Abstract
Introduction
Cancer has a major effect on the population of Europe. Data available for 2020, shed light about this cancer burden. 1 There were about 4 million new cases and about 1.9 million people have died from this disease in Europe that year. 1 The increased cancer incidence has devastating consequences, not only for families and friends of the affected patients, but also for the countries’ health systems, mainly affecting those countries with lower national incomes. 2
Anti-cancer treatment mainly includes surgery, systemic therapy, and radiotherapy. 3 Radiotherapy is roughly used in 50% of cancer patients in European countries, but with a significant wide variation in the indications for external beam radiotherapy. 4 A detailed analysis in some European countries showed that the use of radiotherapy differs not only by cancer type and stage of the disease, but also by country. 5
Therefore, an increase in cancer cases is therefore directly related to an increase in radiotherapy courses. The number of radiotherapy courses is expected in 2025 to increase by 16% over the 2012 figures. 6 By 2025, it is expected that there will be a sharp increase in treatment courses for prostate cancer (24%), lymphoma, head and neck, and breast cancer, mainly due to the effect of aging. 6 Due to the effect of aging on cancer incidence, by 2025, it is expected that there will be not only a sharp increase in treatment courses for prostate cancer (24%), but also lymphoma, head and neck, and breast cancer. 6 According to population characteristics, these expected increases in radiation treatments will vary widely across European countries. 7 This is due to differences in incidences of some cancers across Europe but very much also based on different access to radiotherapy and structural differences in the healthcare systems across Europe. 7
A proportionate increase in human and technical resources will be needed. The European Society of Radiotherapy and Oncology (ESTRO), through the Health Economics in Radiation Oncology (HERO) project, has dedicated more than a decade, to strictly define the adequate number of staff personnel and technical equipment,8–10 needed to provide high-quality radiation treatments.11,12
This sharp increase in radiotherapy treatments will differ among European countries. There are differences in the number of cases needing radiotherapy4,5 but also there is a wide variation of available Radiation/Clinical oncologist (RO/CO) per million inhabitants in Europe (mean 12.8; range 2.5–30.9). 9 A clinical oncologist is a physician trained in radiation oncology and systemic anti-cancer therapy. 13 The number of courses treated by oncologists (mean 200; range: 99.9–348.8) and the country gross national income (GNI) per capita, will influence staffing needs in different European countries. 9 Radiotherapy treatment is rapidly including new and very advanced equipment, able to provide better patient outcomes in terms of cure and treatment tolerance. 14 ROs/COs have to be aware of these advances and be trained in their use. Value-based radiotherapy 15 is the concept behind the adoption of advanced techniques, taking into account, the threat of higher costs. During their training, future European oncologists have to be provided with tools that allow them to take responsibility for the best use of available technical and human team resources to manage change.
The aim of this review is to summarize the European progress toward harmonized training in Radiation and Clinical Oncology in Europe, under the leadership of the scientific society (ESTRO) and the European Medical Association (UEMS).
The increased cancer burden and need for ROs/COs in Europe
The increased cancer burden demands a new generation of RO/CO that, besides strong evidence-based oncological knowledge, will be ready for the leadership in cancer care. Both, knowledge and leadership, are needed to ensure the best patient´s access to “state of the art” radiotherapy. 16
Training programs in Radiation/Clinical Oncology should, therefore, prioritize the development of leadership skills as they have to take responsibility for leading change. 16 This change in cancer care should be defined by a patient-centered system that should be devoted to quality improvement and the development of safety and efficiency initiatives. The ability to envision, successfully bid for, and develop the resources to deliver care to this increased number of patients as well as to improve patient pathways will require an increase in the recognition of the need for competences in leadership.
The leadership curriculum was developed by an international Delphi survey. 16 A global consensus defined the major areas of leadership in radiation/clinical oncology as: (a) contribute to the improvement of cancer care delivery in teams and wider health systems; (b) engage in the stewardship of cancer care resources; (c) demonstrate elements of leadership in practice.
