Radiotherapy has been transformed by technological advances in computing and engineering over the last 20 years [[1]Choudhury A. Budgell G. MacKay R. Falk S. Faivre-Finn C. Dubec M. et al.The future of image-guided radiotherapy.Clin Oncol. 2017; 29: 662-666Abstract Full Text Full Text PDF Scopus (20) Google Scholar] and, in parallel, clinical oncology as a discipline has evolved significantly [[2]Harrison C.J. Spencer R.G. Shackley D.C. Transforming cancer outcomes in England: earlier and faster diagnoses, pathways to success, and empowering alliances.J Healthc Leadersh. 2019; 11: 1-11Crossref PubMed Scopus (6) Google Scholar]. The European Working Time Directive [[3]Council of the European Union Directive 2000/34/EC of the European parliament and of the Council of June 2000, amending Council directive 93/104/EC. Brussels.2000Google Scholar] and the Modernising Medical Careers initiative [[4]Department of Health Modernising medical careers: the next steps. London.2005Google Scholar] reshaped the UK postgraduate medical training environment from 2005. Subsequent expansion of the consultant workforce [[5]NHS Cancer Action TeamChemotherapy services in England, ensuring quality and safety: a report from the. National Chemotherapy Advisory Group, London2009Google Scholar] coupled with a multifactorial national shortage of junior doctors [[6]Black D. The new UK internal medicine curriculum.Clin Med J. 2017; 17: 103-104Crossref PubMed Scopus (10) Google Scholar] necessitates trainees routinely providing ‘middle grade’ cover for several teams, potentially to the detriment of radiotherapy learning [[7]Kosmin M. Brown S. Hague C. Said J. Wells L. Wilson C. Current views on clinical oncology training from the 2015 Oncology Registrars’ Forum survey.Clin Oncol. 2016; 28: e121-e125Abstract Full Text Full Text PDF Scopus (10) Google Scholar]. Although practice under supervision leads to the acquisition of relevant training experiences, and the Royal College of Radiologists (RCR) advocates for dedicated teaching time in consultant job plans [[8]The Royal College of Radiologists Guide to job planning in clinical oncology. 3rd ed. London.2015: 42Google Scholar], trainees are ultimately responsible for their own learning [[9]General Medical Council Continuing professional development. London.2012Google Scholar]. The evolution of the learning environment has introduced both opportunities and challenges, as identified by national surveys in the UK [[7]Kosmin M. Brown S. Hague C. Said J. Wells L. Wilson C. Current views on clinical oncology training from the 2015 Oncology Registrars’ Forum survey.Clin Oncol. 2016; 28: e121-e125Abstract Full Text Full Text PDF Scopus (10) Google Scholar,10Lei M. Stokoe J. MacLeod N. Yates L. Mir R. 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As the medical educational impact of this training transformation has not been quantified in depth for radiotherapy competencies [[25]Walls G. Hanna G. McAleer J. Learning radiotherapy: the state of the art.BMC Med Educ. 2020; 20https://doi.org/10.1186/s12909-020-02054-zCrossref PubMed Scopus (7) Google Scholar], we set out to stock-take ‘on the ground’ logistical and curriculum-related perceptions at our centre. Although stopping short of a formal institutional ethnography approach, medical colleagues engaged generously with bespoke qualitative and quantitative tools, generating granular data on modern radiotherapy learning. The associated original article details the ‘lived experience’ of trainers and trainees at our centre [[26]Walls G. Cole A. Hanna G. McAleer J. A qualitative assessment of radiotherapy training at a regional cancer centre.Clin Oncol. 2021; 33: 261-269Abstract Full Text Full Text PDF Scopus (2) Google Scholar] and herein we crystallise three key messages emerging from those interviews, and from the subsequent questionnaire. Although the curriculum sets out the competencies needed by the end of a trainee's journey, and directions for traversing the plains of service, assessments and life, the day-to-day path for the trainee's voyage is not prescribed. Local factors are inherent to the natural history of each centre, varying with their size, age, staffing structure, regional healthcare connections and academic links. As universal guidance on minimum training infrastructure for all centres would be impossible to formulate, these matters must remain devolved. Each centre therefore has its own unique combination of strengths and weaknesses, which, once identified, should be protected and developed, respectively. The discrete areas for improvement at our centre were inductions, planning facilities and organised teaching. Inductions on joining a new team can accelerate the trainee's competence and confidence (and usefulness) by several weeks, by obviating their reconciliation of the vast array of protocols, atlases and trials. Setting targets for weekly radiotherapy-related activity, and encouraging that these are prioritised, may stoke reward systems, foster individual ambition and engender a sense of belonging in the team. Furthermore, introductions to ‘go to’ interdisciplinary contacts for each stage of the radiotherapy process will further the trainee's assimilation into the team [[27]Thippu Jayaprakash K. Wood K. Shaffer R. Improving clinical oncology trainees’ radiotherapy induction.Clin Oncol. 