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CURRICULUM FOR MEMBERSHIP IN RADIOTHERAPY AND

ONCOLOGY

GHANA COLLEGE OF PHYSICIANS AND SURGEONS

2016/17

CURRICULUM FOR MEMBERSHIP IN RADIOTHERAPY AND ONCOLOGY 2016

Table of Contents1 General Information...........................................................................................................................................2

SYLLABUS FOR PART I MEMBERSHIP IN RADIATION ONCOLOGY...........................................................8

2 Physics Curriculum............................................................................................................................................8

3 Radiobiology and Cancer Biology...................................................................................................................15

4 Applied Anatomy.............................................................................................................................................16

SYLLABUS FOR PART II EXAMINATION:.......................................................................................................17

5 Tumour pathology and General oncology........................................................................................................17

6 Radiation and Medical Oncology.....................................................................................................................19

7 Systemic Therapy (Chemotherapy, hormonal therapy, biological therapy)......................................................20

8 Basics of Biostatistics in Medicine...................................................................................................................20

9 Table of General topics....................................................................................................................................21

10 Suggested Reading.......................................................................................................................................23

11 Minimum Requirements for Log Book Acceptance.....................................................................................24

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1 General Information1.1 Rationale

There is the need to develop a well-structured programme for the training of CLINICAL ONCOLOGIST for the country. These locally trained oncologists will fill the vacancies in institutions as appropriate and will help in the further training and research for technical staff and graduate support staff needed for sustainability of cancer control in the Country.

1.2 Goal The aim of the College of Surgeons therefore is to train high calibre oncologist to provide accessible high quality oncological service throughout the country.

1.3 Objectives

The Trainee by the end of the program will function effectively as specialist and consultants provide optimal, ethical and patient-centered medical care. Demonstrate a commitment to their patients, profession, and society through ethical practice.

Establish and maintain clinical knowledge, skills and attitudes appropriate to Radiation and Oncology treatments.

Demonstrate effective clinical problem solving and judgment to address patient problems, including interpreting available data and integrating information to generate differential diagnoses and management plans including use of chemotherapy.

Effectively communicate and contribute to multidisciplinary team managing cancer patients based on evidence based practices.

Demonstrate competent planning and execution of radiation therapy. This will include knowledge of relevant clinical examination and imaging techniques to acquire information on the extent of the volumes to be treated; use of treatment simulation equipment; interaction with physics and radiation therapy planning personnel; ability to prepare and interpret radiation treatment plans, knowledge of all common types of external beam radiation equipment, intracavitary and interstitial radiation techniques, and unsealed radioisotopes.

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Contribute to the development, dissemination, and translation of new knowledge and practices to undergraduate and graduate medical and allied health support services.

1.4 Proposed title

Member of the Ghana college of Physicians and Surgeons

1.5 Entry Requirements

1.5.1 The candidate must possess MB ChB certificate or its equivalent from a recognized university.

1.5.2 The candidate must be fully registered with the Ghana Medical and Dental Council.

1.5.3 The candidate must have done four post qualification rotations in the four major disciplines: namely Medicine, Surgery, Obstetrics and Gynaecology and Paediatrics.

1.5.4 The candidate must pass a primary examination and interview1.5.5 The candidate must provide 2 Referees, one of whom must be his or

her immediate supervisor

1.6 Key Educational PrinciplesThere are a number of educational principles underpinning the Membership or Fellowship Curriculum Training Program. These principles are described in this section.

Contents Self-directed learning Training, Teaching and Supervision

1.6.1 Self-Directed LearningTrainees are responsible for ensuring that they meet the various assessment and progression requirements throughout the training program. Trainees entering the new training program will be provided with learning and assessment materials that outline the key training

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milestones throughout the years of membership and fellowship residency program.

1.6.2 Training, Teaching and SupervisionTo enable Residents to learn it is essential that they are provided with training, teaching and supervision that is appropriate to their stage of training.Examples of accredited training and teaching in the Curriculum and Training Program include:

Observation of procedures/examinations Completion of in training assessments in the Curriculum and

Training Program Attendance at formal teaching sessions Presenting at formal teaching sessions Participation in clinic-radiologic rounds and meetings Participation in quality assurance activities Participation in journal clubs Completion of experiential training requirements in the

Curriculum and Training Program Report writing Reviewing archived teaching cases

It is essential for trainees to receive appropriate formal supervision during service work. Formal supervision will enable trainees to learn and accrue accredited training time.

