Guidelines

for

Competency Based Training Programme

in

DNB- Radio Therapy and Oncology

(FINAL Version)

NATIONAL BOARD OF EXAMINATIONS

Medical Enclave, Ansari Nagar, New Delhi-110029, INDIA
Email: mail@natboard.edu.in Phone: 011 45593000

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 CONTENTS

INTRODUCTION

OBJECTIVES OF THE PROGRAMME

Programme goal
Programme objective

ELIGIBILITY CRITERIA FOR ADMISSION

TEACHING AND TRAINING ACTIVITIES

SYLLABUS

COMPETENCIES

THESIS & THESIS PROTOCOL

LOG BOOK

NBE LEAVE GUIDELINES

EXAMINATION –

FORMATIVE ASSESSMENT
FINAL THEORY & PRACTICAL

RECOMMENDED TEXT BOOKS AND JOURNALS

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PROGRAMME GOAL

The students after successful completion of their training should be able to provide
 Comprehensive cancer care and empowered for the future development of
the specialty.
 The main goal of the radiation oncology residency programme is to produce
radiation oncologists with the necessary knowledge, skills and attitude to
prevent diagnose and manage various cancers. As a result of training in
radiation oncology, the resident should become competent in the use of the
various radiation equipments, techniques, treatment planning, radiation dose
prescription, treatment verification, treatment delivery;
chemotherapy,immunotherapy administration and management of related
complications.
 In order to be considered a competent radiation oncologist, a resident must
possess humanistic qualities, attitude and behavior necessary for the
development of appropriate patient-doctor relationship.
 Has acquired skills in effectively communicating with the patient, family and
the community.

PROGRAMME OBJECTIVES

Postgraduate students should be well conversant and trained in:

1. Specialized oncology care pertaining to the needs of cancer

patients.
2. The management of cancers prevalent in Indian subcontinent.
3. Knowledge and application of genetic and Molecular Oncology
and Cell biology.
4. Knowledge of Clinical Radio biology and Radiation pathology.
5. Basic knowledge ‘research methodology’ enabling him/her to
develop, conducts and interprets clinical trial and investigations.

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 6. Delivery of radiation and in-depth technical knows how of
equipment as well as physics and sequelae related to
radiotherapy and oncology.
7. Exposure to epidemiology including relevant statistical methods
used in analysis of clinical data, Descriptive and Analytical
Epidemiology.
8. Technical skill in the use of cytotoxic agents for treatment of
cancer.
9. Familiarity with role of surgery in management of oncological
cases.
10. Planning and setting up specialty department of radiotherapy and
oncology and interaction with government machinery.
11. Information Technology in Oncology
12. Pediatric Oncology
13. Geriatric Oncology
14. Palliative Oncology and care of Terminally ill cancer patients.
15. Knowledge of medical education technology for training of
undergraduate and paramedical staff.

Communication Skills:

 Demonstrate communication skills of a high order in explaining management and

prognosis, providing counseling and giving health education messages to
patients, families and communities

 Develop communication skills not only to word reports and professional opinions
but also to interact with patients, relatives, peers and paramedical staff.

 Patient –Doctor relationship

16. National Programmes- Knowledge of National and International programmes

like WHO ,UICC,AJCC etc

At the end of 3 years of post graduate training, a resident must acquire knowledge and
skill as a result of training under the resident education program syllabus which includes
the following:

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1. Basic sciences related to Oncology
Anatomy
Physiology
Biochemistry
Pathology and Radiation Pathology
Radiation Physics
Clinical Radiobiology
Statistical basis for planning and interpretation of clinical trials

2. Principles of Oncology
Etiology and pathogenesis of cancer
Epidemiology of Cancer
Cancer screening and prevention
Cancer Registries and National Cancer Control Programme
Cancer Chemotherapy
Cancer Biotherapeutics
Imaging in oncology
Pharmacogenomics

3 Clinical Radiotherapy
4 Chemotherapy and targeted Therapy in Management of Malignancies
5 Other Disciplines allied to Radiotherapy and Oncology
6 Palliative Care
7 Research, Training and Administration

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ELIGIBILITY CRITERIA FOR ADMISSIONS TO THE PROGRAMME

(A) DNB Radiotherapy and Oncology Course:

1. Any medical graduate with MBBS qualification , who has qualified the
Entrance Examination conducted by NBE and fulfill the eligibility criteria
for admission to DNB Broad Specialty courses at various NBE accredited
Medical Colleges/ institutions/Hospitals in India is eligible to participate in
the Centralized counseling for allocation of DNB Radiotherapy and
Oncology seats purely on merit cum choice basis.

2. Admission to 3 years post MBBS DNB Radiotherapy and Oncology

course is only through Entrance Examination conducted by NBE and
Centralized Merit Based Counseling conducted by National Board of
Examination as per prescribed guidelines.

(B) DNB (Post diploma) Radiotherapy and Oncology Course:

1. Any medical graduate with MBBS qualification who has successfully

completed DMRT (and fulfill the eligibility criteria for admission to DNB
(Post Diploma) Broad Specialty courses at various NBE accredited
Medical Colleges/ institutions/Hospitals in India is eligible to participate
in the Centralized counseling for allocation of DNB (Post Diploma)
Radiotherapy and Oncology seats purely on merit cum choice
basis.

