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Year : 2016  |  Volume : 12  |  Issue : 2  |  Page : 1080-1083

Need of collaborative radiology–radiation oncology workshops in decision making for head and neck cancer (HNC) management in India: Perspectives of the radiation oncologists

Department of Radiation Oncology, Medanta The Medicity, Gurgaon, Haryana, India

Date of Web Publication25-Jul-2016

Correspondence Address:
Trinanjan Basu
Department of Radiation Oncology, Medanta The Medicity, Gurgaon-122 001, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.148681

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 > Abstract 

Background: In India, head and neck cancer (HNC) has always been a challenge to treatment due to its various disease., treatment., and patient.related factors. Recent developments in the field of both radiology and radiation oncology brings us to a stage where combined collaborative efforts are required for proper management of HNC. The article identifies the potential areas of such need through online survey.
Materials and Methods: This anonymous online survey with specific questions and their responses from radiation oncology community identifies potential areas of radiology expertise as perceived by a radiation oncologist. The questions were simple Likert-type and the best possible response was sought for.
Results: There were 57 email responses and majority (37) agreed upon the extreme importance of such collaborative efforts. The major areas where a radiation oncologist would seek help are target volume delineation and response evaluation posttreatment in HNC, though other areas are also important albeit to a lesser degree.
Conclusion: There is urgent need of radiology.radiation oncology workshops in managing HNC in the modern era of image.based and image-guided treatment. Future larger hospital.based survey would determine need on a large scale basis at resolving these issues.

Keywords: Collaborative workshops, head and neck cancer, modern imaging, radiotherapy

How to cite this article:
Kataria T, Basu T, Goyal S, Gupta D. Need of collaborative radiology–radiation oncology workshops in decision making for head and neck cancer (HNC) management in India: Perspectives of the radiation oncologists. J Can Res Ther 2016;12:1080-3

How to cite this URL:
Kataria T, Basu T, Goyal S, Gupta D. Need of collaborative radiology–radiation oncology workshops in decision making for head and neck cancer (HNC) management in India: Perspectives of the radiation oncologists. J Can Res Ther [serial online] 2016 [cited 2020 Jul 13];12:1080-3. Available from: http://www.cancerjournal.net/text.asp?2016/12/2/1080/148681

 > Introduction Top

The burden of head and neck cancer (HNC) in India has been huge and ever increasing.[1] In the past decade, radiation therapy in the management of HNC has witnessed remarkable achievement in terms of treatment modalities and techniques as well as management of quality of life issues. Intensity-modulated radiotherapy (IMRT), image-guided radiotherapy (IGRT), and stereotactic body radiotherapy (SBRT) including Cyberknife once a distant reality has become well-established in India. These modern techniques are still not available in all parts of our country. The other concern being training and expertise related to application of these techniques in daily patient care, especially for young radiation oncologist. Parallel to this, the field of medical imaging has also undergone a lot of changes and now an integral component of diagnosis, radiotherapy planning, and treatment assessment in HNC. Modalities like magnetic resonance imaging (MRI) and positron emission tomography (PET) scan with different advanced techniques related to them can now predict accurate staging, treatment response, and even recurrence at an asymptomatic stage.[2]

The concept of collaborative workshops widely prevalent in Western countries is basically a combination of didactic and practical demonstration sessions over a couple of days. The European Society for Therapeutic Radiology and Oncology (ESTRO) has been pioneer in conducting such masterclass.[3] Compared to West, evidence-based workshops with multidisciplinary approach is quite rare in India. Tata Memorial Hospital Evidence-Based Medicine (TMH-EBM), Indian College for Radiation Oncologist (ICRO) teaching program are few such courses limited by number of participants and often without adequate radiology lectures and hands-on practical demonstration.[4],[5] There is obvious lack of collaboration between radiologist and radiation oncologist in conducting all these courses, and in view of modern imaging and radiotherapy techniques it is the need of the hour in India.

The modern medical imaging techniques and their interpretation as well as radiotherapy facilities like IM/IGRT and the practical aspects related to them is undoubtedly the most demanding aspect of radiation oncology career. Right from the diagnosis to target definition and response evaluation, in all the phases HNC has been supplemented with imaging. The concept of collaborative radiology–radiation oncology workshops to aid in proper delineation, diagnosis, and response evaluation would definitely benefit both the communities; especially clinicians in early phase of their career.