1.7 Course Duration

Council may exempt a candidate from part of the training program and examination following an application and approval, on the recommendation of the Credentials Committee through the Faculty Board.

Duration is 4 years for membership

The examination towards the membership is in 3 parts:

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1.7.1 Primary Examination. This exam is taken prior to the admission interview and examines the candidate on the very basic principles of cancer management.

1.7.2 Part I Membership examination in the Basic Sciences: Applied Physics, Radiobiology, Anatomy and Cancer Biology. This examination can be taken only after completion of pre-

registration internship and full registration by the Medical and Dental Council.

The GCPS, through its Examinations and Credentials Committee, will review all applications for admission to the examination and may also review the ethical and professional standing of candidates

A continuous physical presence of at least 18 months in an accredited radiotherapy department as a clinician.

1.7.3 Part II Membership examination

This examination is on principles of surgical, medical and radiation oncology and applied pathology -in-general. This examination can only be taken after all the following conditions are met by a candidate:

Success at or exemption from the Part I examination. Successful completion of at least 24 months upon completion the

part one examination and instruction and training in fulltime posts in a recognized and accredited department of Radiotherapy and Oncology.

Present a logbook of procedures participated in during the training period three months prior to the examination date to the faculty. This log book should be signed by all college recognized trainers with the head of department verifying that the information and signatures are legitimate.

A book of discussion of 10 cases will also be required and submitted with the log book.

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On successful completion of the Part II Membership examination, the candidate shall be awarded a certificate of Membership of the Ghana College of Physicians and Surgeons (MGCS).The candidate will work under supervision of fellows of the college for a total period of 48 months starting from date of enrolling into the post graduate program and be successful at part 1 and 2 exams before being allowed to practice independently.

1.8 Examinations

1.8.1 The Part I Membership examination shall consist of the following:

Paper 1 – Physics (3 hours)

Paper 2 – Radiobiology and Cancer Biology (3 hours)

Paper 3 – Applied anatomy/ physiology (2 hours)

An oral examination comprising of above subjects with some practicum in physics.

1.8.2 The Part II Membership examinations will consist of:1. Three written papers as follows:

Paper 1 - Tumour pathology and General Oncology (3 hours) Paper 2 - Radiation Oncology (3 hours ) Paper 3 - Clinical Oncology (3 Hours)

2. A viva voce examination consisting of: 2 hour practical inclusive. A clinical examination which will be concerned with

proficiency in clinical examination as well as investigation and treatment of patients

A practical OSCE examination in the technical/practical aspects of radiation therapy.

1.9 Rotations for Part II Membership Program

The Trainee will rotate through the following Specialties:

1.9.1 General Surgery (oncology cases) 2 weeks

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1.9.2 Urology (oncology) 2 weeks1.9.3 Haematology 2 weeks1.9.4 Paediatric Oncology 2 weeks1.9.5 Pathology 4 weeks1.9.6 Radiology (CT/MRI) 6 weeks

1.10. Routine for Residents

Daily scheduled outpatient clinic and simulation for treatment. Once a week teaching with the Consultant Weekly chart rounds/tutorials with the Consultant Weekly film rounds /tutorials with the Consultant At least once a week planning sessions Monthly journal club meeting with the Consultant Biweekly seminars in specific topics with Consultants Trainees will co- author clinical research and publish or present an

abstract or paper per year. Attend all multi-disciplinary meeting in oncology.

