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Volume 16 No 4 / September 2020

Quarterly publication of The Royal Australian and New Zealand College of Radiologists

DIGITAL HEALTH WHITE PAPER Clinical Radiology Forging the Path Toward Interoperability

Also Featured in this edition

Outgoing CEO Reflects on

Seven Years of Achievements

How Loneliness Can Make Us More Vulnerable to COVID-19

RANZCR Standards of Practice for Artificial Intelligence

“We look after each other.” At I-MED Radiology, we have a vision: to be the most respected and trusted medical imaging specialists in the world. And at the heart of that vision is our commitment to treating our patients and work colleagues alike with compassion. If you are interested in working in a welcoming environment, with people who support you in your career, who respect individuality and diversity, then come and talk to us. You’ll be sure of a warm welcome.

Contact our careers team T: +61 2 8274 1080, E: careers@i-med.com.au www.i-med.com.au/careers

Editor’s Pick 5 7

A Message from the President A Final Word from the CEO

8 11 13

Clinical Radiology Forging the Path Toward Interoperability How Loneliness Can Make Us More Vulnerable to COVID-19 The College Unveils Standards of Practice for Artificial Intelligence

Knowledge Building at The Christie NHS Foundation Trust

New Chair of the College’s Clinical Radiology Research Committee

What are your thoughts?

RANZCR Workshops, Courses and Events 2020–2021

RANZCR2021: Elysium Diagnostics and Therapeutics (Now and in Future) with AI

Work on Training and Assessment Reform Continuing!

Targeting Cancer: Improving Cancer Outcomes for New Zealanders

From the Faculty of Clinical Radiology

Chief Censor Update: The College’s Training Program 2020

37 38

Chief of Professional Practice Update Clinical Radiology Trainee Matters

39 41

From the Faculty of Radiation Oncology

Chief Censor Update: Developments in Radiation Oncology Training

Radiation Oncology Trainee Matters

Quality Corner: Volume Delineation in Radiation Oncology

Obituary: Dr David Green

849 53 54 55

New Zealand Branch News New Zealand’s General Election in 2020 News: Special Interest Groups

56 61

If you have thoughts or comments about one of the stories you have read in this issue, we want to hear from you. The submission of letters to the editor, articles and news items is encouraged. Please email any submissions to editor@ranzcr.edu.au

Uterine Fibroid Embolisation- the Past, the Present, and the Future

Starting Out with Medicare Provider Numbers and Compliance Activities

Mammography Quality Assurance Program

Have you moved recently? Log into the MyRANZCR portal and ensure your contact details are up to date at www.myranzcr.com

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Editorial Staff Editor-In-Chief Dr Allan Wycherley Sub Editor Lindy Baker

All rights reserved. No part of this publication may be reproduced or copied in any form or by any means without the written permission of the publisher. Publication of advertisements and articles submitted by external parties does not constitute any endorsement by The Royal Australian and New Zealand College of Radiologists of the products or views expressed.

Introduction

A Message from the President

Dr Lance Lawler

As we enter the eighth month since the first cases of COVID-19 were reported in Australia and New Zealand in February this year, we continue to come to terms as a medical college with the complexities of the public health crisis, first and foremost the complexities that you are experiencing as clinicians. Nowhere is this more evident than in Victoria and I want to reiterate that the College is acutely aware of the tremendous amounts of pressure this places on our members in Melbourne, regional Victoria and in the wider jurisdictions of Australia and New Zealand. Pressure which starts with your work at the forefront of the response from the health system with its effects on your personal lives, and continues in the ongoing implications for the functioning of our health systems under the strain of the global pandemic. We encourage you to take particular care of your physical, mental, emotional and social health and seek support if you need it. A number of links to useful resources to support your health and wellbeing are available on the College website. The Australian Governmentâ€™s digital mental health portal is also a useful reference for information and guidance on how to maintain good mental health during the COVID-19 epidemic, as is the clinician-led Pandemic Kindness Movement website. The College is continuing to navigate the challenges presented under the guidance of the COVID-19 College Taskforce and I want to thank the Taskforce members for their leadership

and their diligence in this exceptional year. The Collegeâ€™s multi-layered response, developed by the Taskforce and detailed on our website (www.ranzcr.com/our-work/coronavirus), has been directed at serving the interests of all Fellows, educational affiliates, trainees, international medical graduates and College staff. The College will continue to provide any and all support that we can. As you would know by now, in a significant development for the College, the Chief Executive Officer, Natalia Vukolova, has resigned to start a family, effective from 25 September 2020, after more than seven years in the role. Natalia has served the College with distinction, reorganising our management systems, strengthening engagement with government and the membership, and helping to build our international reputation as a leading medical college. She has worked for a total of 11 years in senior roles at the College, having served as Executive Officer of the Collegeâ€™s Faculty of Radiation Oncology from August 2009 to March 2013, at which time she accepted the post as the College's first female CEO.

and guiding the organisation out of the shadows as an advocate for the radiological professions. We will miss her energy and untiring enthusiasm. Mark Nevin, previously the College's Head of Policy and Advocacy, will serve as interim CEO for 12 months while the Board chooses a permanent replacement. In Mark Nevin, we have an experienced and qualified interim CEO whose previous role spans both our Faculties, and who has a strong track record in the advocacy work we undertake on behalf of members with health authorities in Australia and New Zealand. Mark is more than capable of safely steering the ship while the Board completes the process of choosing its next CEO. I would like to take this opportunity to wish Natalia all the very best for the future and to welcome Mark back to the College, I am sure both will be impressive in their new roles.

To access useful resources visit: www.ranzcr.com/fellows/general/ your-wellbeing

She has made a major contribution in initiating the College's training and assessment reforms in 2014, embodying potentially the most significant revision to the College's role in specialist medical education since its inception.

Head to Health: Australian Government, Department of Health

You might say Natalia grew with the College, proving to be an effective force for positive change in many areas

www.aci.health.nsw.gov.au/ covid-19/kindness

www.headtohealth.gov.au The Pandemic Kindness Movement: a clinician-led initiative

Volume 16 No 4 I September 2020

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Introduction

A Final Word from the CEO

Ms Natalia Vukolova

My dear colleagues and friends throughout the College . . . As many of you will be aware, I am leaving the College shortly to prepare for big changes in my personal life with the planned arrival of a new member into my family. Planning the transition has been difficult for me and the RANZCR Board, and I am grateful to all who assisted in the process. The Board recognised a need to have certainty and clarity around the executive leadership, so as to maintain the momentum the College had built up in recent years and steer the College through the testing times we know lie ahead. For me personally, of course, it has been the same dilemma countless women have faced countless times—balancing the twin demands of having a career and having children—and trying her best to get the timing and circumstances right so she doesn't give up her choices in life and work. I am pleased to say the Board and I have come to an agreement that works well for both sides. I have resigned as your CEO, effective from 25 September, and handed over the reins to our former head of policy and advocacy, Mark Nevin, to take charge of the management team as interim CEO for 12 months.

Many of you know and respect Mark for his intelligence and impressive track record in a key role at the College. I am certain he will lead the College well while a search for a permanent CEO is underway. It is hard for me to reflect on the experiences of my seven years as CEO, except to say that I was blessed with a very strong management team who trusted me and gave me great support to achieve many things for our members. The list of achievements is formidable: creating fresh policies to ensure patient access to key treatments, advocating powerfully to government, reforming our exams and trainee supports, strengthening member engagement, numerous IT improvements and, recently, navigating the impact of a devastating pandemic. It is a demanding and sometimes tough job that commands your time and energy in full measure. And the job is important because strong leadership in this organisation helps safeguard the critical work of our medical professionals—men and women who save lives every day and are essential to the functioning of a modern healthcare system.

I am grateful for the opportunities I had at the College—to develop professionally, initiate new projects, improve old programs and systems, make a difference. The College is different today to what it was when I took over, and it's better for it. I was just one of many who made that happen. I am deeply grateful that the Board of Directors took a chance on me in 2013 and then supported me to transform the College to what we have today. I am proud of my contribution to your College and I'm thankful to all those who worked and contributed with me. Best regards, Natalia Vukolova RANZCR CEO 2013–2020 @NataliaVukolova

Volume 16 No 4 I September 2020

Features

Clinical Radiology Forging the Path Toward Interoperability Digital health has the potential to transform the way health care is delivered in Australia. A digitally connected health system relies on interoperability. That is, the ability of different information systems to communicate and exchange data, and use the information exchanged to improve the care provided to patients. Unimpeded workflow needs to be seamless, safe and secure for patients and clinical users. For changes to be truly transformational we need to find value-creating solutions that realise benefits for each clinician across the care pathway, and most importantly for the patients, prioritising their choices as consumers. The College has developed a digital health white paper entitled Towards Interoperability: Clinical Radiology Forging the Path Ahead, which is currently under review via consultation. The white paper sets out a new, more open and connected clinical pathway to

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see patients become active participants in their health care and enable a transition towards value-based care. It is only through the careful design of a new digital workflow that we can maximise the benefits and evolve our digital health system.

The time is right to advance digital health The impacts of COVID-19 on the delivery of health care have been substantialâ€”perhaps none more than necessitating the rise in digital health initiatives. This has had positive impacts in some areas, while also highlighting the need for transformation in other areas. Data released by the Australian Digital Health Agency (ADHA) in June 2020 showed healthcare providers accelerated their use of technology during the pandemic. More than 90 per cent of public hospitals are now using My Health Record with 5.2 million

more clinical documents uploaded by hospitals, pathologists or radiologists since March. It appears that the focus on digital health including telehealth consultations during COVID-19 lockdowns has helped fast-track the adoption of some technology. Patients have demonstrated that they are open to using online technology to access and receive care. Current consumer expectations for a digitally enabled and connected health ecosystem are high as empowered and digital-savvy consumers are driving change in patient care and how they are treated. Similarly, health providers have relied on the technology more to consult with their patients, diagnose and deliver care in new ways. There is now unprecedented opportunity to transform the healthcare system towards new, more open and connected clinical pathways.

Features

Despite national leadership, and an overall framework for action to guide, we lack a common shared vision between the key players, and this is holding back technology-led interoperability and realisation of our digital health objectives. The rapid uptake of telehealth during the COVID-19 pandemic has shown what can be achieved when key players work together toward a common goal.

“Unimpeded workflow needs to be seamless, safe and secure for patients and clinical users. For changes to be truly transformational we need to find valuecreating solutions that realise benefits for each clinician across the care pathway, and most importantly for the patients, prioritising their choices as consumers.” The College’s digital health vision A foundational element of interoperability is the use of standardised terminologies to ensure that all participants have a common understanding of the data provided (known as ‘semantic interoperability’). Currently there is not an agreed and common language used throughout the patient’s care pathway by all those contributing along the way.

Importantly, interoperable communications and data will bring us closer towards the fundamental principle of truly enabled patient choice. The College’s vision is to fully utilise available technology in the patient journey from clinical radiology referral, test performance and interpretation, to receiving the results. In building the technological architecture to support this vision, the focus is across five strategic projects with each leveraging and building on existing systems. These include: 1. Standardised terminology—as an essential building block towards interoperability—to ensure consistent use of terminology in referrals to radiology. Multiple global and local catalogues already exist. A targeted project is required, supported by the Department of Health, ADHA and the broader clinical radiology sector, to review the relative merits of existing catalogues, mapping against other relevant systems and standards, such as the Medicare Benefits Schedule (MBS) and existing legacy catalogues. This review would produce a Radiology Referral Set which would establish

the consensus terminology to use for radiology referrals. Agreement of this as the common standard for Australian clinical radiology terminology forms the foundation for the College’s digital health priorities. The College has already started work on a related project to introduce structured radiology reports containing templates for components of the report and providing support for data reconciliation with the request. 2. Streamlining, and improving the quality of, referrals with electronic referrals. Secure electronic referrals can improve how clinical and administrative information is exchanged between healthcare providers, resulting in better delivery of care. Safeguarding patient choice will be the most important factor in implementing eReferral. In prioritising patient choice, the College strongly prefers the exchange repository model for eReferral.

continued over... Volume 16 No 4 I September 2020

Features

“A foundational element of interoperability is the use of standardised terminologies to ensure that all participants have a common understanding of the data provided (known as ‘semantic interoperability’). Currently there is not an agreed and common language used throughout the patient’s care pathway by all those contributing along the way.”

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3. A platform that allows secure access to prior medical images.

5. Leveraging artificial intelligence (AI).

Clinicians subsequently caring for a patient would benefit considerably from having access to prior images to complement the clinical radiologist’s report. The infrastructure of My Health Record can provide a registry of tests performed previously which could be leveraged to a greater degree by incorporating links to historic images, stored at the practice which performed the original test. The College believes a platform is needed to connect My Health Record with the practice’s stored images, while validating who should have access to sensitive patient data.

The potential for AI should be considered when progressing all interoperability projects, particularly in imaging-based specialties such as clinical radiology and radiation oncology. This fifth element will be factored in to streamline the reporting process internally. Later, in the reporting cycle, AI may assist report interpretation by the referrer, where structured reports will be needed.

4. Enabling clinical decision support (CDS) into the workflow. Technology needs to be utilised in a way that allows clinicians to provide evidence-based care for patients. Easy access to clinical guidance on the best radiology test for a particular patient’s presentation would enhance decision-making at the point of care. CDS must be seamlessly integrated to the referrer’s workflow, which is best done by incorporating it into eReferral. This would provide timely access for general practitioners and other referrers to clinical guidelines when they are considering what radiology test or study their patient needs.

In realising the College’s vision to advance interoperability and required standards, strategic partnerships are required to provide the leadership commitment needed to lift the technical impediments currently holding us back. The College has identified several key stakeholders representing consumers, referrers and government, and is engaging with them to ensure active collaboration in codesigning digital health solutions.

The consultation on the College’s digital health white paper is open until 9 October 2022. Please submit your feedback to the consultation via email to fcr@ranzcr.edu.au

Features

How Loneliness Can Make Us More Vulnerable to COVID-19

My neighbor’s elderly father died during the coronavirus pandemic. The virus wasn’t the culprit, at least not directly— the man wasn’t infected. However, right before passing away, he confided in his daughter that what was killing him was loneliness. Loneliness caused by the outbreak. Although that story happened in France, in many countries across the planet, Australia included, the elderly in nursing homes have found themselves on total lockdown during the pandemic—to protect their health, the thinking went. And they were not the only ones. In hospitals, coronavirus patients spend hours sealed off from anyone else, completely alone. As one nurse told me, the healthcare workers often don’t feel like they can connect with their patients and simply be there for them—what with all the safety protocols, the layers of protective equipment.

“We are leaving these people in isolation, alone,” she said. But it’s not just hospitalised COVID-19 patients and nursing home residents who suffer from lack of social connection during the current pandemic. Most of us do. We are told to socially distance ourselves, to limit contacts, not to hug friends. From the perspective of the immune system functioning and health in general, that’s disastrous. Research shows that social isolation and loneliness up the risk of early death, increase the risk of stroke and cancer, and even raise blood pressure—which is a bad thing as COVID-19 goes, elevating the probability of complications. In one study of people in their fifties and sixties, being lonely predicted having higher blood pressure a few years down the road. For the most lonely individuals, their systolic blood pressure would hike up as much as 3.6 mm per

year—meaning you could go from a perfectly normal measurements of 119 mm Hg to 130 mm Hg, which is already hypertension, in a mere three years. There are also direct links between social isolation and how resistant our bodies are to viruses. In one series of experiments more than 300 people were voluntarily infected with common cold viruses (the volunteers were paid $800 for their participation, which could explain their willingness to suffer for science). For several days after exposure they were assessed for the symptoms of cold—from weighting their nose mucus to measuring virus-specific antibody titers in their blood. The results showed that those volunteers who were the most socially isolated before infection had about 45 per cent higher risk of developing the cold from the dose they’ve received. continued over... Volume 16 No 4 I September 2020

Features

Although in this particular study the viruses used were from the rhinovirus family, another study done back in the 1990s showed that stress really ups your risk of developing symptoms of common coronaviruses (the mild type, those that used to cause us colds for centuries). And what really counteracts stress? The answer is connection with others, kindness, even simple touch—which can lower the levels of the stress hormone, cortisol. What’s more, research shows that people who experience chronic social isolation have different expression of genes responsible for the antiviral response and for antibody production, making them more susceptible to such pathogens. Of course, this is not to say that we should just throw in the towel and stop isolating coronavirus patients on hospital wards or give up on lockdowns and social distancing. Not at all. But there are things we can do to minimise the feelings of loneliness. We can, for instance, connect with others online— and certain ways are better than others. For one, try to call instead of texting. Research reveals, for example, that hearing your mother’s reassuring words on the phone causes a larger oxytocin release than does receiving similar support through a text message. Oxytocin, in turn, dampens stress and may lower plasma C-reactive protein levels (although for now this is only based on animal studies). Researchers in China, meanwhile, have recently found that elevated levels of C-reactive protein may predict aggravation of symptoms of COVID-19. Some great initiatives to counter social isolation during the pandemic are already under way. In Australia, programs such the Community Activation and Social Isolation initiative in Victoria, provide a hotline and, at the same time, link people to community

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connectors for local practical supports and social activities such as video chats, online book clubs or fitness groups. In some states in the US, nursing care facilities can now apply for funding to buy tablets, webcams and headphones for their residents—to help them reconnect with their loved ones online. In New York, a new program is now being proposed that would allow coronavirus survivors to visit and console hospitalised COVID-19 patients. As for me and my family, we simply try to pay more attention to each other, be empathetic, hug each other often, find time to talk. To make sure all of us feel connected. Marta Zaraska is a Polish-Canadian science journalist and author of ‘Growing Young: How Friendship, Optimism and Kindness Can Help You Live to 100’ www.growingyoungthebook.com @mzaraska

To access useful resources visit: www.ranzcr.com/fellows/general/ your-wellbeing Head to Health: Australian Government, Department of Health www.headtohealth.gov.au The Pandemic Kindness Movement: a clinician-led initiative www.aci.health.nsw.gov.au/ covid-19/kindness

Features

The College Unveils Standards of Practice for Artificial Intelligence The College continues to be a world leader in the application of artificial intelligence (AI) in health care, becoming the first professional peak body in the world to launch AI Standards of Practice. The standards align with the existing Standards of Practice for Clinical Radiology and are guided by the College’s Ethical Principles for AI in Medicine. Clinical radiology and radiation oncology have always been early adopters of new technology and AI is no exception. Application of the professional standards will maximise the opportunities AI presents, allowing for a more efficient and accessible healthcare system that delivers improved outcomes for patients. The standards are intended to mitigate clinical risks and ensure best clinical care when using AI in radiology. They set out what is expected across a series of domains and what specific evidence would need to be shown to demonstrate compliance. The standards cover key components to the application of AI and machine learning (ML) including:

• • • • •

Algorithm development Information management Algorithm deployment Professional standards Audit and governance.