 > Materials and Methods Top

A total of 59 radiation oncologists were communicated over e-mail and a formal questionnaire was send out. In the feedback they were requested to rate and also to add their comments. The feedback had three parts. The first part had questions regarding need of collaborative radiology–radiation oncology masterclass over a simple Likert-type scale ranging from 1 to 5 with 1 being not appropriate and 5 being extremely important. The second part of the feedback asked for three areas where a radiation oncologist would take help from a radiologist viz. a. diagnosis and staging work-up of cancer, b. target volume delineation for radiotherapy planning, and c. response evaluation imaging. The third part of the feedback assessed the most critical aspect regarding practice changing behavior viz. a. whether after consultation with a radiologist there is a change in staging of cancer, b. change in target volume delineation, and c. distinction between post-radiotherapy changes and recurrence in HNC.

This online survey was entirely anonymous and no financial or personal benefit was gained from it and it does not advocate any practice changing policy. The basic aim was to highlight a certain need of knowledge and practice in Indian scenario. The responses to these questions were then analyzed and most common responses were noted. The basic frequencies were calculated using Statistical Package for Social Sciences (SPSS) version 18.0. The demographic profile of the e-mail respondents are given in [Table 1].
Table 1: Demographic profile of the online survey

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 > Results Top

Out of 59 emails, 57 responses were received over e-mail. There were 40 postgraduate students of radiotherapy and 17 post Doctor of Medicine (MD) registrars who participated in the online survey. Respondents were equally divided between their working facilities with 25 having basic radiotherapy facilities like telecobalt machine and 32 had linear accelerator available at their center. A large number of people (50/57 = 87.7%) agreed upon regular need of radiologist in different stages of cancer diagnosis and treatment. Respondents were asked to give the best possible answer from each section and they also had the liberty of not answering all the questions. The questions as sent over e-mail have been given in [Table 2].
Table 2: The online questionnaire

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While analyzing, it became evident that majority believes in collaborative workshops and 37 out of 57 responses were in favor of extremely important category. Regarding the need of radiologist in different sectors, the responses again majorly favored target volume delineation in radiotherapy planning for HNC (37 out of 57). The opinion was divided between change in target volume and response evaluation in part 3 of the questionnaire and some people also wished to refrain from answering. The detail results are depicted in [Table 3].
Table 3: Detail analysis of the questions

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 > Discussion Top

The shortcomings in terms of radiology and radiation oncology joint efforts have been evaluated in 2008 through multidisciplinary meetings in the West.[6] Their consensus statement was that a gap does exist between radiation oncology and various imaging specialties and that improved interactions can change the nature of clinical practice as well as enhance research opportunities. Several other guidelines also came into the practice highlighting the benefit of PET-CT based radiotherapy planning and role of imaging in all the five steps of radiotherapy process.[2],[7] The Australian community have actually evaluated the role of a radiologist in radiation oncology department through prospective study and concluded that advice over diagnostic images and target volume delineation were the main reasons for the consultations, which resulted in a change of practice in 45% of cases, ranging from changing target volumes (25%) to carrying out further imaging (20%).[8]

The value of joint clinics often put forward as a solution has several advantages and often patients can actually arrive at a treatment decision.[9],[10] These are well-established and time tested. As the present scenario stands, we need to propose the second stage of joint clinics combining radiologist and radiation oncologist after the initial management decision being made. The same multidisciplinary clinic (MDC) in Indian scenario might be little different. Gupta has highlighted few of the pitfalls of MDC like a. Teams make decisions by lack of response, autocratic choice made by one or two individuals, default, deference to expert opinion, majority vote, consensus, or unanimity. b. More often than not, an egoist individual or an egoist group of individuals dominate proceedings and dictate terms in an MDC, rendering the whole exercise farcical and futile. c. Collective decision-making may falsely reduce the sense of individual responsibility for decisions and patient care and lull the members into believing that their decisions are more ethical because they are based on “consensus” opinion.[11],[12],[13]

The complexity of HNC during target volume delineation or response evaluation posttreatment, calls for help of a qualified radiologist specializing in HNC. An article form British community beautifully highlighted the role of a radiologist and it stated that; “The role of the radiologist lies not only in detecting recurrent neoplastic disease, but also identifying nonneoplastic changes that may account for clinical presentation and symptoms in this patient group. There are a number of nonneoplastic as well as neoplastic changes and disease entities that can present on surveillance imaging, such as primary resection and reconstructive surgical change, surgical neck dissection changes, radionecrosis, posttreatment denervation change, and radiotherapy-related secondary tumors”.[14] The Indian scenario especially in HNC is lagging far behind when radiology collaboration is concerned. The neuro-oncology society has been quite exemplary regarding joint clinics and especially the Tata Memorial Hospital Joint Neuro-Oncology Meet (JNOM) has set the benchmark by providing guidelines online.[15]