2016; 28e220Abstract Full Text Full Text PDF Scopus (1) Google Scholar]. Practically, the scarcity of workstations with the necessary planning software licenses, and sufficient space for the trainer and trainee, compromised precious learning interactions. Fortunately, prior to the COVID-19 pandemic, licenses were expanded and hardware updated, enabling clinicians to contour, evaluate plans and review online imaging remotely. Teaching from local physics colleagues was commended as crucial for First FRCR examination preparation, and treatment planning trainee meetings, although infrequent, were highly rated. Recommended examination preparation courses have been reviewed recently, and both the radiological anatomy teaching and greater senior involvement requested have been introduced through a reinvigorated regional, multidisciplinary teaching programme. Despite the weaknesses listed, a unanimous perception that the adequacy of radiotherapy cases and techniques for passing the college examinations was evident from the rich data generated in the study. Given their contrasting responsibilities and levels of experience, the discordance in trainer and trainee perceptions could be anticipated. The trainer–trainee relationship is complex due to the many paired guises that may co-exist: craft expert and apprentice; ‘boss’ and ‘worker’; consultant and specialty trainee; supervisor and supervisee; mentor and mentee; possibly even friends! Better insight into the perspective of the other could lead to alignment of views and constructive opportunities for improvement. Trainees at our centre readily recognise the value of consultant participation in organised teaching but perceive training activities as additional burden for the consultant – a view refuted by trainer responses. This is problematic, as it is possible that the behaviour of a trainee striving to minimise extra work for the consultant could be misinterpreted as a lack of enthusiasm, with further downstream implications. An alternative explanation for the finding that trainee enthusiasm can be lacking (reported by trainers only) is that the two groups have diverging objectives and expectations. The agreement of putative learning outcomes and service commitments at an induction meeting as outlined above, could go some way to resolve this problem. Incongruent views were also demonstrated in relation to trainee contributions on certain radiotherapy tasks, the impact of days off after ‘on call’ and the role played by senior radiographers in training. Contradictory opinions may also arise in part from a blend of naivety on the part of the trainee and/or less detailed awareness on the part of the trainer. Regular dialogue between those coordinating local training and local trainee representatives could improve the level of mutual understanding and define expectations. The pervasive tension between training and service delivery is important due to the particular susceptibility to imbalance in craft disciplines. Trainees may be allocated insufficient regular opportunity for certain radiotherapy tasks within a team due to constraints on their time from systemic therapy clinics or cross-cover. Furthermore, regular interruptions regarding unscheduled clinical matters may disrupt learning when such opportunities materialise, reducing the trainee's radiotherapy focus via diluted continuity. This can be accentuated where the trainee regularly attends peripheral clinics in the region. There are no easy solutions for these issues, but acknowledgement at high levels will ensure that team or service reconfiguration is conducted in a manner supportive of radiotherapy training. Many aspects of the extant training conditions have arisen organically over time, rather than by design. Elements summarised above may pertain to other UK centres (and beyond), but most departments will have evolved to have an alternative constellation of flaws. A standard method for centres to ‘self-assess’ radiotherapy-specific training conditions has not been established, and although centralised surveys collect useful data, including temporal patterns, they can lack depth due to their broad focus. Further to the interview process [[26]Walls G. Cole A. Hanna G. McAleer J. A qualitative assessment of radiotherapy training at a regional cancer centre.Clin Oncol. 