RO/CO leadership in the context of the ESTRO core curriculum envisages collaboration not being “in charge” of cancer care, especially today, when the multidisciplinary approach to cancer care is widely accepted. 17 The elements of leadership training recommended in the ESTRO curriculum include (a) discuss the context in which they work and apply the principles of change management including quality improvement methodology in this context; (b) use resources appropriately; and (c) demonstrate the ability to work in, build, and lead teams.
Indeed, multidisciplinary team conferences (MDTs) have become routine in clinical practice and also facilitate an optimum treatment itinerary for each individual patient. Therefore, training should not only relate to the own specialty competences, but formal interdisciplinary clinical rotations have to be part of the training program. This “exposure” to other specialties would enhance the value of multidisciplinary meetings and strongly support the leader role of RO/CO in MDTs.18,19
Mutual recognition of professional qualifications of Radiation/Clinical Oncology in the European Union (EU)
In 1975 the named European Commission (EC) already recognized the need for making possible the free movement of professionals within the EC boundaries. Then the European Commission in its Council Directive 75/362/EEC 20 of 16 June 1975 “concerning the mutual recognition of diplomas, certificates and other evidence of formal qualifications in medicine, including measures to facilitate the effective exercise of the right of establishment and freedom to provide services” already recognize mutual professional qualifications only for the specialty of radiotherapy in those member states (Belgium, France, Ireland, The Netherlands, United Kingdom). The Council of the European Community directive 75/363 /EEC of 16 June 1975 “concerning the coordination of provisions laid down by law, regulation or administrative action in respect of activities of doctors” 21 stated 4 years as the minimum training period for radiotherapy in Europe.
In 1993, the European Commission presented the Council Directive 93/16/EEC of 5 April 1993 22 to facilitate the free movement of doctors and the mutual recognition of their diplomas, certificates, and other evidence of formal qualifications. The specialty was named Radiotherapy for countries involved in the EC at that time (Belgium, Denmark, Germany, Greece, France Ireland, Luxembourg, The Netherlands, Portugal, Spain, United Kingdom).
The European Union produced the Council Directive 2005/36/EC 23 “establishes rules according to which a Member State which makes access to or pursuit of a regulated profession in its territory contingent upon possession of specific professional qualifications (referred to hereinafter as the host Member State) shall recognize professional qualifications obtained in one or more other Member States (referred to hereinafter as the home Member State) and which allow the holder of the said qualifications to pursue the same profession there, for access to and pursuit of that profession.”
Therefore, professional qualifications obtained in one EU country are recognized in other EU countries, a qualified professional in one member state is qualified to exercise the same profession in another member state. This directive is related to a regulated profession that “is one where access to, or practice of, a profession is restricted by national law to those holding specific qualifications. Each EU member state decides its own national system of education and training, leading to its own professional qualifications.”
This directive was amended by EU Directive 2013/55/EU 24 for Mutual Recognition of Professional Qualifications. In the Annex V of EU directives 2005/36/EC/ and 2013/55/EU the mutual European recognition of Radiotherapy/Radiation Oncology/Clinical Oncology remained unchanged. The specialty was named radiotherapy and a minimum of 4 years of training was stated.
Unfortunately, the data included in the annex V was not showing the full reality of Radiation/Clinical Oncology in Europe. 18 Data from a survey completed by 28 European countries, revealed that there are 7 countries where radiation oncology is a part of a common oncology specialty, named clinical oncology. Mean training length is 5 years (range 4–7 years) and the number of trainees varied from less than 1 to 6.6 per million inhabitants. 18
Perhaps the most striking result of this very important survey, 18 is again, the wide variation of training characteristics, contents, and evaluation across Europe. Most countries have a national curriculum (93%) that is hospital-based and regulated by national authorities. As in most countries, RO/CO prescribe oncological drugs, 93% of the national programs include competences in medical oncology, and all but three countries have mandatory rotations in medical oncology. For those specialists in clinical oncology, medical and radiation oncology are fully integrated in their training program. Training assessment also varied from logbook continuous assessment (81%) and/or final formal examination (82%).