The scope of the AI standards is to guide the development, deployment and monitoring of artificial intelligence and machine learning in public and private radiology settings. They also serve to guide governance bodies and others involved in areas where decisions are made external to a practice or hospital department that have the potential to impact on patient care in radiology. The development of the standards was led by the College’s AI Committee with extensive consultation with a broad range of industry, academic, commercial, government stakeholders and other medical colleges. The launch of these landmark standards follows the release of the Ethical Principles for Artificial Intelligence in Medicine last year. The ethical principles outline the most appropriate use of

AI and ML, including how both can successfully help drive even better patient care. The nine ethical principles were developed specifically to guide the: • development of standards of practice for research in AI tools • regulation of market access for ML and AI • development of standards of practice for deployment of AI tools in medicine • upskilling of medical practitioners in ML and AI, and • ethical use of ML and AI in medicine. AI presents many opportunities for a more efficient and accessible healthcare system. While it may be some time until the technology is clinically appropriate and safe for patients, it is important for the College to continue positioning itself as a leading player in the application of AI in health care. It will also allow the College to further its advocacy efforts in the digital health sphere. Over the past decade, Australia has invested significant funds into attempting to harness and facilitate the adoption of digital health care. Digital health provides numerous opportunities for providing better informed and quality care and improving access, particularly for those in regional and remote areas. Through our advocacy, the College aims to ensure that patients and doctors have access to all relevant healthcare information, to enhance patient safety and reduce duplication of imaging, waste and costs. Digital health strives to connect healthcare providers and clinicians across all environments to deliver a seamless experience and quality care for patients. continued over...

Volume 16 No 4 I September 2020

What’s in Issue 4? Medical Imaging Review Article: Investigation and diagnostic imaging of suspected pulmonary embolism during pregnancy and the puerperium: A review of the literature Corresponding author: Dr Jodie Tester, c/o Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Parkville, Vic. 3050 Australia. Pulmonary embolism (PE) is a leading cause of maternal mortality with women at increased risk of PE during pregnancy and the early postpartum period. Clinical assessment of suspected PE during pregnancy is challenging as signs and symptoms associated with PE overlap with physiological changes of pregnancy. Clinical tests and rules commonly used to assess pre‐test probability of PE were historically not well validated in the pregnant population. The challenges of clinical assessment in the pregnant and postpartum population result in a lowered threshold for diagnostic imaging. Computed tomographic pulmonary angiography (CTPA) and nuclear medicine lung scintigraphy or ventilation/perfusion (V/Q) scans are the main types of diagnostic imaging for suspected PE. Both methods are associated with small levels of ionising radiation exposure to mother and foetus. Accuracy of the diagnostic imaging tests is paramount. Haemodynamic changes of pregnancy, including increased heart rate, increased blood volume and altered flow velocity in the pulmonary arteries, may influence the quality of imaging. This comprehensive review examines the literature and evidence for the investigation and diagnostic imaging of suspected pulmonary embolism during pregnancy with CTPA and V/Q. Clinical decision‐making tools, biomarkers and diagnostic imaging during pregnancy and postpartum will be considered with a focus on diagnostic accuracy and yield, radiation dose exposure (maternal–foetal) and protocol modifications. Current practice guideline recommendations and recent literature on diagnostic pathways are also presented.

Medical Imaging Technical Article: Lipiodol hysterosalpingogram: A modified HSG technique to minimize risks associated with lipiodol use Corresponding author: Dr Jane Michele Peart, Auckland Radiology Group, PO Box 9889, Newmarket 1149, Auckland, New Zealand. Assessment of tubal patency and therapeutic tubal flushing using Lipiodol, an oil‐soluble contrast media (OSCM), has been shown to enhance fertility, resulting in increased interest in the use of Lipiodol. A modified hysterosalpingogram (HSG) technique, including a supplementary ultrasound with the contrast in situ, is recommended when using Lipiodol, taking into account both safety issues and technical challenges specific to Lipiodol.

Radiation Oncology Original Article: Incidence of hippocampal metastases in non‐small‐cell lung cancer Corresponding author: Dr Sophia Ly, Department of Radiation Oncology, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, Qld 4102, Australia. Objectives Patients with locally advanced non‐small‐cell lung cancer (LA‐NSCLC) develop brain metastases in 25–50% of cases during the course of their disease. Data on the incidence of metastases occurring in the hippocampus/perihippocampal zones are limited. This is important when considering hippocampal‐sparing brain radiation (HS‐BR), a method that could potentially reduce the neurocognitive impact of such treatment. The aim of this study was to assess the incidence of hippocampal/perihippocampal metastases in a cohort of patients with advanced NSCLC treated at our institution. Methods This retrospective cohort study included NSCLC patients discussed at our institutional lung cancer multidisciplinary meeting between 2000 and 2016. MRI and contrast‐enhanced CT (ceCT) brain images were reviewed to assess the incidence of hippocampal/perihippocampal metastases including metastases within the hippocampal subgranular zone and a 5 mm margin (hippocampal avoidance region) defined as per the RTOG 0933 study. Results Of 2146 patients reviewed, 357 (16.6%) had brain metastases. A total of 335 patients had available MRI/ceCT brain images for review. Thirty (9%) patients had brain metastases in the hippocampal avoidance region, 8 (2.4%) with hippocampal metastases and 22 (6.6%) with perihippocampal metastases. Univariate analyses did not show an association between developing metastases in the hippocampal avoidance region and age (P = 0.75), gender (P = 0.91) and tumour type (P = 0.298). Conclusion The incidence of metastases in the hippocampal avoidance region in our large cohort of patients was 9%. With low rates of metastases in this region, HS‐BR can be considered a feasible option in the management of patients with advanced NSCLC.

Radiation Oncology Original Article: Does institutional patient accrual volume impact overall survival in patients with inoperable non‐small‐cell lung cancer receiving radical (chemo)radiation? A secondary analysis of TROG 99.05 Corresponding author: Dr Mun Yee Tan, Department of Radiation Oncology, Peter MacCallum Cancer Centre, 300-305 Grattan Street, Melbourne Vic. 3000, Australia. Introduction Increased hospital patient volume, reflecting greater experience, has been shown to be associated with improved survival for some cancers. However, there is no evidence to support the volume–outcome hypothesis for inoperable non‐small‐cell lung cancer (NSCLC) patients within the Australasian setting. We examined the relationship between overall survival (OS) and institutional patient accrual volume (IPAV) in a large prospective Australasian NSCLC database (TROG 99.05). Methods TROG 99.05 was an observational study which accrued patients from 1999 to 2007 to examine the relationship between primary lung cancer volume and survival. To be eligible for inclusion, patients had to have inoperable, biopsy‐proven NSCLC planned for radiotherapy to a minimum dose of 50Gy in 20 fractions, with or without chemotherapy. Participating institutions were de‐identified and grouped according to whether accrual was low, medium or high. OS was compared between groups and adjusted for prognostic factors using Cox regression. Results About 509 patients were accrued from 16 centres. Median potential follow‐up time was 60 months. Median survival for all groups was 20 months (95% CI 18.3–21.8 months). There were no statistically significant differences in OS with increasing patient accrual across the three groups after adjustment for prognostic factors (P = 0.84, 2 df). The hazard ratios (HR) for group accrual volumes, relative to that for high‐accrual volume, were as follows: low, 1.18; medium, 1.14. Test for trend: HR = 0.91 per group (95% CI 0.76–1.09, P = 0.31). Conclusion In the setting of a clinical trial with rigorous quality assurance, we found no evidence for an association between institutional accrual and survival.

Access your College journal online If you are a member of the Royal Australian and New Zealand College of Radiologists, access JMIRO free online. - Go to www.ranzcr.edu.au - Log in using your College username and password = FREE access to all JMIRO current and digitised backfile content from volume 1, 1957!

Features

“The standards are intended to mitigate clinical risks and ensure best clinical care when using AI in radiology. They set out what is expected across a series of domains and what specific evidence would need to be shown to demonstrate compliance.”

As technology continues to advance at a rapid rate, it is vital that the digital health solution is properly considered and implemented effectively. The College has a clear vision for how Australia can harness the benefits of digital technologies and improve the quality of care for patients who need radiology services. The College’s focus in digital health centres around five key priorities: • the establishment of an eReferral system • access to historic images • standardised terminology • development of imaging guidelines, and • the managed roll out of artificial intelligence (AI).

The College continues to be a thought leader in digital health and AI in healthcare settings, and is committed to equipping the membership to be at the forefront of the next frontier in medicine. Work continues on profession-led implementation and workforce transition to support the effective implementation of AI in clinical practice. We must continue to be pioneers in this space and work with stakeholders to help them recognise the potential and risk of AI and the integral role it could play as digital health and interoperability projects progress. If you have further questions about artificial intelligence or digital health in clinical radiology please contact Melissa Doyle, Executive Officer at the College at melissa.doyle@ranzcr.edu.au

lnsid1 eR01diology

Clinical Radiology Information for

HEALTH CONSUMERS & HEALTH PROFESSIONALS Raises awareness of medical imaging and the role of the clinical radiologist. Written by RANZCR Fellows and other Australian and New Zealand health professionals, edited by consumer and GP contributors. ✓ Information about clinical radiology tests and procedures in plain English ✓ Additional technical information for health professionals ✓ Approximately 100 information items with new items added regularly

Volume 16 No 4 I September 2020

Features

Knowledge Building at The Christie NHS Foundation Trust The Thomas Baker Fellowship It was such an honour to have been selected as the recipient of the Thomas Baker Fellowship last year, providing welcomed support for my appointment as a Clinical Fellow at The Christie NHS Foundation Trust in Manchester in the United Kingdom (UK). The Thomas Baker Fellowship awards financial support to the value of $AU20,000 to one Fellow toward their return travel and living costs for a period of up to 18 months of overseas experience, allowing a qualified radiologist or radiation oncologist to further their knowledge by studying abroad.

“I was particularly interested in expanding my experience in paediatric oncology. Though I had done most of my radiation oncology training in a centre treating paediatric cases, I felt my volume of handson experience with paediatric patients and pathologies was still limited. ” My post commenced in December 2019, but the preparation process commenced many months prior. I made a site visit in March 2019, spent several days shadowing clinics and observing clinical operations and arranged a face-to-face meeting with the Fellowship supervisor at The Christie to demonstrate my keen interest for the Fellowship post, knowing

The Christie Proton Beam Therapy building on a blue UK morning

that it would be a competitive process. Following a video interview in June 2019, I was offered the position and the process of obtaining the necessary visas, satisfying background checks, obtaining UK medical registration and the logistics of moving across the world would then subsequently take another four to five months. The Fellowship is based in The Christie NHS Foundation Trust—the largest single site cancer centre in Europe and the first UK centre with an NHS funded Proton Beam Therapy (PBT) centre. It is a part clinical, part research Fellowship working in the PBT centre with four-month rotations through the following subsites: sarcoma, head and neck tumours, paediatric body and central nervous system tumours, and adult central nervous system tumours. As more indications are added to the UK’s Proton Beam Therapy indications list, this may expand in the future. These tumour subsites aligned well with my personal subspecialty interest areas, and I was particularly interested in

expanding my experience in paediatric oncology. Though I had done most of my radiation oncology training in a centre treating paediatric cases, I felt my volume of hands-on experience with paediatric patients and pathologies was still limited. The majority of paediatric tumour cases across the UK is referred to The Christie PBT centre which sees, on average, 15 new children of less than 17 years old per month. My experience with paediatric patients very quickly increased by the sheer volume of patients I was seeing along their treatment pathway from clinic to discussion of their case in paediatric MDTs, developing and assessing their radiotherapy plans, and being involved in surveillance through follow up reviews. Adapting to a new workplace, within a new healthcare system took some adjustment but in itself was an opportunity to learn of the different ways daily work processes and structures could be run. continued over... Volume 16 No 4 I September 2020

Features

The friendly and colourful paediatric waiting room area

Proton beam therapy is an area of interest that has developed with my growing passion for paediatric oncology. With Australia now having started construction on their first PBT centre at the Australian Bragg Centre for Proton Therapy Adelaide, patients, particularly parents, will be asking all the more about its role in management of their or their childâ€™s tumour. The clinical experience working in proton therapy has been invaluable and one which was only made possible by me venturing overseas. I have been able to learn the intricacies of working with a new form of radiotherapy, with its inherent differences to conventional photon therapy and how this manifests dosimetrically as well as clinically as patients undergo proton therapy and in their ensuing follow up years into the future.

The benefits of the Fellowship however extend far beyond the specifics of PBT itself. It has developed in me a very detailed, almost forensic level of scrutiny with volume delineation, and allowed a systematic approach to plan assessment and evaluation. I have no doubt it has enhanced my overall ability in technical radiotherapy which will extend into my photon practice. Given its new implementation in the UK, there is significant emphasis on systematic, accurate and consistent collection of clinical outcome data, integrated into daily clinical practice. This has developed my diligence in documentation and robust data collection, and created opportunities for progression of my PhD with projects that I have become involved with. It has allowed me to gain a sharper eye to recognise and record particular toxicities observed during treatment and beyond. It goes without saying that aside from the immense academic and clinical opportunities, the social aspect of meeting, working with and connecting with new people while living here in the UK has been invaluable.

The Proton Fellows crew: Dr Simona Gaito (left), Dr Shermaine Pan (middle), Dr Eunji Hwang (right)

Inside News

Now almost eight months into my Fellowship post and having lived through the onset of a global pandemic, colleagues have become friends, and my husband and I have integrated into a community here in Manchester that we love. Though the pandemic has limited our initial plans for global travel particularly around Europe, we have taken the opportunity to explore more

of the UK itself with its varied beautiful countryside, amazing peaks and lakes and towns embedded in historical charm. I would encourage any Fellow or trainee who has passed their Part II examinations to apply for opportunities overseas that align with their interest areas and to apply for the Thomas Baker award to support their endeavours.

Applications for the 2021 Thomas Baker Fellowship will open in December 2020. The application opening date will be announced via email and on the College website: www.ranzcr.com/college/ grants-and-awards/educationalfellowships

Dr Eunji Hwang RANZCR Fellow Faculty of Radiation Oncology

Features

New Chair of the College’s Clinical Radiology Research Committee Professor Paul Parizel Professor Paul Parizel was appointed as the inaugural David Hartley Chair in Radiology, based at Royal Perth Hospital (RPH), in September 2019. The chair was established by the University of Western Australia to improve clinical governance, education and research, and to develop closer ties within the medical professions and also with the wider community of WA. Born and raised in the historic city of Antwerp, Belgium, he completed his medical school education at the University of Antwerp before working at the Antwerp University Hospital and undertaking Fellowships at centres of international renown including at Massachusetts General Hospital and Harvard Medical School.

In 2002, during the Annual Scientific Meeting, held in Adelaide, I became an Honorary Fellow of the College and served as Kodak visiting professor. Somewhere, in the back of my mind, I had always been thinking how nice it would be to work in Australia and share my professional experience with younger colleagues. There is a famous quote by Ralph Waldo Emerson that states that “life is a journey, not a destination”. To travel successfully on the journey of Life, one needs an ambitious plan, a steady compass, and—importantly—the ability to avoid the doldrums and make good use of the prevailing winds.

In February, Prof Parizel was appointed as Chair of the College’s Clinical Radiology Research Committee (CRRC).

“Human interaction between professionals is the force that enables the transfer of knowledge, and the development of scientific collaboration, and the College is an essential catalyst to drive these processes.”

When did you move to Australia and why? I arrived in Perth, WA on Sunday 22 September 2019, which happened to be my birthday. I had signed my contract more than a year earlier, but it took a very long time to get all the red tape sorted out. In fact, there were times that I was not even sure if I would ever succeed in getting all the documents together. My reasons for coming to Australia were manifold. For more than 30 years, I have been friends with Professor Mark Khangure, and thanks to him, I’ve had the occasion to visit Perth several times, and always was impressed by the high professional and ethical standards of radiology in Australia.

In Europe, I finished my terms as President (2017) and Chairman of the Board (2018) of the European Society of Radiology (ESR), and as President of the European Congress of Radiology meeting in Vienna in 2017. It seemed

like a perfect moment to consider a new professional and personal challenge. And what better place to do so than in Perth, Western Australia, one of the nicest cities on the face of this earth?

How does your experience of radiology in Australia compare to your experience in Belgium? First of all, I would like to say that I am grateful for the opportunity to share some of my thoughts and visions with the readers of Inside News. There is an expression in French that says ‘plus ça change, plus c’est la même chose’ (the more things change, the more they stay the same). In a way this holds true for working as a radiologist in Australia. Compared to Belgium, there are many similarities in the work we do, and in the organisation and structure of radiology departments. The technical platform at RPH is very similar to what I had in my department at Antwerp University Hospital. The patient population in a tertiary referral centre is very diverse, interesting, and, at times, challenging. RPH is unique in that we see many patients referred through the State Major Trauma Unit and the State Spinal and Scoliosis Service. However, a similarity between Australia and Belgian is the juxtaposition of a public health system and a private system, both with their specific and individual roles. Of course, there are also some differences in the type of examinations and protocols we perform, but overall I would say that the similarities are far, far greater than the differences. continued over... Volume 16 No 4 I September 2020

ELYSIUM: DIAGNOSTICS AND THERAPEUTICS (NOW AND THE FUTURE) WITH AI

Official Presenting Partner of RANZCR2021

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Features

What are your areas of interest within radiology? I trained as a neuroradiologist and have always been interested in imaging of the brain and spine in a variety of disease conditions. In the last 10 years, my main areas of interest have been imaging in traumatic brain injury patients and the implementation of quantitative imaging and artificial intelligence techniques within our field. However, as chair of the Department of Radiology at Antwerp University Hospital, and as supervisor of many PhD and Master students, I always considered that it was my duty to keep abreast of developments in other areas of radiology as well. Our discipline has undergone such an amazing transformation in the past couple of decades. Radiology, or imaging in the broadest sense of the term, has become the crossroads in any modern hospital.