SYLLABUS FOR PART I MEMBERSHIP IN RADIATION ONCOLOGY

2 Physics Curriculum2.0 Atomic and nuclear structure

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2.1 Structure of the atom2.1.1 Nucleus, orbital shells, energy levels, binding energy2.1.2 Particles - proton, electron, neutron, positron2.1.3 Describe atomic number, atomic mass, isotopes

2.2 Wave and quantum models of radiation2.2.1 Energy and wavelength, energy spectrum

2.3 Radioactivity2.3.1 Decay processes2.3.2 Activity, half life2.3.3 Parent – daughter relationships and equilibrium2.3.4 Nuclear reactions, bombardment and reactors

2.4 Production of photons and electrons

2.4.1 Physical concepts of beam production Bremsstrahlung X-ray tube design Energy spectrum Characteristic radiation

2.4.2 Generation of beams Filters Gamma sources Linear accelerator Beam geometry

2.4.3 Attenuation of beams Half value layer Attenuation, energy transfer, and absorption Attenuation co-efficient

2.5 Interaction of x-rays and gamma rays with matter2.5.1 Absorption and scatter of x-rays in matter2.5.2 Photoelectric effect2.5.2 Compton effect2.5.4 Pair production

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2.6 Interactions of particulate radiation2.6.1 Direct and indirect ionization2.6.2 Elastic and inelastic collisions2.6.3 Linear energy transfer2.6.4 Heavy particles interactions2.6.5 Interactions of Neutrons2.6.6 Interactions of Electrons

2.7 Radiotherapy equipment2.7.1 Linear accelerator

Construction of radiotherapy machines Principles of beam production Beam collimation and modifiers

2.7.2 Cobalt units

2.7.3 Simulators Operation Fluoroscopy and Intensifiers CT simulation

2.7.4 Other imagers Principles of ultrasound, CT, MRI, PET Applications and limitations of above imaging to radiotherapy

2.7.5 Brachytherapy Sources used Calibration of sources Radioprotection

2.7.6 Equipment selection and specifications

2.8 Radiation beam quality and dose2.8.1 Mono energetic and hetero-energetic beams

2.8.2 Dose quantities and units Kerma Exposure Absorbed dose

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Dose equivalent RBE dose Calculation of absorbed dose from exposure Relationship between kerma, exposure and absorbed dose

2.9 Radiation measurement and calibration2.9.1 Ionization chambers2.9.2 Principles of beam calibration2.9.3 Other methods of measuring absorbed dose

Calorimetry Chemical dosimetry Solid state detectors Film dosimetry

2.10 Photon beam treatment2.10.1External beam planning principles

Inverse square law Backscatter factor Electron build-up Percentage depth dose Equivalent squares Tissue-air ratio

2.10.2Dose calculations Monitor unit calculations

Output factor Field size correction factors Collimator and phantom scatter factor Beam modifier factors Patient attenuation factors

Calculations in practice SSD technique SAD technique

2.10.3Translation of planning to calculations Beam parameters Beam weighting Arc rotation therapy

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Irregular fields

2.10.4Computerized treatment planning Isodose curves (beam characteristics) Surface dose Parallel opposed beams Wedge techniques, isodose curves, angles Beam combinations

2.10.5Surface corrections and heterogeneities Surface obliquity Inhomogeneity correction

2.10.6Adjoining fields and special dosimetry problems Two-fields Three-fields Craniospinal gapping Pacemaker Gonadal dose Pregnant patient

2.11 Electron beam treatment2.11.1Basic characteristics

Depth-dose curves Interactions Obliquity

2.11.2Treatment planning principles Selection of energy, field size Skin dose Bolus Field shaping Field-matching Inhomogeneities

2.12 External beam quality assurance2.12.1 Goals2.12.2 Roles and duties2.12.3 Staffing

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2.12.4 Linac QA Commissioning linear accelerators (principles)

2.12.5Routine Quality assurance requirements Daily, monthly, annually

2.13 Radiation protection and shielding

2.13.1Definitions and standard2.13.2Dose equivalent and effective dose equivalent2.13.3Types of radiation exposure

Background Man-made National recommendations on exposure limits

2.13.4Protection regulations2.13.5Administrative requirements

Safety program Staff monitoring

2.13.6 Radiation shielding principles Treatment room design Types of barriers Neutron shielding for high energy beams Sealed source storage Protection equipment and surveys Monitoring equipment

2.14 Imaging in radiation oncology2.14.1Routine diagnostic imaging principles2.14.2Port films2.14.3Processors2.14.4Other imaging

Electronic portal imaging devices

2.15 3D Conformal Therapy2.15.1Concepts and goals vs traditional RT

Technology and methods for planning Multiple volume images

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Image processing Virtual simulation DRR’s Multiple beams and non-coplanar beams