Admission to 2 years post diploma DNB Radiotherapy and Oncology _ course

is only through PDCET Centralized Merit Based Counseling conducted by
National Board of Examination as per prescribed guidelines.

Duration of Course :

For Primary candidates : 3 years

For Secondary Candidates : 2 years

Every candidate admitted to the training programme shall pursue a regular

course of study (on whole time basis) in the concerned recognized institution
under the guidance of recognized post graduate teacher for assigned period of
the course.

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TEACHING AND TRAINING ACTIVITIES

The fundamental components of the teaching programme should include:

1. Case presentations & discussion- once a week
2. Seminar – Once a week
3. Journal club- Once a week
4. Grand round presentation (by rotation departments and subspecialties)-
once a week
5. Faculty lecture teaching- once a month
6. Clinical Audit-Once a Month
7. A poster and have one oral presentation at least once during their training
period in a recognized conference.

The rounds should include bedside sessions, file rounds & documentation of case
history and examination, progress notes, round discussions, investigations and
management plan) interesting and difficult case unit discussions.

The training program would focus on knowledge, skills and attitudes (behavior), all
essential components of education. It is being divided into theoretical, clinical and
practical in all aspects of the delivery of the rehabilitative care, including methodology of
research and teaching.

Theoretical: The theoretical knowledge would be imparted to the candidates through

discussions, journal clubs, symposia and seminars. The students are exposed to recent
advances through discussions in journal clubs. These are considered necessary in view
of an inadequate exposure to the subject in the undergraduate curriculum.

Symposia: Trainees would be required to present a minimum of 20 topics based on the

curriculum in a period of three years to the combined class of teachers and students. A
free discussion would be encouraged in these symposia. The topics of the symposia
would be given to the trainees with the dates for presentation.

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Clinical: The trainee would be attached to a faculty member to be able to pick up
methods of history taking, examination, prescription writing and management in
rehabilitation practice.

Bedside: The trainee would work up cases, learn management of cases by discussion
with faculty of the department.

Journal Clubs: This would be a weekly academic exercise. A list of suggested Journals
is given towards the end of this document. The candidate would summarize and discuss
the scientific article critically. A faculty member will suggest the article and moderate the
discussion, with participation by other faculty members and resident doctors. The
contributions made by the article in furtherance of the scientific knowledge and
limitations, if any, will be highlighted.

Research: The student would carry out the research project and write a thesis/
dissertation in accordance with NBE guidelines. He/ she would also be given exposure
to partake in the research projects going on in the departments to learn their planning,
methodology and execution so as to learn various aspects of research.

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SYLLABUS
Structure:

1) Basic Sciences
a. anatomy and Physiology as related to Radiation oncology
b) Cancer Pathology
c. Radiation Physics
d. Radiobiology
e. Statistical basis for planning & interpretation of clinical trials.
2) Clinical Radiotherapy
3) Clinical Cancer Chemotherapy
4) Other disciplines allied to Radiotherapy and Oncology
5) Preventive and community oncology
6) Palliative care
7) Training
8) Administration

BASIC SCIENCES

ANATOMY

 Knowledge of surface anatomy pertaining to Oncology

 Detailed knowledge of the all organs
 Detailed knowledge of the lymphatic system of all organs-regions
 Practical familiarity with the radiographic appearance of important regions (living
anatomy)
 Cross sectional anatomy

CELL BIOLOGY
 The cell: structure and function
 Relative radio sensitivity of nucleus and cytoplasm
 Mitosis, cell cycle
 Principles of DNA, RNA and protein synthesis
 Radiation effects on DNA, strand breakage and repair

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  Common molecular biology techniques.

TUMOR PHYSIOLOGY
 Angiogenesis
 Microenvironment
 Hypoxia and Re oxygenation
 Cell proliferation in tumor that is cell cycle and cell cycle control
 Proliferation and cell death
 Tumor heterogeneity metastasis

PATHOLOGY

 Definitions of & distinction between different types of growth disorders (i.e;

distinction between hyperplasia, hypertrophy, regeneration, malformations and
neoplasia.
 Malignant transformation:
o Initiation and promotion stages of carcinogenesis.
o Mode of origin – monoclonal, polyclonal, unifocal, multifocal structural and
o Functional changes in cellular components.
 Etiology of cancer including genetic predisposition & congenital syndromes
chromosomal abnormalities & hereditary tumors, Protooncogenes, oncogenes,
tumor suppressor genes & viruses in the causation of malignancy.
 Multifactorial causation including Nutritional aspects in cancer causation and
prevention

 Environmental causes of cancer:

Biological – protozoal, bacterial, viral

Chemical – classes of carcinogenic chemicals, smoking
Physical – trauma, irradiation (UV rays, other electromagnetic radiation including, X-
rays and gamma rays and particulate radiation)
Common occupational cancers & experimental tumors in animals relationship to
human mutagenicity.

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 Etiology, mechanisms of carcinogenesis, known types of carcinogens & their
effects upon the cell.
 The relative importance of different factors in the causation and spread of
human cancer including :
1. Rate of tumor growth
2. Methods of measurement
3. Factors affecting growth rate
4. Mechanisms of spread
5. Local effects of tumors
6. Local & systemic reactions to tumors
7. Effects of therapy on tumors & normal tissues

 Criteria for tumor diagnosis macroscopic, histological & cytological uses & value
of biopsy material.

