A Pilot Study Using Simulation To Train Residents Implantation In Interstitial Breast Brachytherapy

Accelerated partial breast irradiation (APBI) using multi-catheter interstitial brachytherapy can be used as adjuvant local therapy post-lumpectomy in early stage breast cancer. In a recent survey, over 50% of residents reported being dissatisfied with the training they received in high-dose rate (HDR) breast brachytherapy. Furthermore, only 15% of residents felt they were competent to perform the procedure. The purpose of this study is to demonstrate that participation in a simulation program for HDR breast brachytherapy will improve resident confidence, competence and efficiency in implanting catheter needles. From July 2019-August 2019, 10 radiation oncology residents from first year to fourth year were recruited. They all attended a didactic lecture in HDR breast brachytherapy, followed by a demonstration on an anthropomorphic phantom performed by a radiation oncologist experienced in breast brachytherapy. Participants then completed a pre-simulation survey prior to starting the simulation procedure. Using an opaque anthropomorphic plastic breast phantom with an internal target, each resident placed a total of 5 needles, in two parallel planes, 1 cm apart. The first row consisted of 3 needles and the second row was made up of 2 needles. Each resident repeated this procedure three times over a period of one month and there was no time limit to complete the implantation. A CT scan of the phantom was acquired after the first and the last session. A researcher assessed participant performance by evaluating the number of needles within the target and the correct geometry. A further survey was then done evaluating participant satisfaction and confidence with the procedure by using a 10-point Likert scale from low (1) to high (10). Of the 10 participants in this study, only one resident had implanted a needle under direct supervision. The number of catheters placed within the target ranged from 2-5 needles in their first attempt. In the final attempt, all participants were able to place the needles within the target. The mean deviation of the needles from the ideal distance of 1 cm in their first attempt was 3.4 mm +0.11 mm compared to 2.9 +0.11 mm in their final attempt. Residents reported in the surveys that their confidence to implant a needle in a supervised setting on a patient and their confidence to explain brachytherapy in an oral exam increased by a magnitude of 1.5 (Wilcoxon Signed Rank Test, p<0.05). We believe this is the first simulation program for teaching HDR breast brachytherapy implant skills. We have shown that simulation can help residents improve their skills and confidence in inserting needles. This model has the potential to be developed into a module for teaching residents breast brachytherapy in a competency-based curriculum.