2021; 33: 261-269Abstract Full Text Full Text PDF Scopus (2) Google Scholar], we designed a novel questionnaire tool to add a quantitative layer to this research that brings centre- and radiotherapy-specific training factors to the foreground [[28]Walls G. McAleer J. Hanna G. Perception of modern radiotherapy learning: study protocol for a mixed methods analysis of trainees and trainers at a United Kingdom cancer centre.BMJ Open. 2020; 10e037171Crossref PubMed Scopus (3) Google Scholar]. Similar questions were put to trainers and trainees (with adaptation of phrasing in some instances to ensure consistent meaning) as we see these two parties as equal co-investors in radiotherapy learning processes. Questionnaire items across five domains were developed using the clinical oncology curriculum [[29]The Royal College of Radiologists Specialty training curriculum for clinical oncology. London.2016Google Scholar], the Oncology Registrar's Forum (ORF) 2017 training survey [[11]Casswell G. Shakir R. Macnair A. O’Leary B. Smith F. Rulach R. et al.UK training in clinical oncology: the trainees’ viewpoint.Clin Oncol. 2018; 30: 602-604Abstract Full Text Full Text PDF Scopus (10) Google Scholar] and the annual General Medical Council Training Survey [[30]General Medical Council National training surveys reports. London.2018Google Scholar]. The iterative process was guided by feedback from the ORF, a clinical oncology medical education research fellow [[31]Evans E. Radhakrishna G. Gilson D. Hoskin P. Miles E. Yuille F. et al.Target volume delineation training for clinical oncology trainees: the role of ARENA and COPP.Clin Oncol. 2019; 31: 341-343Abstract Full Text Full Text PDF Scopus (2) Google Scholar] and representative local colleagues across the staffing spectrum. In its first application in summer 2018, there were 32 anonymous responses (13/13 trainees; 19/21 trainers); the main findings are expanded in the Supplementary Material. Several of the highlighted issues in our study have been addressed in the intervening period, showing the feasibility of responsive positive adaptation of local conditions. The freedom to modify conditions at a local and regional level is the upside of these conditions not being regulated nationally. One mechanism for enhancing standards is quality improvement methodology, which has recently come to the fore in the National Health Service [[32]The Health FoundationQuality improvement made simple: what everyone should know about healthcare quality improvement. London.2013Google Scholar] and longitudinal questionnaire findings could verify the success or failure of interventions. Successful solutions at a local level will probably translate into improved attainment of the curricular outcomes, and a better training atmosphere generally. Examination entrance timings and pass rate data over time could document if local conditions ultimately influence trainee progression. Enhanced bidirectional understanding means that the experience of trainers, as they seek to fulfil their role as educators, also benefits. The fresh impetus afforded by the adoption of a revitalised clinical oncology curriculum in 2021 may ease the introduction of the introspective principles illustrated [[33]The Royal College of Radiologists Clinical oncology specialty training curriculum. London.2021Google Scholar]. The main advantage of our questionnaire tool is its perspicacity for ‘on the ground’ local factors. Furthermore, in those questions aligned with the ORF survey [[11]Casswell G. Shakir R. Macnair A. O’Leary B. Smith F. Rulach R. et al.UK training in clinical oncology: the trainees’ viewpoint.Clin Oncol. 2018; 30: 602-604Abstract Full Text Full Text PDF Scopus (10) Google Scholar], responses correlated well, providing a degree of validation (personal communication with ORF Co-Chairs). Pooled views reflecting the sense of partnership in radiotherapy learning are ascertainable with the tool, as well as distinctive trainer and trainee perspectives, owing to role-adapted versions. The questionnaire is adaptable for the circumstances and nomenclature of other centres, and could be refined to vary the focus on particular themes as necessary. In conclusion, local factors can imprint significantly on a trainee's radiotherapy learning experience. Centre-specific findings where local troubleshooting has taken place can be targeted via quality improvement mechanisms, to accelerate positive change in radiotherapy medical education. The themes identified in our centre may be broadly applicable, and should be considered by stakeholders involved in future service evolution. Trainees and trainers should regularly discuss local radiotherapy training conditions, to maximise mutual awareness of each other's roles and perceptions in the radiotherapy learning process. The authors declare no conflict of interest. The lead researcher was supported by Friends of the Cancer Centre to undertake this research as part of an MSc Clinical Education at Queen's University Belfast via the Dr Gary McGowan Scholarship. His position is currently funded via a Wellcome-Health Research Board Irish Clinical Academic Training Fellowship.