 Apoptosis and cell signaling pathways

 Mechanisms of spread

 Local effects of tumors

 Local & systemic reactions to tumors

 Effects of therapy on tumors & normal tissues

 Tumor Markers

 Tumor Immunology

 Cytogenetics, Molecular Pathology and Immunohistochemistry

 Classification of tumors – histogenic, histological, behavioral & immunological

nomenclature – solid tumors, lymphoproliferative disorders
 Structure & organization of tumors- vascular supply, stroma etc.
 Systems of grading Endocrine aspects of malignancy:
 Production of hormones by tumors, effect of hormones on tumors,
 Paracrine effects of tumors Paraneoplastic syndromes.
 Tumor Immunology including organization & development of the immune system
and the role response in disease,
 cellular basis of immunity & measurement of immune function,

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  Graft versus host reaction, tumor immunity,
 Tolerance, enhancement, Immune surveillance hypothesis
 Immunological markers in diagnosis & monitoring, the I ILA systems & molecular
biology for diagnostic and therapeutic purposes.

PRINCIPLE OF ONCOLOGY

 Genetic pre disposition

 Congenital syndrome
 Chromosomal abnormalities
 Hereditary tumors
 Protooncogenes ,Oncogenes And Tumor Suppressor genes
 Multifactorial causation
 Nutritional aspects in cancer causation and prevention.
 Environmental causes of cancer
 Biological - protozoal, bacterial, viral
 Chemical - Classes of carcinogenic chemicals, smoking
 Physical - trauma, irradiation (UV rays, other electromagnetic radiation including
X rays and Gamma rays and particulate radiations)
 Occupational cancers.

RADIATION PHYSICS/RADIATION ONCOLOGY PHYSICS

 The aim of this subject is to provide the Oncologist with the knowledge of physics
required in clinical practice.
 An understanding of the principles of planning & carrying out treatment is a
necessary prerequisite & will be enhanced by the study of this subject.
 A familiarity with the physics of electromagnetic radiation and atomic structure
will be required.

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 With respect to their implications for accurate dose delivery in clinical radiation
therapy, applicability, limitations, advantages & disadvantages of the various
devices & techniques should receive particular attention.
 Candidates should be encouraged to observe & gain practical experience with
the equipment & techniques used in radiotherapy in clinical oncology
departments.
 Structure of Matter:
1. Constituents of atoms,
2. Atomic and mass numbers,
3. Atomic and mass energy units,
4. Electron shells,
5. Atomic energy levels,
6. Nuclear forces,
7. Nuclear energy levels,
8. Electromagnetic radiation,
9. Electromagnetic spectrum,
10. Energy quantization,
11. Relationship between Wavelength,
12. Frequency
13. Energy Nuclear Transformations: Natural and artificial radioactivity, Decay
constant, Activity, Physical, Biological and Effective half-lives, Mean life, Decay
processes, Radioactive series,

 Radioactive equilibrium Production of X-rays :

1. The X-ray tube,
2. Physics of X-ray production,
3. Continuous spectrum,
4. Characteristic spectrum,
5. Efficiency of X-ray production,
6. Distribution of X-rays in space,
7. Specifications of beam quality,
8. Measurement of beam quality,

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 Filters and filtration Interaction of radiation with matter:
1. Attenuation, Scattering,
2. Absorption,
3. Transmission,
4. Attenuation coefficient,
5. Half Value Layer (HVL),
6. Energy transfer,
7. Absorption and their coefficients.
8. Photoelectric effect,
9. Compton Effect, Pair production Relative importance of different attenuation
processes at various photon energies Electron interactions with matter

 Energy loss mechanisms –

1. Collisional losses,
2. Radioactive losses,
3. Ionization,
4. Excitation,
5. Heat production,
6. Delta rays,
7. Polarization effects,
8. Scattering,
9. Stopping power
10. Absorbed dose,
11. Secondary electrons.

 Interactions of charged particles:

1. Ionization vs. Energy,
2. Stopping Power,
3. Linear Energy Transfer (LET),
4. Bragg curve,
5. Definition of particle range.
6. Measurement of radiation: Radiation Detectors: Gas, Solid – state, Scintillation,
Thermo luminescence, Visual Imaging (Film, Fluorescent screens), and their

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 examples. Exposure, Dose, Kerma: Definitions, Units (Old, New), Inter-
relationships between units, Variation with energy and material.
 Measurements of exposure (Free air chamber, Thimble chamber),
 Calibration of therapy beams:
1. Concepts,
2. Phantoms,
3. Protocols (TG 21, IAEA TRS- 398, TG 51)
4. Dose determinants in practice (brief outline only, details not required)

 Radiotherapy Equipment:
1. Grenz rays,
2. Contact,
3. Superficial, Orthovoltage or Deep therapy,
4. Super voltage,
5. Megavoltage therapy.