What motivated you to get involved with the College? As stated previously, I fondly remember the 2002 ASM in Adelaide, and I remember being very much impressed by the traditions and solid organisation of the College. During my years as a member of the board of directors of the ESR, I have had several meetings with College representatives, in particular with the College's President, Dr Lance Lawler. I strongly believe that for a medical practitioner, engagement with their professional organisation is important, both for individual professional development and growth, and perhaps even more importantly, to engage in the training of junior radiologists. It is our responsibility to ensure that the next generation of radiologists has a future that will be just as exciting and productive as the professional career that my generation has had until now.

“In my view, research is an essential component in the delivery of excellent patientcentred health care. Radiology is moving along a trajectory from an ‘art’ to a ‘science’, from producing ‘pretty images’ to quantitative data sets.” Human interaction between professionals is the force that enables the transfer of knowledge, and the development of scientific collaboration, and the College is an essential catalyst to drive these processes.

Why is research so important to the specialty? Radiology, or medical imaging in the broader sense, has become a very broad, horizontally integrated field, cross-linking with many, if not most other specialties in medicine. This is a great strength and offers wonderful opportunities for research. Conversely, the time is long gone that imaging could be considered the exclusive domain of radiology. Many of our clinical colleagues have discovered the potential of performing imaging-driven research and have learnt to explore the potential for using quantitative imaging biomarkers. We as radiologists are by no means any longer the sole custodians of imaging equipment or even of image analysis software. It is therefore of paramount

importance to teach (junior) radiologists how to conduct research, how to best interface with clinicians, and how to use software applications to extract information from the big data sets, which are the constituent parts of all cross-sectional imaging techniques. We must provide radiology excellence to the next generation, which can best be done through fostering research.

What is your vision for the CRRC and research at the College? With the CRRC, the College has an instrument to develop and steer the present and future course of our discipline. In my view, our plan should be to stimulate and foster excellence in research, and to enable the intellectual awakening of radiologists, by offering support and encouragement. But, our CRRC should be much more than just an instrument to select the best presentations and publications, or to award prizes and Fellowships. In my view, research is an essential component in the delivery of excellent patient-centred health care. Radiology is moving along a trajectory from an ‘art’ to a ‘science’, from producing ‘pretty images’ to quantitative data sets. Our communication with clinicians is moving away from descriptive reports in flowery prose, towards standardised, structured reporting. These developments will force radiologists to transmogrify their ‘analogue’ minds to the requirements of a digital, quantitative and researchdriven working environment. These changes are also reflected in the spectrum of what we do as radiologists: the focus has shifted away from performing brilliant feats of diagnostic wizardry to the more mundane tasks of accurately staging and following up patients with known diseases. continued over... Volume 16 No 4 I September 2020

Features

Thanks to advancements in medicine, some previously fatal diseases have been reduced to chronic conditions. The growth of precision medicine is likely to become a key issue in how we perform and interpret imaging studies. Radiology plays a much more important role in the diagnosis, follow-up and outcome prediction of patients with chronic disorders (all kinds of cancer, degenerative disorders, inflammatory diseases) by developing biomarkers based on volumetric measurements, perfusion studies (blood flow), spectroscopy (metabolic information), hybrid imaging (molecular information) and functional studies.

The future of medicine is researchdriven, and the engagement of radiologists will help us to grow, as individuals and as doctors. Ideally, through the CRRC, we can help to create and develop a culture so that radiologists can be a part of, or even take the lead in, imaging-driven research studies. Importantly, through research, we can attract the best and brightest young minds to our discipline, and offer them perspectives in academic and professional development.

The Royal Australian and New Zealand College of RadiologistsÂŽ The Faculty of Radiation Oncology

Inside News

We need to encourage an environment of innovation and improve the breadth and scope in the delivery of radiology services. This is essential to the future growth and success of radiology in the care for our patients.

Education

RANZCR Workshops, Courses and Events 2020–2021

As members are aware, the COVID-19 pandemic has had a significant impact on public health, social wellbeing and the economy. There has been widespread cancellation of conferences and meetings in line with current government guidelines. The College’s COVID-19 Taskforce and the Board of Directors have been monitoring the situation closely to foresee and mitigate any risks to members, staff and general community. Unfortunately, this has meant we have had to postpone some of our upcoming events. This has been done bearing in mind that social distancing restrictions may continue well into the end of this year with strict restrictions on international travel as well as mass gatherings.

RANZCR Webinar Series The Conferences and Events team are working on running a series of educational webinars in the coming months. If you would like to suggest a webinar topic, please don’t hesitate to email: events@ranzcr.edu.au

Confirmed topics and dates

ESTRO Radiobiology Course

Clinical Radiology Faculty Forum 8 October 6–7.30 pm AEDT

An introduction to radiation biology as applied to radiotherapy, focusing on technology, biology and molecular oncology. The ESTRO Radiobiology Course has been postponed to 15–18 April 2021. Trainees who have already registered and cannot attend the new dates will be issued a full refund.

Radiation Oncology Faculty Forum 9 October 2–3.30 pm AEDT Imaging Emergencies of the Vascular System 14 October 8–9 am AEDT To register and for further information please visit the Events Page on our website: www.ranzcr.com/whats-on/events

Further topics will be released shortly.

New Zealand Branch Annual Scientific Meeting The NZ ASM has been postponed to 6–8 August 2021, to be held at the InterContinental Hotel, Wellington.

If you have any questions relating to any College events please don’t hesitate to contact the Conferences and Events team at events@ranzcr.edu.au

RANZCR Annual Scientific Meeting The ASM has been postponed to 16–19 September 2021, to be held at the Melbourne Convention and Exhibition Centre. For more information on RANZCR2021 visit our website: www.ranzcr2021.com

Volume 16 No 4 I September 2020

Education

RANZCR Artificial Intelligence Kaggle Challenge The CLiP dataset will remain publicly available after the challenge to allow researchers to develop algorithms on the dataset and to allow for side-by-side evaluation of algorithms. The RANZCR Artificial Intelligence Competition Committee comprising of Dr Jennifer Tang, Dr Jarrel Seah, Mr Adil Zia and Professor Meng Law worked hard to develop and curate this dataset, along with the invaluable help of more than 40 volunteer radiology consultants, registrars and residents.

The College is launching its inaugural artificial intelligence (AI) challenge in November this yearâ€”the Catheter and Line Position (CLiP) challenge. As radiologists, we have a responsibility to ensure that artificial intelligence algorithms are suitable for clinical practice and hence must participate in their development rather than simply being end users. In hosting this challenge, we hope to bridge the divide that is sometimes present between engineers and clinicians and hope that this encourages engineers to work alongside radiologists to develop clinically useful AI algorithms which will enrich and grow our specialty.

Inside News

The competition will be open to researchers worldwide, challenging them to develop algorithms which can detect the presence and position of catheters demonstrated on chest radiographs. The CLiP dataset comprises more than 40,000 manually labelled and segmented chest radiographs from the publicly available National Institute of Health (NIH) ChestXRay14 dataset. Radiographs remain the gold standard for confirmation of line and tube position with correct catheter position crucial to ensuring appropriate function and avoiding complications.

â€œIn hosting this challenge, we hope to bridge the divide that is sometimes present between engineers and clinicians and hope that this encourages engineers to work alongside radiologists to develop clinically useful AI algorithms which will enrich and grow our specialty.â€? We would like to thank the volunteers for their efforts and contribution to the dataset. The dataset was developed using the MD.AI platform which is an online browser-based annotation interface.

Education

We would like to thank Dr George Shih and Dr Anouk Stein for allowing us to use the MD.AI platform and for their assistance throughout the dataset curation process. The challenge will be run on the Kaggle platform which is the premier data science and artificial intelligence competition host. Researchers competing in this challenge will have access to a training set and given a fixed timeframe to train and develop their algorithms which will then be validated on a test set. The results of the algorithm will be compared to the true annotations of the test dataset and the accuracy of their algorithm will then be calculated to determine the winners. Results will be announced in 2021 with the top submissions invited to present their work at the RANZCR2021 ASM, the winners and their solutions will be celebrated in the RANZCR artificial intelligence showcase. RANZCR AI Competition Committee @kaggle @MengLaw1

Volume 16 No 4 I September 2020

The Best Worklist is the One You Don’t Need to Look At Radiology Workflow at your Fingertips

Clario SmartWorklist™ offers a functionally-rich, vendor-neutral, zero-footprint worklist that aims to achieve worklist perfection for each individual radiologist in your imaging group. Designed with flexibility in mind, Clario SmartWorklist ensures the right radiologist is presented with the right case at the right time, regardless of the complexity or disparate nature of your environment. With the ability to launch over 50 other applications through highly tailored and dynamic worklists, Clario SmartWorklist can adapt to the unique needs of any enterprise. › Multiple-viewer support to integrate disparate medical image repositories › Auto-next reading mode radiologists can trust to present the most appropriate examination, without having to return to the worklist › Fully integrated and automated triage and clinical findings workflows with Odyssey™ and Odyssey Navigator™

› Automatic examination distribution based on real-time variables such as availability, subspecialty, workload, location and more › Dynamic worklist activations to automatically show and hide overflow worklists based on criteria-driven thresholds

To learn more or book a demo visit us at www.intelerad.com Australia: 1300 700 333 | New Zealand/International: +61 7 5452 9822 | sales@intelerad.com

Education

RANZCR2021 Elysium Diagnostics and Therapeutics (Now and in Future) with Artificial Intelligence Melbourne will host the College's 71st Annual Scientific Meeting: ‘Elysium Diagnostics and Therapeutics (Now and in Future) with Artificial Intelligence’ in September 2021 at the Melbourne Convention and Exhibition Centre. Not only does the meeting promise to deliver a thought provoking program, you will also have the opportunity to enjoy the cosmopolitan city of Melbourne. RANZCR2021 will showcase emerging trends in radiology and radiation oncology AI software and hardware; regulatory and industry perspectives; and the impact of AI on health care and patient outcomes. A varied and engaging range of international and national speakers and an interactive program will highlight the opportunities in radiology and radiation oncology in the future. There will be a series of multidisciplinary sessions to discuss current clinical topics, an increased number of international experts and collaboration with affiliated organisations to deliver captivating sessions. We are fortunate to have support from our global radiology partners to send world-renowned speakers to RANZCR2021. The RSNA are supporting a Thoracic AI speaker (TBD). The American Society of Neuroradiology (ASNR) are supporting legendary Anne Osborn and Ramon Gil Gonzalez. The European Society of Neuroradiology (ESNR) are supporting Majda Thurnher, Johan Van Goethem and Turgut Tali to speak at our meeting. There will also be speakers in other specialist areas including the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) and expert AI speakers.

An innovative radiation oncology program with a range of national and international speakers is planned. International speakers will cover a range of sites including: Fiona McDonald (Royal Marsden, lung and stereotactic radiotherapy and adaptive radiotherapy); Desiree van den Bongard (Amsterdam UMC, breast and oligometastic disease); Andrew Loblaw (University of Toronto, prostate and GU cancers); and Clifton David Fuller (MD Anderson, head and neck and functional imaging). In 2021 it is expected that there will be an ASTRO speaker who is generally the immediate past ASTRO president, an ESTRO leadership representative will also be in attendance.

The CLiP dataset comprises over 40,000 manually labelled and segmented chest radiographs from the publicly available National Institute of Health (NIH). These chest radiographs were curated by Dr Jennifer Tang, Dr Jarrel Seah, Mr Adil Zia and Professor Meng Law, with more than 40 volunteer radiology consultants, registrars and residents working hard to develop and label this dataset. We will shortly announce the prize money, sponsorship and launch date for this AI challenge. We believe developing an AI model to detect chest x-ray catheters is relevant in the ongoing global pandemic.

What’s new in 2021?

RANZCR2021 will feature the RANZCR Little Rascals Kids Club (on site creche facilities for your little ones) and Lunch and Learn Sessions (educational presentations hosted by a leader in the industry over lunch).

We are happy to welcome our first ever ASM presenting partner, Intelerad. A note from Intelerad: the College and Intelerad have a strong partnership that will emerge from the COVID-19 crisis stronger than ever. With the postponement of the Annual Scientific Meeting this year, Intelerad will proudly serve as a presenting partner of RANZCR2021. Our roots run deep in Australia and New Zealand. We’re energised and excited to be presenting partners of RANZCR2021. Through this partnership, we are reconfirming our ongoing commitment to the medical imaging and radiology community of Oceania. AI Kaggle Challenge: the College is launching its inaugural artificial intelligence (AI) Kaggle challenge in November this year: the Catheter and Line Position (CLiP) challenge. The competition will be open to researchers and “Kagglers” worldwide challenging them to develop algorithms which can detect the presence and position of catheters demonstrated on chest radiographs.

Winners will be invited to present at the ASM in Melbourne in 2021.

We look forward to hopefully all catching up face-to-face in Melbourne in 2021. Melbourne, Stay Strong! Prof Meng Law Clinical Radiology Convenor A/Prof Farshad Foroudi Radiation Oncology Convenor

Sponsorship opportunities: for the opportunity to sponsor the RANZCR Little Rascals Kids Club or Lunch and Learn Sessions plus many more opportunities, get in touch with the team at Encanta to tailor your package today at: ranzcr@encanta.com.au

Volume 16 No 4 I September 2020

Education

Work on Training and Assessment Reform Continuing! An Update on the Reforms 2020 is shaping up to be both an unpredictable and challenging year, however, one thing that has been constant during these uncertain times is the hard work and dedication both the Implementation Working Groups (IWGs) have been putting into the Training and Assessment Reform (TAR). Despite the COVID-19 related hiccups and subsequent TAR deferment, the TAR project has made reasonable progress over the last couple of months. Both IWGs have been busy refining the learning outcomes and assessment tools and facilitating training and communication activities to ensure we are well prepared when the enhanced training programs are introduced in 2022.

Stakeholder consultation In order to engage with both internal and external stakeholders and give our members an opportunity to provide input, we conducted a period of stakeholder consultation on the enhanced Radiation Oncology and Clinical Radiology Training Program and Learning Outcomes between June and August 2020. We would like to thank all members and stakeholders who provided their input on the training programs. Your feedback was greatly appreciated and valued. College staff have collated the feedback and the IWGs and other relevant committees are currently reviewing the feedback and will incorporate it where appropriate, to update and refine the training program and learning outcomes for both faculties.

Inside News

Key concepts underlying the training programs During the stakeholder consultation process, some members stated that they would like to learn more about the key concepts that underlie the enhanced training programs, especially constructive alignment, programmatic assessment and the entrustability scale.

â€œWe would like to thank all members and stakeholders who provided their input on the training programs. Your feedback was greatly appreciated and valued.â€? Constructive alignment Constructive alignment requires clear articulation of the learning outcomes of the training program while ensuring they are aligned with the teaching strategies, learning activities and assessment tasks. Within the training programs, we ensured constructive alignment by maintaining a balance between theory and practice and having a welldefined framework of assessments and examinations to evaluate the learning outcomes throughout the different phases.

Programmatic assessment Programmatic assessment is about having a holistic view of performance across multiple events. It recognises that competency develops over time, so assessment information is gathered progressively, with all available data assessed in measuring the achievement of learning outcomes. The foundation of programmatic assessment is based on assessment for learning (in addition to assessment of learning). Within the enhanced training program, we have ensured the use of programmatic assessment by developing several assessments that mirror the work activities that a radiation oncologist or clinical radiologist is expected to do on a daily basis (termed work-based assessments or WBAs). Through the use of WBAs, a detailed picture of the traineeâ€™s competencies develops. It allows assessment information to be collected progressively as a trainee progresses through each phase of training, taking into account all available data across a range of assessments and activities. This then allows decisions to be made about trainee competence based on aggregate information (from real-world assessments) rather than on high-stakes examinations alone. The WBAs also help to track the progression of a trainee in developing competencies in various areas and allows us to identify areas where the trainee is not progressing, so that appropriate support and remediation can be provided in a timely manner. One of the key success factors of WBAs is immediate constructive feedback and this needs to be recorded accordingly.

Education

Clinical Radiology Entrustability Scale The scale is based on the level of supervision the trainee requires.

Entrustability scale The concept of the â€˜entrustability scaleâ€™ is at the forefront of modern medical education theory and offers ongoing formative feedback and tracking of competency milestones based on realworld supervisory judgements. The entrustability scale reflects how ready the clinical supervisor feels the trainee is for independent clinical practice. The scale was incorporated into some of the work-based assessment tools for both specialties. The scale ranges from one (1) to four (4) to allow clinical supervisors to make judgements of competency based on the level of supervision or guidance a trainee requires when they are performing a task. It is expected for example, that in the early phases of training, a trainee will require more supervision and guidance from their clinical supervisor and will be operating at an entrustability level of 1 or 2. However, towards the final years of training and particularly before sitting the Phase 2 Examinations, it is expected that a trainee would require little to no supervision and guidance and hence be assessed as meeting entrustability level 3 or 4. The overall benchmark is a competent specialist who is capable of safe practice on their first day of independent practice.

Entrustability Level

Description

Example: Fluoroscopic Procedures Logbook

Level 1

Constant Direct Supervision Required

Procedure performed in conjunction with the consultant.