AIMS:Specialty trainees in clinical oncology must be competent in the coordination of both radiotherapy and systemic therapy at the completion of their training. Radiotherapy technology and postgraduate medical education have evolved significantly over the last two decades, but little is known of the educational impact of those changes within the dual training of the clinical oncology programme. A qualitative assessment of the radiotherapy component of training was undertaken at a single regional cancer centre in order to identify potential areas for improvement.MATERIALS AND METHODS:Consultants and trainees (n = 10) at a regional cancer centre underwent semi-structured interviews regarding their lived experience of learning radiotherapy skills and knowledge. As consultants and trainees can be considered equal co-investors in the process of radiotherapy learning, the same question stems were used for both groups. An interpretative phenomenological analysis was undertaken by the investigators to elicit the perception of both groups.RESULTS:Consultant and trainee assessments of current radiotherapy learning standards differ for several aspects of training, as do their expectations of the other in learning processes. A lack of time is a major barrier in modern practice, and both groups can propose novel measures to improve learning locally.CONCLUSIONS:Arrangements for learning radiotherapy have not kept pace with the rate of change in the clinical oncology discipline. Trainees and consultants have contrasting views on the state of training, its strengths and weaknesses, and pathways to improvement, which should be reconciled by programme coordinators charged with upgrading the training system.

Background: Ipilimumab was the first immune checkpoint inhibitor to demonstrate a survival benefit for metastatic melanoma patients and has been available in Northern Ireland (NI) since 2012. With the advent of more novel checkpoint inhibitor options and combinations, single-agent Ipilimumab use has declined, but evidence indicates it may continue to have a role after PD-1 inhibitor monotherapy failure. We investigated our clinical outcomes in the earlier era of this treatment. Methods: Ipilimumab-treated patient data were retrospectively collected using electronic record systems and clinical notes. Descriptive and inferential statistics using Microsoft Excel® and SPSS® were employed to evaluate outcomes, including objective response rates (RR) according to RECIST criteria, disease control rates (DCR), progression free survival (PFS) and overall survival (OS). Results: 70 patients were treated with Ipilimumab in NI between November 2012 and December 2015. 57 patients had a cutaneous or unknown primary, and of these, 40.3% harboured a BRAF mutation. 56.4% of all patients had received prior systemic therapy. Median follow-up duration was 12 months (range 0.63 to 51.2 months), and median number of cycles administered was 4, with 65.7% completing 4 cycles. RR and DCR were 10.1% and 31.9% respectively, and the median PFS was 2.9 months and OS 11.7 months. 50.7% of patients with disease progression received subsequent systemic therapy but 52% of deaths occurred prior to access to PD-1 inhibitor and BRAF/MEK targeted therapy in NI. Grade 3-4 toxicities occurred in 31.4% of patients. The 30-day mortality was 5.7% (4 patients), with only 1 suspected treatment-related death. Serum LDH>upper limit of normal, serum neutrophil:lymphocyte ratio>4, M1c disease, uveal primary, presence of brain metastases and ECOG performance status 2 were identified as clinical factors which correlate with worse PFS and OS, and all early mortality cases had two or more of these factors. Conclusions: Efficacy and toxicity data, and prognostic indicators for our cohort, are similar to other published data. Ipilimumab is deliverable in a non-clinical trial setting with acceptable outcomes, and may remain relevant as a viable treatment option. Patient selection is key to optimal results. Legal entity responsible for the study: Belfast Health and Social Care Trust Funding: None Disclosure: O. Oladipo: Served on advisory boards for MSD and BMS and supported for travel to educational meetings by both companies. V. Coyle: Almac Diagnostics, Craigavon, UK, Corporate Research Collaboration. All other authors have declared no conflicts of interest.

