Maintenance of Certification (MOC) Program in
Radiologic Physics. SR Thomas, WR Hendee and BR Paliwal. Medical Physics,Vol.32, No.
1, 2005
 Faulkner, A. & Maguire, P., Talking to cancer patients and their relatives, Oxford
University Press, 1994

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 IV. RADIOTHERAPY PHYSICS KNOWLEDGE, SKILLS AND COMPETENCIES

The field of radiation therapy physics is a dynamic, fast evolving discipline with constant
development, introduction and implementation of new advanced imaging and treatment
technologies and optimisation of existing techniques. Because of their key role in this
processes, radiotherapy physicists require broad scientific interests and need to constantly
learn and acquire new knowledge. An excellent knowledge of radiation therapy physics
remains the central competence, whilst interdisciplinary knowledge is also needed for
active involvement in development of new combinatory therapeutic technologies.

The radiotherapy physicist have to demonstrate and apply their knowledge in clinical
practice through skills and appropriate attitude. Therefore medical physicists should be
able to:
 examine medical information critically and apply it appropriately to practice decisions;
 maintain and enhance professional knowledge through ongoing lifelong learning (e.g.
develop and maintain a personal continuing-education plan);
 facilitate the learning and promote the scientific expertise of students, colleagues and
other health professionals;
 perform a systematic review and interpretation of scientific literature;
 follow the current research and development in radiation therapy, understand and
implement the new technologies in clinical practice;
 carry out, conduct and supervise scientific research and development in radiotherapy
physics;
 optimize the quality, the practical effect and/or the scientific value of research;
 build, have and/or maintain a good national and international network;
 recognise the limits of their expertise.

The following sections provide more detail on the required areas of base knowledge (Core
Curricular) and required competencies (demonstration of knowledge application) for the
contemporary radiotherapy physicist.

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 FUNDAMENTAL KNOWLEDGE

1. Fundamentals of human anatomy and physiology

Short description

Basic understanding and knowledge of human anatomy is required to safely undertake treatment
simulation and planning in radiation oncology. It is also a prerequsite for communication and
exchange of patient and disease related treatment information. Likewise is a basic understanding
and knowledge of the human physiology is essential to the understanding of treatment related
adverse affects, and is as such a prerequisite for treatment optimisation. As a part of a
multidiciplinary radiation oncology team the radiotherapy physicist requires a background in basic
human anatomy and physiology.

Competences

 Demonstrate an understanding of human anatomy and physiology;

 Ability to recognise the various anatomical structures of the human body relevant to the RT
process, especially with emphasis on 3D and projection of 3D anatomical structures;
 Demonstrate an understanding of the consequences of treatment related adverse effects and
how this influences treatment planning.

Core curriculum items

 Nomenclature of human anatomy;

 The anatomy of scelletal structures;
 The anatomy of muscles;
 The anatomy and physiology of organs and tissue at risk in radiotherapy.

Assessment of the amount of time to be spent in this topic – 2 ECTS

Recommended literature
 Eric Widmaier, Hershel Raff, and Kevin Strang, Vander, Sherman and, Luciano‘s Human
Physiology, McGraw-Hill, 2004.
 Michael McKinley and Valerie O'Loughlin, Human Anatomy, McGraw-Hill, 2005.
 Elaine N. Marieb and Katja N. Hoehn, Human Anatomy and Physiology, Benjamin Cummings,
2006.

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 2. Fundamentals of oncology

Short description

A basic understanding of the fundamentals of cancer development, diagnostics and

treatment is required. Modern radiotherapy is increasingly a part of a multi-modality treatment
approach, including novel drugs targeting specific molecular pathways interacting with the response
to radiation on the molecular level. Treatment planning will need to incorporate knowledge about
the molecular and cellular response mechanisms of combined radiation and medical oncology .
Individualised therapy also requires detailed knowledge of the molecular and cellular mechanisms
involved in the response to treament.

Competences

 Ability to participate in a multidisciplinary radiation oncology team with respect to the

communication and exchange of relevant patient information;
 Demonstrate a basic understanding of the development of cancer, the nature of the various
forms of cancers, their molecular and cellular features as well as diagnostics of cancer;
 Demonstrate knowledge of the various treatment options;
 Ability to integrate knowledge of multi-modal therapy into the planning of radiation therapy of
cancer patients.

Core curriculum items:

 Carcinogenesis;
 Onogenes and supressorgenes;
 Major signaling pathways of importance for repsonse to radiation;
 Principles of diagostics and staging of cancer;
 Principles of surgical, medical and radiation oncology.

Assessment of the amount of time to be spent in this topic – 2 ECTS

Recommended literature
 Raymond W. Ruddon, Cancer Biology, Oxford University Press, 2007
 Introduction to the Cellular and Molecular Biology of Cancer, Eds. Margaret Knowles and Peter
Selby, Oxford University Press, 2005.
 Raymond E Lenhard Jr, Robert T Osteen, Ted Gansler Eds. Clinical Oncology, American Cancer
Society.

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 3. Principles and applications of radiobiology and molecular biology

Short description

Modern radiation oncology is characterised by multi-modality treatment, including novel drugs

targeting specific molecular pathways interacting with the response to radiation on the molecular
level. This development has an impact on the activities of radiotherapy physicists and requires a
solid knowledge in the field of radiobiology and its clinical implications being the basis of therapy
strategies in radiation oncology.
Treatment planning will need to incorporate knowledge about the molecular and cellular response
mechanisms of combined radiation and medical oncology . Individualised therapy, optimisation and
the development of novel treatment strategies requires detailed knowledge of the molecular and
cellular mechanisms involved in the response to treament. Furthermore, the availability of new
radiation modalities, like protons or light ions, and the increasing inclusion of patient related
individual biological information into treatment planning will require a solid knowledge of biology.
Therefore, radiotherapy physicists have to be trained in the fundamentals of cellular and molecular
biology as well as tumour and radiation biology.

Competences

 Ability to demonstrate the understanding of the fundamentals of cellular, molecular and

radiation biology of tumour and normal tissue;
 Demonstrate a basic understanding of the mechnisms involved in novel drugs commonly used in
combination with radiation;
 Ability to understand the basics of how radiation sensitivity of tumour and normal tissues is
caused by combined medical and radiation therapy;
 Abilty to practically apply radiobiological knowledge to the fields of radioprotection as well as
to diagnostic and therapeutic application of ionising radiation;
 Ability to demonstrate the understanding of the radiobiological background of treatment
strategies in radiation therapy.

Core curriculum items

 Fundamentals of cellular and molecular biology;

 The physical and biological background of the effect of electromagnetic and hadronic ionising
radiation to living cells;
 The response to radiation on molecular, cellular and macroscopic levels;
 Deterministic and stochastic effects of ionising radiation;
 The response of tumours and normal tissue to therapeutic levels of radiation;
 Early and late radiation effects;
 Effects of fractionation, dose rate, radiosensitation and reoxygenation;
 The linear quadratic model;
 Therapeutic ratio, tumour control probability, normal tissue complication probability, tolerance
doses;
 Dose-volume effects.

Assessment of the amount of time to be spent in this topic – 3 ECTS

17
Recommended literature

 B. Alberts, D. Bray, K. Hopkin, A. Johnson, J. Lewis, M. Raff, K. Roberts, P. Walter, Essential

cell biology, Garland, 2009
 G.G. Steel, Basic Clinical Radiobiology, Arnold, 2009
 E. Hall, A.J. Giaccia, Radiobiology for the radiologist, Lippincott, Wilkins & Williams, 2006
 Introduction to the Cellular and Molecular Biology of Cancer, Eds. Margaret Knowles and Peter
Selby, Oxford University Press, 2005
 Douglas Hanahan and Robert A. Weinberg. The Hallmarks of Cancer. Cell, Vol. 100, 57–70,
January 7, 2000,

18
 4. Overview of radiation physics

Short description

The radiotherapy physicist should have a good knowledge of radiation physics in order to understand
the manner in which ionising radiation is applied in medical diagnostics and radiotherapy. Since X-
rays of energies ranging from kV to several MV, gamma-rays of several MeV and a variety of
corpuscular radiations, including heavy ions, are nowadays applied in medical diagnostics and
radiotherapy, a broad knowledge of nuclear and atomic physics is required of the radiotherapy
physicist. Medically relevant descriptions of the different sources of ionising radiation as applied in
their different modalities (such as beam specifications for radiodiagnostics or radiotherapy) should
be included. Of great importance is the knowledge of the physics of interaction of different types of
radiation with matter, as it forms the basis for understanding the advantages and limitations of
various techniques applied in diagnostics and radiotherapy, also leading to insight as to their
biological effect (cf. radiobiology). Elements of statistical methods applied to estimate the
uncertainty of radioactivity measurements with an overview of medical uses of radiation should also
be included.

Competences and skills

 Ability to recognise the difference between the physical interactions of indirectly and directly
ionising radiation;
 Ability to specify the different mechanisms of generation of ionizing radiation, including
radioactive decay;
 Ability to describe different mechanisms of energy loss of various type of radiation through
various media;
 Demonstrate an understanding of the basic concepts of dosimetry and principles of operation of
several dosemeters;
 Ability to describe quantitatively radiation fields applied in radiodiagnostics and radiotherapy;
 Ability to describe quantitatively the various radioactive sources use in nuclear medicine for
diagnostics and radiotherapy;
 Demonstrate an understanding of and the ability to apply principles of radiation protection in
radiodiagnostics and in radiotherapy;
 Ability to identify a physical problem and to develop an experimental procedure of resolving it
using appropriate measurement equipment;
 Ability to estimate measurement uncertainties and their categories.

