Investing in emerging technologies is critical to the ongoing provision of the highest quality of evidence-based radiation therapy (RT) care. Novel technologies, however, are only as good as the people, systems, and processes established to leverage them. Too often, the education required to maximize the capabilities of the innovation is approached as an afterthought to the development, sourcing, and commissioning of the technology itself.

Historically, RT was fairly stable until the late 1900s; technology changed slowly and most operational decisions were clinical rather than technological. Beginning in the late 1980s, as academic researchers and then vendors took advantage of computed tomography (CT), the pace of technological innovation accelerated. Disruptive innovations, those that are ideally realized with concurrent changes to roles and workflows, have been studied in the past for the impact of the implementation work on the change experience. Within the RT context specifically, the benefits of proactive and coordinated education efforts have been espoused in the implementation of a number of practice-changing innovations, including the shift to 3D simulation and treatment planning,1 intensity-modulated RT (IMRT),2 and image-guided RT (IGRT).3

Looking ahead to innovations currently gaining traction or on the horizon, such as magnetic resonance (MR)-integrated RT and adaptive treatment strategies, there is value in reflecting on previous implementation experiences in the field to optimize future efforts. Thompson et al. in considering the disruptive potential of artificial intelligence (AI) in RT, referenced the reported challenges in system-level adoption of IMRT twenty years previously,2 cautioning that “the haphazard adoption of intensity-modulated radiation therapy provides a compelling harbinger of how AI could similarly be integrated into clinical practices in a piecemeal fashion, which may be driven in part by skepticism, bias, or early challenges.”4

Thoughtful consideration of how to most effectively ensure people and processes are prepared to work alongside novel technologies can support organizations and systems to ensure the fullest potential of the innovation can be realized. This article will consider the principles and strategies of education and competency in a landscape of rapid innovation and the contributions of various interest-holders to supporting these principles and the broad educational needs with respect to technology implementation, including academic institutions, professional associations, industry, and individual organizations.

One of the challenges of RT is that the staff that work for the vendors that manufacture these technologies are not necessarily clinically-trained, or as recently engaged in practice, so they may produce devices and systems that are highly flexible, meaning that each clinic may use them differently, which complicates training. This generality does not extend to training in the specific use of both software and hardware, often termed buttonology. Vendors can train staff in buttonology, but the overall application and utilization space of the devices or software remains broad.

As noted above, the pace of innovation has accelerated, with each technological advance requiring first an informal and later a more formalized education and training process. The evolution of technological development and implementation can be summarized into 6 steps, named IDEPTH, that support the concept of the discovery-care continuum5:I:

Invention by investigators or corporate scientists

D:

Development by corporation to product

E:

Early post commercialization, many papers not relevant to clinical introduction

P:

Preliminary work by clinics, associations, vendors for developing early protocols and tests

T:

Templated work by associations to formalize protocols and tests

H:

High education curricula, certification exams, and credentialing for trials

The purpose of this section is to demonstrate the purpose and characteristics of each step, focusing on the educational considerations and implications, and this is done through the historic example of IMRT. This example has the advantage of being both relatively modern, such that the approaches developed during its introduction remain relevant, and old enough that it could be considered mature and will therefore demonstrate all 6 steps.

I: Invention by investigators or corporate scientists

IMRT began as an extension of treatment planning,6, 7, 8, 9, 10, 11 and was made possible by the introduction of multileaf collimators (MLCs).12, 13, 14, 15, 16 Boyer and Yu17 proposed a method for delivering a desired fluence distribution using dynamically moving MLCs, where the leaf velocity and linac dose rate were managed to assure that the proper integrated fluence was delivered.

By mid 2000s, IMRT was in the process of becoming mainstream. Two commercial implementations were available to clinics, both using a rotational technique whereby a narrow radiation field was delivered using either sequential abutting deliveries or in an overlapping helical pattern.