 Therapy and diagnostic X-ray units – comparison. Filters, factors affecting output.
Co-60 units :
1. Comprehensive description of the unit,
2. Safety mechanisms,

Source capsule Linear accelerators,

 Source capsule Linear accelerators :
1. History,
2. Development,
3. Detailed description of modern Dual mode linear accelerator,
4. Linac head and its constituents ,
5. Safety mechanisms,
6. Computer controlled linacs,
7. Record and Verify systems.
 Relative merits and demerits of Co-60 and linac units.
 Simulators:
1. Need for them,
2. Detailed description of a typical unit,

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 3. Simulator CT. Dose distributions,
4. Beam modifications and shaping in Teletherapy beams.
 Characteristics of photon beams:
1. Quality of beams,
2. Difference between MV and MeV,
3. Primary and scattered radiation.
 Percentage depth dose, Tissue-Air Ratio, Scatter Air Ratio, Tissue-Phantom
Ratio, Tissue Maximum Ratio, Scatter Maximum Ratio, Back Scatter Factor,
Peak Scatter Factor, Off-Axis Ratio, Variation of these parameters with depth,
filed size, source-skin distance, beam quality or energy, beam flattening filter,
target material. Central axis depth dose profiles for various energies

 Equivalent square concept, Surface dose (entrance and exit), Skin sparing effect,
Output factors.
 Practical applications:
1. Co-60 calculations (SSD, and SAD technique),
2. Accelerator calculations (SSD, and SAD technique)
3. Beam profiles Isodose curves,
4. Charts,
5. Flatness,
6. Symmetry,
7. Penumbra (Geometric, Transmission, and Physical),
 Field size definition Body inhomogenities
1. Effects of patient contour,
2. Bone, Lung cavities,
3. Prosthesis on dose distribution
4. Dose within bone / lung cavities,
5. Interface effects, Electronic disequilibrium

 Wedge filters and their use, Wedge angle, Wedge Factors, Wedge systems
(External, In built Universal, Dynamic / Virtual), Wedge Isodose curves
 Other beams modifying and shaping devices:
1. Methods of compensation for patient contour variation and / or tissue
inhomogeniety– Bolus,

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2. Buildup material,
3. Compensators,
4. Merits, and Demerits of beam modifying devices

 Shielding of dose limiting tissue :

1. Non-divergent and divergent beam block,
2. Independent jaws,
3. Multileaf collimators,
4. Merits and Demerits

Principles of Treatment Planning

 Treatment planning for photon beams: ICRU 50 an NCAP terminologies.
Determination of body contour and localization: Plain film, Fluoroscopy, CT, MRI
, Ultrasonography, PET CT
 Simulator based. Methods of correction for beam’s oblique incidence, and body
Inhomogeneties
 SSD technique and isocentric (SAD) technique: Descriptions and advantages of
SAD technique
 Combination of fields:
1. Methods of field addition,
2. Parallel opposed fields,
3. Patient thickness vs. Dose uniformity for different energies in a parallel
opposed setup,
4. Multiple fields (3 fields, 4 field box and other techniques).
5. Examples of above arrangements of fields are SSD and SAD techniques,
Integral Dose. Wedge field technique, Rotation Therapy (Arc, and Skip),
Tangential fields. Beam balancing by weighting. Total and hemi-body
irradiation. Field junctions. Limitations of manual planning.

 Description of a treatment planning system (TPS):

1. 2D and 3D TPS
2. Beam data input,

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 3. Patient data input (simple contour, CT, MR data, Advantages of transfer
through media)
4. Input devices Digitizer, floppies, DAT devices, Magneto-optical disks, direct
link with CT, MR)
 Beam selection and placement, Beam selection and placement, Beam’s Eye
View (BEV),
 Dose calculation and display (Point dose, Isodose curves, Isodose surfaces,
Color wash).
 Plan optimization
 Plan evaluation tools:
1. Dose volume Histograms (Cumulative and Differential),
2. Hard copy output,
3. Storage and retrieval of plans.
 Alignment and Immobilization:
1. External and internal reference marks,
2. Importance of Immobilization methods (Plaster of Paris casts, Perspex casts, bite
block, shells, head rests, neck roll, Alpha-Cradles. Thermoplastic materials,
polyurethane foams
3. Methods of beam marks, and front / back pointers

Treatment execution: Light field, Cross hair, ODIs, Scales in treatment machines.
Treatment verification : Port films,
 Electronic portal imaging devices,Invivo patient dosimetry (TLD, diode detectors,
MOSFET, Film, etc) Changes in patient position, target volume , and critical
volume during course of treatment. Electron Beam
 Therapy Production of electron beams:
1. Production using accelerators
2. Characteristics of electrons
3. Surface dose,
4. percentage depth dose,
5. beam profiles,
6. Isodose curves and charts,
7. Flatness and Symmetry.
8. Beam collimation,

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9. variation of percentage depth dose and output with filed size, and SSD, photon
contamination

 Energy spectrum, Energy specifications, variation of mean energy with depth.

 Suitability of measuring instruments for electron beam dosimetry Treatment
planning:
1. Energy and field size choice,
2. air gaps, and obliquity,
 Tissue in- homogeneity : lung, bone, air filled cavitites. Field junctions (with either
electron or photon beam). External and internal shielding. Arc therapy, Use of
bolus in electron beam.

 Total Skin Electron Irradiation, Intraoperative Radiation therapy.