Core Curriculum items

 Ionising radiation;
 X-ray generation;
 Radioactivity (units and quantities);
 Poissonian statistics;
 Radiation sources and source types (e.g. sealed, unsealed, applications);
 Interaction of photons (X-rays, gamma-rays) with matter;
 Scattering and attenuation of a photon beam in matter and living matter;
 Interaction of electrons, heavy charged particles and neutrons (slow and fast);
 Linear energy transfer (LET);
 Overview of medical uses of radiation;

19
 Overview of clinical specification of radiotherapy beams.

Time to be spent on the topic : 6ECTS

Recommended literature

 Dendy P.P., Heaton B.: Physics for Diagnostic Radiology. 2nd Ed.IoP Bristol and Philadelphia 1999
 Graham D.T., Cloke P.: Principles of Radiological Physics. 4th Ed. Churchill Livingstone 2003
 Hobbie R.K.: Intermediate Physics for Medicine and Biology. 3rd Ed. Springer-Verlag 1997

20
 5. Principles of quality management

Short description

Quality management requires an organisational structure where responsibilities, procedures,

processes and resources are clearly defined. It should be supported by the department management
in order to work effectively and should be as comprehensive as is required to meet the overall
quality objectives. It must have a clear definition of its scope and of all the quality standards to be
met and requires collaboration between all members of the radiotherapy team. The quality system
must incorporate compliance with all the requirements of national legislation, accreditation, etc.
and requires the development of a formal written quality assurance program that details the quality
assurance policies and procedures, quality control tests, frequencies, tolerances, action criteria,
required records and personnel.

Competences:

 Ability to participate in quality management and facilitate quality improvement;

 Abiltiy to define quality objectives;
 Ability to measure effective quality performance;
 Abiltiy to improve effective quality performance;
 Ability to define control tests, frequencies, tolerances, action criteria, records and personnel;
 Ability to assess the national legislation, accreditation requirements.

Core curriculum items

 Meaning of quality, quality assurance and quality control;

 Quality standards;
 Assessment of quality;
 Quality management systems, records, audit and improvement of quality.

Assessment of the amount of time to be spent in this topic – 1 ECTS

Recommended literature

 ESTRO, Quality assurance in radiotherapy, Radiother. Oncol. 35 (1995) 61–73.

 ISO, Quality Management and Quality Assurance Standards — Part I. Guidelines for Selection and
Use, ISO 9000, ISO, Geneva (1994).
 WHO, Quality Assurance in Radiotherapy, WHO, Geneva (1988).
 Stelios Christofides. The European Federation of Organisations for Medical Physics.
Policy Statement No.13: Recommended guidelines on the development of safety
and quality management systems for medical physics departments. Physica Medica
(2009), DOI: 10.1016/j.ejmp.2008.11.002 (article in press)

21
 6. Statistical methods

Short description

An important approach in biomedical research is to derive the properties of a whole population

from the knowledge of the properties of a random sample of that population. This research
methodology, widely applied to studies in radiation oncology and radiobiology, requires the
utilisation of methods of mathematical statistics. Radiotherapy physicists are frequently involved in
such studies in particular in designing, analysing and interpreting the experiments and processing
the data. Moreover, they shall be able to correctly and critically analyse published research results.
Therefore, radiotherapy physicists have to be trained in the fundamentals of statistical methods and
their application to biomedical research.

Competences

 Ability to demonstrate the understanding of the fundamentals of biostatistics;

 Ability to design studies in clinical and biomedical research;
 Abilty to perform practically the most common statistical tests;
 Ability to apply computational techniques and dedicated software packages for statistical data
analysis;
 Ability to analyse and interprete experimental results;
 Ability to apply experimental outcomes to evidence based medicine approaches.

Core curriculum items

 Descriptive statistics;
 Probability distributions;
 General principles and application of statistical tests;
 Survival analysis;
 Study design and power analysis;
 Uncertainty analysis;
 Regression and correlation.

Assessment of the amount of time to be spent in this topic – 1 ECTS

Recommended literature

 S. A. Glantz, Primer of biostatistics, McGraw Hill, 2005

 B. Rosner, Fundamentals of biostatistics, Thomson, 2006

22
 7. Organisation, management and ethical issues in health care

Short description

The radiotherapy physicist should be able to understand the structure of, and to participate in the
management of a hospital department. The trainee should acquire basic knowledge of the
organisation and management of the local health care system and of the relevant guidelines and
recommendations from national or international organisations. The trainee should be familiar with
national regulations and EU directives in the area of medical uses of radiation, including radiation
protection of the patient and gain working knowledge of quality management systems.

Competences:

 Demonstrate an understanding of the position of the trainee‘s own institution as part of the
organisation of health care at local and national levels;
 Demonstrate knowledge of the development of medical physics and radiotherapy in the trainee‘s
country;
 Ability to acquire EU Directives, national regulations and guidelines and/or recommendations
from national and international organisations;
 Demonstrate knowledge of ethical considerations in medical practice;
 Demonstrate knowledge of equipment management (e.g., servicing, purchasing of new
equipment, etc.);
 Demonstrate understanding of written procedures of a departmental quality management
system.

Core Curriculum items

 National and local system, global view of other European systems;

 National regulations and EU Directives in medical application of ionising radiation;
 Guidelines and recommendations from national and international organizations;
 Ethical considerations in medical practice;
 Principles of management as applied to hospital departments and projects, etc.;
 Principles of personnel management ;

Time to be spent on this topic: 1ECTS

Recommended literature

 Directive 96/29/EURATOM laying down basic safety standards for the protection of the health of
workers and the general public against the dangers arising from ionizing radiation.
 Directive 97/43/EURATOM on health protection of individuals against the dangers of ionizing
radiation in relation to medical exposure
 Shortell S. M., Kaluzny A.D.: Essentials of Health Care Management. Delmar Publisher
 Brown M.: Health Care Management . Strategy, Structure&Programs. Health Care Management
Review. An Aspen Publication
 Duncan W.: Handbook of Health Care Management. Blackwell Science
 Ghaye T.: Building the Reflective Health Care Organisation. Willey-Blackwell

23
 Grifith J.R., White K.R.: The Well-Managed Health Care Organization. 6th Ed. Health
Administration Press US
 Walshe K., Smith J.: Healthcare Management. Open University Press
 Moulin M.: Delivering Excellence In Health And Social Care. Open University Press
 Sherriff SB, Dendy PP. The European Federation of Organisations for Medical Physics. Policy
Statement No 11. Guidelines on Professional Conduct and Procedures to be implemented in the
event of alleged misconduct. Physica Medica Vol. XIX, N. 3, July-September 2003. pag: 227-229

24
 8. Quality and risk management in radiotherapy

Short description

The process of radiotherapy is becoming more and more complex which requires a high level of
safety and constant quality improvement. The quality management of this process is a dynamic
system that should continuously be improved and modified to meet the evolving needs and demands
of the hospital environment. Among other professionals, radiotherapy physicists are encouraged to
implement and maintain a safety and quality management system for the management of their
departments to achieve the following objectives:
 Increase the safety of the patient undergoing diagnostic and therapeutic procedures related to
radiotherapy physics
 Increase the safety, quality and efficiency of the medical physics services
 Increase its cost effectiveness
 Introduce the concept of improvement and upgrading of the radiotherapy physics services.

The Quality Assurance (QA) process in radiotherapy involves all steps of the treatment:
simulation (imaging processes), planning, verification, delivery and reporting. In particular, it
includes the commissioning and quality control (QC) of treatments units, TPS, imaging systems used
in RT, dosimetry systems and networks. QA of individual patients includes independent monitor unit
calculation and dosimetric verification of the treatment plan for special techniques like stereotactic
treatments, IMRT, IMAT

Competences:

 Ability to identify and formulate improvements to upgrade the quality program

 Ability to evaluate and prevent the risks of a given procedure or protocol;
 Ability to set specifications, measure performance, compare with specifications, and, as
required, adjust the process to meet specifications in accordance with the recommandations
and standards (including documentation and training of other professionals);
 Ability to evaluate whether service agreements and software updates for major equipment
(including, but not limited to, accelerators, imaging equipment, treatment-planning computers,
and patient management computer systems) are adequate to ensure patient safety and service
continuity;
 Ability to assess additional needs in the quality program consistent with the scope of clinical
services being provided and/or in the process of implementation;
 Ability to prevent and investigate incidents and implement corrective actions;
 Ability to evaluate effective safety performance;
 Ability to manage and plan for emergency situations;
 Ability to assess human factors and safety-related behavior;
 Ability to assess sources and levels of uncertainty in geometry and dose delivery and the
methods for monitoring and controlling them;
 Demonstrate knowledge of national and international recommendations and local protocols for
QA;
 Ability to perform the commissioning and QC of treatment units, TPS, imaging systems,
dosimetry system and networks.

25
Core curriculum items

 Meaning of quality, quality assurance and quality control;

 Meaning of risk;
 Quality standards;
 Assessment of quality;
 Assessment of risk;
 Risk management;
 Quality management systems, records, audit and improvement of quality;
 Quality audit, analysis and improvements.

Assessment of the amount of time to be spent in this topic – 5 ECTS

Recommended literature

 G. J. Kutcher, L. Coia, M. Gillin, W. Hanson, S. Leibel, R. Morton, J. R., Palta, J. A. Purdy, L. E.

Reinstein, G. K. Svensson, M. Weller, and L. Wingfield, ―Comprehensive QA for radiation
oncology: Report of AAPM Radiation Therapy Committee Task Group 40,‖ Med. Phys. 21, 581–618
1994.
 AAPM Report No. 47. ―AAPM Code of Practice for Radiotherapy Accelerators.‖ (American
Institute of Physics, New York, 1994).
 B. Fraass, K. Doppke, M. Hunt, G. Kutcher, G. Starkschall, R. Stern, and J. Van Dyk, ―American
Association of Physicists in Medicine Radiation Therapy Committee Task Group 53: Quality
assurance for clinical radiotherapy treatment planning,‖ Med. Phys. 25, 1773–1829 1998.
 International Organization for Standardization, ―Quality management and quality assurance
Standards. 1. Guidelines for selection and use,‖ ISO 9000, ISO, Geneva 1994.
 P. H. Halvorsen, I. J. Das, M. Fraser, D. J. Freedman, R. E. Rice, III, G. S. Ibbott, E. I. Parsai, T.
T. Robin Jr., and B. R. Thomadsen, ―AAPM Task Group 103 report on peer review in clinical
radiation oncology physics,‖ J. Appl. Clin. Med. Phys. 6, 50–64 (2005).
 Radiotherapy risk profile. Technical Manual. World Health Organization. (2008)
 ESTRO Booklet series (Booklets 2 and 7)
 NCS Report 11. Quality control (QC) of simulators and CT scanner and some basic QC methods
for treatment planning systems, current practice and minimum requirements. NCS,
September 1997.