D: Development by corporation to product

The early commercial IMRT systems delivered radiation in narrow slices, one in a cine arrangement by abutting these slices, and one with a low-pitch helical approach These were available by the late 1990s. The cine system, created by the NOMOS corporation, was first cleared by the FDA in 199618 and by 2001, had treated more than 8000 patients worldwide.19 The NOMOS corporation sponsored one of the earliest IMRT Conferences in Durango, Colorado in 1996, which led to a book edited by Sternick.20,21 Within 2 years, other courses and educational opportunities were emerging related to IMRT.20

E. Early Implementation and commercialization

Well before the commercial introduction of IMRT, some academic institutions had taken advantage of the combination of having written their own treatment planning systems and the introduction of MLCs on conventional linear accelerators. They supported the core tenet of the discovery-care continuum in the role of the academic health sciences system in the transformation of clinical care.5 The University of Wisconsin started treating patients with IMRT in 1994,22 beginning with an in-house system that combined treatment planning and treatment delivery control and verification imaging. Another clinical use of MLC-based IMRT was at Memorial Sloan Kettering as reported by Ling et al. in 1996.23 The University Hospital Gent had developed a process for delivering IMRT to head and neck cancer patients using a single treatment plan composed of static fields and the normalization of monitor units to account for the specific patient's geometry.24

Academic interest in IMRT was high. In 2000, the thirteenth triannual convening of the International Conference on the use of Computers in Radiation Therapy was held in Heidelberg, Germany. This conference was seen as the preeminent conference on technology development for RT, including treatment planning, radiation measurements, radiation dose simulations, and patient imaging.

The interest in technical delivery prompted medical physics faculty and institutions to create educational courses as well as the research conferences. Andy Beavis of the University of Hull and Daniel Low of Washington University, for example, hosted the first IMRT conference in the United Kingdom (UK) in 1997. The conference, entitled IMRT, A Clinical Perspective, was an educational program intended to instruct British medical physicists in the technology and applications of IMRT. The University of Florida subsequently sponsored 2 ocean cruises, one entitled IMRT at Sea that occurred in 2003 and the follow-up entitled AGIMRT at Sea that was hosted in 2005. In 2010 the Princess Margaret Cancer Centre in Toronto established a series of IMRT Education Courses through its Radiation Medicine Accelerated Education Program.2,25

P. Preliminary work by clinics, associations, vendors for developing early protocols and tests

The first large-scale educational program on IMRT sponsored by the American Association of Physicists in Medicine (AAPM) was the 2003 summer school entitled IMRT: Implementation and Quality Assurance.26 The summer school provided a general broad course on the background of IMRT.

The AAPM and the American Society for Radiation Oncology (ASTRO) then conducted joint workshops in 2002-2004 to educate clinicians on implementing IMRT. These workshops also had vendors that provided demos and case-based treatment planning exercises.

The National Cancer Institute (NCI) formed a collaborative working group of experts in IMRT to develop consensus guidelines and recommendations for the implementation of IMRT.27 They described the state of IMRT in 2001 as being in its beginning phase, with only a few thousand patients having been treated worldwide, including those by commercial systems28, 29, 30 and those by university researchers.22, 23, 24

As can be seen in the AAPM example depicted in Figure 1, the peak interest in continuing professional development (CPD)-type content related to IMRT in RT annual meetings came in the years immediately subsequent to this early roll-out phase.

T: Templated Work by Associations to Formalize Protocols and Tests

As IMRT matured, academic clinics developed their protocols and educated the community about them, and associations, especially the AAPM and the European Society for Radiotherapy and Oncology (ESTRO) started to codify these protocols by convening committees to review the literature and develop expert opinions, typically published by the associations as formal reports. AAPM, for example, has published 6 task group reports between 2003 and 2023 that directly dealt with IMRT.

H: Higher Education Curricula & Certification Exams

The final stage of implementing a new technology is to codify its processes and expectations in training regimens. In the United States, The Commission on Accreditation of Medical Physics Educational Programs (CAMPEP) sets the requirements for medical physics graduate and residency education and the Accreditation Council for Graduate Medical Education (ACGME) does the same for radiation oncologists. The AAPM, via report 365, Academic Program Recommendations for Graduate Degrees in Medical Physics, describes the core medical physics graduate curriculum and under the category of photon beam treatment planning includes Modulated Delivery Techniques.31 CAMPEP requires the education of graduate students in IMRT under the topic of Radiation Therapy Physics, External beam treatments. The content of the IMRT section typically uses the relevant AAPM task group reports as well as relevant textbooks.