Level 2

Direct Supervision Required

Level 3

Minimal Direct Supervision Required

Level 4

Direct Supervision Not Required

Procedure performed by trainee and the consultant observes the performance. Procedure performed by trainee and there is direct and timely access to a consultant. Procedure performed by trainee and the consultant is available if needed. Capable of independent practice.

Radiation Oncology Entrustability Scale The scale is based on the level of guidance the trainee requires. Entrustability Scale

Description

Level 1

Direct Input Required

Level 2

Substantial Guidance Required

Level 3

Some Guidance Required

Example: Contouring and Plan Evaluation Tool (CPET) Required direct instructions and inputs to fill knowledge gaps or deliver effective treatment. Required substantial guidance to complete. Major corrections needed in order to deliver effective treatment. Required minimal supervision, but some guidance. Minor corrections needed to proposed treatment. Did not require guidance or support.

Level 4

Competent

Any suggestions for improvement had no significant impact on proposed treatment. Capable of independent practice.

Volume 16 No 4 I September 2020

Education

Terminology changes There have been some terminology changes under the enhanced training programs. These changes have been made to better reflect current medical education and learning practices. Curriculum to Learning outcomes The shift in terminology from ‘curriculum’ to ‘learning outcomes’ streamlines the alignment between the learning content, teaching strategies, assessment tools and what trainees need to demonstrate to prove that they are a competent radiation oncologist or clinical radiologist. The term curriculum does not portray this alignment well. Learning outcomes are statements that describe the knowledge, competencies and skills trainees should acquire by the end of the training program. Curriculum on the other hand refers to a syllabus or outline of the training program as a whole, rather than focusing on individual competencies or skills. Non-medical expert roles to Intrinsic roles The shift in terminology from ‘Nonmedical expert roles’ to ‘Intrinsic roles’ has been made to incorporate changes made to the CanMEDS framework in 2015, upon which the roles are based. This shift aims to establish defined milestones that incorporate various competencies together to support holistic professional development at every stage of the training program. We recognise the importance of emphasising intrinsic roles and have continued to be guided by the CanMEDS framework, incorporating the roles of Communicator, Collaborator, Leader, Health Advocate, Scholar and Professional into the enhanced training programs. Trainees must develop the skills and competencies that combine their role as a medical expert with the intrinsic roles to be able to provide high quality care.

Inside News

Clinical Radiology Part 1/Part 2 Examinations to Clinical Radiology Phase 1/Phase 2 Examinations In order to better align with the different phases of the Clinical Radiology Training Program, and add consistency between the training programs for both specialties, there has been a shift in terminology of the Clinical Radiology Examinations from ‘Part 1/ Part 2 Examinations’ to ‘Phase 1/Phase 2 Examinations’.

“Through the use of WBAs, a detailed picture of the trainee’s competencies develops. It allows assessment information to be collected progressively as a trainee progresses through each phase of training, taking into account all available data across a range of assessments and activities.” Keeping your training records up-to-date IT infrastructure is critical to the success of the delivery of the enhanced training programs. The Trainee Information Management System (TIMS) will be replaced by a new fit-for-purpose Training e-Portfolio System to support the delivery of the enhanced training programs, measure identified outcomes and allow tracking of trainee progression.

To expedite the transition from TIMS to the new system, all trainees are asked to keep their relevant information and records under the current training programs up-to-date in TIMS, including details of training status, rotation, training requirements, logbooks and work-based assessments. This will ensure that the data being transferred to the e-Portfolio system is as accurate as possible. The existing training programs will continue throughout 2020 and 2021, notwithstanding the temporary arrangements related to the pandemic and its aftermath. Trainees are required to complete and record all the assessments and training requirements under the current training programs.

Stay informed and involved It is important that you read information and keep abreast of changes shared with you through College communication channels, including the College website, e-newsletters, printed newsletters and direct correspondence. We would like to thank all members who have contributed their time and expertise to this important project.

If you would like more information or have any questions regarding the project, please visit the TAR webpage on www.ranzcr.edu.au/tar or contact Faeha Tashkeel, Project Officer, Training and Assessment Reform on faeha.tashkeel@ranzcr.edu.au

Education

Improving Cancer Outcomes for New Zealanders Earlier this year the New Zealand Government released the New Zealand Cancer Action Plan 2019–2020, with a view to providing a pathway to improve cancer outcomes for all New Zealanders. The plan recognises the importance of cancer care across the whole healthcare system. The Cancer Control Agency has responsibility for implementing the plan and will have a wide scope to prioritise and action it. New Zealand representative on the Targeting Cancer Management Committee, Dr Ramesh Pandey said, “Successful delivery of the plan will depend on increasing radiation oncology workforce capacity, further investment in technology and clear national leadership. We know that around 22,000 people will be diagnosed with cancer this year and that number will likely increase with the ageing population. Given this, it will be vital to ensure that suitable workforce planning, infrastructure and training measures within radiation oncology are put in place.” Following the 2019 Horizon Summit, it was pleasing to see a multi-million dollar commitment to radiation oncology, with the Government announcing the replacement of 12 linac machines across New Zealand. The first replacement linac was officially opened in Palmerston North in July 2020. While this is a welcome first step, the College continues to advocate for additional machines and facilities closer to patients to ensure equitable access to radiation services that can meet the increasing need. Dr Pandey said that it will be critically important to complete workforce planning to address current shortages and meet demand. “Demand and workforce modelling shared by Health Workforce and the Cancer Control Agency demonstrates that there is a need to train more radiation oncologists,” said Dr Pandey.

“It will be important to develop career pathways and a retention scheme to ensure a sustainable workforce is available to provide quality cancer care right across New Zealand, now and into the future. We look forward to continuing to work with the government and Cancer Control Agency to ensure all New Zealanders have access to radiation therapy.”

Cancer Council Australia resources for medical students Cancer Council Australia has developed a web book aimed at providing an overview of the principles of cancer care for medical students. Clinical Oncology for Medical Students was developed by the oncology education committee of Cancer Council Australia, with contributions from universities and cancer centres across Australia and New Zealand. To access the web book, visit the Cancer Council Australia website at www.wiki.cancer.org.au/ oncologyformedicalstudents/ Clinical_ Oncology_for_Medical_ Students

Building on these findings, an Australian-developed technology for targeting cancer continuously during treatments was investigated in a multi-centre prostate cancer trial. Continuously targeting cancer enabled shorter and more accurate treatments. This second study found that targeting cancer continuously ensured higher radiation target dose to the cancer target2. New information image-guided radiation therapy (IGRT), stereotactic body radiation therapy (SBRT), intensitymodulated radiation therapy (IMRT) and brachytherapy for prostate cancer is now available online. Information on symptoms, treatment options, the role of radiation therapy and potential side effects has been updated for the following cancer types: • Breast cancer • Lymphoma • Skin cancer • Bladder cancer • Prostate cancer. Thanks must be extended to the Targeting Cancer Management Committee and Targeting Cancer Reference Panel for their time and effort to review the website pages.

Sharing the latest advancements and information with patients Over the past few months, Targeting Cancer has been updating the information and resources available on the website to ensure it remains a contemporary and trusted source of information for health professionals and those touched by cancer, now or in the future. Notable new research findings have been included to the site, including a randomised trial of targeting daily compared with targeting weekly when treating prostate cancer1. The study found that targeting cancer daily significantly improves tumour control and reduces rectal toxicity.

References 1. de Crevoisier R, Bayar MA, Pommier P, Muracciole X, Pêne F, Dudouet P, Latorzeff I, Beckendorf V, Bachaud JM, Laplanche A, Supiot S. Daily versus weekly prostate cancer image guided radiation therapy: phase 3 multicenter randomized trial. International Journal of Radiation Oncology* Biology* Physics. 2018 Dec 1;102(5):1420-9. 2. Keall P, Nguyen DT, O’Brien R, Hewson E, Ball H, Poulsen P, Booth J, Greer P, Hunter P, Wilton L, Bromley R. Real-Time Image-Guided Ablative Prostate Cancer Radiation Therapy: Results from the TROG 15.01 SPARK Trial. International Journal of Radiation Oncology* Biology* Physics. 2020 Mar 29.

Volume 16 No 4 I September 2020

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Clinical Radiology

Our Continued Progress in 2020 A Message from the Dean

Clin A/Prof Sanjay Jeganathan Nelson Mandela said part of being optimistic is keeping oneâ€™s head pointed towards the sun, oneâ€™s feet moving forward. In the middle of this pandemic when optimism can be hard to find, I am very pleased that we at the College have kept our heads pointed towards the sun and made great progress on several key issues of strategic importance to the future of our profession.

Artificial intelligence Members regularly talk to me of their concerns about how AI is being incorporated into radiology practice. It is clear to all of us that AI will reshape the future of radiology. The Artificial Intelligence Committee under the Chair of Professor Liz Kenny has been working tirelessly to get our College to a great start. We have been pro-active in positioning ourselves as a leading player in the application of AI in health care. Leading gives us the best opportunity to ensure that AI is implemented in a way that enhances patient care and avoids the risks that are already apparent to us all. One of our key roles as a peak body is to set standards which benchmark safe and high-quality practice. From this perspective our first step for AI was to establish an ethical framework for its application, which was achieved last year with the publication of Ethical Principles for Artificial Intelligence in Medicine. The College was a world leader as one of the first medical organisations to publish such ethical principles. Based on the ethical principles the AI Committee has developed standards

of practice for AI, which have recently been published. These standards of practice provide greater detail to guide the development, deployment and monitoring of AI in radiology. Further, the standards will inform governments, regulators and others when they are faced with decisions on the application of AI. We will continue our advocacy with the governments of both New Zealand and Australia to ensure that appropriate regulations are developed to ensure the safe and appropriate use of AI in medicine.

Digital health Radiology went digital over two decades ago. Image sharing and reporting across hospital and practice boundaries has been possible in our sector for years. Regrettably, the transfer of clinical information from referrer to clinical radiologist remains mired in 20th century technologies. The lack of true digital connectivity means we only have access to patchy historical information about patients, thereby hampering our clinical role The Faculty has recently published a white paper for consultation titled Towards Interoperability: Clinical Radiology Forging the Path Ahead, A Vision for Clinical Radiology in the World of Digital Health. This paper sets out our vision for a future that harnesses the true potential of digital health providing a seamless and secure communications flow of patient information between clinical radiology and the rest of the healthcare system. Our five priorities for digital health are clearly explained in the

document. The priorities are eReferral, radiology request set (a terminology catalogue), systemised access to historic images, imaging guidelines, and preparing the ground for artificial intelligence. A Digital Health Working Group has recently been formed to carry this important work forward. Please take some time to read the paper and provide feedback. As a membership-based organisation, we need to harness the knowledge and expertise of our members to drive positive development.

Interventional Radiology The Interventional Radiology Committee (IRC) has begun an exciting new piece of work to develop a contemporary post-Fellowship training program for interventional radiology and interventional neuroradiology that meets the Medical Council of Australia and Medical Council of New Zealandâ€™s requirements for speciality recognition. The IRC will draw on the expertise of a medical educationalist and collaborate with both the Interventional Radiology Society of Australasia (IRSA) and the Australian and New Zealand Society of Neuroradiology. This is a groundbreaking initiative for our College and it will take a few years to achieve our stated goal. I look forward to providing updates to you on the progress of this work. Despite all the challenges that COVID-19 has imposed upon us we are keeping our feet moving forward and progressing the important work of the College.

Volume 16 No 4 I September 2020

Clinical Radiology

The College’s Training Program 2020 Chief Censor in Clinical Radiology

Dr Meredith Thomas

In considering what I would write for this report, I looked back on the Inside News report that I drafted in mid-February. At that time, we could all move freely and unrestricted about our daily lives and the Specialty Training Unit (STU) was very focused on implementation of our Training and Assessment Reforms (TAR), with frequent meetings and a planned roadshow in Australia and New Zealand to educate trainees and trainers about the planned changes. By the time Inside News went to print in March however we had an early recognition of the impending disruption, not only to the TAR, but to the way we conduct our training and our assessments, and our daily STU business. In mid-February, the “novel coronavirus” had just been renamed COVID-19. Global case numbers were approaching 4,500, with Australia having recorded its first case in late January, the USA and UK yet to record cases and only a handful of cases in Europe. While Australia declared a pandemic two weeks later on 27 February, a global pandemic was not declared until almost a month later, on 11 March, by which time global cases had reached almost 100,000. How things have changed. Today, in early August, global case numbers are approaching 19 million, with in excess of 700,000 deaths. Australia has had approximately 20,000 cases, with 260 deaths, and daily cases numbers up to 700+. While some jurisdictions have avoided escalating case numbers, our Victorian colleagues are again under “lockdown” and other states are winding up restrictions and border

Inside News

closures to limit the spread of the disease, with increasing anxiety in the health sector regarding personal protection for health practitioners and system capacity. The uncertainty of this pandemic is such that no-one can envisage how things will look by September when this is printed. What does this mean for our training program? The broader changes have been well communicated and are likely well recognised. Implementation of TAR has been pushed back by 12 months, now planned for 2022, with Phase 1 examinations to change in 2022 and Phase 2 in 2023. The delay has allowed for longer consultation periods, recognising and accommodating for distractions and disruptions to usual practice for our stakeholders, and our planned educational “roadshow” will become a virtual one, with online meetings and information webinars. After cancellation of the Series 1 examinations, we are all very pleased that Series 2 examination dates have been announced. I would like to personally thank everyone who has been, and will be, involved in the organisation and running of these examinations. Jurisdictional restrictions on gatherings and travel mean the examinations cannot be “as usual”, and they will be run locally, supervised and organised by the local Branches with central secretariat support. Anyone who was involved with the exam

options discussions will recognise the tremendous amount of work involved. Thanks to all secretariat, Branch Education Officers (BEOs), Network Training Directors (NTDs), members of Clinical Radiology Examination Review Panel (CRERP), Clinical Radiology Education and Training Committee (CRETC), Faculty Council and the Board who have contributed, particularly those who have dealt so calmly with the associated frustrations and anxieties. Training department disruptions have been variable in degree and duration, and the Directors of Training are to be commended in the way they have accommodated these disruptions, rapidly transitioning their educational activities onto online forums, while ensuring that day-to-day training activities and supervision are maintained. Particular commendation to all the new DoTs who have taken up positions during the most challenging times for specialty medical training. Supervised reporting from home remains an option for trainees where it can be accommodated by the training site, to optimise flexibility, trainee safety and well-being. Accreditation processes remain disrupted, with physical accreditation visits on hold. The accreditation team remain in close contact with the sites and networks and continue to work with them and the health jurisdictions to ensure that training standards are upheld, particularly in sites recognised as being at risk.

Clinical Radiology

International Medical Graduate interviews have been transitioned to a virtual format to allow assessments to continue despite travel restrictions. Those deemed partially comparable and eligible to sit the Part 2 examinations who are residing in Australia or New Zealand will be able to present for the Series 2 2020 examinations in their local jurisdictions. There are other STU disruptions that are not as well recognised. Our secretariat staff have been working from home since March, and while this affords protection by reducing potential exposure, Iâ€™m sure it brings with it many challenges, particularly the social isolation for those who live alone, possibly a long way from family, and the difficulties associated with childcare and home schooling. We are mostly social animals, and the reduction in social interaction with peers and friends can create its own challenges. While Teams and Zoom and Skype can

facilitate work and decision-making, they cannot replace the camaraderie and collaborative outcomes that face-to-face interaction promotes. Our trainees have had to deal with unprecedent disruptions to their training, many maintaining â€œexam readinessâ€? while also dealing with personal disruptions. Many are training away from home and are unable to be with their families. Many have children whose schooling has been interrupted, some required to home school. Weddings have been delayed, babies born without anticipated family support, and holidays cancelled. Family members may have lost jobs, with the associated financial stressors. Again, I would encourage you to be alert to signs of distress in your friends and peers, and to look out for each other. Please contact the Trainee Liaison Officer Senice So via senice.so@ranzcr.edu.au or 0437 893 913 if you would like to discuss any issues or concerns.

On a personal level, I now have in excess of 20 COVID-19 related email folders and, like so many others, I am continually considering workarounds, alternative options and innovative solutions to newly identified challenges, recognising that these solutions will likely have long-lasting impacts on the way we teach, assess and undertake our daily business. Like most, I have an unhealthy obsession with COVID-19 related news but recognise the pessimism that brings. On a positive note, my sourdough is pretty good, the family unit is strong, the dog is happy, all relatives (and some friends) are stocked with knitted beanies, scarves and jumpers, and crocheted rugs are back in fashion. If you have any questions or comments about this article please contact Legend Lee, Manager, Training Programs, on radtaa@ranzcr.edu.au

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Volume 16 No 4 I September 2020

Advertorial

Varian’s HyperArc Proves Itself in Study after Study: A Brief Survey of Recent Literature CyberKnife and HyperArc plans showed no statistically significant dosimetric differences. The study concluded that HyperArc-based SRS plans were comparable to CyberKnife plans dosimetrically. However, the average CyberKnife treatment time was 113 minutes versus an estimate of 9 minutes for HyperArc.

HyperArc stands up to Gamma Knife with shorter delivery time for comparable plans

When a new treatment technology comes on the scene, clinicians naturally want to be assured that it meets or exceeds the performance of established and familiar ones. Since Varian’s HyperArc® high-definition radiotherapy was introduced in 2016, at least 80 centres have delivered HyperArc treatments for thousands of patients. From those centres at least 14 independently conducted studies have demonstrated that HyperArc can be used with confidence for stereotactic radiosurgery (SRS). HyperArc plans for delivery on Edge® or TrueBeam® systems are comparable to plans for other SRS approaches, often with significant benefits in delivery time. This review highlights some of these studies.

According to an evaluation by Vergalasova et al2, whose multiinstitutional study looked at 16 patients with 112 metastases, HyperArc and Gamma Knife® both produced clinically acceptable plans with only one significant difference. For targets of 1 cm or less, conformity and whole brain dose were comparable, with a slightly lower gradient index for Gamma Knife. On the other hand, for targets larger than 1 cm, HyperArc had superior conformity. Comparing beam-on times, Gamma Knife was 140 ± 24 minutes while HyperArc was 4.8 ±0.89 minutes. In short, the study showed that HyperArcVMAT is “capable of achieving similar low-dose brain spillage and conformity as Gamma Knife, while significantly minimising beam-on time.”