The need for harmonization. The ESTRO and UEMS efforts toward a European Common Curriculum for RO/CO leadership
As stated above, to provide state-of-the-art cancer care to their citizens, Europe needs well-trained, leadership-oriented RO/CO. The available data depicted a scenario of a wide variation in radiotherapy use, staffing, and training. Harmonization initiatives have been set up in all these three areas.8,9,25
Regarding the mutual recognition of professional qualifications. the EU directives made fully equivalent professional qualifications, acquired with different training programs, length of duration, and evaluation.18,25 Therefore, a harmonization process was needed to ensure a minimum common professional background to European specialists.
The European Union for medical specialties (UEMS)
The European Union of Medical Specialists (UEMS) 26 is the representative organization of 41 National Associations of Medical Specialists in the European Union and its associated countries and represents over 1.6 million medical specialists. UEMS major role is to sets standards for high-quality healthcare practice, propose those standards to the EU and the National Medical Associations and finally to encourage implementation by competent authorities.
One of these major tasks of UEMS, is to provide tools for real harmonization of a high-quality medical training at the European level. Major actions related to this task include setting the basis for European Standards in Medical Training that should be competence-based and fully evaluable through competence assessment mechanisms. 27
The UEMS European Standards in Medical Training have been produced by the continuous work of the different Specialist Sections, European Boards, Divisions, and Multidisciplinary Joints Committees (MJCs). These European Training Requirements (ETRs) would help the National Authorities to provide European harmonized higher quality training. 27
The Radiotherapy/Radiation Oncology Section of the UEMS (also named European Board of Radiotherapy), succeeded in producing important guidelines for training infrastructure 28 and evaluation. 29 The close collaboration between UEMS and ESTRO resulted in their endorsement of the ESTRO Core Curriculum as the ETR for radiation oncology/radiotherapy to apply for the UEMS endorsement to the proposed ESTRO Core Curriculums. This has invaluable importance in the recognition of the Core Curriculum by other specialties related to cancer care, as is accepted and endorsed by all specialties represented in the organization. This European “validation” of the core curriculum, helps national authorities to improve their curriculum and to state the competences of RO/CO in relation to other oncological specialties. The UEMS has endorsed the ESTRO Core Curriculum (ETRs) presented in 2004, 30 2013, 31 and 2019. 32
There is also a wide variation in the training assessment for ensuring that a trainee is ready for independent practice. The UEMS Council for European Specialists Medical Assessment (CESMA) aims to provide recommendations for European examinations for medical specialists. The main objectives of CESMA are the harmonization of the European Board assessments through providing guidelines to the Boards, to encourage take-up of Board assessments as a quality mark and in some cases, as an alternative to National assessments. At the present time, there are European Board Examinations for 34 specialties. 33
The ESTRO core curriculum
The European Society of Radiotherapy and Oncology (ESTRO) was aware of the need for training harmonization across European countries. Therefore, the need for knowledge about cancer care, radiation resources, and training requirements at European level was stated by the Committee on Education within ESTRO in 1985. The Commission produced a first survey disseminated to European national societies involved in radiotherapy in 1986. Questions were related to oncology teaching in medical school, specialty organization, and training. Differences among European countries were very important in all these three issues, but generally speaking, oncology was not an independent subject in medical schools, radiation oncology was the most established oncology specialty and training regulations and programs differed widely among countries. 34
The first ESTRO core curriculum. Acquiring knowledge
Although national authorities would not change rapidly their own training organizations, the political support of student's mobility programs by the European Community 35 made visible the future of free movement of professionals within Europe. Therefore, the task of designing a European Core Curriculum in Radiotherapy seemed worthwhile.
A second questionnaire was disseminated in 1989 with a more detailed questions about the organization and training of the specialty. The results were discussed with national societies representatives and in March 1991 representatives from 22 national radiotherapy societies in Europe officially endorsed the “Minimum Curriculum for the Postgraduate Training of Medical Practitioners in the Modality Radiotherapy Within Europe.” 34
This First ESTRO Core Curriculum in Radiotherapy (1991) defined “Radiotherapy (radiation oncology) as the use by medical practitioners of ionizing radiation, either alone or in combination with other modalities, for the treatment of patients with malignant and other diseases. It can be practiced as an independent oncological specialty or it may be integrated into broader medical practice. Radiotherapy (radiation oncology) includes in a multidisciplinary approach, responsibility for the diagnosis, treatment, follow up and supportive care of the cancer patient.”