For physicians, the ACGME publishes Program Requirements for Graduate Medical Education in Radiation Oncology.32 This describes that the training clinics need to have IMRT as a core resource. The utilization of IMRT as a planning and delivery technique is so prevalent now that the requirement for learning planning techniques has been absorbed within general medical physics instruction that includes use of state-of-the-art treatment planning systems. This is often the culmination of the journey of the implementation of technology innovation, as it becomes no longer innovative but rather a ubiquitous element of practice and thus more deeply embedded in related curricula. Further consideration of establishing professional competency requirements for novel technologies, and integrating them effectively in curricula, is discussed later in this paper.

As demonstrated in this historical IMRT example, IDEPTH provides a conceptualization of the organic evolution of education and training alongside technological innovation. Bak et al’s 2011 case study of the facilitating and impeding factors in system level IMRT adoption experienced in Ontario, Canada, further highlights the role of education to support coordinated, safe, and efficient uptake of IMRT.2

Building on the historical IMRT example that explored the fulsome discovery-care continuum with an IDEPTH lens, in this section we consider some emerging technologies, including AI, adaptive radiotherapy, magnetic resonance imaging (MRI)-guided RT, particle therapy, and brachytherapy.

Given the transformative potential for AI in radiation oncology, there is an emerging need to improve literacy among all specialties. Recent surveys of oncology trainees, medical physicists, and radiation therapists (RTTs) indicate positive attitudes towards the potential of AI to improve patient care and reduce the use of manual resources, as well as desire to formally integrate AI into the professional curricula.33, 34, 35, 36

In 2021, the NCI held a workshop to discuss action points relevant for future trainees interested in radiation oncology AI.36 Several themes emerged from the workshop including (1) creating AI awareness and responsible conduct, (2) implementing a practical didactic curriculum, (3) creating a publicly-available database of training resources, and (4) accelerating learning and funding opportunities.

Regarding the practical implementation of an AI curriculum for general oncology training, a recent publication by Almeida et al.37 suggested a framework with 4 pillars: (1) how to use AI to cope with information overload in oncology, (2) exploring AI tools through the eyes of a patient, (3) acquiring a deeper theoretical knowledge on the fundamental concepts of AI, and (4) hands-on exercises in developing AI models.38 A similar model could be adopted for radiation oncology, with an additional focus on how to use AI for the technical elements of radiation planning.37 What was not addressed explicitly, however, is how these pillars could be effectively integrated into existing training curricula.

In medical physics, the European Federation of Organizations for Medical Physics developed a proposed curriculum consisting of 2 levels: Basic (introducing medical physicists to the pillars of knowledge, development, applications, and ethics of AI, in the context of medical imaging and RT) and Advanced.39

In RTT practice, Chamunyonga et al. recommend that the fundamentals of AI and machine learning are introduced at an undergraduate level to ensure students understand the applications, potential benefits and the associated risks of their clinical applications.40 It is also suggested that RTTs provide perspective to students on how AI and machine learning technologies are impacting or likely to impact contemporary health care and patient management more broadly.

Adaptive RT (ART) broadly refers to an advanced technology where during 1 or more fractions, the patient is imaged, the current treatment plan is evaluated, and if needed, due for example to changes in patient anatomy, the plan is modified or a new plan is created. Most of the change management and literature around education and training for ART is focused on RTTs, where technological innovation has suggested the need for fundamental workflow reorganization to maximize treatment efficiencies. To prepare the RTT workforce for ART, several course initiatives are available at Royal Marsden Hospital (UK), Royal Surrey County Hospital (UK), the Princess Margaret Cancer Centre (Canada), Medisch Spectrum Twente (Enschede, The Netherlands), and University Medical Centre (Utrecht, The Netherlands). These courses integrate hands-on experience with the technology and interprofessional mentorship to deliver online ART (oART) via RTT-led or independent workflows. These programs emphasise experiential and practice-based education, focusing on decision-making in contouring and the use of oART in simulations where possible. Given the growing evidence for RTTs to lead the oART workflow in partnership with decision support tools, Shepherd et al. propose a pathway for training and credentialing.41,42 Their step-by-step guide is detailed for initial certification including completion of site-specific e-learning modules and associated reading, anatomy contouring training and assessment, real-time online adaptive treatment observations, treatment simulations/emulations and real time patient case treatments.