 Physical Principles of Brachytherapy:
1. Properties of an ideal brachytherapy source,
2. Sources used in brachytherapy: Ra-226, Cs-137, Ir-192, Au-198, Co-60, I-125,I-
131 ,P-32,Sr-90, Yt-90, Ru-106, Ta-182 and other new radionuclides.
3. Therapy with Unsealed sources
4. Complete physical properties of all the sealed and unsealed sources.
5. Radiation hazards
6. Source construction including filtration, comparative advantages of these
radionuclides
 Historical background.
 Radiation and Dose units:
1. Activity used, Exposure, Absorbed dose, mg-hr, curie, milli-curie destroyed,
milligram Radium equivalent, Roentgen, Rad, Gray.
2. Source strength specification, Brachytherapy Dose calibrator
3. Technique: Preloaded, after loading (manual and remote),
4. Merits and Demerits.
5. Surface, Interstitial, Intracavitary, Intraluminal, Intravascular , Systemic
brachytherapy , Low, Medium, High and Pulsed Dose Rates.
 Remote after loading machines.
 Dosage Systems: Manchester System, Paris System Treatment Planning:
Patient selection, Volume specification, Geometry of implant, Number, Strength

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 and Distribution of radioactive sources, Source localization, Dose calculation,
Dose rate specification, Record keeping ICRU 38.
 Radiation Safety: Planning of brachytherapy facility, Rooms and equipment,
Storage and `Movement control, Source inventory, Disposal, Regulatory
requirements Beta-ray brachytherapy including methods of use, inspection,
storage and transport of sources, dose distribution
 Unsealed Radionuclides: Concepts of uptake, distribution and elimination,
Activities used in clinical practice, Estimation of dose to target tissues, and critical
organs, Procedures for administering radionuclide to patients
 Quality Assurance in radiotherapy.(QART) Overview of QART:
1. Need for quality system in Radiotherapy,
2. Quality system: Definition and practical advantages, Construction, Development
and implementation of a Quality system
3. Quality Assurance of simulator/CT simulator Co-60, Linear Accelerator
Acceptance testing of Simulator, TPS, Co-60, Linear Accelerator
 Radiation Protection and Regulatory Aspects: Statutory Framework
1. Principles underlying International Commission on Radiation Protection (ICRP)
recommendations, ICRP and National radiation protection
a. i.e; Atomic Energy Regulatory Board (AERB) standards. Effective dose
limits (ICRP and AERB)
2. Protection mechanisms: Time, Distance and Shielding.
3. Permissible doses for Radiation workers and Public including Pregnant Women.
 Concept of “As low as Reasonably Achievable” (ALARA) Personnel and Area
Monitoring; Need for personnel monitoring, Principles of film badge, TLD badge
used for personnel monitoring. Pocket dosimeter
 Need for area monitoring, Gamma Zone monitors, Survey meters Regulatory
aspects and Calliberation.
 Procedural steps for installation and commissioning of a new radiotherapy
facility (Teletherapy and Brachytherapy). Approval of Standing Committee on
Radiotherapy Development Program.
 Type approval of unit. Site plan, Layout of installation / Associated facility:
Primary, Secondary barriers, leakage and scattered radiation. Regulatory
requirement in procurement of teletherapy / brachytherapy source(s).

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 Construction of building, qualified staff, Procurement of instruments, and
accessories, installation of unit and performance tests. Calibration of unit,
AERB/DRP approval for clinical commissioning of the unit.
 Other regulatory requirements: Regulatory consent, NOCs, Periodical reports to
AERB and Radiological Physics and Advisory Division (RP & AD) , Bhaba Atomic
Research Centre (BARC)
 Conformal radiotherapy (CRT): Principles, Advantages over conventional
methods, Essential requirements for conformal radiotherapy.
 Various methods of CRT:
1. With customized field shaping using conventional coplanar beams.
2. Multiple non-coplanar MLC beams conforming to target shape.
3. Stereo tactic radiotherapy
 Principle of inverse planning and Intensity Modulated Radiation Therapy (IMRT)
1. Using 3D compensator
2. Static IMRT (Step and Shoot technique)
3. Dynamic IMRT (sliding window technique)
4. Dynamic arc IMRT
5. Micro –MLC
6. Tomotherapy methods
7. Time gated (4D) radiotherapy
8. Merits and demerits of IMRT

Stereo tactic irradiation methods:

 Physics Principles,
 Techniques,
 Description of units
 1.Gamma Knife
 Linac based
 3.Cyber Knife
 4.Tomotherapy
 Stereo tactic Radio surgery (SRS) and Stereo tactic Radiotherapy (SRT),
Stereo -tactic body Radio therapy (SBRT).
 Merits and demerits

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  Networking in radiotherapy: Networking of planning and treatment units in
radiotherapy department including Picture Archival Communication
System (PACS), Advantages.

 Patient Data Management, Oncology information systems(OIS)

High LET Radiation

Comparison and contrast with low LET radiation.
Neutron source (including 252 Cf) and Boron Capture Neutron Therapy (outline only).
Advantages and disadvantages of neutrons, RBE values, hazards of low dose and low
energy neutrons, RBE values, hazards of low dose and low energy neutron, use in
radiotherapy, combination with low LET, current clinical results.
Other high LET particles: protons, high energy heavy nuclei, application to radiotherapy,
current clinical results.