26
 9. General safety principles in the medical environment

Short description

Whilst undertaking their work the radiotherapy physicist may be exposed to many radiological,
electrical, chemical, mechanical and biological hazards. Radiotherapy physicists must be familiar
with the hazards and necessary precautions. They should have a sufficient appreciation of best
practice concerned with safety and risk management to be able to contribute, facilitate, implement
and improve safety management systems.

Competences:

 Ability to discuss and manage safety;

 ability to identify and minimize risks in order to avoid preventable incidents
 Ability to plan an investigation following an incident to analyse its consequencies and suggest
changes to practice to avoid repetition;
 Ability to measure and improve effective safety performance;
 Ability to define emergency plan;
 Ability to manage and control human factors and safety-related behavior;
 Ability to assess national regulations.

Core curriculum items

 Principles of safety and risk management;

 Electrical, electro-magnetic, and magnetic safety;
 Mechanical safety;
 Principles of Radiation Protection, ionising radiation and non-ionising radiation (microwave, RF
and magnetic fields, ultraviolet, lasers, ultrasound).

Assessment of the amount of time to be spent in this topic – 1 ECTS

Recommended literature

 IAEA. Lessons Learned from Accidental Exposures in Radiotherapy, Safety Reports Series No. 17
(2000).
 IAEA Method for the Development of Emergency Response Preparedness for Nuclear or
Radiological Accidents, IAEA-TECDOC-953 (1997).
 IEC standards publications (specifically IEC standards publications (specifically: IEC 601-2-8
(1987), IEC 60601-1-4 (1997), IEC 60601-2-11 (1997), IEC 60601-2-1 (1998), IEC 60601-2-17
(1998), IEC 60601-2-29 (1999), 62C/62083 (in preparation).

27
 10. Health technology assessment

Short description

Health technology assessment (HTA) is a multidisciplinary process that analyses information

regarding the use of a particular health technology. It summarises medical, social, economic and
ethical issues in a systematic manner, aiming to inform the formulation of safe and effective health
policies that are patient focused and seek to achieve best value. HTA crosses the ideological divide
between scientific investigation and political decision making, however remains firmly rooted in the
research and scientific methodologies.

For example, a HTA related to radiotherapy may seek to address these questions:
- Do we really need empirical evidence to determine effectiveness?
- Is it ethical to randomise patients between two treatment modalities when it is obvious from
a theoretical point of view that one is better than the other?
- What kind of trials needs to be designed to answer the question of whether a clinical
improvement is worth the added expence?

Competences:

 Demonstrate an understanding of the basic methodology employed in HTA;

 Ability to perform a systematic review of the literature to evaluate the clinical effectiveness of
a new technology or technique;
 Ability to assess the safety and efficacy of a new technology/technique.

Core Curriculum items

 General aspects related to an HTA report: general impressions, motivation for the report,
methodology used, interpretation of available information and implementation of the finding of
the report.
 Development of methodology for critical assessment of health technology as a complement to
randomized controlled trials.

Assessment of the amount of time to be spent in this topic – 1 ECTS

Recommended literature

 Quality indicators in radiotherapy, Cionini et al. Radiother Oncol 82 (2) 2007, 191-200
 Does health technology assessment put patient care at risk? McEwan AJ, J Nucl Med. 2005 Dec;
46(12):1939
 Randomized controlled trials in health tecnology assessment: Overkill or overdue?, Bentzen S ,
Radiother Oncol 86 (2008) 142-147.
 A difference between systematic reviews and heath technology assessment; a trade-off between
the ideals of scientici rigor and the realities of policy making. Rotstein D and Laupacis A. Int J
Technol Assess Health Care 2004, 20, 177-183.

28
 11. Information and communication technology

Short description

There is a clear need for the modern radiotherapy physicist to have a good understanding of
Information and Communication Technology (ICT). The contemporary radiotherapy department has
a number of computer systems which are used to design, manage and deliver highly complex
radiotherapy. Hence the need to safely transfer data across a number of software and hardware
interfaces is essential. It is not necessary for all physicists to become experts in ICT, however they
are required to work effectively with IT professionals from inside and outside the hospital
organisation.

Competencies

 Ability to understand and discuss ICT concepts, with other healthcare professionals, to assist
with the specification, commissioning, implementation and safe operation of contemporary
radiotherapy equipment;
 Ability to understand and discuss healthcare data connectivity standards with colleagues from
other disciplines to facilitate the integration of general systems within radiotherapy
departments;
 Demonstrate a good understanding of hardware configuration, operating systems and typical
software applications;
 Demonstrate a good understanding of the contemporary planning, treatment management,
delivery and dosimetry systems.

Core Curriculum items

 Operation of the major components of computers, including hardware, software, computer

topologies and networks;
 The principles of local and wide area networking (LAN, WAN) and protected (including firewalls)
sub-nets as a security precaution for 'mission critical' equipment whose safety of operation may
be compromised otherwise;
 IP terminology, port assignment, ftp, telnet, ping testing, network gates/ router procedures,
firewall technology;
 virus infection risks: different types and routes of propagation , precautionary measures;
 Different types of software licensing principles;
 Data exchange formats and standards (for example: FTP) and their implementation (DICOM);
 Relevant data and ICT security standards for collection, storage and transmission and Data
Protection Legislation;
 The operational relationships between hospital information systems and management systems
used in radiotherapy/ oncology;
 Data warehousing for archiving and storage and relevant legislation regarding the required time
such information must be kept for;
 DICOM – general understanding of DICOM and its operation;
 PACS – general understanding of PACS and its operation.

Assessment of the amount of time to be spent in this topic – 3 ECTS

Recommended literature
 W. Buchanan, Mastering networks. 2010

29
 APPLIED KNOWLEDGE AND SKILLS

12. Dosimetry

Short description

Accurate dose determination is one of the most important tasks of the radiotherapy physicist. The
concept of absorbed dose and kerma, and dosimetric quantities and units should be well
understood. The radiotherapy physicist should be familiar with the principle of the calibration chain
from primary standard to field instrument, and understand the physics and techniques of the
different dosimetry detectors. Determination of the absorbed dose in a clinical beam under
reference conditions by applying a national or international recommended protocol is an important
issue, but also the dose determination in non-reference conditions should be handled. The
radiotherapy physicist should be familiar with the different practical measurement systems that can
be used for dosimetry and quality control in the hospital and understand their advantages and
limitations in order to be able to select the most appropriate system for each dosimetric problem.
Acceptance testing, calibration and quality control of these measurement systems should also be
included. Dosimetry audits are an important step in a well designed quality control program.

Competences and skills:

 Demonstrate a good understanding of the fundamental theoretical and practical aspects of all
reference dosimetry for high-energy photons, electrons and brachytherapy sources;
 Demonstrate knowledge of dosimetric standards and traceability;
 Ability to understand and apply the current national and international Codes of Practice for the
determination of absorbed dose to the water (e.g. IAEA);
 Ability to perform absorbed dose measurements in clinical situations;
 Ability to select the most appropriate detector to use to measure absolute dose and relative
dose distributions in different irradiation conditions for photons and for electrons beams;
 Ability to set up a system for In-Vivo dosimetry;
 Ability to understand and apply a protocol for quality control of treatment units;
 Ability to setup a program for acceptance testing, calibration and quality control of the
measurement systems.

Core curriculum items

Principles of dosimetry:
 Concept of absorbed dose and kerma;
 The cavity theory;
 Relationship between different dosimetric quantities and units.

Physics, techniques and instrumentation of radiation detector systems:

 Calibration chain for dosimetry detectors;
 Properties of dosimeters;
 Evaluation of uncertainties;
 Ionisation chambers;
 Film dosimetry;
 Luminescence dosimetry;

30
 Semiconductors;
 Diamond dosimeters;
 Alanine dosimetry system;
 Scintillation detectors;
 Gel dosimetry;
 Calorimetry;
 Chemical dosimetry.

Dose determination and quality control in the hospital:

 Dosimetry recommendations based on Air-Kerma standards;
 Dosimetry recommendations based on absorbed dose in water;
 Application of a protocol for absorbed dose determination in a clinical beam;
 Determination of the absorbed dose under non-reference conditions;
 In-vivo dosimetry;
 Quality control of treatment units;
 Dosimetry audits;
 Measurement systems and phantoms used for dosimetry and quality control;
 Choice of dosimetry systems;
 Technical specification, acceptance testing, calibration and QC of practical systems.

Assessment of the amount of time to be spent in this topic : 15 ECTS

Recommended literature

 Absorbed Dose Determination in External Beam Radiotherapy, TRS-398, IAEA 2000.