2.15.2Optimization methods Uniform vs non-uniform delivery Margins DVH’s

2.15.3Implications of treatment variabilities Set-up Patient factors ICRU 50 and 62 prescribing recording and reporting

2.16 Assessment of patient setup and verification2.16.1Immobilization devices and methods2.16.2Positioning devices and methods2.16.3In-room treatment imaging

Cone-beam CT Ultrasound Fiducials On-line correction of set-up errors Adaptive planning concepts

2.17 Brachytherapy planning2.17.1Calculation of dose distribution

Calculation of dose from a point source/line source

2.17.2Systems of implant dosimetry2.17.3Implantation techniques

Surface Interstitial Intracavitary

2.17.4Gynecological implants Manchester system Bladder and rectal dose ICRU

2.18 IMRT

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2.18.1Delivery systems2.18.2Principles of dose prescription and inverse planning2.18.3QA

2.19 Special procedures2.19.1Stereotactic radiosurgery

Delivery systems Principles of planning and delivery QA

2.19.2Total body irradiation Principles of planning and delivery

2.20 Particle therapy2.20.1Protons

Energy deposition Equipment Beam dosimetry Principles of production and delivery

2.20.2Neutrons Basic interactions Principles of production and delivery

3 Radiobiology and Cancer Biology

3.1 Basic Principles of radiobiology3.1.1 Interaction of radiation with matter3.1.2 DNA damage by radiation3.1.3 Cell survival curves3.1.4 Cell radio sensitivity and radio curability3.1.5 Cell cycle3.1.6 Lethal, potentially lethal, sub lethal damage and repair3.1.7 Dose rate effects3.1.8 The basis of fractionation: 4 R’s of radiobiology3.1.9 Factors that modify clinical radiation response and methods to

overcome limitations. The oxygen effect, radio sensitizers, radio

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protectors, hypoxic cell sensitizers, hyperthermia, linear energy transfer.

3.1.10Biological equivalent dose and linear quadratic equation (including practical clinical calculations)

3.1.11Other radiation modalities (neutrons, protons), relative biological effectiveness

3.1.12Tumour growth kinetics (T pot, growth fraction, cell loss).

3.2 Effect of radiation on normal tissue3.2.1 Normal tissue tolerance – organ and volume specific3.2.2 Acute and late effects of radiation on normal tissues, including the eye

and gonads (also hereditary effects, carcinogenesis)3.2.3 Total body radiation3.2.4 Effect of irradiation on the embryo and fetus

3.3 Cancer biology3.3.1 Terminology of molecular biology of cancer3.3.2 Carcinogenesis3.3.3 Oncogenes3.3.3 Tumour suppressor genes3.3.4 Growth factors and signal transduction pathways3.3.5 Apoptosis3.3.6 Angiogenesis3.3.7 Invasion and metastasis.

4 Applied Anatomy4.1 Keeping the goal of treating the oncology patient in mind:

4.1.1 The structure, boundaries, vascular and lymphatic pathways, and neurological supply of: head and neck, the central nervous system, thoracic and abdominal organs and upper limbs proximal to mid humerus and lower limbs proximal to and including the femoral triangle.

4.1.2 Landmark localization: On surface anatomy Imaging

4.1.3 The relation of organs to one another and their movement4.1.4 Radiological anatomy on relevant imaging techniques4.1.5 Routes of potential cancer spread.

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SYLLABUS FOR PART II EXAMINATION:

5 Tumour pathology and General oncology5.1 Tumour Pathology.

For each Tumour site and type, the following aspects should be studied:

5.1.1 Epidemiology and etiology Natural history Clinical presentation Characteristic imaging findings Laboratory diagnosis of disease:

Macroscopic and microscopic appearance of Tumour compared with normal tissue of origin and differential diagnosis.

Grading and staging systems in use Immunohistochemistry AND special stains Tumour markers Molecular techniques available (brief overview)

The candidate should be able to interpret a pathological report including pathologic prognostic and predictive factors

5.2 General Oncology

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The candidate should be familiar with all aspects of oncological disease:

5.2.1 Physiology of oncologic symptoms and syndromes Pain Nausea and vomiting Tumour lysis syndrome Hypercalcaemia

5.2.2 Symptoms, signs, differential diagnoses, work up and staging of patients with Tumours seen in oncological practice should be known. The candidate should be able to adequately interpret X-rays, scans, pathology and other laboratory results.