RADIOBIOLOGY AND APPLIED RADIOBIOLOGY

 Introduction to Radiation Biology
 Radiation interaction with matter
 Types of radiation, excitation and ionization.
 Radiation chemistry: direct and indirect effects, free radicals, oxygen effect and
free radical scavengers, LET and RBE theory, dual action theory, intracellular
repair, general knowledge of repair models.
 Introduction to factors influencing radiation response.
 Physical factors: dose, dose quality, dose rate, temperature Chemical factors:
Oxygen, radio sensitizers, radio protectors
 Biological factors: type of organism, cell type and stage, cell density and
configuration, age, sex.
 Host factors: Partial or whole body exposure.
 Relevance of radiation biology to radiotherapy
 Interaction of ionizing radiation on mammalian cells.
 The cell: structure and function; relative radio sensitivity of nucleus and
cytoplasm, mitosis, cell cycle, principles of DNA, RNA and protein synthesis,

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 radiation effects on DNA, strand breakage and repair, common molecular biology
techniques.
 Cell injury by radiation: damage to cell organelle like chromatids, chromosomes;
interphase death, apoptosis, mitotic death, micronucleus induction, SLD, PLD
 Oxygen effect: mechanism, hypoxia, OER, reoxygenation in tumors, significance
in radiotherapy.
 Dose rate
 Brachytherapy sources including sealed and unsealed sources.
 Radiobiology of low, high dose rate & pulsed brachytherapy, hyper fractionation,
significance in radiotherapy.
 Effects of low LET and high LET radiation on cell.
 Cell survival curves.
 Effect of sensitizing and protective agent.
 Dose modifying factors and their determination. Variation of response with
growth and the progression of cell through the phases of cell cycle. Physical
factors influencing cell survival
 Relative biological effectiveness (RBE); its definition and determination,
dependence upon linear energy transfer, dose, dose rate and fractionation.
 Hyperthermic and photodynamic injury
 Biological hazards of Radiation; Stochastic and Non Stochastic effects or
radiation. Radiation effects on the embryo and the foetus
 Life shortening.
 Leukemogenesis and carcinogenesis, genetic and somatic hazards for exposed
individuals and population.
 Biological basis of radiological protection.
 Organ radiosensitivity and radioresponsiveness, Concept of therapeutic index.
 Acute effects of Radiation, Concept of mean lethal dose, Radiation Syndromes:
Bone Marrow, Gastrointestinal system, Central Nervous System, Cutaneous
Suppression of immune System: mechanism, Consequences.
 Total Body irradiation Biological dosimetry: Blood counts, BM mitotic index.
Chromosome aberrations in peripheral blood lymphocytes
 Radiation accidents: typical examples
Radiation effects on major organs/tissues

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 Acute & late effects on all normal organs & tissues including connective tissue,
bone marrow, bones, gonads, eye, skin, lung, heart, central nervous system
tissues, peripheral nerves, oesophagus, intestine, kidney, liver & thyroid with
special reference to treatment –induced sequelae after doses employed in
radiotherapy.
 Normal tissue tolerances
 Late effects of radiation (somatic)
 Sterility, cataracts and cancer
 Carcinogenesis: mechanism in vitro and in vivo, oncogenes and antioncogenes
Radiation induced cancer of occupational, medical or military origin.
 Recent controversial results for low-level exposure, risk estimates
 Late effects of Radiation (Genetic)
 Mutations: definition, types, potential hazards.
 Low level radiation: sources, potential hazards, stochastic and deterministic
nonstochastic effects, high background areas and cancer.
 Effects of Radiation on Human Embryo & Fetus
 Lethality, congenital abnormalities and late effects (Leukemia and childhood
caner), severe mental retardation. Doses involved.
 Biology and Radiation Responses of Tumors
 Tumors growth: Kinetics of tumor response. Growth fraction, cell loss factor.
 Volume doubling times, potential volume doubling times, repopulation, and
accelerated repopulation.
 Radio curability: definition, factors involved, tumor control probability curves
 Factors determining tumor regression rates. Causes of failure to control tumors
by radiation: tumor related, host related technical/mechanical errors.
 Relationship between clonogen numbers and tumor control probability. Local
tumor control and impact on survival.
 Applied Radiobiology
 Fractionation : rationate, factors involved (4 R’s)
 Time, Dose and fractionation relationship isoeffect curves, isoeffect relationships,
e.g.; NSD, CRE formalisms and their limitations, partial tolerance, means of
summating partial tolerance, steepness of dose response curves. Multi-target,
two component and linear quadratic model. Alfa/ beta ratios for acute and late

24
 effects and means for deriving these values. Isoeffective formulae. Clinical
applications of the L-Q model.
 Hyperfractionation, accelerated fractionation, hypofractionation, CHART, split
dose treatments.
 Brachytherapy –low dose rate, high dose rate and pulsed treatments.
 Introduction to new techniques to optimize radio-curability; combination therapy
(adjuvant surgery or chemotherapy), hyperthermia, hypoxic cell radio-sensitizers,
high LET radiation. Photodynamic therapy.
 The volume effect, general principles and current hypotheses.
 Shrinking Field technique.
 Combination Radiation-surgery
 Pre, post and intra operative radiation.
 Rationale, radiobiological factors, current clinical results.
 Irradiation of sub-clinical disease, debulking surgery, importance of clonogen
numbers.
 Combination Radiation-Chemotherapy
 Definitions of radiosensitiser and Radiation protectors, synergism, potentiation,
antagonism, Radiosensitisers/Radiation protectors- types, and mechanism.
 Hyperthermia
 Sources, rationale (historical examples), advantages and disadvantages,
thermotolerance.
 Cellular damage: comparison and contrast with radiation, thermal and non-
thermal effects of ultrasound, microwaves, radiofrequency, etc. general host
responses (immunology, metastases)
 Use along with radiotherapy and chemotherapy: optimum sequencing of
combined modalities.
 Current limitations to the clinical use of hyperthermia.
 High LET Radiation
 Comparison and contrast with low LET radiation
 Neutrons: Source (including 252 Cf) and boron neutron capture (outline only).
Advantages and disadvantages of neutrons, RBE values, hazards of low dose
and low energy neutron, use in radiotherapy, combination with low LET, current
clinical results.