A domain that also benefits from educational pathways to prepare the workforce for ART is MR-integrated RT. The potential clinical benefits of MR guidance in RT have long been appreciated. However, until recently, the roles of MRI and therapy were separate. With technological advances allowing for the integration of MRI and treatment units on the same machine, there are new needs and requirements for multidisciplinary education. Several professional bodies have provided guidance on this topic: 2 international guidelines on the use of MRI in radiotherapy were published in 202143,44 to define a baseline level of competence and standardization from which MRI guidance can be developed more efficiently. A report from 2022 provides a framework for establishing an MRI safety program in a radiation oncology department45 and many programs follow the MRI safety standards of practice from the American College of Radiology.

A key educational challenge for MR-guided radiotherapy is for RTTs to be able to perform image-guidance and treatment adaptation using MR images, which do not tend to be currently part of entry-to-practice RTT curriculum. Li et al. described a 3-phase training strategy to enable RTT-driven prostate MR-Linac treatment, by the end of which a transition to an independent RTT driven workflow was achieved46 Further discussion of large-scale competency-building in the MR-integrated RT domain is provided later in the discussion of how best to integrate training in entry-to-practice and CPD curricula.

Given the niche indications for particle therapy, as well as its costs and availability (eg, fewer than 2% of patients in North America are treated with particle therapy), it is unlikely everyone in radiation oncology needs to have a deep understanding of these technologies. The International Atomic Energy Agency gave perspective on the challenges and recommendations for developing countries when setting up a particle therapy facility, which are also broadly applicable to other settings.47 They highlighted that few facilities had established long-term training programs for newcomers in the field, that the training costs should be included in the initial budget of any new project, and that training should focus on the particle that will be used in the planned facility. Various networks such as the Particle Therapy Co-Operative Group and ESTRO have developed in-person and online courses and modules for implementation of particle therapy that cater specifically to centers with these technologies. However, there is also a need for non-proton therapy specialists to understand the benefits and risks of this technology as well, to ensure that patients are appropriately referred to these centers, and evidence-based indications continue to emerge. To address broader education needs, Oncolink has a specific webinar titled Proton Therapy for the Non-Proton Therapy Provider for this purpose.48 Additionally, to help with decision making for individual cases, hospitals have also started to offer proton therapy dosimetry consultation services by providing a quantitative estimate of potential dosimetric benefits of a proton plan versus a photon plan for a specific patient, helping physicians evaluate its value and also further educate non-proton therapy specialists.49

Brachytherapy has been long established as an evidence-based treatment and is a cornerstone of care for cervical and prostate cancers. However, several studies have shown suboptimal rates of brachytherapy utilization in these settings.50,51 A substantial barrier to utilizing brachytherapy is radiation oncologists’ exposure and competence, as illustrated in a report by Macrom et al. who noted that 59% of residents believed that a limited caseload was the greatest barrier to achieving independence in brachytherapy. Increasing exposure to brachytherapy is the most robust means to overcome this issue, but this is dependent on casemix and infrastructure available at individual programs. A novel approach to brachytherapy training involves simulation-based training, which has been well established in surgical specialities. Several recent studies evaluating the results of simulation-based workshops have shown improvements in both self-reported confidence and interest in pursuing brachytherapy.52 There are ongoing efforts to develop a roadmap for brachytherapy simulation to improve competency.

Given the numerous emerging technologies described above, and many others, the current pace of innovation in radiation oncology suggests a need for academic training curricula to consider how best to prepare the future of the relevant radiation medicine professions. While vendor training, as noted above, may be current and important, the appropriate principles for related learning must be established early in academic training curricula and competency profiles, and institutional upskilling. Professional association-led CPD must then also consider how best to layer practice-related considerations alongside "buttonology." This final section will provide a pedagogical lens to formal education in an era of accelerated innovation and disruptive technology implementation.

The pace of technological advancement does not easily lend itself to comprehensive attention of individual innovations in entry-to-practice curricula, competency profiles, or certification examinations. Drafting, validation, and implementation of updates can involve lengthy development and approval processes led by academic and professional bodies, meaning that there is often a lag of up to a few years before those entering clinical training or even the professional workforce are meaningfully exposed to novel technologies.53, 54, 55 Outdated curricula can be especially problematic for professions like radiation therapy, that rely heavily on didactic classroom learning and standardized certification examinations. Calls have been made to address the so-called “lag time dilemma” in fields like engineering53 and nursing,54 through concepts like rapid curriculum renewal,53 but these have not gained sufficient traction in regulated professions to mitigate challenges in incorporating novel technologies into curricula. Additional challenges can exist when faculty are isolated from the evolving clinical environment, limiting their practical literacy in the novel concepts they might be required to teach.55, 56, 57

CPD can often be more nimble than pre-licensure programs in addressing learning needs with emerging technologies, fulfilling an important role in maintenance of competence. CPD, however, cannot reasonably attain the same level of standardization and pervasiveness as accredited entry-to-practice programs. It thus behooves these programs to focus on common technology-agnostic principles, equipping the future RT workforce to be flexible to emerging technologies and related skills and workflows.