 Calibration of Reference Dosimeters for External Beam Radiotherapy, TRS-469, IAEA 2009
 Attix F.H. Introduction to Radiological Physics and radiation Dosimetry, Ed. Wiley-VCH Verlag
GmbH & Co. 2004.
 Knoll G.F. Radiation detection and measurement. Third edition. Ed. Wiley. 2000
 ESTRO booklet no. 5. Practical guidelines for the implementation of In Vivo Dosimetry with
diodes in External Radiotherapy with photon beams (Entrance Dose). Huyskens D.P. et al. (2001)

31
13. Principles of medical imaging and image handling

Short description

Medical Imaging is an essential tool in all state-of-the-art planning and delivery techniques: (i) to
identify the anatomical areas in the study, (ii) to enable planning of the desired treatment, (iii) to
verify the treatment is delivered as planned and (iv) to follow-up treatment outcome to monitor
that the treatment has had the desired effect. Radiotherapy relies heavily on medical imaging to
determine the extent of disease and the spatial relation between target region and neighbouring
healthy tissues. In addition, imaging plays an indispensable role in patient positioning and the
accuracy of treatment delivery. Functional and 3D molecular-imaging modalities (e.g. PET, SPECT,
PET/MRI, MRI spectroscopy and fMRI) provide non-invasive information about biological and
physiological processes of relevance for the response to treatment.

Competences and skills:

 Demonstrate an understanding of the principles of imaging in the radiotherapy process, the

sources of image errors, the uncertainties and the resolution limits;
 Ability to understand and interpret the images from the various modalities (CT / MRI / PET and
US); recognise the anatomical areas, understand the organs in the body, the effect of contrast
media in different modalities and the limits of the imaging signal for appropriate application;
 Demonstrate an understanding of the different acquisition protocols in CT and MR imaging and
the effect of the adjustable parameters to the appearance and the properties of the image;
 Demonstrate an understanding of functional imaging techniques fMRI and spectroscopy;
 Ability to set the requirements of PET studies specifically for radiation oncology planning;
 Ability to perform acceptance and commissioning tests and set up a QA programme for all
imaging modalities used in radiation therapy to evaluate performance, image quality and
geometric accuracy;
 Ability to evaluate the imaging modalities, conduct specifications and select imaging systems;
 Ability to assess and evaluate discrepancies of the images acquired during the radiotherapy
procesess;
 Ability to observe and assess the engineering maintenance of the imaging equipment.

Core Curriculum items:

 Physics of image formation;

 Image handling, digital image processing, reconstruction algorithms;
 Noise and measurements of image quality;
 Principles, equipment, and practical applications in radiotherapy of the imaging modalities
(radiography & fluoroscopy, CT, conventional & CT simulators, MRI, US, PET, PET/CT, SPECT;
 Principles of the different imaging systems on treatment units (portal imaging devices, flat
panels, kV & MV CBCT, US);
 Anatomical and functional imaging using different modalities and techniques;
 Effect and management of patient organ motion;
 Geometrical accuracy, reproducibility and methods of assessment;
 QA programmes.

32
Assessment of the amount of time to be spent in this topic – 15 ECTS

Recommended literature

- WEBB, S., The physics of medical imaging, IoP 1992

- BUSHBERG, J.T. et al., The essential physics of medical imaging, 2002
- MUTIC, S., et al., Quality assurance for computed-tomography simulators and the computed-
tomography-simulation process: report of the AAPM Radiation Therapy Committee Task
Group No. 66, Med Phys (2003) 2762-92.
- IPEM, Report 80: Quality control in magnetic resonance imaging, IPEM, York (1995).
- AMERICAN ASSOCIATION OF PHYSICISTS IN MEDICINE, Quality Assurance. Methods and
Phantoms for Magnetic Resonance Imaging, AAPM, Maryland (1990).
- MURPHY, M., et al., The management of imaging dose during image-guided radiotherapy:
Report of the AAPM Task Group 75, Med Phys 10 (2007) 4041-4061.
- Xing L. Quality assurance of PET/CT for radiation therapy. Int J Radiat Oncol Biol Phys 2008;
71(Suppl.):S38–S42.

33
 14. External beam radiotherapy

6.14.1 Treatment equipment

Short description

External beam radiotherapy devices include all treament units used to irradiate the patient either
with the use of kV and MV X-ray beams, gamma rays or with electron beams. Devices to simulate
the treatment include conventional and virtual (CT) simulators.
Imaging systems have been developed and installed in the treatment room to localise the target on-
line before the treatment or even to track its motion during treatment (image-guided radiotherapy,
IGRT).

Competences and skills

 Ability to describe the function and characteristics of all treatment units and in-room imaging
equipment;
 Ability to operate treatment units and in-room imaging equipment safely;
 Ability to perform commissioning and quality control of treatment units and in-room imaging
equipment;
 Ability to specify, justify and rank the criteria for specifying and selecting treatment units and
in-room imaging devices.

Core Curriculum Items

 kV X-ray units;
 Cobalt units;
 Linear accelerators and other systems for MV X-ray and electron beams (tomotherapy unit,
robotic linacs, mobile linacs for intra-operative radiation therapy);
 Stereotactic irradiation devices;
 Conventional and CT simulators;
 Imaging systems on treatment units: electronic portal imaging devices, kV-MV cone beam CT;
 Imaging systems at treatment units: opto-electronic systems, stereoscopic X-ray imaging
systems, in-room CT, radiofrequency-based and ultrasound devices.

Assessment of the amount of time to be spent in this topic 5 ECTS

34
6.14.2 Clinical dosimetry of conventional treatment beams

Short description

Basic dosimetry of conventional photons and electrons beams, in isocentric and fixed-SSD
approaches, is the first step for the implementation of the treatment planning system and of any
manual dose calculation.

Competences and skills

 Demonstrate a working knowledge of the terminology used in clinical dosimetry;

 Demonstrate an understanding of national and international protocols for the determination of
absorbed dose to the water;
 Ability to calibrate ionisation chambers and diodes;
 Ability to perform constancy checks (eg strontium-90 based) on ionisation chamber dosimeters;
 Ability to perform absolute and relative dose measurements (output factors, PDDs, beam
profiles, etc) in air, in water and solid phantoms for photon and electron beams using different
equipment (ionisation chambers, diodes, film, TLD);
 Ability to select the most appropriate detector to use to measure absolute and relative dose in
different irradiation conditions for photons and electrons beams;
 Demonstrate understanding of the dependence of relative dosimetry on treatment parameters;
 Demonstrate understanding of the influence of beam modifiers on the beam characteristics;
 Ability to acquire beam data for the treatment planning system;
 Demonstrate knowledge of dosimetric standards and traceability.

Core Curriculum Items

 Terminology used in clinical dosimetry (e.g.: PDD, TMR, TPR, OAR…);

 Definition of ―reference conditions‖ in fixed-SSD and isocentric approaches;
 Beam quality specification (quality index for photons, range and energy parameters for electron
beams);
 In air and in phantom characteristics of clinical beams;
 Absolute and reference dosimetry. Absorbed dose in reference conditions: national and
international protocols (e.g. IAEA);
 Relative dosimetry:
- central axis dose distribution in water
- output factors: effects of head scatter and phantom scatter, dependence on treatment
parameters
- 3D dose distribution: beam profiles (penumbra region, flatness, symmetry, etc.)
- effects of beam modifiers: hard wedges, virtual wedges, compensators, bolus etc;
 Requirements and methods of data acquisition for treatment planning;
 Basic dosimetry in non-reference conditions (e.g. extended SSD, off-axis);
 Dosimetric standards and traceability.

Assessment of the amount of time to be spent in this topic 10 ECTS

35
6.14.3 Treatment techniques

Short description

Radiotherapy during the last decades has developed from simple 2D techniques to 3D conformal
radiotherapy and intensity-modulated radiotherapy (IMRT). The recent technological developments
allowed a more efficient and sophisticated method to deliver IMRT using rotational techniques.
Special techniques are used in particular clinical situations.

Competences and skills

 Demonstrate understanding of the capabilities and limitations of all different irradiation

techniques;
 Ability to implement all treatment techniques, from commissioning to treatment simulation,
planning, verification and quality assurance;
 Ability to choose the most appropriate technique according to the tumor site and intent of the
treatment;
 Ability to compare national and international treatment protocols for different irradiation
techniques with those used at the institution.

Core Curriculum Items

 Conventional techniques: wedges, bolus, compensators, beam shaping, beam combinations,

weighting and normalization, field matching;
 More advanced techniques: 3D conformal radiotherapy, rotational techniques (conformal arcs,
conformal dynamic arcs), non coplanar techniques;
 IMRT: fixed-gantry IMRT: MLC-based static or dynamic delivery, compensator based IMRT
rotating-gantry IMRT: serial and helical tomotherapy, intensity-modulated arc
therapy (IMAT);
 Special techniques: stereotactic radiosurgery (SRS) and radiotherapy (SRT), intraoperative
radiation therapy (IORT), total body irradiation (TBI), total skin electron irradiation (TSEI),
gated irradiation of mobile targets;
 Corresponding knowledge and skills will need to be acquired for new upcoming techniques.

Assessment of the amount of time to be spent in this topic 10 ECTS

36
6.14.4 Treatment simulation and planning

Short description

Treatment simulation and planning consist of all procedures used to determine the optimal
irradiation plan for a patient. The first step is the immobilisation and simulation of the patient.
Except for simple cases, treatment planning is now performed with computerised systems, which
rely on computer hardware, software and networking. Using dosimetric data of the treatment
beams obtained with phantom measurements, 3D patient anatomical model created with
multimodality imaging, and applying dose calculation algorithms, dose distributions of different
irradiation techniques can be calculated. Detailed knowledge of the effect of beam arrangements,
modification devices, beam weights, normalisation, optimisation techniques and dose prescription is
necessary to produce a good treatment plan. Plan evaluation methods are essential to clinically
accept the treatment plan.