5.2.3 Physiology which is relevant to therapy Endocrine systems – particularly the thyroid and Pituitary Adrenal

gonadal axis. The immune system as (applied to Oncology – especially HIV

infection) Haematopoiesis

5.2.4 The candidate should know and be able to plan and describe oncological treatment options for all patients including those routinely treated by other specialties e.g. Medicine, Surgery and Gynaecology. Principles as well as complications of curative and palliative cancer surgery should be known.

5.2.5 The expected benefits, complications and limitations of all treatment options should be known.

5.2.6 Knowledge of diseases that are non-malignant, but are treated in the practice of radiotherapy and/or chemotherapy is required. (E.g. Pituitary adenoma, acoustic neuroma, arterio-venous malformation, keloid, heterotopic ossification, thyroid eye disease, etc.)

5.2.7 Candidate should have knowledge of cancer prevention techniques, screening, early detection and education of the public.

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5.2.8 Some knowledge of effective communication techniques used to adequately and accurately inform cancer patients and family about disease and treatment is required.

5.2.9 Management of common psychological reactions in oncology patients.

5.2.10 The candidate should be able to discuss supportive care/symptomatic treatment in oncology and terminal care.

5.2.11Knowledge of the practice of medicine in accordance with medical ethics is expected.

5.2.12 Knowledge of quality of life assessment is required.

5. 2.13 Impact of surgical interventions on oncological procedures

5.2.14Integrating multidisciplinary team approach into practice.

5.2.15Treatment continuum planning

6 Radiation and Medical Oncology

6.1 Radiotherapy:An in depth knowledge of the use and applications of radiotherapy and chemotherapy as well as biological and hormonal therapy applicable to Tumours is essential. The candidate must be able to contrast this with other forms of treatment available and justify its use.

The candidate should be able to:6.1.1 Justify the intent of radiation treatment and explain the rationale of

sequencing in relation to other treatment modalities.

6.1.2 Describe the treatment planning process with respect to: Positioning and immobilization Simulation/scanning Delineation of Tumour/treatment volumes and critical structures

each Tumour site.

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6.1.3 Describe and justify the likely beam arrangement for a given Tumour

6.1.4 Prescribe a course of treatment and describe: Dose, fractionation schedules, and treatment length. Normal tissue tolerances and limitations

6.1.5 Discuss plan assessment/appraisal6.1.6 Discuss treatment supervision including:

Verification Diagnosis, grading and treatment of acute toxicities of treatment

and assessment of the impact of treatment on quality of life.6.1.7 Discuss clinical applications, rationale and techniques of:

brachytherapy Radio-isotope therapy Other specialized radiation techniques

7 Systemic Therapy (Chemotherapy, hormonal therapy, biological therapy)The candidate should have an in depth knowledge of the principles and indications for systemic therapies used in the curative and palliative setting and is able to describe:-

7.2.1 Classification and mechanism of action of cytotoxic.7.2.2 Side effects and toxicities, as well as management of these7.2.3 Commonly used therapeutic regimens and schedules7.2.4 Rationale of sequencing in relation to other treatment modalities7.2.5 Interactions with radiotherapy7.2.6 Biological therapies7.2.7 Indications for radiosensitisers7.2.8 Knowledge of recent literature pertaining to oncologic diseases is

expected

8 Basics of Biostatistics in Medicine 8.3.1 Statistics which analyse relationships 8.3.2 Statistics which analyse survival8.3.3 Compare risk 8.3.4 Statistics which analyse clinical investigations and screening8.3.5 Test differences 8.3.6 Test confidence 8.3.7 Describe data

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9 Table of General topics

Category FOCUS RADIATION

SYSTEMIC THERAPY

Breast Breast Cancer YES YES

Lung andMediastinum

Non-Small Cell Lung CancerSmall Cell Lung CancerSuperior Vena Caval ObstructionTumours of the Mediastinum

Mesothelioma

YES

no

YES

Head and Neck Mucosal CancersSalivary Gland Tumours

YES YES

Skin Non-melanoma Skin CancerMelanomaKaposi’s Sarcoma

YES YES

Male ReproductiveSystem

Prostate CancerSeminoma of the TestisOTHER Germ Cell Tumours of the TestisPenile Cancer