HyperArc plans are comparable to other linac-based mono-isocenter techniques In a study of 20 patients with multiple brain metastases, Ruggieri et al3 found that mono-isocenter HyperArc plans achieved a higher CI and lower GI than standard multi-isocenter VMAT plans. Additionally, HyperArc performed well among other monoisocenter techniques with non-coplanar arcs. As an example, another study by Ruggieri et al4 compared HyperArc plans to Brainlab’s Multiple Brain Mets Elements (MBME), a dynamic conformal arc technique. CI was significantly improved for HyperArc vs MBME: 0.94 vs 0.75 and V12 was lower for HyperArc compared to MBME: 23.7 vs 37.3 cm3. So while the authors concluded that dosimetric consistency and plan quality were satisfactory for both techniques, HyperArc achieved near-equal plan quality based on key indices. In conclusion, these and other studies suggest that HyperArc is clinically comparable to other SRS techniques in use today, with some distinct advantages.

HyperArc & CyberKnife: Small differences in plan quality; big differences in efficiency Several studies evaluated HyperArc and CyberKnife® plans side-by-side. Kadoya et al1 compared HyperArc and CyberKnife SRS plans for multiple cranial metastases. Eleven patients treated with CyberKnife were replanned with HyperArc for SRS on the TrueBeam STx. Blind scoring of

Inside News

References 1 Kadoya N et al. Automated noncoplanar treatment planning strategy in stereotactic radiosurgery of multiple cranial metastases: HyperArc and CyberKnife dose distributions. Med Dosim. 2019 Winter;44(4):394-400. 2 Vergalasova I et al. Multi-Institutional Dosimetric Evaluation of Modern Day Stereotactic Radiosurgery (SRS) Treatment Options for Multiple Brain Metastases. Front Oncol. 2019 Jun 7;9:483.

Clinical Radiology

Chief of Professional Practice Update

A/Prof Dinesh Varma As the year has continued in a state of ‘new normal’, the Professional Practice Committee (PPC) has continued with their planned work for the year. The key piece of work that is currently underway and pieces of work that have recently been finalised include:

Revalidation and recertification As many of you are aware, the Medical Board of Australia (MBA) and the Medical Council of New Zealand (MCNZ) are introducing changes to medical licensing requirements as related to ongoing recertification. This will greatly change the CPD program currently run by the College and is a big focus for the PPC. Members on the Committee are committed to ensuring a smooth transition to the new program, working with the recommendations provided by the MBA and MCNZ. The new program is expected to commence after the current triennium, in January of 2022. I strongly encourage all members to read the College resources on this change found on the College website under www.ranzcr.com/fellows/general/ changes-to-cpd-requirements

Changes to CPD requirements The PPC at its most recent meeting constituted a small group to revise and update the CPD handbook to align it with the changes proposed by MBA. We hope to have this finalised before the proposed changes are implemented.

Certificate pathways in cardiac MRI

2020 CPD exemptions due to COVID-19

Early in the year, I was pleased to represent the PPC at a meeting between the Cardiac Society of Australia and New Zealand (CSANZ) and the College to finalise the initial pathway and maintenance of recognition pathway for members to attain certification in cardiac MRI. The meeting was highly successful, resulting in an agreement on a position statement and a stronger relationship between the College and CSANZ.

Just a reminder that due to COVID-19 both the Medical Council of New Zealand (MCNZ) and the Medical Board of Australia (MBA) have acknowledged that the COVID-19 work will impact on the ability of all doctors to maintain CPD requirements in the coming months.

The initial pathway and maintenance of recognition pathway have been outlined in the position statement, which underwent external review by way of membership consultation with College members in 2018 and was approved by the Faculty Council of Radiology and the CSANZ Board in February 2020. The Conjoint Committee for Cardiac MRI, comprised of members from both the College and CSANZ with an active interest in supervising and reporting cardiac MRI scans, is now able to start taking initial applications. The College would like to invite those who provide cardiac MRI services to submit their applications. The application forms and the position statement can be found on the College website: www.ranzcr.com/fellows/ clinicalradiology/quality-assuranceandaccreditation/certification-incardiac-mri

As a result, the College has revised the CPD requirements for the 2019–2021 triennium with clinical radiology members only requiring a total of 125 points required for the triennium (usually 180 points). There are no minimum annual requirements for CPD points to be met in 2020 or 2021. If you have any questions about the revised CPD requirements for 2020, please contact the team via cpd@ranzcr.edu.au. In closing, if you have any questions regarding the work of the Professional Practice Committee please get in touch via professionalpractice@ranzcr.edu.au. I would like to extend my best wishes to everyone and hope that yourself and your families remain safe during these times. I am confident we will come out of this in a stronger way and hopefully learn to live a new normal and more meaningful life. Yours sincerely, Dinesh A/Prof Dinesh Varma Chief of Professional Practice Faculty of Clinical Radiology

Volume 16 No 4 I September 2020

Clinical Radiology

Clinical Radiology Trainee Matters

From a trainee’s perspective, I would encourage you to keep the following points in mind: • Examinations will be as close to the typical format as possible, so study and prepare the content as usual. • Updates and changes may come as the level of restrictions changes in each local area. As outlined in the email update from the Chief Censor, a contingency plan exists should an area be under high-level restrictions. Please check your email frequently so you do not miss an announcement. Dr Matthew Lukies Alfred Health

As much of Australia and New Zealand goes through the cold winter months, we are used to hearing about seasonal influenza and its often sizable seasonal impact—and being jealous of the warm northern states we all wish we could holiday in right now. Instead, the news across the globe has been dominated by a once-in-100-year pandemic. With promising vaccine trials underway and many brilliant scientific minds around the world working hard to develop treatments, perhaps a future where COVID-19 is low risk and manageable is not too far away. The College has now announced examination dates and formats for October and November this year. This will be a welcome relief for many of you, who have had disruption to your progress over the last six months by the cancellation of the first sitting this year. A lot of work has gone into ensuring these examinations are deliverable in the current climate of an evolving pandemic and changing restrictions by state and even micro-jurisdiction in some areas.

Inside News

• Directors of Training and the Branch Education Officer in your local area will be closely involved in the delivery of examinations this year, so please check for their instructions and announcements. • Given the disruptions this year, unsuccessful candidates in the October/November 2020 sitting will be automatically granted an additional attempt (that is, this sitting will not accrue towards the maximum of four allowable attempts). This is an extension of goodwill in acknowledgement of the interruptions, changes in work and study environment and personal stress that have affected all trainees this year. Please also keep in mind that the typical outcome of successful applications for special consideration in examinations is granting of an additional attempt, which is being granted automatically in this case. If you have any questions, I encourage you to speak to your Director of Training or contact the trainee committee at the email below.

Finally, with all the damage done to the bottom line of many public and private hospitals and radiology practices, make sure you don’t take shortcuts on your own personal protection. Much like your parents, we would love to hear from you more often! Please feel free to email the Clinical Radiology Trainee Committee (CRTC) at clinicalradtc@gmail.com with your thoughts, questions, and feedback. Dr Matthew Lukies Chair, CRTC 2020 @matt_lukies

News

Obituary Dr David Green 22/07/1923 to 10/07/2020

Dr David Green was the head of Radiation Oncology at the Royal Prince Alfred Hospital in Sydney and the Chief Censor for Radiation Oncology until 1985. His career spanned the first megavoltage era of radiation oncology and he made a significant contribution to the high standard of clinical practice in Australia and New Zealand. Dr Green joined the Department of Radiation Oncology at Royal Prince Alfred Hospital in 1958 to guide the transition from deep X-ray therapy and Radium based brachytherapy to megavoltage teletherapy with the opening of Sydney’s first Cobalt units. Dr Green’s appointment followed a most auspicious predecessor, Dr (later Sir) Brian Wyndeyer, Sydney’s first radium registrar. The RPA machine, funded by the New South Wales Cancer Council, was hastily installed in a converted Scott’s Pie factory (that remains as the central core of the current department) complemented a second at St Vincent’s hospital, funded by a public appeal. The Health Ministry of the time had delayed the installation of the Cobalt machine because ‘the cure for cancer was just around the corner’—hormone therapy. A recurring theme in Australia. Dr Green’s breadth of knowledge, huge clinical experience, and firm opinion gained him the respect of his clinical colleagues, and contributed to the incorporation of radiation therapy into contemporary multidisciplinary cancer care. He had particular interests in gynecological cancers and paediatrics.

He always had the largest list of patients on treatment. The new RPA department consolidated with superficial and deep X-ray units moved from the main hospital, and supported the Radium clinic (by then moved to King George V hospital). Dr Green oversaw the installation of a second Cobalt unit in 1969, and in the evolution to the linear accelerator era, purchased the first Varian Clinac 800 in 1981. Dr Green worked to update the technical base of radiotherapy at RPA. He oversaw the introduction of a simulator to replace a C-arm image intensifier and the transition from Radium to remote afterloader using High Dose Rate Cobalt. Dr Green remained as head of department until his retirement in 1988. Under his leadership, activity increased year on year, with the RPA department consistently one of NSW's busiest departments. He and his colleagues, Dr John Donovan and Dr Peter Duval provided outreach clinics at Parramatta and Newcastle until departments opened at Westmead and Newcastle. In 1968, Dr Kaye Scott resigned as Warden of College but continued as Senior Examiner of Radiotherapy, as it was then called. The exact date he retired as Senior Examiner is unclear but David presumably took the position at Kaye Scott’s instigation circa 1970, continuing until 1985. Because of the small number of examinees, sometimes one but more often two or three, David felt maintenance of standards and consistency would more likely be

achieved with a designate Coexaminer, Robert (Nobby) Bourne, with Observers (future Coexaminer) as needed. If there was a candidate in New Zealand, David attended there with a New Zealander as Coexaminer. His trainees always felt very fortunate that David trained them. His experience as a GP before doing radiotherapy gave him a broad practical medical knowledge. In that era, most radiation oncology trainees read the text book, learned what their mentors did and copied them. He was chief examiner and didn’t like it but said that if a candidate was asked why they were using a particular technique or dose the answer “because that’s what we do at our institution” had to be accepted. David encouraged his trainees to read the literature and look for evidence and was well ahead of his time in that regard. Dr Green enjoyed a well-earned, gracious retirement of travel and his beloved garden with his life partner Ross Barlow. He was a loved and cherished uncle and friend to many. He will be remembered as an outstanding clinician who made a major contribution to cancer management through his leadership in the clinic and in setting a high standard of practice in radiation oncology in Australia and New Zealand.

Volume 16 No 4 I September 2020

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Radiation Oncology

Influencing the Future of Our Specialty A Message from the Dean

Dr Madhavi Chilkuri When I last wrote my message for Inside News, I commented ‘These are interesting times we are living in….’. In my last message no one could have imagined that the pandemic would have had the impact it has had on Victorians in particular. Our thoughts continue to be especially with candidates in Victoria as they prepare for their examinations in the midst of the COVID-19 second wave and the ongoing challenges of being in isolation for substantial periods during the year. I am pleased, however, that in the midst of all that is happening around us, the College has kept on track with our stakeholder engagement to continue shaping our specialty.

Hypofractionation The Faculty of Radiation Oncology recently had the opportunity to provide feedback to the Department of Health in relation to the use of hypofractionation in radiation therapy. We were given to understand that concerns were raised with the Department that hypofractionated treatments implemented by practices in the context of the pandemic may not revert back. As we all know, the pandemic has placed increasing focus on hypofractionation as one of the risk mitigation strategies. It has driven evidence-based protocols to be developed nationally and internationally for safe continuity of cancer care. At least some of these fractionations were already becoming the standard of care. As clinicians, we have seen the landscape of radiation therapy change

rapidly. While the move towards hypofractionation has been facilitated by advances in technology, techniques and tumour imaging enabling precision, accuracy and safe delivery of treatment, this has also brought additional resourcing requirements. The implication of this on patterns of practice, clinical workflows, patient outcomes, and funding policies will continue to emerge. Moving forward, the College is committed to working with the Department to ensure that there is neither incentive nor disincentive for moving to more hypofractionated radiation therapy where appropriate. The Faculty will also continue to actively engage with key stakeholders and government about these important matters.

Review of the Radiation Oncology Health Program Grants Scheme (ROHPG) The Federal Government’s Radiation Oncology Health Program Grants (ROHPG) scheme provides a contribution towards the capital cost of eligible radiation therapy equipment at approved health facilities. In 2017, the Commonwealth Department of Health implemented revised arrangements for the administration of the ROHPG scheme with a commitment to review the Scheme before 30 June 2021. The Department will shortly commence this review to assess the effectiveness of the Scheme. The Department has engaged Healthcare Management Advisors Pty Ltd (HMA) to conduct the review and to further inform its

objectives. The College will provide a submission and is very keen to get your feedback on any issues encountered with the scheme or difficulties encountered from the removal from this current scheme of many items apart from linacs.

Radiation Oncology Roundtable For those who are familiar with the outcome of the last ROHPG review, you will remember that it led to some unfavourable changes. The College was concerned with inadequate consultation during the review and recognised that there was a lack of regular dialogue with the government about issues relating to our sector. Following our discussions with the health minister’s office, from 2017 the Department of Health established the Radiation Oncology Roundtable, hosting it twice a year. It provides professions within our sector opportunities to share and discuss issues of importance with the Department. The pandemic has not allowed a meeting this year, but we have been having regular teleconferences with the Department to discuss matters relating to regional facilities, workforce, MBS review, Medical Treatment Overseas Program, and proton therapy. The MBS review has reached its next stage with the data collection for modelling scheduled to start in September/ October 2020. The data collection will occur over several months. continued over...

Volume 16 No 4 I September 2020

Radiation Oncology

A number of people continue to put in considerable work to assist this important work and I express my sincere thanks and appreciation for their dedicated work.

Medical Services Advisory Committee (MSAC) applications and Proton Therapy In 2018, the Department of Health submitted an MSAC application to support funding arrangements for proton therapy at a centre announced by the federal government to be established in Adelaide. There is currently no proton therapy facility in Australia until the South Australian proton therapy facility becomes operational, planned at this stage to be in 2023. There is no mechanism for private or public funding of proton therapy in Australia. Currently, patients can only be funded to travel overseas for proton therapy through the Medical Treatment Overseas Program. The Department of Health MSAC application submitted in 2018 was not supported and the outcome was made publicly available in 2020. Following this outcome, the South Australian

Health and Medical Research Institute (SAHMRI) submitted an amended MSAC application for proton beam therapy for paediatric and rare cancers. The Department has approached the College recently as part of a targeted consultation for the SAHMRI MSAC application and a response is being developed. Public funding is central to ensuring patient access to proton therapy in Australia. We met with the Department to discuss our concerns and will continue to strongly advocate for nationally coordinated planning for proton therapy in Australia.

Medical Services Advisory Committee Technical Guidelines Review The Department of Health has commenced a review of the Medical Services Advisory Committee technical guidelines to ensure assessment processes are aligned with best practice in Health Technology Assessment for therapeutic and investigative medical technologies and services. The updated guidelines will provide guidance for newer technologies, including genetic testing for heritable diseases and other screening tests. An external contractor,

Adelaide Health Technology Assessment (AHTA), has been tasked to review and develop draft TG and IG guidelines for consultation. Stakeholders will have the opportunity to engage with (and provide comments on) these draft guidelines during the call for public submissions. Notification of the call for submissions will be placed on the MSAC website: www.msac.gov.au/internet/msac The College recognises the challenges of the MSAC process with new technology assessment and will make a submission. As I close, I would like to thank everyone for keeping safety of patients and staff central during these challenging times while ensuring continuity of service. I take pride at the way our profession has maintained our high patient care focus especially for those patients living near borders and proactively managing their care arrangements. If you have any questions or comments about this article, please contact the Dean via faculty@ranzcr.edu.au

COVID-19 UPDATE: Find the latest advice in relation to the impact of the COVID-19 outbreak on College activities at www.ranzcr.com/our-work/coronavirus

Inside News

Radiation Oncology

Developments in Radiation Oncology Training Chief Censor in Radiation Oncology Dr Yaw Chin

As I write this report, I hark back to the quote by the American mathematician, John Allen Paulos: “Uncertainty is the only certainty there is and knowing how to live with insecurity is the only security.” It would seem that this quote is never more relevant than the present time when just as we were acclimatising ourselves to the easing of social restrictions in this country, we are now faced with Stage 4 restrictions being enforced in metropolitan Melbourne. Similarly, all facets of education and training for the Faculty continue to be affected by the COVID-19 global plight as we are all forced to manage and adapt to its constantly changing landscape. The angst and apprehension experienced by many of our trainees in relation to the examinations has been obvious and keenly felt by all of us who are heavily invested in their future. The uncertainties of timing, logistics and format of delivery of the examinations that we have been struggling with however, interestingly stems from the stipulation in the overarching priorities and principles document that the resumption of safe delivery of examinations is a priority of the College. In order to achieve this priority before the end of the year, risk mitigations strategies are needed to be conceptualised and implemented to account for the various different scenarios that may emerge as the COVID-19 situation continues to shift and change.

and appreciation to Dr Sean Brennan, as Chief of Examinations, and his examination team for their willingness to deal with and adapt to the rapidly changing requirements that have been asked of them. Following extensive deliberations and stakeholder consultations, the College Board has approved the planned delivery of the examinations in a modified format for this year only and this has been articulated by myself in an earlier communication. The planned examination dates have now been determined to be as follows: • Phase 1 – 16 October 2020 • Phase 2 (Writtens) – 26 and 27 October 2020 • Phase 2 (Vivas) – 9–11 December 2020. The format of the written examinations is to remain as per previous years in a paper-based format. Details for the Phase 2 for the Phase 2 Vivas are still being worked out due to the required modifications for the conduct and marking of the examinations, the number of trainees who are going to sit and its impact on the timeline of the Vivas. Trainees who do not feel sufficiently prepared to sit the examinations either due to the impact of COVID-19 or other personal reasons are encouraged to seek a deferment via an application for consideration of special circumstances, as per the policy.