The content of the curriculum itself was defined into four main areas related to:
General oncology, Principles of cancer treatment, Therapeutic use of ionizing radiation, Clinical research.
The term “radiotherapy” was adopted, as was the term used in the EC directives 75/362/EEC
20
and 75/363/EEC.
21
Although the term radiotherapy was used, the clinical role of RO/CO was clearly stated in the definition of the specialty, including treatment with oncological drugs. According to the directive 75/363/EEC
21
such training should consist of a minimum of four years full-time theoretical and practical instruction. No evaluation system was proposed in the curriculum.
The second ESTRO core curriculum. Acquiring knowledge and skills
The second ESTRO Core Curriculum in Radiotherapy (Radiation Oncology) 36 was developed by the European Core Curriculum Working Party by an join ESTRO and the European Board of Radiotherapy mandate. The updated European Core Curriculum for Radiotherapists (Radiation Oncologists) was endorsed by representatives of 35 European nations. The updated document, kept the definition of the specialty in the same terms, high lightening the clinical role of specialists in radiotherapy/radiation oncology. It is described for the first time that “Radiotherapy (radiation oncology) can be practiced as an independent oncological specialty or it may be integrated into the broader medical practice of oncology,” thus defining clinical oncology.
The second Core Curriculum contained more specific recommendations for organizational and infrastructural aspects of the teaching departments following the recommendations of the European Board of Radiotherapy
28
of the UEMS. Other major changes in this second core curriculum were:
the curriculum content both in Basic and Clinical sciences of Radiation Oncology. the requirements that each trainee should acquire knowledge (level 1) plus skills (level 2) in the learning topics. the logbook
29
was proposed as an assessment of the training achievements of the trainee. a 5-year duration of training was recommended to acquire the proposed knowledge and skills.
This Core Curriculum was endorsed at European Level by the UEMS.
30
The third ESTRO core curriculum. Acquiring competences
The third ESTRO Core Curriculum in Radiotherapy (Radiation Oncology) 37 was the result of the 2007 ESTRO proposal to revise the core curricula for radiation oncologists, but for the first time also, the curricula for medical physicists and RTTs. The main objective, as in previous editions of the Core Curricula, was to facilitate mobility between EU member states, through a real harmonization of training.
The most important characteristic of these third CC is that, the curricula have been changed from knowledge to competency-based education, including training, teaching methodology, and assessment. Competence-based education must result in a trainee that should be able to adequately perform a medical intervention, through careful integration of acquired knowledge, skills, and attitude. As defined by the CanMEDS system 38 the independent specialist should be competent in medical expertise, communication, collaboration, knowledge/science, health advocacy/social actions, management/organization, and professionalism. This new competence-based training program requires special emphasis on training in a practical environment, competency-based supervision, and consequently, a different method for evaluating the traineés progression as specialist.
The updated third version of the CC for clinicians defined in its first part the role of radiation oncology, the infrastructure, and organizational aspects. The general competencies in the CC using the CanMEDS system are defined in the second part, whereas the third part describes the specific competencies.
One of the most important modifications in the curriculum for clinicians was the emphasis on the role of radiation oncologist in the multimodality approach of treating cancer. The clinical competences to be acquired included the use of drugs concomitant to radiotherapy. All radiation oncologists should have a basic knowledge of medical oncology, being able to recognize and initiate treatment of oncology emergencies and taking clinical responsibility for the delivery of radiation therapy together with systemic agents. New knowledge in radiation treatment techniques or integration of drugs and radiation was also included. 37
The fourth and last part is dealing with the assessment of trainee’s competency in the roles previously described. Evaluation of trainee’s competencies needs:
direct observations in practical situations, mini-CEX evaluations, 360° evaluations, delineation tools and tests like the FALCON project, formal supervision during medical practice or clinical placement.
