Pediatric Proton Fellowship

Overview

This is a one-year fellowship program designed to familiarize the trainee with the indications for, techniques of, and results from proton radiation therapy treatment.

Trainees will spend approximately 6 months of the year on clinical radiation oncology services which use proton radiation therapy. Six months of the year will be spent on clinical, physics, or biology research projects related to proton radiation therapy and its use in the pediatric population.

While on clinical service, the fellow will be expected to evaluate new patients under consideration for proton radiation therapy, dictate appropriate consultation notes, present the patient for discussion at Proton Rounds in the Department of Radiation Oncology and at other appropriate multidisciplinary patient management conferences (i.e. Sarcoma Conference, Pediatric Tumor Board, etc.), review diagnostic studies with the attending Radiation Oncologist and specialists from other services (i.e. Pathology, Diagnostic Radiology), and actively participate in the Proton Radiation Therapy treatment planning process.

Currently there are no more than 2 fellows accepted for year-long proton fellowship positions; one fellow is dedicated to pediatrics.

Goals of Fellowship Program

By the end of the fellowship, the pediatric proton clinical research fellow will become adept in:

• The appropriate patient selection for protons
• How patients are referred and brought in for treatment and how to appropriately communicate the plan to referring doctors
• The importance of primary review of the notes, scans, and pathology
• The management of patients and outcome gathering from both clinic visits and distant care management
• The physics of proton radiotherapy and how it differs from photon therapy and will learn critical rules of proton therapy treatment planning based on the characteristics of RBE
• The intricacies of 3D conformal proton radiotherapy and their advantages and limitations
  1. Including patching fields and matching fields
  2. Basic treatment planning rules
  3. Appropriate incorporation of IMRT
  4. In-depth understanding of range uncertainties, effects of set up error and how proton planning differs from photon planning to achieve highly conformal dose distribution
• Patient management within the multidisciplinary team at MGH, which is inclusive of the referring institution and team
• The promise and pitfalls of scanning technologies including universal scanning, pencil beam scanning, and intensity modulation and when apertures or beam modifiers are needed and how target motion affects these
• CMS and ASTROID proton treatment planning manipulation through a 1-month rotation in proton physics

Clinical Activities
Clinical rotations will be weighted toward the beginning of the year to familiarize the fellow with the proton technologies. The research rotations will be more towards the end of the year.

All clinical rotations will be pediatric centered with some elective time with the skull base service, which treats the pediatric chordomas and chondrosarcomas.

Research Opportunities
Scholarly activities and good citizenship are an integral component of the program. To demonstrate mastery of the concepts of proton radiotherapy in children, a review article on the evidence to date supporting proton radiotherapy in children will be written.

In addition to participation in ongoing clinical research protocols, it is also expected that the fellow will develop and complete at least three clinical research projects or manuscripts, one of which must be generated and planned by the research fellow based on a question that has arisen in the clinic.

The fellow is encouraged to draw upon their experience to further enhance the MGH pediatric proton research program. The research fellow is expected to take advantage of the current resources MGH has to offer, including the pediatric clinical research database and data manager, as well as the extensive ongoing prospective collection of Quality of Life data, the many classes offered at MGH through the Clinical Research Program, and the multicenter pediatric proton data registry.

Furthermore (depending on the funding available), some funds may be made available to take up to two classes at the Harvard School for Public Health, or for a clinical correlation study, or for an added research assistant help to answer a targeted research question not already collected and present in the databases.

Two of the three projects may be chosen from a list of broad project ideas below, but all three may be from the fellow specific research interests and require approval from the pediatric MD research team (Yock, MacDonald, Tarbell).

Possible studies:

• Patterns of care study
• Understanding the circumstances where scanning is technologies improve upon 3D conformal technologies
• Comparative study of CMS and Eclipse capabilities with a pediatric H and N cancer, brain tumor, and CSI
• Pediatric QoL, (correlating with disease, neuropsych, socioeconomic status)
• Incorporating imaging to answer a pressing problem (ie perfusion, PET, functional MRI)
• Correlating dose to critical structures and outcomes (ie hippocampal irradiation dose response and memory tests on neurocognitive evaluation)
• Pediatric second tumor rates after protons, match control comparison with SEER
• Measuring functional outcomes in the pediatric sarcoma patient population
• Dosimetric comparison studies within COG and MGH
• Cross proton center study of a specific rare disease (ie pediatric esthesioneuroblastoma)
• QA measures in pediatric proton plans
• Comparison of capabilities across protons centers
• Cost effectiveness research

National Meetings
We will make every effort to make funds available to support fellow travel to a national oncology meeting. Additional funds will be sought for presentation of research finding arising from their research projects.

Fellow Evaluation
Evaluation will be provided in two formats:

• Informal, ongoing evaluation throughout the individual rotations: Fellow will receive and be expected to become familiar with the goals of the fellowship Staff will offer ongoing input, feedback, and encouragement to the resident so that the fellow and staff can assess whether performance expectations are being met. This process should begin immediately upon the start of the rotation, to maximize opportunities for interventions if performance deficits are noted. If staff recognizes performance deficits, this should be communicated to the fellow on the service and, in conjunction with the fellowship director, corrective action(s) should be instituted.

• Formal written evaluation: Departmental fellowship review form to be completed by staff at the completion of the rotation. The program director will meet with fellow at least twice yearly to discuss, as well as provide career counseling and obtain feedback from the fellow about the program and faculty. The program director will ensure that teaching faculty evaluate the trainees in writing at least twice yearly and provide frequent, timely verbal feedback. The program director will keep a file of written evaluations on each trainee.