To seek feedback from clinical oncologists as to their experiences of specialty training and, where applicable, the transition to working as a consultant in the National Health Service.All clinical oncologists gaining a Certificate of Completion of Training between 1 July 2012 and 30 June 2014 were identified through records held by the Royal College of Radiologists and approached in May 2015 to take part in an online survey.The survey was completed by 38 of 80 clinical oncologists invited to take part (48% response rate). Most respondents (>87%) agreed that specialty training equipped them well with clinical skills in radiotherapy planning, systemic therapy and tumour site diagnosis and treatment. This fell to 58% with advanced radiotherapy techniques. Of the non-clinical skills, respondents felt training had equipped them less to deal with leadership and management (53%) and research (48%) than clinical governance (61%). Despite wanting to do so, 42% of respondents did not undertake any out-of-programme (OOP) activity to gain new skills. Most of those respondents who did undertake OOP activity agreed that it helped to prepare them for their first consultant post. There is broad support for the FRCR Examination. The First FRCR Examination modules in physics, pharmacology, tumour biology and radiobiology were seen to be very relevant to clinical practice by 50% or more of respondents. The Final FRCR Examination was seen as essential in a technical specialty like clinical oncology by 92% of respondents. Working as a new consultant, the survey revealed a heavy workload for most respondents, with 69% always or almost always working beyond contracted hours. Other issues of concern identified were discrepancies in advertised consultant job plans and ineffectiveness of the job plan review process. The trainee–consultant transition is often a difficult time, yet only 19% of respondents were allocated a formal mentor. Most respondents had to rely on informal arrangements in seeking support and advice from medical colleagues.In general, respondents were satisfied with their specialty training and the transition from training to working as a new consultant. Areas for possible improvement have been identified for employers as well as those involved in organising specialty training.

1150 Background: Metastatic breast cancer (MBC) is incurable. Palliative chemotherapy treatment prolongs survival and taxanes are among the most active agents used. HER2 overexpression is associated with poorer overall survival. The development of the HER2 targeted monoclonal antibody, trastuzumab, resulted in greatly improved outcome for patients with HER2 overexpressing MBC patients in clinical trials. We sought to evaluate outcomes of taxane chemotherapy in our patients and also the implication of HER2 overexpression. Methods: We carried out a retrospective analysis of patients who were referred to breast cancer specialist clinics within the Belfast City Hospital between January 2003 and December 2005. We identified all patients who received a taxane based regimen as palliative chemotherapy for MBC. Results: A total of 77 patients (7.3% of overall number) received taxane based palliative chemotherapy for MBC. Thirty-four (44.2%) were ER+/HER2, 24 (31.2%) were triple negative (TN) and 19 (24.7%) were HER2-positive (and so received docetaxel/trastuzumab). Median age was 48.3 years (range 29-68). Median times from original diagnosis of breast cancer to taxane treatment for MBC were similar in all 3 groups. Median overall survival from the start of taxane based treatment was 14.6 months for ER-positive/HER2-negative patients, 8.0months for TN patients and 36.8 months for HER2-positive patients (p=0.004). Median overall survival from time of diagnosis was 35 months (ER-positive), 27.5 months (TN) and 72.5 months (HER2-positive). Conclusions: Trastuzumab in combination with taxane-based chemotherapy has greatly improved clinical outcomes for patients with HER2 overexpressing metastatic breast cancer. However, it is recognized that these patients were treated before the use of adjuvant taxanes and trastuzumab became standard of care. In taxane- and trastuzumab-naïve patients who are fit enough for chemotherapy HER2 can be regarded as a good prognostic factor. No significant financial relationships to disclose.