This third edition was accepted by the National Societies and endorsed by UEMS.
31
The fourth ESTRO core curriculum. Acquiring entrustable professional activities (EPAs), competences, and enabling competences
The fourth edition of the ESTRO Core Curriculum (fourth CC) was published in 2019 39 as an effort to update the training to a new reality. Multidisciplinary in modern cancer care led a need to increase interdisciplinary training of RO/CO and to promote their leader role. The curriculum also took into consideration that in some European countries radiation oncology is practiced as clinical oncology with doctors trained in both medical oncology and radiation oncology.
The process for the 4th CC edition was started in 2017 with a meeting of representatives of European National Societies, Canada, representatives of yESTRO including trainees, and other Radiation Oncology professionals. After multiple iterations of the document for the different groups, this fourth edition of the ESTRO Core Curriculum was endorsed by 29 National Societies. The training program was devoted to educate physicians to become independent specialists in Radiation Oncology/Radiotherapy. A full-time, 5-year training period was strongly recommended.
The aim of the fourth CC is “to describe the minimum competences necessary to deliver ionizing radiation therapy including when this forms part of combined modality treatment with systemic therapies. It is recommended that all radiation oncologists should have sufficient knowledge of systemic therapies to be able to take clinical responsibility for the integration of care of the cancer patient.”
The novelty of this training program is the change from competences to Entrustable Professional Activities, Competences, and Enabling Competences. The curriculum defined the outcomes of training as Entrustable Professional Activities (EPAs) “A key task of a discipline that can be entrusted to an individual who possesses the appropriate level of competence.” 40
The training program included (a) basic sciences learning outcomes. For achieving this learning outcomes in the cognitive domain, trainees require formal teaching provided in national or international courses. (b) Clinical proficiency in treating cancers at different sites expressed as the level of the EPAs, that trainees would be expected to achieve in relation to each tumor site. The level of expected EPAs for different clinical situations, ranges from Level 1 (observation only) to Level 5 (trainee supervises more junior trainees).
This Core Curriculum was endorsed at European Level by the UEMS. 32 Unfortunately, when an audit about implementation of the fourth CC was undertaken a wide variation in the adoption of the curriculum at a national level was observed. 41 The National Societies that endorsed the fourth CC (29 countries) were approached to fill a 37 questions survey and 26 completed it.
Although a major agreement was observed for the contents and values of the 4thCC, there were some barriers in most countries, to the implementation of the program at a national level. National-related barriers were focused in both: (a) the government support and coordination for adequate funding for training faculty members and implementation of the program and (b) the internal organizational support oriented to improve coordination, the faculty’s teaching staff, and influential leadership.
The clinical oncology curriculum
As described above, radiation oncology can be practiced as independent specialty or as a part of a broader specialty named Clinical Oncology36,37,39 and this has been fully endorsed at European level.30–32 Furthermore, the Medical Oncology UEMS ETR 42 defines medical oncology as “a medical specialty concerned with the study, research, diagnosis and medical management of the neoplastic diseases. It may be practiced as an independent oncological specialty or may be integrated in the broader practice of clinical oncology.”