“This has been an arduous and challenging process for all parties and I want to express my sincere thanks and appreciation to Dr Sean Brennan, as Chief of Examinations, and his examination team for their willingness to deal with and adapt to the rapidly changing requirements that have been asked of them.” Trainees who choose to sit and who record a ‘fail’ in the 2020 examinations will be granted an additional examination opportunity in view of the adverse impact in terms of training delivery and preparation for the examinations. I hope that some of these measures will provide welcome relief for our trainees living in extraordinary times. continued over...

This has been an arduous and challenging process for all parties and I want to express my sincere thanks Volume 16 No 4 I September 2020

Radiation Oncology

• College policy/process changes associated with the new training program • Training and Assessment Reform (TAR) online modules to replace communication originally planned via face-to-face roadshows. I am pleased to report that the external stakeholder consultation process for the learning outcomes in the new training program ended on 27 July, with largely positive feedback. The collated feedback is currently under review and any necessary revisions will be made accordingly. I would like to take this opportunity to congratulate Dr Lisa Sullivan on her appointment as Chief of Training and Assessment and Chair of the IWG. I am eagerly looking forward to collaborating with Dr Sullivan in this crucial role of coordinating the monitoring and refining of the new training program and ensuring that it will be ready for implementation in 2022. At the same time, I would like to express my deepest gratitude to Dr Matthew Seel for his immense contribution and input into the new training program. Specific acknowledgement needs to be made in his roles as Chair of the Oncology Sciences Working Group, member of the Steering Committee and also as Acting Chair of the IWG between September 2019 to August 2020. I wish Dr Seel all the best as he considers how he can utilise his vast experience and skills in other College activities.

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Inside News

Cardiac CT Training 2020

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If you have any questions or comments about this article please contact Legend Lee, Manager, Training Programs, on ronctaa@ranzcr.edu.au

AUSTRALIAN

With the cancellation of the annual DoT workshop this year, additional resources have been organised and implemented to provide support to a large number of new DoTs who have stepped up to this role for the first time. The first of three DoT induction webinars was held successfully on 7 August 2020. The

In addition, the College has commissioned an external consultant, Brendan Grabau and Associates, to run a series of two practical upskilling webinars for both DoTs and Clinical Supervisors. These two webinars are designed to complement each other. The first of these was held on 27 July 2020 and focused on the roles and responsibilities of Clinical Supervisors, common challenges associated with supervision and strategies to remediate trainees who need extra support.

Lastly, as we continue to face the uncertain road ahead of us, I think back to another quote, this time by the Portuguese author, Fernando Sabino Everything is going to be fine in the end. If it's not fine, it's not the end.

ULAR CT

• refining the enhanced training program and learning outcomes with feedback received from stakeholder consultation

The second webinar was held on 7 September 2020. This session delved into situational teaching and supervision, as well as building a healthy workplace. It is highly recommended that all DoTs join all ongoing induction and upskilling webinars offered as they provide invaluable pragmatic tools to enhance your clinical supervisory skills.

ASC

• managing disruptions caused by COVID-19 with regards to transitioning requirements

induction webinars are intended to introduce new DoTs to College policies and processes, accreditation standards, Training and Assessment Reform and the key upcoming changes to the training program. If you are a new DoT or a current DoT who wishes to refresh your knowledge regarding revised College policies and processes, I would encourage you to join in one of the other the other webinars to be held later this year.

With regards to the implementation of the new training program, which is now deferred to 2022, the Implementation Working Group (IWG) continues to meet on a regular basis and is working on:

TE OF CAR

Radiation Oncology

Radiation Oncology Trainee Matters consultation with all parties within the College—his is definitely not an enviable position to be in during this stressful time! Also, considering the unique plights and challenges faced by different trainees in the lead up to the examinations, it might be worthwhile having a read through of the Consideration of Special Circumstances Policy in case it applies to you.

Dr Wee Loon Ong As we enter the third quarter of 2020, COVID-19 continues to dominate our daily lives. Unfortunately, Australia has been plagued by a second COVID-19 wave, mandating further lockdown restrictions in certain states and jurisdictions. At the time of writing, COVID-19 appears to have crept back into New Zealand as well—the COVID-19 situation across the Tasman will continue to evolve in the coming weeks and months. It is inevitable that our training is affected by COVID-19 in many different ways. The deferred Phase 1 and Phase 2 examinations have been one of the major concerns for many trainees over the past few months. It is hoped that the recent announcement of the examination dates will provide some reassurance to affected trainees. Acknowledging the examination-related stress among trainees, it is important to recognise the mammoth effort that Dr Yaw Chin, our Chief Censor, has put into drafting an examination process and contingency plan, which accommodates COVID-19 considerations, in

As we adapt to the new norm in the COVID-19, online education or webinars have become an important part of our education resources. Following the virtual TROG ASM earlier in the year, many other major international conferences (for example, ASCO and ASTRO) have been/ will also be conducted in virtual format. While the College ASM has been deferred to 2021, the ASM committee is actively exploring the possibilities of holding a webinar series this year, involving some keynote speakers and top-rated abstracts submitted for the 2020 ASM. ROTC will continue to share any radiation oncology-related education webinars with trainees across Australia and New Zealand in the coming months. For Australian trainees, many of you may remember the Medical Board of Australia (MBA) and Australian Health Practitioner Regulation Agency (AHPRA) Medical Training Survey (MTS) that was conducted in 2019. Some of the issues highlighted in the survey centred around bullying, harassment, discrimination, and trainee wellbeing. The annual Medical Training Survey is now live for 2020— upon completion of your AHPRA annual registration renewal process, you will receive a link for the Medical Training Survey. I would encourage trainees to complete this survey as it will allow the College to gather a more representative response, to better understand the quality of our training program, and identify ways to improve our training

experience, in particular from a trainee’s health and wellbeing aspect. More information can be found on www.medicaltrainingsurvey.gov.au As many specialist training colleges, including the College, are bi-national, future surveys may be conducted in collaboration with the Medical Council of New Zealand (MCNZ). In this edition of Trainee Matters, we have two ROTC members, Dr Revadhi Chelvarajah and Dr James Gallo, telling us a bit more about their involvement in the Radiation Oncology Education and Training Committee (ROETC) and the Economic and Workforce Committee (EWC) respectively. Lastly, it is important to look out for one another, providing mutual support during this unprecedented time. Not only will the various COVID-19 restrictions in place impact our daily routines and training, but they will also affect our physical, mental and social wellbeing. Stay safe and well! Dr Wee Loon Ong Chair, ROTC 2020 @weeloonong

continued over...

Volume 16 No 4 I September 2020

SUPPORT THAT’S AS INDIVIDUAL AS THEY ARE *

*Helping to meet the needs of patients with prostate cancer and healthcare professionals through initiatives such as patient support materials and supporting educational activities.

Zoladex is indicated for:1 Palliative treatment of metastatic ( M+ ) or locally advanced prostate cancer where suitable for hormonal manipulation. Adjuvant and neoadjuvant therapy in combination with radiotherapy for the management of locally advanced prostate cancer in men suitable for hormonal manipulation.

Before prescribing please review full Product Information available on request from AstraZeneca on 1800 805 342 or at www.astrazeneca.com.au/ PI PBS Information: Zoladex 10.8mg. Restricted benefit for locally advanced

( equivalent to stage C ) or metastatic ( equivalent to stage D) carcinoma of the prostate. Zoladex® 10.8 mg Implant ( goserelin acetate ) Minimum Product Information. Indications: Metastatic ( M+ ) or locally advanced prostate cancer; adjuvant and neoadjuvant therapy in combination with radiotherapy for locally advanced prostate cancer. Contraindications: Hypersensitivity to LHRH, LHRH agonist analogues or any components of ZOLADEX. Precautions: Not indicated for use in females or in children; patients with metastatic cancer at risk of developing ureteric obstruction or spinal cord compression - use of ZOLADEX should be carefully considered and monitored closely in the first month; injection site injury, including pain, haematoma, haemorrhage and vascular injury, care with patients of low BMI and /or receiving full anticoagulation medications; bone pain; serum testosterone concentrations may rise if implant is omitted or delayed; loss of bone mineral density; hyperglycaemia and increased risk of developing diabetes – periodically monitor blood glucose and /or glycosylated haemoglobin ( HbA1c ). Androgen deprivation therapy may result in prolongation of QT/QTc interval- consider benefits versus risks in patients with congenital long QT syndrome, congestive heart failure, frequent electrolyte abnormalities or taking drugs known to prolong the QT interval. Correct electrolyte abnormalities. Monitor for symptoms and signs of development of cardiovascular disease and manage appropriately. Effects on fertility – see full PI. Adverse reactions: Very common ( ≥10% ): decreased libido, hot flush, abnormal blood pressure, hyperhidrosis, erectile dysfunction, gynaecomastia, breast tenderness, paraesthesia, decreased bone mineral density; Common ( ≥1% to <10% ): impaired glucose tolerance, spinal cord compression, incontinence/urinary frequency ( post-radiotherapy ), rash, bone pain, arthralgia, injection site reaction, cardiac failure, myocardial infarction, increased weight, mood swings; For less common adverse reactions, see full PI. Dosage: One implant ( 10.8 mg ) injected subcutaneously into anterior abdominal wall every 3 months. Caution should be taken while inserting ZOLADEX into the anterior abdominal wall due to the proximity of underlying inferior epigastric artery and its branches. Use extra care when administering ZOLADEX to patients with a low BMI and /or who are receiving full anticoagulation medication. Date of first inclusion in the ARTG: 22 May 1996. Date of most recent amendment: 16 May 2017. References: 1. Zoladex 10.8 mg Approved Product Information. Zoladex® is a registered trademark of the AstraZeneca group of companies. Registered user AstraZeneca Pty. Ltd. ABN 54 009 682 311. 66 Talavera Road, Macquarie Park, NSW 2113. www.astrazeneca.com.au. For Medical Information enquiries: 1800 805 342 or medinfo.australia@astrazeneca.com. To report an adverse event: 1800 805 342 or via https://aereporting.astrazeneca.com. AU -5913, WL302306, April 2019

Radiation Oncology

Radiation Oncology Education and Training Committee (ROETC) I had the fortunate opportunity to be the ROTC Representative for ROETC for 2020. Amid a very tumultuous and unprecedented pandemic era, I have been lucky enough to gain great insight into how our College ensures consistent and standardised education and training. We usually convene every two to three months via video conference. As the trainee representative, I have been asked by ROETC to consistently provide feedback and perspective on many trainee issues including timing and restructuring of examinations, and how education and training can be adapted in the context of working-from-home arrangements.

ROETC has provided a safe space to help advocate for trainees and raise their concerns at a College level. I liaise with network trainee representatives and fellow ROTC members, and have also been contacted directly by trainees wanting to raise their individual concerns. I am happy to continue advocating for trainees, feel free to get in touch if I can help.

is interested in education and training, to consider applying for ROTC and the ROETC Representative. Good luck to all the Phase 1 and 2 exam sitters for 2020! Dr Revadhi Chelvarajah, Trainee Rep (NSW-S), ROETC

Exciting future ROETC agendas include the implementation of the new Phase 1 and eventual Phase 2 curriculum. I would strongly advocate for any trainee who wants to further their leadership, communication and advocacy skills and

Economic and Workforce Committee (EWC) 2020 has been a tumultuous year for many but the EWC has not missed a step in continuing to advocate on behalf of the Faculty regarding the resources, both human and economic, that allow us to provide world-class care for our patients.

Keep an eye out for the Reporting for Better Cancer Outcomes annual report, an analysis of data from NSW and the ACT regarding cancer prevalence, prevention, screening and treatment. The 2019 report was published on 14 September.

The committee has provided consultation and support for a number of projects and proposals from promoting awareness of the costs of care, advocating for better radiotherapy coverage under private health insurance policies and supporting the expansion of PSMA PET and brachytherapy in Australia.

It has been a difficult year for trainees with the disruptions to their training and workflow caused by the pandemic. I am proud of your resilience and hard work during this time and it has been a privilege to represent you on the EWC this year.

To all my fellow trainees, but especially for those of us who are preparing to sit examinations, I wish you every success and look forward to many more years in this great professional community with you. Dr James Gallo, Trainee Rep (QLD), EWC

To view the Reporting for Better Cancer Outcomes annual report www.cancer.nsw.gov.au/howwe-help/quality-improvement/ reporting-for-better-canceroutcomes

Volume 16 No 4 I September 2020

Radiation Oncology

Quality Corner Volume Delineation in Radiation Oncology: Where to Draw the Line? Volume delineation is arguably the greatest source of error in radiation oncology. While new radiotherapy technologies are heading toward millimetre precision, volume delineation can be highly variable depending on interpretation of imaging and pathology, type and resolution of imaging modality and clinician knowledge and experience. FRO has just updated its Quality Guidelines for Volume Delineation in Radiation Oncology (currently available for member consultation) to guide clinicians during this crucial step. References to a number of new contouring atlases have been added across a number of tumour sites. New information on organ-at-risk (OAR) delineation has been added. Clinicians should be particularly cognisant of length of OARs delineated where whole organs are not (eg rectum), and volume subtractions (lung) to ensure that dose volume histograms pertain to those volume definitions. Although OAR delineation is frequently left to radiation therapists, it is the ultimate responsibility of the radiation oncologist to check and accept these. One of the Radiation Oncology Practice Standards (criterion 9.1) states that treatment planning protocols which encompass contouring and target definition need to be documented and endorse evidence-based practice. Guideline 2 in the update makes recommendations to meet this practice standard. These protocols also need to be followed by all members of the department to ensure consistency of practice and minimise unwarranted variation.

Guideline 2 1. It is recommended that radiation oncologists use standard contouring protocols and atlases for target and organ-at-risk volume delineation. 2. It is recommended that all departments have radiotherapy planning protocols (encompassing volume delineation) for major tumour sites. 3. It is recommended that all members of a department follow their standard departmental protocols for volume delineation and radiotherapy planning.

â€œAlthough OAR delineation is frequently left to radiation therapists, it is the ultimate responsibility of the radiation oncologist to check and accept these.â€? Accurate volume delineation is critical for highly conformal treatment (eg IMRT, VMAT) and where curative radiotherapy is given with high doses per fraction (eg SABR, gynaecological brachytherapy). In these scenarios, review of volumes by another radiation oncologist or a radiologist is recommended.

For all other scenarios there should be some element of peer review, whether this is done as a random audit or for all curative intent radiotherapy for a particular cancer type. Smaller departments can be linked to larger ones for this to occur. If you are embarking on a new treatment technique, there may be a need to upskill your delineation skills through visiting another centre or credentialing within a clinical trial context. In addition to accurate volume delineation, standardised volume nomenclature is also important in the era of automated radiotherapy planning. Ideally volume names should be autopopulated into the planning system and not changed by clinicians. This will aid in consistency of planning across the department. Going one step further for obsessional clinicians like myself, I highly recommend standardised colours for common volumes eg GTV, CTV, ITV, PTV. You can even use different shades of the same colour for sub-volumes which add up to these overall volumes! Apart from overall clinical management of the patient, our most important role as radiation oncologists is to delineate accurate volumes for radiotherapy planning. Please give this important task the necessary time it needs, ask for better imaging if needed, consult a colleague if you are unsure and never ever be afraid to approach a radiologist, nuclear medicine physician or surgeon for input. Happy contouring! Professor Shalini Vinod Liverpool Hospital @shalinivinod13 To provide feedback on the Quality Guideline for Volume Delineation in Radiation Oncology please visit: www.ranzcr/our-work/consultations

Inside News

Interventional Radiology

Uterine Fibroid Embolisation: the Past, the Present, and the Future The past Uterine fibroids are estimated to be present in up to 75 per cent of women, and cause symptoms in up to 35 per cent. Patients with small fibroids or with mild symptoms may be suitable for conservative treatment options. For women with large fibroids or who have failed conservative treatment, a more definitive approach is needed [1]. Fibroid embolisation (UFE) was first described in 1974 by interventional radiologist Jean-Jacques Merland. It became a mainstream treatment option following a landmark paper in The Lancet in 1995, followed on by the REST and EMMY trials in the early 2000s [1]. High-level evidence now shows us that fibroid embolisation performed by interventional radiologists (IRs), provides women with similar improvement in quality of life at up to 10 years after embolisation compared with traditional surgical treatments, including hysterectomy and myomectomy [1]. In 2006, the Medical Services Advisory Committee (MSAC) compared the efficacy, cost, and safety of UFE. They recommend public funding of embolisation (MBS item 35410), however placed a condition that referrals should come from a gynaecologist in order for Medicare to provide the rebate [2].

The present While the provision of a Medicare item number seemed like a milestone in Australia, the reality has been a stark contrast. Recent data from five consecutive years in Australia shows that there has been an average of only 145 Medicare-rebated UFEs per year, compared to an estimated over 6,000 fibroid-related surgeries and over 30,000 uterine surgeries in total![1] (see figure 1). A similar disparity is also being presented in overseas data.

Figure 1: Comparing the number of UFE procedures with the number of surgeries for fibroid disease in Australia. Source: Department of Human Services website www.medicarestatistics.humanservices.gov.au/statistics/ mbs_item.jsp A study from France showed there are approximately 2,000 UFEs being performed each year compared with 40,000 uterine surgeries [3]. In Spain, a study showed that less than 150 UFEs were being performed each year compared with 50,000 hysterectomies [3]. These numbers are likely representative of a worldwide trend, including in New Zealand. It is important to also consider these numbers in the context with recommendations from the Royal Australian and New Zealand College of Gynaecologists. They recommend that gynaecologists should counsel the patient about all treatment options before offering surgery, including UFE. The worldwide numbers presented don't support the notion that women are being offered a balanced view on the safety and efficacy of UFE.