YES YES

Female Cervical Cancer YES YES

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ReproductiveSystem

Uterine CancerVulvar CancerVaginal CancerGestational Trophoblastic Disease

Ovarian Cancer

NO

Urinary Tract Bladder Cancer Kidney CancerCancer of the Ureter

YES YES

Gastrointestinal Tract

Esophageal CancerGastric CarcinomaPancreatic CancerRectal CancerAnal CancerBiliary Tract & Gall Bladder CancersHepatocellular CarcinomaGastrointestinal Stromal TumoursCarcinoid TumourColon CancerLiver Metastases

YES

NO

YES

Non-Malignant Non-Malignant diseases treated with radiation therapy

YES NO

Central NervousSystem

Adult GliomaMedulloblastomaPrimitive Neuroectodermal TumourCerebral MetastasesMalignant Spinal Cord CompressionEpendymomaPineal & Germ Cell TumoursMeningiomaPituitary Tumours

YES

NO

YES

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Haematology Hodgkin LymphomaNon-Hodgkin LymphomaMultiple MyelomaLeukaemia

YES

N0

YES

Musculoskeletal &Connective Tissue

Soft Tissue SarcomaPrimary Tumours of the BoneAggressive Fibromatoses Bone Metastases

YES YES

Paediatric Cancers YES YES

EndocrineThyroid CancerAdrenal Tumours

YES

NO

YES

Metastatic Disease Metastatic Carcinoma of Unknown PrimarySiteMetastases at sites not otherwise specifiedabove

YES YES

Clinical Oncology Symptom ControlQuality of Life

YES YES

10 Suggested Reading 1. DEVITA, V.T., HELMANN, S., ROSENBERG, S., Cancer: Principles and Practice

of Oncology, 7th ed. Lippincott Williams & Wilkins.2. GUNDERSON, L.L., TEPPER, J.E., Clinical Radiation Oncology, 2nd ed. Elsevier

(2007).3. HALL, E.J., GIACCIA, A.J., Radiobiology for the Radiologist, 6th ed., Lippincott

Williams &Wilkins (2005).4. KHAN, FAIZ M., Treatment Planning in Radiation Oncology, 2nd ed., Lippincott

Williams &Wilkins (2006).5. LEIBEL, S.J., PHILLIPS, T. J., Textbook of Radiation Oncology, Saunders (2004).

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6. PEREZ, C.A., BRADY, L.W., HALPERIN, E.C., Principles and Practice of Radiation Oncology, 5th ed. Lippincott Williams & Wilkins, (2007).

7. PODGORSAK, E., Radiation Oncology Physics: a handbook for teachers and students,International Atomic Energy Agency (2005).

8. STEEL, G., Basic Clinical Radiobiology, 3rd ed. Hodder Arnold (2002).9. Applied sciences in oncology distance learning available at

https://humanhealth.iaea.org/HHW/RadiationOncology/Training/Teaching/ASO/index.html

11 Minimum Requirements for Log Book Acceptance

A) BRACHYTHERAPY Cervix 20 observed 20 performed Endometrium 10 observed 20 performed Prostate 5 observed Thyroid 5 Benign 5 Malignant (observed)

B) SIMULATION Gynaecology 30 observed 40 performed Head and neck 20 observed 40 performed Prostate curative 20 observed 20 performed Upper gastrointestinal 10 observed 20 performed Lower gastrointestinal 10 observed 20 performed Breast cancer 20 observed 50 performed Brain Tumours 20 observed 20 performed Sarcoma 10 observed 10 performed Paediatric 10 observed 20 performed Haematology 10 0bserved 20 performed Lung 5 observed 5 performed Skin lesions 10 observed 10 performed Palliative 20 observed 50 performed

C) TREATMENT PLANNING At least one third of the cases performed should be planned with contours drawn by the candidate. (See log book for details for conformal planning)

D) SYSTEMIC THERAPY PRESCRIPTION Breast 40 Gynaecology 60

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Head and neck 30 Sarcoma 20 Colorectal 30Prostate 20Lung 10Stomach 10

E) DIDATIC LECTURES Minimum of 5 presentations per year

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