Teaching Experience Evaluation
Fellows will be asked to comment on their learning experience on the rotation and communicate this information to the fellowship director through a formal evaluation instrument.

Vacation
Three weeks of vacation time are allotted for the fellows. Sick leave and parental leave will be allotted according to Mass General Brigham policies for residents.

Service and On-Call Responsibilities
Fellows are not scheduled to take evening, night, or weekend call but are expected to be available to see patients during the treatment day at the Proton Center (currently 7:30 am-5:30 pm) on an as-needed basis.

Fellows are expected carry a beeper and be available for paging during this time period.

During the research elective, fellows may be asked to periodically check a patient’s on-treatment set-up; if called to do so, this is expected to occupy no more than 2 hours per day.

Appropriate cross cover arrangements (i.e. by the other proton fellow, radiation therapy resident, or radiation therapy staff) with the approval of the Medical Director of the Proton Center can be arranged to allow for uninterrupted periods during which fellows may be engaged in research projects or other clinical pursuits.

The program director will ensure that the educational process is not undermined by excessive service requirements and that appropriate back-up and supervision are provided at all times.

Moonlighting is allowed with approval of the Medical Director, provided it does not interfere with the responsibilities outlined above.

Written Contract
The standard Mass General Brigham contract will be amended as necessary to reflect specifics of the fellowship program. A contract should be signed by each fellow each year. A copy of the contract should be provided to applicants no later than the time that they are offered a position.

Position Funding
The pediatric clinical proton research fellowship is currently funded by grant funds, corporate funding, departmental funds, or some combination thereof. No fellow will be accepted without sufficient funding to cover the anticipated costs for that fellow’s fellowship year.

Curriculum

Educational Content and Didactic Activities

The resident will spend their clinical rotation on the particular proton radiation therapy service, working closely with radiation oncology specialty board-certified, attending radiation oncology staff involved in the care of these patients. The attending physicians will supervise the fellow directly as they see selected in-patient consultations as well as selected outpatient new patient consultations in the Radiation Oncology and the combined modality, multidisciplinary clinics. Selected follow-up patients who provide appropriate education opportunities for the fellow will also be seen. Supervision and teaching during these clinic sessions will include review of the patient presentation, discussion about patient work-up, review, and discussion of pertinent imaging, discussion, and formalization of a treatment plan.

The fellow will see patients weekly during their radiation therapy and be available at other times during the week to see patients experiencing treatment-related complications. Fellows will be expected to work with residents and students on the clinical service, offering guidance and teaching to the more junior trainees based upon the greater clinical experience of the fellow. Patient assignment will be based upon departmental guidelines that recognize the other demands on and responsibilities of the fellows, such as treatment planning and time for reading and study.

Treatment planning will be performed by the fellow in selected cases with direct supervision by the attending radiation oncologist. This will include discussion of the type of treatment immobilization, discussion of the appropriate CT treatment planning technique (intravenous, oral, and or intrathecal contrast, slice thickness, anatomic region and appropriate margins to be scanned), acquisition and fusion of additional tumor imaging (PET, MRI), contouring of the clinical target volumes, and in-depth review of the target volumes, target dose prescriptions, and normal tissue constraints with the attending radiation oncologist.

Didactic activities will include one-hour morning teaching conferences in the Department of Radiation Oncology (Monday, Wednesday, Thursday), one-hour chart Rounds on Tuesday morning, weekly Proton Rounds on Tuesday morning and the monthly pediatric tumor board, monthly journal clubs, as well as multiple subspecialty tumor boards and teaching conferences.

Teaching can be formally divided into:

• Faculty precepting, one-on-one, as patients are evaluated, planned, and treated.
• Conferences: Fellows are expected to attend and participate in regularly scheduled teaching conferences on the assigned clinical service.
• Individual study: Pertinent references will be provided to fellow by staff.

Fellow is expected to read:

• Chapter(s) in appropriate Radiation Oncology textbooks on Proton Radiation Therapy as well as in Pediatric Radiation Oncology.
• Literature reprints of references provided to fellow by staff. These will change frequently as the literature evolves. The fellow will be expected to also do appropriate literature searches as well as is clinically needed or needed for their research project.

How to Apply

Selection Process

Fellowship applicants will submit a letter of interest and their CV. These will be reviewed by the Fellowship Director, Medical Director of the Proton Center, and Radiation Oncology Senior Executive Committee.

Applications must be received by December 1 of the year prior to initiation of training. The application review and selection process are expected to be completed by April 1 of the fellowship year.

Three letters of recommendation from their residency program director and faculty members will be required for review.

The most promising candidates will be scheduled for a visit to the facility to meet with the fellowship director and radiation oncology proton staff.

Fellows will be offered a training fellowship position based upon the assessments of the fellowship director, the radiation oncology proton staff, and the Radiation Oncology Senior Executive Committee.

The selection criteria will include the qualifications of the trainee as evidenced by performance during residency training, publication record, level of interest, and anticipated level of clinical and academic performance by the fellow.

Mass General Brigham and Harvard guidelines for diversity consideration will be followed.

Prior to the initiation of the fellowship position, fellows must have completed an approved Radiation Oncology Residency Program. For trainees from outside the United States, successful completion of USLME 1, 2, and 3 and acquisition of at least a limited medical license in Massachusetts are required for their credentialing and for their contract to be in force.