As stated in definitions produced by either radiation oncology or medical oncology ETRs, there is a clear European acceptance that Clinical Oncology includes a broader knowledge than any of the previous specialties. National curriculums in Clinical Oncology are available for all those countries where this is a major (or only) oncology specialty (Croatia, Denmark, Estonia, Finland, Norway, Sweden, UK). 43 These competences are acquired in addition to those related to radiation oncology. Clinical oncologists are, therefore, able to prescribe both treatment modalities either alone or as a combination and are particularly skilled at treating induced side effects. The most important role of the clinical oncologist is to deliver a patient-centered oncological assistance, focused on caring for patients through their whole journey. 43
There was a need for defining a curriculum in Clinical Oncology at the European level, that would be of help to the national curriculums and able to shed light about the role of this important specialty in cancer care in Europe. 44 The UEMS Radiation Oncology Section representatives, met in Las Palmas de Gran Canaria, February seventh-ninth, 2020. This meeting was held to discuss the value and feasibility of developing a clinical oncology curriculum. After several iterations of the document among participants, the draft was improved by the ESTRO Education Council. The Clinical Oncology module was also shared with and endorsed by the National Societies. The Clinical Oncology Module structure was designed, that would allow an easy combination with the 4th CC, enabling clinical oncology trainees to follow only one curriculum. 44
Clinical oncologist are defined 44 as “physicians with the competencies to manage cancer patients with a wide variety of tumor types through the full disease pathway combining the competencies of radiation and medical oncologists. Clinical oncologists safely and effectively deliver and manage patients receiving systemic anti-cancer therapies as well as treatments with ionizing radiation in the curative, neo-adjuvant, adjuvant and palliative settings, either as sole modalities or in combination. Clinical oncologists take part in research using new systemic therapies. They also possess the competencies to focus on symptom control, supportive care, and palliative medicine, when neither modality is appropriate.”
As described in the fourth CC, RO/CO trainees will demonstrate competences in systemic anti-cancer treatment and radiotherapy, so the group developed those additional enabling competencies (not included in the 4th CC), required for the safe and effective practice of clinical oncology. Twenty enabling competences were identified. A minimum training period of 5 years was recommended.
Future initiatives
The existing curricula could be strengthened in future editions by further development of other RO/CO already described CanMed roles as Medical Expert, Communicator, Collaborator, Advocate, Professional & Management areas of expertise.
Indeed, several initiatives to improve, disseminate and carefully evaluate training in radiation/clinical oncology at the European level are ongoing.
The training of Radiation Oncology/Clinical Oncology in relation with other radiological specialties and professionals are included in the EU program: Strategic Agenda for Medical Ionizing Radiation Applications (SAMIRA) adopted in February 2021, “to support a safe, high quality and reliable use of radiological and nuclear technology in healthcare.” The SAMIRA project, included in its action plan, a “service contract for analysis on workforce availability, education, and training needs for the quality and safety of medical applications involving ionizing radiation in the EU (HADEA/2022/OP/0003).” A group of representatives of radiological-related European societies, including ESTRO, are trying to define the acquired expertise in radiation of the radiological professionals in Europe. 45
The training of Radiation/Clinical Oncology in relation to other oncological specialties and professions is analyzed by the INTERACT-EUROPE project. This project aims to “the development of an inter-specialty cancer training program across Europe, involving all main oncology disciplines and professions, cancer centers and patient groups, based on relevant needs assessments. The project is aiming to improve cancer care through the promotion of multidisciplinarity.” 46
The requirement for a leadership role for ROs/COs led to a basic leadership program for professional groups involved with radiation oncology. The FLiRO program implantation has been very successful including participants from 36 countries. 47
The major limitation to this review is that it is oriented to summarize the European progress toward harmonized training in Radiation and Clinical Oncology in Europe, under the leadership of the scientific society (ESTRO) and the European Medical Association (UEMS). No data regarding the actual contents of the training, nor recommendations for future educational programs are provided.
Conclusions
For almost 50 years, European workers’ free-movement rights made necessary the mutual recognition of national qualifications. This mutual recognition was endorsed in several ECC/EU directives from 1975 to 2015. In this directive, Radiation Oncology/Clinical Oncology specialties are named Radiotherapy and 4 years minimum training was recommended.
If qualifications are mutually recognized, the training supporting these qualifications should be also harmonized. Since 1991, ESTRO produced several editions of the Core Curriculum in Radiation Oncology (1991, 2004, 2012, 2019). These Core Curricula were endorsed as European Training Requirements by the UEMS in 2004, 2013, and 2019. A core curriculum for Clinical Oncology was also produced to provide this harmonization tool to countries where radiation oncology is practiced inside the broader specialty of clinical oncology. New initiatives are in place to continuously adapt the training programs to the rapidly evolving cancer care organization.
Footnotes
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Author contributions
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