Competencies and skills

 Demonstrate an understanding of immobilisation devices and their application;

 Demonstrate familiarity with steps of conventional and CT simulaton;
 Demonstrate knowledge of the hardware and software components of a TPS and networking;
 Ability to import measured beam data into the TPS;
 Ability to perform the commissioning of the TPS;
 Ability to acquire multimodality imaging data and perform image fusion for target volume
delineation and planning;
 Demonstrate working knowledge of the ICRU terminology regarding the target volumes and
organ at risks;
 Demonstrate awareness of the limitations of dose calculation algorithms for heterogeneity
corrections in low density tissue and tissue interface where electronic equilibrium is not fully
established;
 Ability to manually create a number of plans for a variety of different irradiation techniques;
 Ability to produce computer-supported plans for simple techniques, using appropriate beam
modifiers such as wedges, blocks, MLCs, compensators and bolus;
 Ability to create a number of computer-supported plans for sophisticated and special techniques
(e.g. IMRT, stereotactic radiosurgery, etc.);
 Ability to perform manual monitor unit or time calculations for MV and kV X-ray beams, gamma
rays and electron beams for a variety of clinical situations;
 Ability to check computer calculations of monitor units on treatment plans using the
institution‘s charts or independent monitor unit calculation program, taking into account field-
size factors, wedge factors and other relevant factors;
 Ability to compare different levels of treatment planning complexity in relation to clinical
requirements and the uncertainties involved;
 Ability to perform plan optimisation and evaluation using uniformity criteria, constraints, DVHs
and biological parameters (TCP, NTCP);
 Ability to record and report dosimetric parameters according to international recommendations;
 Ability to specify, justify and rank the criteria for specifying and selecting TPS.

Core Curriculum Items

 Immobilisation devices and their application;

 Principles of CT simulation;

37
 Multimodality image registration and fusion for target volume delineation and planning;
 Hardware and software components of a treatment planning system (TPS) and networking
(dicom, dicom RT etc.);
 Specification of dose and volumes, margin decisions, including international recommendations
(ICRU 50, 62);
 ICRU terminology regarding target volumes and organ at risks (GTV, CTV, PTV, PRV, etc);
 Principles of treatment planning: manual and computer supported;
 Dose calculation algorithms (correction-based, model-based and Monte Carlo) for photon and
electron beams;
 Monitor unit calculation for fixed-SSD and isocentric approaches;
 Computer-supported plans for all different irradiation techniques;
 Virtual simulation and tools: BEV, DRR; DCR (Digitally composited radiographs)
 Effect of various beam arrangements, beam modification devices (wedges, compensators,
blocks, MLCs, bolus) and beam weights on dose distribution;
 IMRT planning: forward vs. inverse planning, fluence optimisation;
 Plan optimisation and evaluation methods: uniformity criteria, constraints, DVHs and biological
parameters (TCP, NTCP);
 4D TPS;
 Recording and reporting dosimetric parameters according to international recommendations;
 Archiving, back-up and restore of plans.

Time to be spent with this topic 15 ECTS

38
6.14.5 Treatment verification

Short description

Treatment verification includes all procedures to verify the different steps of the treatment:
patient positioning, target localisation, data transfer from the TPS to the treatment unit through
the record and verify system and dosimetric verification of the irradiation plan. Patient set-up and
target localisation before treatment can be verified with different IGRT techniques with on-line or
off-line correction protocols. Techniques have been developed to minimise the effects of organ
motion due to breathing during treatment.
The dosimetric verification of the irradiation plan may include pre-treatment verification in a
phantom and in-vivo dosimetry during treatment. In-vivo dosimetry may include verification of the
delivered dose in single points or planar dosimetry, like transit dosimetry with portal imaging.

Competences and skills

 Ability to implement different IGRT techniques;

 Ability to implement the techniques to control respiratory motion;
 Ability to assess intra and inter-fraction set-up errors and target motion;
 Ability to apply different set-up and IGRT correction protocols;
 Ability to perform pre-treatment dosimetric verification of standard and sophisticated RT
technique‘s plans in a phantom;
 Demonstrate knowledge of different approaches and appropriate detectors to perform in-vivo
dosimetry;
 Ability to use a record and verify system.

Core Curriculum Items

 Patient alignment and set-up on the simulator and on treatment units;

 IGRT techniques at the treatment unit to optimise the set-up and target localisation;
 Techniques to control breathing motion during treatment (respiratory gating, breath hold and
tumor tracking);
 Dosimetric verification of standard 3D-CRT plans;
 Dosimetric verification of special technique plans;
 Dosimetric verification of IMRT plans;
 In-vivo dosimetry;
 Record and verify systems.

Assessment of the amount of time to be spent in this topic 5 ECTS

Total: 45 ECTS for External beam radiotherapy (Chapter 14)

39
Recommended literature

 D. Greene and P.C. Williams. Linear accelerators for radiation therapy. IoP 1997
 J.R. Williams, D.I. Thwaites (Eds.). Radiotherapy physics in practice, Oxford University Press,
Oxford, 2nd Edition 2000.
 A.R. Smith (Ed). Radiation Therapy Physics. Springer-Verlag, New York, 1995.
 IPEM Report No 94. Commissioning and quality assurance of linear accelerators, IPEM, York,
2006.
 Absorbed Dose Determination in External Beam Radiotherapy, An International Code of Practice
for Dosimetry Based on Standards of Absorbed Dose to Water. TRS-398, IAEA, Vienna, 2000.
 ESTRO booklet series (Booklets 1 (1994), 3 (1998), 6 (2001) and 9(2008))
 Determination and use of scatter correction factors of megavoltage photon beams. Report 12 of
the Netherlands Commission on Radiation Dosimetry.
 S. Webb. Contemporary IMRT Developing Physics and Clinical Implementation. IOP Publishing
Ltd. Bristol, UK, 2005.
 S. Webb. The physics of conformal radiotherapy / advances in technology. IOP Publishing Ltd.,
1997.
 T.R. Mackie, T. Holmes, S. Swerdloff, P. Reckwerdt, J.O. Deasy, J. Yang, B. Paliwal, T. Kinsella.
Tomotherapy: a new concept for the delivery of dynamic conformal therapy. Med. Phys. 20:
1709-1719, 1993.
 AAPM Report series (report 54 (1995), 55 (1995), 85 (2004)
 G. Ezzell et al. Guidance document on delivery, treatment planning, and clinical
implementation of IMRT: report of the IMRT subcommittee of the AAPM radiation committee,
Med. Phys.: 30, 2089-2115, 2003.
 ICRU report series (reports 50(1993) and 62(1999))
 Kahn FM. Treatment planning in radiation oncology. Lippincott Williams & Wilkins 2007.
 Photon treatment planning collaborative working group. Three-dimensional dose
 calculations for radiation treatment planning. Int. J. Radiat. Oncol. Biol. Phys. 21:25-36, 1991.
 J.W. Wong, J.A. Purdy. On methods of inhomogeneity corrections for photon transport. Med.
Phys. 17: 807-814, 1990.
 K.R. Hogstrom. Treatment planning in electron beam therapy. In: Frontiers of radiation therapy
and oncology. 25
 The role of high energy electrons in the treatment of cancer, 30-52. Eds: J.M. Vaeth, J.L. Meyn.
Karger, Basel, 1991.
 L. Coia, T. Shultheiss, G. Hanks (Eds.). A practical guide to CT-simulalion. Advanced Medical
Publishing, Madison, WI, 1995.
 J.A. Purdy, G. Starkschall (Eds). A Practical Guide to 3-D Planning and Conformal Radiation
Therapy. Advanced Medical Publishing, Madison, WI, 1999.
 J. Dobbs, A. Barrett, D. Ash. Practical radiotherapy planning, 4th Edition. Edward Arnold,
London, 2009.
 Keall PJ, Mageras GS, Balter JM et al. The management of respiratory motion in radiation
Oncology. Report of AAPM Task Group 76. Med. Phys. 33:3874-3900. 2006.
 Bortfeld T, Schmidt-Ullrich R, De Neve W and Wazer DE, Image Guided IMRT, Springer, Berlin &
Heidelberg, 2006
 J. van Dyke (Ed.).The Modern Technology of Radiation Oncology Volume 2. Medical Physics
 Publishing, Madison, Wisconsin, 2005.
 E.B. Podgorsak (Tech. Ed.). Radiation oncology physics: a handbook for teachers and students.
 IAEA, Vienna, 2005.

15. Brachytherapy

40
Short description

Brachytherapy (BT) is a radiotherapy technique based on the use of sealed radioactive sources
placed inside the tumour or in close proximity to it. It has been used widely for many years to treat
a large variety of tumours. The treatment is delivered at very short distances, with small sources
and so dosimetry protocols and procedures have to be applied, often using measurement systems
and treatment planning systems that are specifically designed. Therefore, BT physics is often
considered a specific subdivision of radiotherapy physics.

In recent years, Brachytherapy has undergone important changes due to different factors.
a) New isotopes have been introduced, expanding the scope of possible proceedures
b) Developments allowing changes to source geometry and ―activities‖ have allowed wider
utilisation of automatic afterloading systems.
c) Image Guided Brachytherapy has become a common technique in most of the applications
(utilising CT, MR, US)

Competences and skills:

 Ability to report on the results of source calibration, QA controls, clinical dosimetry, etc. in
written and oral presentations;
 Demonstrate an understanding of the basic operation of the afterloading systems commercially
available, and of the locally available systems;
 Ability to assess the advantages and limitations of the locally available afterloading systems and
BT sources;
 Ability to apply calibration protocols for the BT sources used locally, and to determine the
uncertainties of the measurement;
 Ability to assess the functional characteristics of the source calibration equipment, and to
perform quality control of this equipment;
 Ability to participate in the overall clinical process of brachytherapy from operating theatre
through simulator localisation, treatment planning and treatment delivery;
 Ability to discuss the use of the different closed/sealed brachytherapy sources;
 Demonstrate an understanding of the dosimetry systems for intracavitary brachytherapy and
interstitial brachytherapy (GEC—ESTRO, Manchester, Paris, image based dosimetry);
 Ability to assist in the preparation of brachytherapy sources for clinical use;
 Demonstrate an understanding of the basic principles of imaging systems for brachytherapy
 Demonstrate an understanding of the TG 43 dose calculation algorithm and modern model based
algorithms;
 Demonstrate understanding of the use and limitations of optimisation techniques in
brachytherapy treatment planning;
 Ability to perfom independent verifications of the calculated treatment times of intracavity
insertions and interstitial implants using manual methods;
 Ability to setup a quality control program of the brachytherapy sources, applicators and
equipment, including the TPS;
 Ability to handle basic radiation safety procedures, such as leakage tests on the sources,
disposal of sources, prevention and actions in case of source loss;
 Ability to discuss national and international regulations for the use and transport of radioactive
materials;

41
Core curriculum items

Equipment
 Sources: radionuclide types and source design;
 Applicators;
 After-loading systems: low dose rate (LDR), high dose rate (HDR), pulsed dose rate (PDR);
 Source calibration equipment;
 Imaging systems for brachytherapy.