Undergraduate medical education has evolved in recent decades—followed by other professions—to broadly embrace the concept of “learning to learn,” with transformative changes to academic programs to focus on problem- and case-based learning, lifelong learning, and reflective practice.58,59 Applied to preparing future radiation medicine professionals for emerging technology, a similar reframing could be of value. A 2021 scoping review of AI education programs for healthcare professionals summarized that entry-to-practice programs might be best-served by focusing on fostering familiarity with AI terminology, high level AI and machine learning capabilities, limitations, and ethical implications, and “how to identify opportunities and applications in health where AI would be appropriate with a health equity lens.”57 This represents a focus on the transferable AI knowledge and skills, rather than the in-depth mechanisms of algorithms or specifics of individual AI solutions. The ability to recognize and problem-solve when technology has failed, through understanding its intended function, limitations, and role of human oversight, may be a more universally valuable skillset to support safe and effective practice beyond the lifespan of the present technological landscape.

In instances such as medical physics training, where such intricacies of the technology, and its quality control and ultimately its advancement, may be at the core of the professional scope of practice, other strategies exist to foster the ability to transfer learning to novel innovations. A recent review of the evolution of medical physics training and education reflected on the value of “incorporation of research/innovation explicitly into the training pathway, thereby emphasizing that a clinical physicist must learn ‘how to learn’ as the technological landscape is expected to evolve over their career.”60 This also applies as it cannot always be feasible that trainees in any profession are exposed to all technologies in the current market during the course of their clinical training, be it brachytherapy (as noted earlier), protons, MR-integrated units, or even just different vendor solutions.

Along with the technology, there comes the need to prepare for aligned professional roles and workflows that must accompany it for fulsome implementation. These tend to evolve meaningfully only as the technology gains traction in the clinical environment, and an evidence base begins to emerge to support them55 A collaborative approach to mobilizing around a novel technology can ensure that roles, boundaries, and common goals are well-defined, and that professional expertise is ideally leveraged within individual scopes of practice1,3 As noted in the earlier case study, with the more mainstream integration of online adaptive technologies, many jurisdictions have begun to adopt RTT-led adaptive workflows, suggesting the need for novel knowledge, skills, and judgement, as well as changing communication practices and common terminology considerations for all radiation medicine professions. In the MR-integrated RT domain specifically, the introduction of such workflows, as well as RT-specific MR safety screening needs, have led to the acknowledgement by the radiation therapy profession that bringing MR into RT was not just a question of equipping select RTTs with additional training through traditional diagnostic MR technologist academic program pathways. A consensus exercise undertaken by a Canadian Association of Medical Radiation Technologists (CAMRT) National Taskforce on MR in RT identified net new competencies that extended beyond those in either its RTT or MR technologist competency profiles, relating to “practical integration and application of MR” in RT.61

Planning and decisions regarding what warrants being added to entry-to-practice curricula or CPD program offerings cannot be fully considered without also being willing to address what may need to be dropped from training to accommodate attention to a novel technology. Historically, many programs and training initiatives have suffered from what has been known as an “additive curriculum”62 or “‘curricomegaly,' an affliction whereby the curriculum metastasizes beyond reason”60 As noted by White and Kane in their reflection on the advent of computerized radiation treatment planning, “no longer were dose distributions calculated and then drawn by hand, although this was a skill required for certification examinations in both radiation therapy and radiation oncology for a long time after computerized dosimetry was established as a standard component of practice.”55 As many historically manual processes become augmented and made more efficient by technology, such as auto contouring and other applications of automation strategies, it may become relevant to re-evaluate what oncologists, dosimetrists, or medical physicists need to know to be competent in their roles in treatment planning. If it is determined that certain core skills remain essential despite being primarily managed by technology, the consideration then becomes how to maintain the skills when not regularly employed in practice.