Our study was just a preliminary effort in assessing the need of collaborative workshops through online survey. The e-mail responses were analyzed in our department. We must admit that the overwhelming response (57 out of 59) itself raised few doubts about the actual belief and need. Since it was e-mail communication and moreover anonymous, there would always be a chance of reply without even reading the details. However, the clear indication of a radiologist in target volume delineation and response assessment needs no further explanation. The post response prospective assessment is something that we are definitely considering to evaluate and the practice-changing behavior can only be commented at a later date.

The cost-effective and varied role of radiation oncology community has been well-accepted in low- to middle-income countries like India. The techniques of advanced treatment are now available across the country and gone are the days when we would look forward to Western world for better treatment techniques. The major lacunae though are the collaborative effort which is the benchmark for any well-established HNC care center in the West. This online survey kind of reassured the global findings in terms of responses to the served questions.

 > Conclusions Top

This informal and small sample size online survey digs at the burning issue of collaborative efforts of radiology and radiation oncology for mutual benefit of both the communities. The future would be more structured joint clinics, evidence-based mutual exchange of knowledge, and improvement in cancer care to expedite cure in HNC. The technology will advance from photon to proton in HNC and imaging also will bring about more and more biological parameters, but the basic understanding will only be established with joint collaborative radiology–radiation oncology workshops.

 > References Top

Takiar R, Nadayil D, Nandakumar A. Projection of number of cancer cases in India (2010-2020) by cancer groups. Asian Pac J Cancer Prev 2010;11:1045-9.  Back to cited text no. 1
Lecchi M, Fossati P, Elisei F, Orecchia R, Lucignani G. Current concepts on imaging in radiotherapy. Eur J Nucl Med Mol Imaging 2008;35:821-37.  Back to cited text no. 2
Available from: https://tmc.gov.in/clinicalguidelines/clinical.htm TMH EBM guidelines [Last accessed on 2014 Oct 25].  Back to cited text no. 4
Available from: http://www.aroi.org/Indian-College-of-Radiation-Oncology.html ICRO website [Last accessed on 2014 Oct 25].  Back to cited text no. 5
Balter JM, Haffty BG, Dunnick NR, Siegel EL. Imaging Opportunities Workshop Participants. Imaging opportunities in radiation oncology. Int J Radiat Oncol Biol Phys 2011;79:342-7.  Back to cited text no. 6
MacManus M, Nestle U, Rosenzweig KE, Carrio I, Messa C, Belohlavek O, et al. Use of PET and PET/CT for radiation therapy planning: IAEA expert report 2006-2007. Radiother Oncol 2009;91:85-94.  Back to cited text no. 7
Dimigen M, Vinod SK, Lim K. Incorporating a radiologist in a radiation oncology department: A new model of care? Clin Oncol (R Coll Radiol) 2014;26:630-5.  Back to cited text no. 8
Edwards D. Head and neck cancer services: Views of patients, their families and professionals. Br J Oral Maxillofac Surg 1998;36:99-102.  Back to cited text no. 9
Ziegler L, Newell R, Stafford N, Lewin R. A literature review of head and neck cancer patients information needs, experiences and views regarding decision-making. Eur J Cancer Care (Engl) 2004;13:119-26.  Back to cited text no. 10
Gupta T. Multidisciplinary clinics in oncology: The hidden pitfalls. J Oncol Pract 2007;3:72-3.  Back to cited text no. 11
Lowe JI, Herranen M. Conflict in teamwork: Understanding roles and relationships. Soc Work Health Care 1978;3:323-30.  Back to cited text no. 12
Sharp HM. Ethical decision-making in interdisciplinary team care. Cleft Palate Craniofac J 1995;32:495-9.  Back to cited text no. 13
Offiah C, Hall E. Post-treatment imaging appearances in head and neck cancer patients. Clin Radiol 2011;66:13-24.  Back to cited text no. 14
Available from: https://tmc.gov.in/SBF/Nouro/FINAL%20Neuro_DMG.pdf [Last accessed on 2014 Oct 25].  Back to cited text no. 15


  [Table 1], [Table 2], [Table 3]


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