Source specification
 Quantities and units: activity, reference air kerma rate (RAKR), exposure rate, etc.;
 ―Source strength‖ determination according to national and international protocols, including
IAEA recommendations;
 Interpretation of the source calibration certificate from the manufacturer
 Dosimetry measurement methods.

Treatment techniques and methods

 Permanent and temporal implants;
 Standard applications;
 Classical implantation and dose calculation systems (LDR), e.g: interstitial, the ―Paris System‖
and intracavitary, the ―Manchester System‖;
 Extension to other dose rate categories: HDR, PDR;
 Special brachytherapy techniques, e.g.: permanent prostate seeds, stereotactic brain implants,
eye plaques, partial breast irradiation.

Treatment planning and dose calculation

 Dose calculation algorithms, TG 43, model based algorithms;
 General structure of brachytherapy planning systems;
 Source and points position reconstruction algorithms: radiographic films, CT and other image
based algorithms;
 Optimisation algorithms for HDR, PDR;
 Dose-Volume Histograms in BT, DVH-related planning evaluation parameters
 Treatment planning optimisation and evaluation; Uniformity criteria and constraints.

Specification of dose and volumes

 According to national and international protocols, including ICRU 38 and ICRU 58, GEC ESTRO
and ABS recommendations.

Quality Assurance
 Equipment specifications, commissioning and QC of after-loading equipment (LDR, HDR, PDR),
treatment planning systems (reconstruction algorithms and calculation algorithms), sources and
applicators, imaging systems in BT, dosimetry systems, networks, etc.;
 National and international recommendations and local protocols;
 Overall QA of the BT treatment process;
 Verification, checking and QA of individual patients treatment plans;
In-vivo dosimetry in brachytherapy.

 Radiation Protection and Radioactive substances regulation;

42
Assessment of the amount of time to be spent in this topic:
3 – 4 months full time: 15 ECTS

Recommended literature
 The Physics of Modern Brachytherapy for Oncology. Series in medical physics and biomedical
engineering. Dimos Baltas, Loukas Sakelliou, Nikolaos Zamboglou. CRC Press. ISBN: 0750307080,
9780750307086. 2007.
 The GEC ESTRO Handbook of Brachytherapy. Alain Gerbaulet, Richard Pötter, Jean-Jacques
Mazeron, Harm Meertens and Erik Van Limbergen, Editors. Ash D, Briot E, Haie-Meder C,
Lartigau E, Scalliet P, Venselaar J and Wambersie A. ISBN 90-804532-6. 2002
 Dutreix A, Marinello G, Wambersie A. Dosimétrie en Curiethérapie.. Ed.Masson, París, 1982
 ICRU Report series (reports 38(1985) and 58 (1997).
 IAEA. International Atomic Energy Agency. ―Calibration of photon and beta ray sources used in
brachytherapy‖. Guidelines on standarized procedures at SSDLs and Hospitals. IAEA-TECDOC-
1274.March, 2002.
 ICRP. International Commission on Radiological Protection ―Radionuclide Transformations.
Energy and Intensity of Emissions‖ ICRP Report 38, 1983.
 ESTRO Booklet series (Booklet 8 (2004))
 Haie-Meder C, Pötter R, Van Limbergen E, et al. ―Recommendations from Gynaecological (GYN)
GEC ESTRO Working Group (I): concepts and terms in 3D image-based 3D treatment planning in
cervix cancer brachytherapy with emphasis on MRI assessment of GTV and CTV‖ . Radiother
Oncol; 74:235–45, 2005
 Pötter R, Haie-Meder C, Van Limbergen E, et al. ―Recommendations from Gynaecological (GYN)
GEC ESTRO Working Group (II): concepts and terms in 3D image-based treatment planning in
cervix cancer brachytherapy – 3D dose volume parameters and aspects of 3D image-based
anatomy, radiation physics, radiobiology‖. Radiother Oncol; 78:67–77, 2006
 AAPM Report series (reprot 43 (1995), 56 (1997), 59 (1998), 64 (1999), 43 Updated (2004), 43
Supplement (2007), 128 (2008)
 Salembier C.; Lavagnini P.; Nickers P.; Mangili P.; Rijnders A.; Polo A.; Venselaar J.; Hoskin P.
―Tumour and target volumes in permanent prostate brachytherapy: A supplement to the
ESTRO/EAU/EORTC recommendations on prostate brachytherapy.‖ Radiotherapy and Oncology
83, 3-10, 2007.
 Kovacs G., Potter R., Loch T., Hammer J., Kolkman I., Rosette J., Berteemann ―GEC/ESTRO-EAU
recommendations on temporary brachytherapy using stepping sources for localised prostate
cancer‖ Radiother and Oncol. 74: 137-148, 2005
 Mazeron JJ, Ardiet JM, Haie-Méder C. GEC-ESTRO recommendations for brachytherapy for head
and neck squamous cell carcinomas. Radiother Oncol. 91: 150–156, 2009.
 Pötter R. Image-guided brachytherapy sets benchmarks in advanced radiotherapy. Editorial.
Radiother Oncol. 91:141–146, 2009
 Arthur D.W, Vicini F.A, Kuske R.R, Wazer D.E and Nag S. Accelerated partial breast irradiation:
an updated report from the American Brachytherapy Society. Brachytherapy. 2 (2): 124-130,
2003.
 Major T, Frohlich G, Lovey K, Fodor J, Polgar C. Dosimetric experience with accelerated partial
breast irradiation using image-guided interstitial brachytherapy. Radiother Oncol. 90: 48–55,
2009.

43
 16. Particle therapy

Short description

Due to their favourable physical and radiobiological properties, beams of ions (protons and heavier
ions) are expected to have an increasing role in radiotherapy for certain indications. Radiotherapy
physicists will play a key role in developing and installing particle therapy facilities, in performing
and controlling the technical and clinical operation of the equipment and in technological, physical,
biological and clinical research on the further development of particle therapy. Therefore, they
have to be trained in all physical and technological aspects of particle therapy.

Competences and skills

 Ability to demonstrate a deep understanding of the electronic and nuclear interactions of ions
with matter;
 Ability to derive from the physical characteristics of ion beams, implications on the technical
equipment for accelerating and delivering ion beams, radiation protection of patients, staff and
equipment, dosimetric measurements, quality assurance, treatment planning, radiobiology and
therapeutic strategies;
 Ability to evaluate the performance parameters of ion therapy equipment;
 Ability to demonstrate an understanding of the operation of ion accelerators and beam transport
components;
 Ability to demonstrate an understanding of the techniques of field formation with ion beams
including intensity modulation and organ motion compensation;
 Ability to discuss the concepts of treatment planning for therapeutic ion beam irradiation
including biological optimisation;
 Ability to discuss the concepts of dosimetry and quality assurance at ion beams;

Core curriculum items

 Electronic and nuclear interactions of ion beams with matter;

 Particular biological effects of ion beams;
 Accelerators for ion beams;
 Therapeutic ion beam deliveries;
 Field formation (passive, active) and intensity modulation;
 Motion compensation techniques in ion therapy;
 Dosimetry of ion beams;
 Quality assurance for therapeutic ion beam deliveries;
 Range measurements and in-vivo dosimetry by positron emission tomography;
 Treatment planning for ion therapy including biological optimisation.

Assessment of the amount of time to be spent in this topic – 3 ECTS

Recommended literature

 U. Linz (Ed.), Ion beams in tumor therapy, Chapman and Hall, 1995
 W.H. Scharf, Biomedical particle accelerators, American Institute of Physics, 1994
 Kraft G. Tumor therapy with charged particles, Progr. Part. Nucl. Phys. 45: 473-544, 2000

44
 Scholz M., Kraft G. Track structure and the calculation of biological effects of heavy charged
particles, Adv. Space Res. (1-2): 5-14, 1996
 M. Krämer et al. Treatment planning for heavy-ion radiotherapy: physical beam model and dose
optimization, Phys. Med. Biol. 45 (2000) 3299–3317
 O. Jäkel et al. Treatment planning for heavy-ion radiotherapy: clinical implementation and
application, Phys. Med. Biol. 46 (2001) 1101–1116

45
 17.Unsealed source therapy

Short description

The absorbed radiation dose from internally deposited radionuclides is a major factor in assessing
the therapeutic utility and risk when using unsealed sources for radiotherapy . Individualised
dosimetry is currently the only accurate methodology available to calculate absorbed dose to the
target organ and surrounding tissues. From this the therapeutic response (effectiveness) and related
toxicities can be assessed.

It is recognised that this type of treatment is not necessarily within the remit of the radiotherapy
physics groups and reside with nuclear medicine departments.