The cause of this disparity between UFE and surgery is multifactorial [1,3]. Many IRs will argue that scepticism from gynaecologists remains a primary reason for the lack of referrals. The inability of GPs to provide a direct referral pathway due to restrictions on the Medicare item number is also likely to be a contributor. There is also a general lack of awareness about UFE amongst GPs and the public. Finally, for IRs to provide a service they must be recognised as clinicians and this means working in the patient's healthcare team but also taking 'ownership' of the primary care of the patient for that procedure. This will include clinical duties of a specialist doctor expected by the general public, such as consultation, admission, procedure, post-procedure care, and follow-up. continued over... Volume 16 No 4 I September 2020

Interventional Radiology

Treating patients in this manner is different to the traditional role of radiologists who generally provide a technical adjunct while handing holistic care back to the referring clinical team.

The future We still have some work ahead if Australian and New Zealand women are to have access to this low-cost uterinesparing treatment. Our College, via the Interventional Radiology Committee, has developed a position statement outlining aspects of evidence on the safety, efficacy, and cost of UFE. This included the vital role of IRs in fibroid management and supports the MBS review recommendations to remove the restriction of gynaecologist referral [4] which is in the current Medicare item 35410 [5]. This will allow more open access for women via direct referral from their GP, and allow IRs, GPs and gynaecologists to work in a multidisciplinary team. Now is the time that we make the clinical radiology specialty of interventional radiology exist in Australia and New Zealand. For IRs to own a procedure, we must be recognised as frontline physicians and not secondary caregivers like we have been in the past. If this does not happen, ownership of procedures that IR designed and developed will be taken over by other specialties, just like what happened with coronary angiography and what is happening currently with peripheral angiography. All College Fellows can play a role in this process including diagnostic radiologists who do not perform advanced proceduresâ€”we need support from all radiologists to have the mandate to make this reform to allow IRs to practise in the manner that we need.

Inside News

Only once IR exists as a specialty, can we truly take ownership of the procedure and establish better referral and treatment pathways. This will work in tandem with education for GPs and the general public around what IR is, and what we can do for women with fibroids. Excellent College resources such as the Inside Radiology website (www.insideradiology.com.au) are available as a resource for patients who are considering their treatment options. Social media is also a modern platform that we must harness. There may also be a role to work with industry in this regard where we can mutually advocate for our craft. By the end of this year, an Australian website will go live, providing support for advocacy of UFE in Australia (www.ask4UFE.au). Don't look behind, look ahead, as there is an optimistic future for UFE in Australia and New Zealand. I foresee that within the next five years we can show College Fellows that our collective work has provided many thousands of women with uterine-saving treatment and at the same time grown the specialty of IR. Dr Warren Clements Interventional Radiologist Alfred Heath and Monash University Interventional Radiology Committee, RANZCR @Warren_IR

References 1. Clements W, Ang WC, Law M et al. Treatment of symptomatic fibroid disease using uterine fibroid embolisation: An Australian perspective. ANZJOG. June 2020. 60(3) pp 324-329. www.doi.org/10.1111/ ajo.13120 2. Medical Services Advisory Committee. Uterine artery embolisation for the treatment of symptomatic uterine fibroids, Assessment Report, January 2006. [Accessed November 2018.] Available from URL: www.msac.gov.au/ 3. Makris GC, Butt S, Sabharwal T. Unnecessary hysterectomies and our role as interventional radiology community. CVIR Endovasc. 2020 Dec; 3: 46. doi: 10.1186/s42155-020-00138-x 4. Australian Government Department of Health, Medicare Benefits Schedule Review Taskforce. Report from the Vascular Clinical Committee. 2018. [Accessed 5 August 2020]. Available from: www1.health.gov.au/internet/main/publishing. nsf/Content/mbs-review-2018-taskforce-reportscp/$File/VCC-Final-Report-Consultation-Report.pdf 5. Australian Government Department of Health, Medicare Benefits Schedule Online. [Accessed 5 August 2020]. Available from: www9.health.gov.au/ mbs/fullDisplay.cfm?type=item&q=35410

Interventional Radiology

If this is how other women live, I have not been living!:

How uterine fibroid emobolisation changed a young woman’s life Stephanie got used to managing difficult periods, so much so that it became the norm. “I was used to heavy bleeding and a lot of cramping during my periods,” said Stephanie. “I was diagnosed with endometriosis when I was 20 and eventually had surgery for the condition 10 years later.” It was during the surgery that the gynecologist identified several uterine fibroids that were about 5 cm big. Over the course of the next two years, they grew to about 12 cm. “As the fibroids got bigger my symptoms intensified. Bleeding during my periods got even heavier and I could hardly stay awake during my cycle. I was completely exhausted.”

“I was a mess, feeling exhausted, in pain and hopeless so much of the time. I never felt rested, never felt energetic and most days took a huge amount of effort to get through.” The symptoms quickly altered the way Stephanie was able to live her life. “I was in constant pain. My stomach was so bloated that I looked like I was six months pregnant and even sitting down or tying up my shoes was excruciating. I could only wear loose-fitting clothing as I couldn’t stand any pressure on my stomach and I wanted to hide how swollen it was.

“It eventually got to the stage where I needed to go to the toilet every 30 minutes. I had to plan my whole day around where and when I could get to a bathroom—which isn’t easy when you have an hour commute just to get to work! “I was a mess, feeling exhausted, in pain and hopeless so much of the time. I never felt rested, never felt energetic and most days took a huge amount of effort to get through.” Stephanie’s gynecologist made her aware of treatment options ranging from hormonal medications to major surgery. “I considered getting a hysterectomy for about six months, but as a young woman, I couldn’t believe that was my only option.” Stephanie sought out more specialists for a second opinion and during her research found an old YouTube video on uterine fibroid embolisation (UFE). She said,” I found an interventional radiology clinic in Sydney who

offered the procedure and I made an appointment as soon as I could. The doctor took me through the procedure, and I knew this was the right option for me. To be honest, it seemed too good to be true, given the improvements that could be gained and avoiding a surgery under general anesthetic.” After the procedure, Stephanie’s symptoms improved dramatically. “The bleeding during my first few periods was basically non-existent compared to how they had been before. I remember thinking, ‘If this is how other women live, I have not been living!’” “The relief and improvement in all my other symptoms were drastic—it was beyond worth it. I wanted to share my story so that other women who are suffering like I was can learn more about UFE and consider if it is the right treatment option for them. It gave me back my life and I am extremely grateful to my medical team for that. I couldn’t recommend the team and the procedure enough, I haven’t looked back since.” Volume 16 No 4 I September 2020

NEW ZEALAND ASM AUGUST 6 - 8 2 021

M E E T I N G U P D AT E

NEW DATES ANNOUNCED 6 - 8 AUGUST, 2021

NZ Annual Scientific Meeting 2021 Intercontinental Hotel, Wellington

www.ranzcr2021.co.nz

News

New Zealand Branch News

Dr Gabes Lau

Kia ora. 2020 continues to be the year of COVID-19. Just when the College was starting to think Oz and NZ had it sussed, Victoria and Auckland have shown that we can’t let our guard down. On 15 September, the WHO confirmed 29, 155, 581 global cases and 926, 544 deaths with no end in sight for those nations hardest hit. I hope our colleagues on both sides of the Tasman and your families are staying well. The impact of COVID-19 on the health workforce may be felt for many years to come.

Annual general meeting (AGM) and NZ branch election outcome The New Zealand Branch Committee held its first virtual AGM on 1 August. The key business of accepting last year’s minutes, my annual report and the annual report from the Chair of the New Zealand Radiology Education Trust were all completed. One hopes that the NZ ASM is a go in Wellington next year and more of you are able to attend. The outcome of the NZ Branch election was also announced at the AGM. Congratulations to the following on their re-elections to the NZ Branch Committee: Mark Coates, Joe Feltham, Quentin Reeves, Stephen Wood and Verity Wood.

clinical radiology training programme and nine applications for five radiation oncology positions. For the first time the interviews were completed in a virtual format. Feedback has indicated the process went well. Congratulations to the Networks and the Wellington office for their great work. These newly selected trainees will not be starting until February 2021 as the DHBs have agreed to align New Zealand’s training year to Australia’s for house officers and registrars. The news was a bit of a surprise, particularly given the resistance from the junior doctors previously. However, there are gains to be made for administration of training and alleviating long-running safety concerns related to having new doctors start work during the holiday period.

Examinations 2020 We now have confirmed dates for all examinations in New Zealand. I can only speak for clinical radiology but I am feeling fairly proud of New Zealand. It may appear that we are punching above our weight, but it really speaks

to the Kiwi spirit and our members’ long running commitment to support education and training. Well done and thanks to all who have dropped tools and offered to help with the vivas.

New linear accelerator (linac) There have been some COVID-related delays on the new linacs the government promised last year. However, on 2 July there was an official opening ceremony at Palmerston North Hospital for one of the new machines. The new linac is more efficient so more patients can be treated. MidCentral DHB Cancer Screening, Treatment and Support Clinical Executive Dr Claire Hardie (and College Fellow) says the new linac meant the service was now on par with anywhere else in the world using the most modern techniques possible. This is fantastic news for cancer patients in Palmerston North. Bring on the rest of the new linacs. Kia kaha. Stay safe, vigilant and strong.

NZ registrar recruitment and the training year moving to February 2021 Registrar recruitment has now been completed for 2020. We received 46 applications for 23 positions for the

Volume 16 No 4 I September 2020

News

New Zealand’s General Election in 2020 Certainly, the COVID-19 pandemic has proved a challenging and interesting environment for the New Zealand general elections with deferment of the election date by a month and the subsequent difficulty in gaining access to politicians.

A summary of these is available on the College website.

The NZ Branch Committee and the New Zealand Radiation Oncology Executive discussed the College’s priorities for New Zealand and have distilled members’ concerns to two things: workforce and infrastructure. The details have been fleshed out in Election Priorities 2020: Policies to support a world-class health system in New Zealand, which is available on the College’s website. An outline of the priorities and the milestones are found in Table 1.

Engaging with the politicians

Investment in infrastructure

Radiation Oncology

The NZ First response reiterated the Government’s achievements including the Radiation Oncology National Plan 2017–2021, new linac machines and the recommendation of a National Health Information Platform which is awaiting Cabinet approval. They have expressed interest in our workforce asks and we look forward to further engaging with them on this. The Green Party believes that health funding should keep pace with the growing population and the need to engage both the public and health professionals to find solutions to ethical problems, such as those involved in resource allocation priorities. They have indicated tax reform is needed to help

To gauge support for the College’s priorities, an Election Survey was sent to all the major political parties: Labour, National, NZ First, Greens, ACT and the Māori Party. Responses have now been received for all parties approached with varying levels of detail in their responses.

Clinical Radiology

Prior to the election all parties have outlined general commitments to health with few answers to the College’s specific priorities. Hopefully, as the election progresses, and policies are progressively revealed there will be more specific answers to our questions.

Investment in Workforce

•

Upgrade to a • Nationwide Radiology Information System - Picture Archiving and Communication Systems (RIS-PACS).

•

Enable clinical information sharing (interoperability) through eReferral, access to historic images and shared patient records.

•

• Increase overall number of linacs to ensure better access to treatment for more New Zealanders.

•

Fund the buildings to house linacs in new locations.

•

Increase the number of funded training positions for clinical radiology in New Zealand. RANZCR's modelling and the Workforce modelling done by Health Workforce proves a need to train more radiologists. Increase the number of consultant posts for diagnostic and interventional radiologists.

Increase the number of funded training positions in New Zealand. Demand and workforce modelling shared by Health Workforce and the Cancer Control Agency proves a need to train more radiation oncologists. Develop a career pathway and retention scheme for radiation oncologists.

Inside News

fund public services. Additionally, on workforce issues the Green Party wants to ensure that there are no barriers to tertiary education. The National Party has committed to undertake a disciplined approach to health information technology which includes digitally-enabled service delivery and primary care providers supported towards better practice-based software integration with DHBs, ACC and community providers (including radiology). They have committed to ensure linacs determined to be necessary by regional strategy and planning collaborations are deployed on time, scope and budget. The National Party will also work with Health Workforce to identify the looming gaps in the workforce and engage with tertiary education providers to ensure the pipeline fills those gaps. As predicted in New Zealand media, the Labour response is focused on achievements during this term of government and the adoption of the plans outlined in various reviews. Labour has accepted the case for reform and the direction from the Final Report Milestones

2021: Health Workforce approves funding for additional trainees and commits to maintaining the increase until modelling demonstrates the workforce shortage has been resolved. 2023: NZ implements a national strategy for clinical information sharing by upgrading technology, while ensuring interoperability in technology and data management. Funding is provided for the purchase of new technology. New Zealand has a national strategy to ensure the DHBs are employing enough radiologists to meet demand. 2026: New Zealand has current and nationally integrated RIS/PACS systems that ensure efficiency of care. 2029: Technology/telehealth is being used to ensure equitable provision of care; NZ regions with sufficient numbers of radiologists support the care of patients in underserved regions. 2021: Health Workforce approves funding for additional trainees and commits to maintaining the increase until modelling demonstrates the workforce shortage has been resolved. 2023: Funding is approved for 10 additional linacs, and associated facilities, to expand capacity. New Zealand has a national strategy to ensure the DHBs are employing enough radiation oncologists to meet demand. 2026: Funding is provided for a minimum of one fellowship position each year to ensure NZ trained radiation oncologists can develop their subspecialist skills effectively within New Zealand. 2029: Establish 4 additional radiation therapy services in new regions to resolve some of the equity of access issues.

General Interest

for the Health and Disability System Review. Regarding radiation oncology, they are committing to the New Zealand Cancer Action Plan 2019–2029 investing in particular in workforce, technology and the treatment capacity for radiation oncology. ACT has indicated that their health policies will be revealed at their campaign launch hinting that they will be announcing better alignment of care pathways between tertiary, secondary and primary health care providers and a national, integrated IT and supply chain. They also emphasised the need for enhanced technology.

The College met with Julie Anne Genter, current Associate Minister for Health and health spokesperson for the Greens. Efforts to secure a meeting with the health representatives for the Labour Party and the National Party were hamstrung by the musical chairs of pre-election politics. Post-election, the College will arrange to meet with the new Minister of Health and health spokespersons from each of the elected parties to advance our members’ priorities and open a dialogue with the political decision-makers and influencers.

Please contact nzbranch@ranzcr.org.nz if you have questions or feedback about the College’s activities related to the election in New Zealand.

Faculty of Radiation Oncology Genito-Urinary Group (FROGG) What a crazy year we are having! COVID-19 is cancelling all our usual conferences and face-to-face meetings. However, the FROGG Executives have been busy and continuing to meet every two months by teleconference. A big thank you to Dr Amy Hayden for her time as Chair of the FROGG Executive. Following on from the FROGG Bladder Cancer meeting in Cairns last year, the committee has continued to work on an update to the 2011 FROGG Consensus Guidelines for Bladder Cancer and work on bladder cancer advocacy within the community. We are very pleased to announce a partnership with BEAT Bladder Cancer Australia. Under the guidance of CEO Adam Lynch, BEAT offers bladder cancer patients and their families support and information, their mission is to increase bladder cancer awareness within the community and health profession. Dr Renee Finnigan has joined the BEAT Health Advisory Team and together with Dr Stephen Chin, Dr Dinesh Vignarajah and myself will be working with the BEAT team to update their website patient information, with a more comprehensive education package about the use of radiation treatment for bladder cancer. In the prostate cancer arena, under the guidance of Dr Amy Hayden and

Dr Andrew Kneebone, FROGG are working with the Prostate Cancer Foundation of Australia (PCFA) to update their patient information booklets hoping for these to be available to patients by the end of the year. We have also been working with the College to support a number of Medical Services Advisory Committee (MSAC) applications including the application to have Medicare reimbursement available for PSMA PET imaging for staging of prostate cancer patients. While advocacy is an important role for FROGG, we are always looking to engage Fellows and trainees in educational forums and are working toward our next FROGG meeting in early 2022. Our next Inside News update will have the dates and location, so watch this space. Recognising the importance of engaging trainees and fostering a love for all things GU, we would like to warmly welcome our newest FROGG executive member and inaugural trainee member Dr Matthew Knox. In reviewing applications for this position, and also for the FROGG trainee travel grant late last year, we were all amazed with the high standard of the applicants and their level of engagement in GU research during their training.

FROGG Committee: Tanya Holt (Chair), David Christie (Deputy Chair), Amy Hayden, Andrew Kneebone, Giuseppe Sasso, Mark Sidhom, Thomas Shakespeare, Sarat Chander, Renee Finnigan, Braden Higgs, Matthew Knox.

@BeatBCAus

FROGG Genitourinary Webinar Sessions for Radiation Oncology Trainees The College is excited to launch, in partnership with Eligard (Mundipharma), a monthly FROGG GU virtual webinar program facilitated by both national and international speakers for Radiation Oncology Trainees.

Session One Monday, 28 September 7.30–9.00 am Register here: www.bit.ly/FROGG Registration is free for RANZCR Trainees. Two additional sessions will run in October and November with more planned for 2021.

Volume 16 No 4 I September 2020

General Interest

Starting Out with Medicare Provider Numbers and Compliance Activities Compliance with the requirements of the Medicare Benefits Schedule (MBS) is one of many professional practice issues that radiologists must come to grips with when starting clinical practice. But it is one where trouble can often arise. The Department of Health (the Department) has a strong program aimed at protecting Medicare through the prevention, identification and sanctioning of incorrect claiming, inappropriate practice and fraud. Last year we saw the Department audit radiologists they considered outliers in various billing behaviours, including coclaiming MBS Item 104 with a diagnostic imaging test. This year, there has been an audit to look at the claiming of certain items when also billed with services which require a personal attendance. It is reasonable to expect that similar audits will continue to be undertaken. We acted for several radiologists whose billings were the subject of the audit into co-claiming Item 104 and we can offer some insights into how new radiologists can minimise the risks of this type of trouble. Many of the large commercial or corporate radiology practices across Australia employ radiologists on a salary to provide services and it is the practice which bills and collects the benefits. When a radiologist starts with a practice, they are typically required to provide their provider number to the practice, and they trust the practice’s administrative staff to bill appropriately for the services provided. It is not uncommon for the radiologists to have no idea of what claims are being submitted by the practice and as they are being paid a fixed salary, they may feel little incentive to check.