25
  Other high LET particles: protons, mesons, high-energy heavy nuclei, application
to radiotherapy, current clinical results.

CLINICAL RADIOTHERAPY
 Cancer Epidemiology & Etiology
 Cancer Statistics- world-wide & India
 Cancer Registries , National cancer registry project of ICMR& National Cancer
Control Programme
 Analysis of data in cancer registries
 Regional Cancer Centers
 Cancer Screening & Prevention
 Patient Care
 Assessment & referral systems for radiotherapy
 Diagnosis & workup
 Staging
 Care & evaluation during & after treatment
 Emergencies in Oncology
 Radiotherapeutic Management of different malignancies
 Radiotherapy for non malignant conditions
 Treatment Response & Result
 Guidelines for treatment response assessment.
 Complete Response, Partial Response, No response, Stable disease.
 End points of treatment results. Loco-regional control recurrence, metastasis,
survival quality of life.
 Treatment related morbidity assessment
 Radiation morbidity (early & late)
 Morbidities of combined treatment
 Grading of morbidity
 Follow up methodologies of treated patients.
CANCER CHEMOTHERAPY

 Basic Principles of chemotherapy

 Chemotherapy drugs

26
 Newer chemotherapeutic agents
 Basic for designing different chemotherapy schedules. Standard chemotherapy
schedules.
 Chemotherapy practice in various malignancies
 Chemotherapy practice & results/toxicities in sequential & concomitant
chemoradiotherapy.
 Supportive care for chemotherapy.
 The basic principles underlying the use of chemotherapeutic agents.
 Classification and mode of action of cytotoxic drugs. The principles of cell kill by
chemotherapeutic agents, drug resistance, phase specific and cycle specific
action.
 Drug administration.
 The general principles of pharmacokinetics; factors affecting drug concentration
‘in vivo’ including route and timing of administration, drug activation, plasma
concentration, metabolism and clearance.
 Principles of combinations of therapy, dose response curves, adjuvant and neo-
adjuvant chemotherapy, sanctuary sites, high dose chemotherapy, and regional
chemotherapy.
 Toxicity of drugs. Early, intermediate and late genetic and somatic effects of
common classes of anticancer drugs.
 Precautions in the safe handling of cytotoxic drugs.
 Endocrine manipulation and biological response modifiers. An understanding of
the mode of action and side effects of common hormonal preparations used in
cancer therapy (including corticosteroids).
 Use of the major biological response modifiers such as interferons, interleukins
and growth factors and knowledge of their side effects.
 Assessment of New Agents. Principles of phase I, II, and III studies.
 Gene Therapy
 Pharmacokinetics and Pharmacodynamics
 Standard chemotherapy schedules
 Drug administration and Precautions in the safe handling of cytotoxic drugs
 Resistance to Chemotherapy
 Basic concepts of Chemotherapy and Irradiation Interaction

27
Molecular and Genetic Oncology.
1. Cell cycle- DNA repair; apoptosis.
2. Invasion and metastasis, angiogenesis and lymph angiogenesis.
3. Cell signaling and interactive networks.
4. Immune response.
5. Gene Therapy
6. Somatic correction of gene defect
7. Genetic pro-drug activation
8. Genetic immunomodulation
Immunotherapy/Targeted Therapy

1 Monoclonal antibody therapy

2 Radio immunotherapy
3 Advances in immunotherapy
4 Nano-Particle therapy

Combination Radiation-Surgery
 Pre, post and intra-operative radiation.
 Rationale, radiobiological factors, current clinical results.
 Irradiation of sub-clinical disease
 Debulking surgery
 Importance of clonogen numbers/Circulating tumor cells(CTC’s )

Combination Radiation –Chemotherapy

 Definitions of radio sensitizers, synergism, potentiation, antagonism.

Radiosenistzers/Radio protectors: type , mechanism of action.

Radio-active isotopes used for diagnosis and therapy

Benign diseases- Radiotherapy in non-malignant diseases

28
Imaging in oncology

Organ radio sensitivity and radio responsiveness, concept of therapeutic

index

Acute effects of Radiation

 Concept of mean lethal dose
 Radiation syndromes : BM , GI, CNS, cutaneous
 Suppression of immune System: mechanism, consequences
 Total Body irradiation
 Biological dosimetry: Blood counts, BM mitotic index. Chromosome aberrations
in peripheral blood lymphocytes
 Radiation accidents: typical examples

Radiation Effects on Major Organs/tissues

Acute & late effects on all normal organs & tissue including connective tissue, bone
marrow, bones, gonads, eye , skin, lung, heart , central nervous system tissues,
peripheral nerves, esophagus, intestine, kidney, liver & thyroid with special reference to
treatment induced sequelae after doses employed in radiotherapy.
Normal tissue tolerances.