Competences and skills:

 Demonstrate an understanding of the principles of radionuclide therapy and the radionuclide

selection criteria;
 demonstrate an appreciation of the issues in managing and measuring the unsealed sources;
 Be able to discuss organ dose calculations;
 Ability to compose safety procedures for the personnel and the patients treated with
radionuclide therapy – perform waste management.

Core Curriculum items:

 Choice of radionuclide; physical properties, imaging properties, labelling compound properties;

 Radiobiological considerations, Dosimetric protocols;
 Dosimetry models (standard man - MIRD, MIRDOSE);
 Use and safety of unsealed sources – radionuclides;
 Management of unsealed sources, waste and patient wastes;
 Therapy procedures;
 Safety procedures and dose evaluation of the personnel and family.

Assessment of the amount of time to be spent in this topic – 3 ECTS

Recommended literature

 R.E.Toohey and M.G.Stabin. Comparative Analysis of Dosimetry, Parameters for Nuclear

Medicine. Oak Ridge Institute for Science and Education 2000; TN37831
 Radiation Dose to Patients from Radiopharmaceuticals, ICRP Publication 80, International
Commission on Radiological Protection, Pergamon Press, 1998.
 Radiation Dose to Patients from Radiopharmaceuticals. ICRP Publication 80 Dec2008; (Addendum
2 to ICRP Publication 53). ICRP Publication 106 (Addendum 3 to ICRP Publication 53).
 Snyder, W.S., M.R. Ford, and G.G. Warner, MIRD Pamphlet No.5, ―Estimates of Specific
Absorbed Fractions for Photon Sources Uniformly Distributed in Various Organs of a
Heterogeneous Phantom,‖ Revised, Medical International Dose Committee, New York. Society of
Nuclear Medicine, 1978.

46
 Snyder WS, Ford MR, Warner GG, Watson SB. , MIRD Pamphlet No. 11, ―"S" Absorbed Dose per
Unit Cumulated Activity for Selected Radionuclides and Organs,‖ New York, NY: Society of
Nuclear Medicine, 1975.
 Siegel JA, Thomas SR, Stubbs JB, et al. ,MIRD pamphlet no. 16, ―Techniques for quantitative
radiopharmaceutical biodistribution data acquisition and analysis for use in human radiation
dose estimates,‖ J Nucl Med., 1999, no.40(suppl), pp.37S–61S.
 Zaidi H, Sgouros G, eds. , ―Therapeutic Applications of Monte Carlo Calculations in Nuclear
Medicine,‖ Bristol, U.K.: IOP Publishing Ltd., 2003, pp.95–102.
 International Basic Safety Standards for Protection Against Ionizing Radiation and for the Safety
of Radiation Sources. Vienna, Austria: IAEA, 1996, no.51, Safety series no. IAEA 115.

47
 18 Radiation protection for ionising radiation

Short description

The acceptance by society of the risks associated with radiation is conditional on the benefits to be
gained from the use of radiation. Nonetheless, the risks must be restricted and protected against by
the application of radiation safety standards.
In the radiotherapy environment, the radiotherapy physicists have a broad scientific knowledge of
radiation protection. They have to be prepared to address the needs of protecting the patient,
personnel and the general public in the radiotherapy department. They have to know the physical
and biological effects of radiation for exposed individuals, the relevant regulations, methods of
compliance and record keeping. This knowledge will allow them to assess the radiation risk and
optimise the medical exposures. They will be asked to apply the ALARA and dose limitation
principles in the design of radiation therapy facilities, treatment and imaging protocols.

Competences and skills:

 Demonstrate an understanding of the principles of radiation safety plans;

 Ability to measure effective performance of radiation safety plans;
 Ability to improve effective performance of radiation safety plans;
 Ability to investigate and assess risk factors of radiation;
 Ability to optimise medical exposures;
 Ability to verify that the clinical physics program is in compliance with applicable state radiation
safety regulations (e.g., radioactive materials licenses, occupational dose limits, and review of
radiation surveys for any new construction);
 Ability to perform radiation surveys of an area using appropriate dose-rate meters
 Ability to perform design calculations for a linac room, simulator room, brachytherapy source
room;
 Ability to discuss the use of personal dosimeters.

Core curriculum items

 The effects of radiation on the embryo and foetus, leukaemogenesis and carcinogenesis, genetic
and somatic hazards for exposed individuals and populations;
 Scientific basis of radiation protection;
 Quantities and units in radiation protection;
 Basic principles of dose limitation. Deterministic and stochastic effects;
 Justification. Optimisation: ALARA principle. Dose limits (workers, population);
 Radiation monitoring: classification of areas, Personal monitoring;
 Administration and organisation of radiation protection. National and international rules and
organisations;
 National and international legislation;
 Design and facilities including: treatment rooms, imaging rooms, sealed and non-sealed source
storage;
 Management of radiation safety, including hazard assessment, contingency plans;
 Accidents in radiotherapy;
 Radioactive material management, transport and waste disposal;
 Patient protection.

48
Assessment of the amount of time to be spent in this topic – 5 ECTS

Recommended literature

 NCRP report series (reports 38 (1971), 49 (1976), 50 (1977), 51 (1977), 53 (1977), 54 (1977), 79
(1884), 82(1985), 84(1985), 112(1991), 116(1993), 122(1995), 128(1998))
 ICRU report series (reports 20(1971), 22(1972), 61(2000))
 ICRP report series (reports 60(1990) and 103 (2007))
 FAO, IAEA, ILO, OECD NEAY, PAHOWHO, International Basic Safety Standards for Protection
against Ionizing Radiation and for the Safety of Radiation Sources, Safety Series No. 115, IAEA,
Vienna (1996).
 IAEA Safety Standards Series No. SF-1 (2006), No 38 (2006), No. RS-G-1.5(2006), No 47 (2006)
and No 16 (2000)
 AAPM Report No 50, Fetal Dose from Radiotherapy with Photon Beams, 1995

49
 19. Mathematical modelling of treatment outcomes

Short description

Mathematical modelling plays an ever increasing role in radiation oncology, and is implemented in
comercially available treatment planning systems, in altered fractionation regimens and out-come
analysis. Radiotherapy physicists, with a strong mathematical background, often take part in and
undertake such activites involving modelling. To safely utilise the existing models a comprehensive
understanding of radiobiological modelling is required.

Competences and skills:

 Ability to critically perform fractionation calculations, response calculations (NTCP/TCP),

effective dose calculations and volume effect corrections using established models;
 Ability to critical assess radiobiological calculations performed by commercial treatment
planning systems;
 Demonstrate an understanding of the limitations in existing models and the parameters
established from published data as well as the underlying biological rational and limitation of
the model;
 Ability to perform detailed dose-response analysis from clinical data and patient series;
 Ability to critically make use of novel modeling strategies like Bayesian statistics and artificial
neural networks.

Core curriculum items

 Models for DNA damage;

 Cell survival, repair and fractionation models;
 NTCP and TCP- models;
 P+, utility function and other relevant models used in optimisation;
 Bayesian statistics and artificial neural networks.

Assessment of the amount of time to be spent in this topic – 3 ECTS

Recommended literature
 Roger Dale and Bleddyn Jones (eds.), Radiobiological Modelling in Radiation Oncology, The
British Institute of Radiology, 2007

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 20. Uncertainties in radiotherapy

Short description

The Radiotherapy pathway comprises of many steps from its preparation until its completion. At all
steps, data needs to be acquired, measured and/or calculated with more or less accuracy and
precision. This will always lead to differences between the dose prescribed by the radiotherapist
and the dose effectively delivered to the patient. The magnitudes, sources, and implications of
day-to-day treatment variability need to be assessed in order to minimise theses differences. The
radiotherapy physicist plays a key role in the evaluation of uncertainties and the definition of
tolerances and action levels.

Competences and skills:

 Ability to discuss measurement theory and manage sources of uncertainties;

 Ability to evaluate the magnitudes, sources, and implications of day-to-day treatment
variability;
 Ability to design experiments and/or surveys;
 Ability to manage the acquisition, editing, analysis, interpretation, presentation, and reporting
of data;
 Ability to set tolerances and action levels.

Core curriculum items

 Measurement theory;
 Sources of uncertainty;
 Management of uncertainty;
 Tolerance and action levels.

Assessment of the amount of time to be spent in this topic – 1 ECTS

Recommended literature

 J. Prins, ―Process or product monitoring and control,‖ NIST/SEMATECH e-Handbook of Statistical

Methods. National Institute of Standards & Technology, Gaithersburg, 2007.
 D. J. Wheeler and D. S. Chambers, Understanding Statistical Process Control, 2nd ed. SPC,
Knoxville, TN, 1992.
 Dutreix, A., When and how can we improve precision in radiotherapy? Radiother. Oncol. 2 (1984)
275–292.
 Mijnheer, B., Batterman, J., Wambersie, A., What degree of accuracy is required and can be
achieved in photon and neutron therapy, Radiother. Oncol. 8 (1987) 237–252.
 ISO Guide to Expression of Uncertainty in Measurement (1992).
 Geometrical Uncertainties in Radiotherapy = British Institute of Radiology, 2003

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 RESEARCH PROJECT

Short description

The radiotherapy physicist plays a key role in the development and advancement of the field of
radiotherapy and in the strengthening of research activities in the medical physics community.
To prepare the radiotherapy physicist for this responsibility, a short, focused research project
should be undertaken at some stage during the training programme, either as a full-time activity
within a well-defined period or on part-time basis over a prolonged time period (e.g. part of the
practical training period).
The project should be performed under supervision of a trained radiotherapy physicist. It should be
well structured and limited in scope, in order to fit within the given time frame. The topic of the
research project should be relevant for radiotherapy physics and practice, typically it would lie
within the clinical and applied side of the span of radiotherapy physics research.
The project should result in a written report, preferably in the form of a manuscript suitable for
submission to a medical physics/radiotherapy journal.