Inside News

In the cases in which we were involved, we sought and obtained indemnification from the practice involved in respect to the radiologist’s expenses and of any repayment of benefits which may have flowed from submitting incorrect claims. Not all employed radiologists may be so lucky.

“We acted for several radiologists whose billings were the subject of the audit into co-claiming Item 104 and we can offer some insights into how new radiologists can minimise the risks of this type of trouble.” To mitigate the risk of incorrect claims being submitted using your provider number, you should: • read carefully and be very familiar with all of the requirements of the MBS, including the item descriptors and the explanatory notes related to the type of services you are providing • when entering into an employment agreement with a radiology practice, ensure that the agreement obliges the practice to: o give you ready access to the claiming records in respect of the services you provide o indemnify you for the expense which may flow from the practice having submitted incorrect claims

• keep a record of the actual services that you provided • make a daily or at least weekly practice of double-checking the daily billing records of the practice in respect of the services you provided. In circumstances where a radiologist is a contractor and is not employed, it is imperative that you are clear on how your provider number will be used when you give it to the practice. We suggest to clients that at the time of commencing practice as a contractor, radiologists should make a notation alongside of their provider number that it is to be used only in strict accordance with the radiologist’s instructions. To ensure you are complying with the requirements of the MBS it is critical that you are very careful about what use is made of your provider number. Andrew Davey Director Unsworth Legal

General Interest

Obstetric and Gynaecology Special Interest Group It’s been a busy few months at OGSIG HQ! We have got ourselves a new logo. Hope you like it as much as we do. We also have a fledgling website: www.ogsig.org Though pretty basic at the moment, we hope to grow it, so it will be a powerful resource for the O&G imaging community. We are also extremely happy to confirm that OGSIG’s first meeting will be on Friday 26 March 2021, at the Brisbane Convention Centre. The keynote speaker will be A/Prof Simon Meagher who will be supported by a strong faculty of sub-specialist radiologists.

restrictions in place (please refer to whatever measures are in place locally). Obviously, in places where there are extreme restrictions, these scans have had to be done differently—essential views only, minimising the number of people in the scanning room, and extra cleaning in between patients—just to name a few. The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and the Australasian Society for Ultrasound in Medicine (ASUM) have issued guidelines to assist practitioners in this regard—these can be found here: www.isuog.org/clinical-resources/ coronavirus-covid-19-resources.html www.asum.com.au/covid-19-resources/

Most of you will also be aware that there is a group on Facebook which is affiliated with OGSIG - Obstetric and Gynecological Imaging Forum: www.facebook.com/ groups/2191071101177763 It is a very active and interactive group—many members post articles, cases, guidelines, webinars etc. I would encourage anyone with an interest in O&G imaging to join. As always, please feel free to contact me if you have any queries on anything related to O&G imaging. Best wishes and stay safe, all. Dr Emmeline Lee emmeline@ogsig.org

Thanks to Dr Ekaterina Alibrahim who is the convenor—she has put so much effort into galvanising the speakers and balancing the program. The program has a wide range of topics covering many aspects of obstetrics and gynaecology which will be useful for radiologists in their day-to-day work. The meeting is being held in conjunction with ARGANZ’s Annual Scientific meeting (thanks to Dr Kirsten Gormley, A/Prof Tom Sutherland and the rest of the ARGANZ Executive who have helped facilitate this) which is on Saturday 27 and Sunday 28 March 2021. Please register your interest via the ARGANZ website. www.arganz.org/index.php/ogsig.html We have all been affected by Covid-19, professionally and personally. The use of medical imaging over the last few months has been interesting, with many centres seeing reduced activity. Obstetrics and some gynaecology is considered essential, and patients are encouraged to attend their appointments, even with strict

Volume 16 No 4 I September 2020

General Interest

Australia and New Zealand Rural Radiology Special Interest Group Update Good wishes to you all. The Australia and New Zealand Rural Radiology Special Interest Group is currently a small SIG and we are keen to get new members. The group is open to all members of the College, but please note our mission to is improve the lot of those radiologists who choose to live and work ‘rurally’ and to also increase the numbers of radiologists who choose to live and work rurally. Improvement means collegiality, education, creating a voice, etc. Over the last two years our main focus has been on trying to increase the non-metropolitan radiologist workforce. Observational evidence from around the world, including very good and recent evidence from Australia, is that the two factors that best determine whether a doctor will choose to live and work in a non-metropolitan settlement are: rural

background plus that of any life partner; time spent rurally in medical school, hospitals and training, especially if the time and work experienced was ‘good’. Thus, the RRSIG supports increasing and improving rural medical schools and rural training pathways. 'Rural radiology’ is often misunderstood. Those of us in the RRSIG find it an amazing career choice—many see ourselves as a multi-specialty radiologist (a term I first found in the American Journal of Roentgenology), experiencing a very wide range of pathologies and patient groups; enjoying great professional relationships with subspecialist, specialist and GP referrers; being involved in acute and outpatient imaging and care and being able to perform a wide range of procedures; getting a lot of MR.

I say this because at the very least it might stimulate student and younger radiologists to consider it as their career choice. Virtually all regional centres now have clinical schools if not a medical school and there are plenty of opportunities for teaching and research. Living in regional and rural communities is very satisfying and in this time of a global pandemic generally much safer than living in one of Australia’s capital cities! Please get in touch if you have any interest or questions. Keep well and safe Nick Stephenson nick.stephenson@i-med.com.au

Cardiac CT Training 2020 We go beyond simply meeting training requirements: l

ASC

AUSTRALIAN

ULAR CT

Maximum allowable course based live and library cases for ANZ credentialing. RANZCR accredited for 117.5/67 CPD points (Level A/Recertification). AICC Officially sponsored and endorsed by GE Healthcare for more than10 years. Live scanning at second highest global NS DI TITU recruiting site in SCOT-HEART study. TE OF CAR Unrivalled venues - Now at Zest, Point Piper, Sydney.

2020 COURSE DATES:

~ In Memoriam ~ The College notes with regret the death of the following member: Dr Ian Benn Fellow NSW Dr Michael Berger Educational Affiliate NSW Dr John Cashman Life Member NSW Dr Ernest Dominiko-vich Fellow NZ Dr David Green Life Member NSW Dr Ihor Kociumbas Fellow NSW

5 Day Level A Course: 8th - 12th October 2020 3 Day Level A Course: 10th -12th October 2020

For more information and online registration log on to: www.aicct.com.au or contact us at: info@aicct.com.au

FLINDERS MEDICAL CENTRE PATHOLOGY COURSE 13 & 14 FEBRUARY 2021 The Division of Medical Imaging at Flinders Medical Centre will offer a two day Pathology Course, consisting of lectures and “pots” sessions to be held on Saturday 13 and Sunday 14 February 2021 at the Adelaide Convention Centre. The course will be of particular value to registrars and candidates preparing for the Part II FRANZCR examination. It will also provide an overview of pathology for practising radiologists who are encouraged to attend. Closing date for registrations is: Monday 30 November 2020 For registration form and further information please contact Helen Sainsbury: helen.sainsbury@sa.gov.au / (08) 8204 4405

Inside News

General Interest

Interventional Radiology Society of Australasia (IRSA) Update Working together with RANZCR IRSA would like to thank RANZCR for the formal inclusion of IRSA representatives on two new committees: the Tripartite Committee with ANZSNR and the IR/ INR Training Pathway Working Group. Through this collaboration we can work together to strengthen both IR and INR in Australia and New Zealand.

2021 ASM Muddassir Rashid, John Grieve and NC Events are busily planning the 2021 ASM, which will be held on the Gold Coast in early July 2021. The theme is Interventional Oncology and details of the venue location will be provided shortly.

Member Engagement Survey A member engagement survey was circulated in May this year, with an aim to:

• gain insight into members’ working arrangements • understand what members value most about their membership; and • gather a clearer understanding of the key issues facing IRs currently. The results show that: • ninety-four per cent of respondents stated that the member fee provides value for money • respondents value the Affiliate memberships offered, being part of a society and maintaining connections with IR colleagues • ninety-eight per cent of respondents would recommend membership to colleagues. The IRSA Executive will continue to ensure engagement with members through the introduction of a quarterly President’s newsletter and a series of education webinars.

Junior Committee Member The IRSA Executive is pleased to announce the appointment of Dr Philip Chan as Junior Member to the Executive. Philip is a junior consultant at Peter MacCallum Hospital. He trained at The Alfred Hospital and recently completed two IR fellowships at Monash Health and at the University of British Columbia in Vancouver, Canada.

IRSA Branch Education Dinners As the uncertainty around COVID-19 continues, the IRSA Executive is pleased to announce that Branch dinners will be held virtually as webinars. Branch coordinators have been contacted and plans for these virtual events is underway. If you would like to be involved, please contact the IRSA secretariat on secretariat@irsa.com.au

The Australian and New Zealand Society of Neuroradiology (ANZSNR) RANZCR IR & INR Training Pathway Working Group ANZSNR looks forward to participating in the newly established RANZCR IR & INR Advanced Training Pathway Working Group. ANZSNR will be represented by Dr William McAuliffe. The group met in August and members will be updated on the important work of this group.

ANZSNR Council Representatives ANZSNR Council is pleased to announce the appointment of the following new state representatives who commenced their positions on 1 July 2020 for a twoyear term: Dr Graham Dunn, NSW Dr Laetitia De Villiers, QLD Dr Ben Moon, New Zealand Dr Ronil Chandra will continue as one of the two Victorian representatives for a second term.

The ANZSNR Executive would like to extend their sincere appreciation and thanks to the following out-going councillors for their distinguished service: Dr Hal Rice Dr Ben McGuinness Dr Jason Wenderoth State representative positions for the ACT and Tasmania remain vacant. To register your interest, please contact secretariat@anzsnr.org.au If you have any issues you would like to place on the agenda for the next Council meeting please email secretariat@anzsnr.org.au or contact your local branch representative which can be found on our website at www.anzsnr.org.au/governance

2021 ASM 11–13 March 2021: Queenstown, NZ Dr Ben McGuiness and NC Events are enthusiastically planning for an excellent 2021 ASM. Council is carefully monitoring the COVID-19 situation locally and worldwide to ensure that the ASM is COVID-safe for all participants and more information will be provided in due course.

DNR and INR Fellowship positions ANZSNR members are invited to advertise DNR or INR positions on a new section of the website dedicated to promoting neuroradiology career opportunities. If you are a member who would like to contribute to this page of the website www.anzsnr.org.au/ fellowships please contact secretariat@anzsnr.org.au

Volume 16 No 4 I September 2020

MEETING 2021

27 - 28 MARCH BRISBANE CONVENTION & EXHIBITION CENTRE

Planning for on-site meeting with live presentations by Australian & New Zealand speakers. Additional virtual presentations during the program from international imaging experts, with live Q&A sessions.

INTERNATIONAL INVITED SPEAKERS PROF SEONG HO PARK University of Ulsan College of Medicine, Asan Medical Center South Korea

DR JONATHAN RICHENBERG Brighton and Sussex University Hospitals NHS Trust United Kingdom

PROF CLAUDE SIRLIN UC San Diego Health USA

Friday 26 March

Scientific Posters

All radiologists are invited to submit a paper poster relating to abdominal imaging. Share your research or present a review topic.

Mendelson Research Prize

All RANZCR radiology registrars and fellows in training are invited to submit an abstract for the Mendelson Research Prize 2021. Oral presentations will fulfill the requirement for sign off of the RANZCR Project 2, with the winner receiving a trip to ESGAR 2022.

KEY DATES 24 January 2021:

Abstract Submissions Close

8 February 2021:

Notice of Submission Acceptance

15 February 2021:

Standard Registration Fee Applies

20 March 2021:

Late Registration Fee Applies

Visit the website for further information.

Pre Meeting Workshop

www.arganz.org

School of ARGANZ

The School of ARGANZ is a Sunday breakfast session for all registrars. The session includes mock vivas for the Part 2 exam and is presented by RANZCR abdominal examiners.

Clinical Radiology

Mammography Quality Assurance Program (MQAP) For more than 20 years, the College has supported mammography services in Australia and New Zealand by operating the Mammography Quality Assurance Program (MQAP). Below is an update on the participation rate.

Annual reviews

Summary of participation rate

Of the submissions assessed in this period 90 per cent passed on their first submission. The number of sites that required a resubmission was due to factors in the Equipment Assessor’s report—this may be due to sites requiring checks on their equipment. Another factor that has emerged is that Equipment Assessors are completing a 2D report instead of a Tomosynthesis 3D report.

December 2014

June 2020

Total number of sites

222

202

Digital Sites – CR (Computed Radiography)

117

87%

Digital Sites – DR (full field digital)

103

187

55%

100%

Analogue Sites – plain film

Difference

The majority of sites accredited a new DR unit, with CR being phased out. Tomosynthesis 3D has steadily been taken on board. Not surprisingly analogue machines have been phased out completely. Sites are passing accreditation on first submission more regularly with less recommendations which is great to see.

Annual reviews are conducted on the first and second anniversary of accreditation being awarded.

• Lower numbers of submissions assessed, with some reviews submitted but unable to be reviewed at present due to COVID-19. • Since mid-March 2020 MQAP has been suspended due to COVID-19.

MRI Quality Program

Year to December 2014

Year to June 2020

Accreditation Assessments

Passed (on first submission)

Participation in the MRI Quality Program is mandatory for MRI systems in Australia that hold a Medicare licence. Participation levels have stabilised and expect to be maintained around current levels of 380 which is in line with MRI licences distributed by the Department of Health. Between January 2015 and June 2020, 105 MRI applications were received, the majority of these applications were to replace older MRI systems. If you would like more information on these programs go to www.ranzcr.com for additional tables.

Accreditation/reaccreditation assessment

Passed with recommendations

Resubmission (on first submission only)

Sites replaced or terminated machine

For any sites interested in participating in the MQAP or MRI Quality Program please email mqap@ranzcr.edu.au or mri@ranzcr.edu.au

Volume 16 No 4 I September 2020

General Interest

Member Rewards Program Update

Our Member Rewards Program delivers maximum value for your membership subscription fee. You can now access a specially selected, exclusive and valuable rewards program which is only for members. The program has been tailored to your needs— financial, insurance, legal, travel and lifestyle products and services are included.

Get an instant quote or find out the conditions of the offer at www.nobleoak.com.au/ranzcr or phone NobleOak on 1300 108 490 and mention the code ‘RANZCR’.

NobleOak Life Insurance NobleOak is an Australian independent life insurer with more than 140 years’ experience. They believe in bringing members life insurance the way it is meant to be—combining quality, nosurprises cover with personal service and lower premiums.

BUPA Health Insurance Bupa’s goals align with our goals—they are committed to helping people live longer, healthier, happier lives, with a focus on preventative health.

NobleOak has just been announced as the national winner of the prestigious 2020 Canstar Outstanding Value Award for its Premium Life Direct Life cover— for the fifth year in a row.

Bupa Corporate offers considerable health cover savings on members’ corporate private cover. Their aim is to give you better, smarter, and more flexible cover options from day one.

RANZCR members are entitled to a 10 per cent lifetime discount on life insurance products, saving 22 per cent on average compared to other insurers. Plus, take out Life Insurance Cover with NobleOak and receive $20,000 in bonus Life cover.

We have worked together to create an exclusive offer tailored specially for members.

Inside News

Bupa Corporate are offering you: • a four per cent discount on Health Insurance

• the waiving of two and six month waiting periods on selected Extras when you combine Hospital and Extras cover—giving you immediate access to general dental, optical, physiotherapeutic, chiropractic services and more • no waiting periods for services you were covered for with your previous health insurer • a range of other discounts and benefits. We encourage you to compare your health plan with Bupa Corporate’s offer for members. Note that terms and conditions apply. Call 134 135 and quote RANZCR ID# 2133228, or find out more at: www.ranzcr.com/college/memberrewards

To see all of the offers available to members in the Member Rewards Program, please go to our website at: www.ranzcr.com/college/ member-rewards

BREAST MRI & CEM COURSES Course Director:

Dr. Allison Rose Head, The Royal Melbourne & The Womenâ€™s Hospital Once again the Breast MRI & CEM courses are leading the way in innovative course delivery. Now you can enhance your knowledge and skills regardless of travel restrictions. All courses incorporate a comprehensive range of real patient MRI and CEM examinations with pathological correlation.

Further information and updates:

www.tniaustralia.com Kathy Nightingale | Conference Manager +61 418 515 090

DEVELOP YOUR PROFESSION WITH THE QSCAN GROUP The Qscan Group’s growing national network offers Radiologists opportunities for career development and earning potential. By partnering with our doctors, we encourage individual professional aspirations and provide market competitive, flexible avenues to join our team.

Why join the Qscan Group?

• Career opportunity customised in line with your skillsets and ambitions; • The ability to be part of a supportive and strong collegiate doctor network; • The very latest in cutting-edge technology;

• Assured access to a broad clinical case mix including tele-reporting which can provide flexibility or additional hours to expand your earning potential. We currently have opportunities for Radiologists, Nuclear Medicine Physicians and Dual-Trained Radiologists for various regions across Australia. Flexible workloads including private practice, public hospital work and teleradiology are available.

Trusted Analysis | Excellence | Compassionate Care

Qscan Fellowships are also available including: • Hybrid Fellowship - 12 months;

• Sub-specialty Fellowship programmes (Musculoskeletal, Body Imaging, Cardiac/Thoracic imaging, Breast imaging and Paediatric); • Dedicated Nuclear Medicine/PET sub-speciality Fellowship.

Your employment offer with Qscan can include: • Above market-rate remuneration package; • Significant sign-on bonus; • Equity opportunities;

• Relocation assistance.

For more information or a confidential discussion please call our Qscan General Manager, Matthew Bellairs on 0412 939 200 or email matthew.bellairs@qscan.com.au

qscan.com.au