11533 Background: Recent large multicentre trials have demonstrated a survival advantage with adjuvant trastuzumab but have also highlighted potential side effects especially cardiotoxicity. We have audited the first year of adjuvant trastuzumab in Northern Ireland, examining adherence to guidelines, toxicity and service impact. Methods: 117 patients were identified as starting adjuvant treatment in the first year. The regional guideline (based on the HERA protocol) advised trastuzumab for patients who were HER2 positive, (immunohistochemistry 3+, or 2+ and positive on fluorescent in-situ hybridisation), who had received adjuvant chemotherapy and had either node-positive tumours or node-negative tumours with a primary larger than 1 cm. Trastuzumab was given on a 21 day cycle for 18 doses and patients were reviewed at cycle 1,2,5,9,13 and 18 with echocardiogram at baseline and repeated at 3 month intervals. Adverse events and reasons for deferring or stopping treatment were documented. Results: From December 2005 to November 2006, 117 patients started treatment and all met the criteria set out in regional guidelines. At analysis in December 2007, 26 patients (22%) had not remained on schedule. Five patients had developed relapse and moved to a metastatic disease protocol. Thirteen patients (11%) suffered a decline in left ventricular ejection fraction (LVEF), with 4 patients continuing after a 4 week deferment and 9 (7%) stopping, one of whom subsequently died from cardiac failure. Two patients stopped because of arrhythmia, without decline in LVEF, two stopped because of severe allergic reaction and a further two had neurological symptoms that led to early discontinuation. One was deferred for one month due to dyspnoea and palpitations, but with no LVEF drop and one was deferred 3 weeks with a line infection. The remaining 90 patients have either completed treatment (87 patients) or are continuing on their planned schedule. Service impact was in very close accord with the pre-implementation estimates in the business case. Conclusions: The introduction of adjuvant trastuzumab in Northern Ireland has been shown to accord with agreed regional guidelines and was associated with toxicity comparable to that described in the registration clinical trials. No significant financial relationships to disclose.

6097 Background: Clinical trials have clearly established that patients receiving taxane-based chemotherapy for metastatic breast cancer (MBC) should be treated with trastuzumab if their tumour is shown to overexpress the human epidermal growth factor receptor 2 (HER2) receptor. This is based on median survival gains for patients with HER2 positive tumours treated with trastuzumab plus taxane chemotherapy compared to taxane alone. Methods: Patients commencing chemotherapy for MBC in Northern Ireland in 2004 were identified from pharmacy records. Their case notes were retrospectively reviewed to determine whether patients in routine clinical practice had HER2 testing and trastuzumab treatment if indicated. Results: One hundred and fifty six patients commenced chemotherapy, of whom 145(93%) had HER2 testing. In 69(44%) patients the HER2 result was already available at the time of this relapse. In the remaining 76(49%) patients the result became available in a median of 41.5 (range 0–368) days. Of those tested, 48 patients (33%) were HER2 positive (immuno-histochemistry 3+ or fluorescence in situ hybridization positive). Thirty eight of these patients were treated with trastuzumab, either as a single agent or in combination with chemotherapy. There were valid reasons for trastuzumab omission in 7 of 10 patients not given trastuzumab (4 given first line anthracycline-based regimen, 1 had cardiac dysfunction, 1 had extensive lung metastastes and 1 was unfit for treatment). The data were examined for variations in chemotherapy and trastuzumab use across the 4 health boards which comprise the region. The number of patients commencing chemotherapy ranged from 6.9 to 11.4 patients per 100,000 population indicating a significantly different utilisation (p<0.001). Conclusions: In our region 145 of 156 patients who received chemotherapy for MBC were tested for overexpression of the HER2 receptor (93%). Of those patients who were eligible to receive trastuzumab 31 out of 34 (91%) received trastuzumab. There were inequalities in the region regarding chemotherapy for MBC and the time required to obtain a HER2 result averaged 41.5 days. Testing of HER2 status at time of original diagnosis would streamline management of metastatic disease. No significant financial relationships to disclose.

The prognostic significance of extragonadal rather than gonadal presentation of germ-cell tumour in 51 patients presenting between 1979 and 1988 with abdominal tumours was compared with that of 51 control patients with testicular primary tumours matched for bulk of disease, serum tumour marker concentration, age and year of treatment. Very large volume tumour was found at initial staging in 24 extra-gonadal cases (47%) and high tumour markers in 29 (57%). Actuarial survival at 2 and 5 years was 82% and 70% for cases and 78% and 63%, respectively, for controls. These outcomes were not significantly different and the relative hazard of death for cases compared with controls was 0.7 (95% confidence intervals 0.3–1.5). Thus the presentation of germ-cell tumours with a retroperitoneal mass does not itself adversely influence prognosis compared with testicular presentation with equivalent disease extent. However it is rare for extragonadal presentation to be associated with small volume disease.