Consider this editorial:
Brachytherapy for the future – Jackson – 2022 – Journal of Medical Imaging and Radiation Oncology – Wiley Online Library
The paper is written with the implicit assumption that more brachytherapy exposure and competence is a good thing for all trainees, but this might not be the case. Most trainees will not go on to be brachytherapists, and this may be why enthusiasm seems to be less among the newly qualified Fellows who perhaps have a more realistic view of the world. If the aim is to have Fellows who can assess the value of brachytherapy for a particular patient and make an appropriate referral, attendance at the ABG Workshop and one case report on each of the two major sites may be sufficient. This is similar to the situation in paediatrics where one would not expect a new Fellow to set up an independent practice. The College Radiation Oncology Training Program Handbook lists brachytherapy as one of the mandatory special techniques with the expectation of being able to perform vaginal cylinder insertions but sensibly requires less detail on cervical and prostate treatment.
I was lucky to have trained with someone who took a special interest in brachytherapy procedures. I did intraluminal, intravaginal, intracavitary procedures; treated with mould brachytherapy by using specific dental moulds and implanting catheters (for surface brachytherapy) and just short of interstitial brachytherapy for prostate. I even assisted for interoperative implantation for adjuvant sarcoma treatments, and used it for locally advanced bronchial cancer treatments for palliation. I ended up losing the momentum, because not everyone was thrilled about it subsequently. It required significant investment of time, patience, energy and coordination with the anaesthetic teams and often gruesome planning schedules. Besides, excellent post-operative care to ensure the catheters don’t “kink”. These are significant barriers for high volume centres too, and despite what the editorial suggests, it is not only the mechanisms related to payouts.
It is difficult, if not impossible, to replace a kinked catheter or return to the drawing board if there is a screw up. The dose distribution may be affected, defeating the entire purpose. However, while the editorial is reflective of the Australasian continent, these trends are broadly visible globally, barring the “middle-income countries”.
Luckily, the editorial is open access and has good points raised therein. A must read, thought-provoking write-up!