Competencies and skills

 Ability to plan, prepare and perform different phases of a research project;

 Ability to acquire first-hand experience in proper scientific evaluation, of both own and
published data;
 Ability to prepare a scientific manuscript for publication.

Assessment of the amount of time to be spent on this topic – 30 ECTS.

Reccommended literature

 Gustavii, B., How to write and illustrate a scientific paper, Cambridge University Press 2003
 Goodman, N.W. & Edwards, M.B, Medical writing – a prescription for clarity, Cambridge
University Press 2006

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Recommended literature for several topics
 Attix F.H.: Introduction To Radiological Physics And Radiation Dosimetry. John Wiley & Sons Inc
1987
 IAEA, Quality Assurance in Radiotherapy, IAEA-TECDOC-1040, IAEA, Vienna (1997).
 Khan F. : The Physics Of Radiation Therapy. Lippincott Williams & Wilkins 1994
 Leo W.R. : Techniques For Nuclear And Particle Physics Experiments/a How-to Approach.
Springer Verlag 1994
 Mayles P, Nahum AE, Rosenwald JC, Handbook of Radiotherapy Physics. Theory and practice.
Taylor & Francis Editor 2007.
 Podgorsak E.B.: Radiation Physics Handbook For Medical Physicists( Series - Biological And
Medical Physics, Biomedical Engineering. Springer Verlag 2005
 Podgorsak E.B.: Radiation Oncology Physics: A Handbook For Teachers And Students.
International Atomic Energy Agency 2005
 Practical Guidelines for the Implementation of a Quality System in Physics for Clinical
Radiotherapy Booklet No. 4, ESTRO, Brussels (1998).
 Practical guidelines for the implementation of In Vivo dosimetry with diodes. ESTRO Booklet 5,
ESTRO, Brussels,
 van Dyke J (Ed.).The Modern Technology of Radiation Oncology Volume 2. Medical Physics
Publishing, Madison, Wisconsin, 2005.
 Webb S, The physics of three-dimensional radiotherapy. IOP Publishing Ltd., 1993.

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 Amount of time to be spent on the topics of the Core Curriculum – general overview

GENERAL FUNDAMENTAL KNOWLEDGE 23

1. FUNDAMENTALS OF HUMAN ANATOMY AND PHYSIOLOGY 2

2. FUNDAMENTALS OF ONCOLOGY 2
3. PRINCIPLES AND APPLICATIONS OF RADIOBIOLOGY AND MOLECULAR BIOLOGY 3
4. REVIEW OF RADIATION PHYSICS 7
5. PRINCIPLES OF QUALITY MANAGEMENT 1
6. STATISTICAL METHODS 1
7. ORGANISATION, MANAGEMENT AND ETHICAL ISSUES IN HEALTH CARE 1
8. QUALITY MANAGEMENT IN RADIOTHERAPY 1
9. GENERAL SAFETY PRINCIPLES IN THE MEDICAL ENVIRONMENT 1
10. HEALTH TECHNOLOGY ASSESSMENT 1
11. INFORMATION SCIENCE IN THE MEDICAL ENVIRONMENT 3

APPLIED KNOWLEDGE AND SKILLS 107

12. DOSIMETRY 15
13. PRINCIPLES OF MEDICAL IMAGING AND IMAGE HANDLING 15
14. EXTERNAL BEAM RADIOTHERAPY 45
15. BRACHYTHERAPY 15
16. PARTICLE THERAPY 3
17. UNSEALED SOURCE THERAPY 3
18. RADIATION PROTECTION 5
19. MATHEMATICAL MODELLING IN RADIATION ONCOLOGY 3
20. UNCERTAINTY IN RADIOTHERAPY 3

RESEARCH PROJECT 30 30

160 160

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 ASSESMENT METHODS TO EVALUATE COMPETENCIES
Adapted from the “CanMEDS Assessment Tools Handbook”
(http://rcpsc.medical.org/canmeds/resources/handbook_e.php)

Whereas a candidate‘s knowlegde can be assessed by means of a written exams, the complete set
of competencies needed to safely act in a health care setting is substantially more complicated to
asses. In the following different components of a possible asessement scheme is described. The
different components must, however, be adopted according to the national education and training
programme. It is recommended that the assessment of competencies includes more that one of the
assessment modules listed below.

1. WRITTEN TESTS

1.1. Constructed-response format (short-answer questions) (SAQ)

The short-answer question (SAQ) format consists of a brief, highly directed question. Answers
usually consist of a few short words or phrases.

1.2. Constructed-response format (essays)

Essays pose questions that require learners to construct an answer based on their knowledge in a
written or computer-based format. They require the synthesis and communication of content
and often require critical thinking skills such as evaluation, analysis and judgment.

1.3. Selected-response format (multiple-choice, matching, extended matching, pick N

and true–false questions)

Selected-response assessment tools consist of a question and a list of options from which the
learner must choose the correct answer.
Common tools within this category are:
Multiple Choice Questions (MCQs): Consist of an opening question or stem that asks the
learner to choose the most correct answer from a list that also includes two to five plausible
yet incorrect distractors.
Matching: Learners are given two lists and are asked to match each item in one column to an
item in the other column.
Extended Matching Questions (EMQs): Learners are given a list of 10 to 20 items and are
asked to match them to a series of corresponding responses. An item may be matched to more
than one response.
Pick N: An amalgam of MCQs and extended matching, pick N items consist of an opening stem
and an instruction to select any given number of correct responses from an extensive list.
True–false: Learners are asked to determine if a given statement is true or false.

2. STRUCTURED ORAL EXAMINATIONS (SOES)

Oral examinations typically consist of the review of four to ten cases (situations), each lasting
five to fifteen minutes. The entire examination, therefore, lasts about one hour. Each case
discussion may include problem-solving, treatment planning, interpretation of results, etc. They
are usually scored using a predefined, structured template.

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3. DIRECT OBSERVATION (DO)

Direct observation refers to the ongoing observation, assessment and documentation of actions
taken by learners in real situations during their training period. The critical factor is that the
learner is observed performing authentic actions that occur naturally as part of daily work
experience.
In a strictly formal arrangement, the learner could be asked to perform a specific task and
would be assessed by means of a standardised rating form. In an informal arrangement, no
specific planning for the observation would be involved and the assessment would not be
recorded on a standardised form.

4. OBJECTIVE STRUCTURED EXAMINATIONS (OSES)

The objective structured examination (OSE) samples the performance of learners as they rotate
through a series of stations representing various scenarios. At each station, learners may
encounter a standardized clinical situation, a structured oral examination, visual information
(e.g., x-ray films), or a written task. Learners are usually asked to perform a specific skill, to
simulate part of a clinical situation, or to answer questions based on the presented material.
OSE circuits typically consist of 8 to 15 stations grouped into a series of rooms and may include
one or two rest stations. Learners are usually given 8 to 30 minutes to complete the tasks
assigned per room. Assessment can be carried out using a standardised checklist, anchored
global rating scales, or the evaluation of brief narrative responses.

5. MULTI-SOURCE FEEDBACK (360-DEGREE EVALUATION) (MSF)

Multi-source feedback (MSF) is often (erroneously) termed 360-degree evaluation or assessment.

MSF uses specific instruments designed to gather data about particular behaviours or
professional constructs (e.g., professionalism and communication skills) of the learner.
MSF usually includes feedback solicited from two or more sources, potentially including the
learner. Observers may include physicians (e.g., resident peers), allied health professionals
(e.g., nurses, technologists). Feedback is typically provided by completing a questionnaire-based
tool consisting of 10–40 items that is designed to assess behaviours that can be observed.
MSF can supplement traditional sources of assessment (e.g., examinations and preceptor
observations) by providing input from people who do not normally have a hierarchal
responsibility for providing feedback, yet may have a different perspective on actual learner
performance. Finally, MSF encourages reflection and promotes development of a self-
improvement plan.

6. PORTFOLIOS AND LOGBOOKS

University faculties may be familiar with portfolios in the context of teaching dossiers that are
used in applications for academic promotion. Portfolios are an extremely flexible educational
technology that can be adapted to multiple purposes, settings and kinds of learners.
Portfolios are really an ―instrument of instruments,‖ or a collection of assessment tools. Their
components may include logbooks, multi-source feedback instruments, continuous quality
improvement projects, learning diaries, encounter cards, essays, etc.

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 Logbooks are defined as those tools that are used to track the incidence of educationally
relevant activities, such as the number of procedures performed (e.g., a list of QC test on a
specific equipment, or the number of treatment plans).
Logbooks are structured instruments for documenting that a learning activity has taken place.

7. ENCOUNTER CARDS

Encounter cards are a type of in-training tool characterised by direct observations that are
documented after brief encounters between the supervisor and the learner in a clinical setting.
They are also known as:
• daily evaluation cards (DECs)
• daily encounter cards (DECs)
• daily operative cards (DOCs)
• daily shift cards
• daily teaching evaluation cards (DTECs)
• teaching encounter cards (TECs)
• interaction cards
• feedback forms
Encounter cards and their variants are a method of direct assessment that helps the assessor to
capture observations of competencies from brief encounters with learners. Encounter cards can
also be used to facilitate the more frequent assessment of teaching

Selected Tools for Assessing the Competencies

Social Knowledge
Organization Professionalism Communication Collaboration
actions and science
Written tests
X X X
(SAQ)
Written tests
X X X
(essays)
Written tests
X
(SRF)
Oral Exams
X X X X
(SOEs)
Direct
X X X X X X
Observation
Objective
Structured X X X X
Exam (OSEs)
Multi-source
X X X X X
feedback
Portfolios
and/or X X X X X X
logbooks
Encounter
X X X X X
Cards

SAQ = Short Answer Questions

SRF = Selected Response Format (multiple-choice, matching, extended matching, pick N and true–false questions)
SOEs = Structured Oral Examinations
OSEs = Objective Structured Examinations

57