Late effects of radiation (somatic)

 Sterility, cataracts and cancer
 Carcinogenesis: mechanisms in vitro and in vivo, oncogenes and antioncogenes.
 Radiation induces cancer of occupational, medical or military origin.
 Recent controversial results for low level exposure, risk estimates

Late Effects of Radiation (Genetic)

 Mutations: definition, types, potential hazards.
 Low level radiations: sources, potential hazards, stochastic and deterministic
(nonstochastic) effects, high background areas and cancer.
 Effects of Radiation on Human Embryo & Fetus

29
  Lethality, congenital abnormalities and late effects (Leukemia and childhood
cancer) severe mental retardation. Doses involved.

Palliative & supportive care:

- Symptoms /Signs of advanced cancer

- Palliation of compression and obstruction due to malignancy
- Palliation of brain & spiral cord metastasis
- Palliation of bleeding catastrophes
- Palliation of bone metastasis
- Palliation of visceral recurrences and metastases
- Pain management: Pain control, WHO guidelines for adults & children
- Patient’s and relatives’ counseling on end stage management
- Guidelines for palliative care
- Management of terminally ill patients.
- Different pharmacologic & non-pharmacology methods
- Palliative radiotherapy
- Palliative chemotherapy
- Home care
- Hospice care
- Physical, social, spiritual & other aspects
- Others

OTHER DISCIPLINES ALLIED TO RADIOTHERAPY AND ONCOLOGY

Surgical Oncology
 Basic principles of surgical oncology, biopsy, conservation surgery, radical
surgery, palliative surgery.
 Basics of surgical techniques – head & neck, breast, thorax, abdomen,
gynecological, genitourinary, musculoskeletal, CNS.
 Combined treatments: with radiotherapy, chemotherapy, and hormone therapy.

30
Diagnostic Radiology and Nuclear Medicine
 Radiographic diagnosis of malignant and non malignant conditions
 Radiological Procedures with reference to Radiotherapy practices
 Study of Ultrasound, CT Scans, MRI Scans, PET scans, as applicable for
management of cancer.
 Other nuclear imaging and therapeutic modalities as applicable to management
of cancer.

PREVENTIVE &COMMUNITY ONCOLOGY

 Cancer Epidemiology & Etiology
 Cancer Statistics- world wide & India
 Cancer Registries & National Cancer Control Programme
 Analysis of data in cancer registries
 Regional Cancer Centers
 Cancer Screening & Prevention

ADMINISTRATION
 Oncologists role as an administrator.
 How to set up a Radiotherapy and Oncology department, planning of
infrastructure, & equipments.
 Role in National Cancer Control Programme (NCCP).
 Responsibilities towards safety & quality assurance.

Cancer Screening and Prevention

Cancer Biotherapeutics
a) Hormonal Therapy
b) Differentiation Agents
c) Monoclonal Antibodies
d) Interferons
e) Interleukins
f) Antiangiogenesis Agents

31
g) Molecular Targeted Therapy
h) Vaccines
i) Gene Therapy

CLINICAL RADIOTHERAPY, CHEMOTHERAPY AND TARGETED THERAPY IN

MANAGEMENT OF SITE SPECIFIC MALIGNANCIES including

 Metastasis of Unknown Origin

 AIDS related Malignancies
 Oncologic Emergencies
 Paraneoplastic syndromes
 Benign Diseases

Rehabilitation
Complementary alternative medicine

Quality Assurance in radiotherapy (QART)

 Overview of ESTRO QART: Need for a quality system in Radiotherapy, Quality

System:
 Definition and practical advantages, Construction, Development and Implementation
of a Quality System
 Quality Assurance of Simulator, TPS, Co-60, linear accelerator
 Acceptance testing of Simulator, TPS, Co-60, linear accelerator
 Quality assurance and acceptance test of newer equipments.

New Radiation Modalities

A Protons
 Production
 Process of absorption
 Depth dose patterns
 Advantages compared with x-rays
 Facilities available

32
B. Neutrons
 Production
 Process of absorption
 Depth dose patterns
 Advantages compared with x-rays
 Facilities available
C. Pions
 Production
 Process of absorption
 Depth dose patterns
 Advantages compared with x-rays
 Facilities available
D High energy heavy ions (Carbon and others)
 Production
 Process of absorption
 Depth dose patterns
 Advantages compared with x-rays
 Facilities available

Hyperthermia
1. Sources, rationale (historical example), advantages and disadvantages, thermo
tolerance.
2. Cellular damage: comparison and contrast with radiation, thermal and non-
thermal effects of ultrasound, microwaves, radiofrequency, etc General host
responses (immunology, metastases).
3. Use along with radiotherapy and chemotherapy: optimum sequencing of
combined modalities. Current limitations to the clinical use of hyperthermia.

4. Methods of heating
 RF Microwaves
 Ultrasound

33
  Water baths
5. Systematic hyperthermia
6. Localized heating
7. Cellular response to heat
8. Repair of thermal damage
9. Thermotolerance
10. Hyperthermia combined with ionizing radiations
11. Time sequence of heat and irradiation
12. Hypoxic cells and heat
13. Effect of PH on the response to hyperthermia
14. Response of transplanted tumours to heat
15. Response of normal tissues to heat
16. Response of spontaneous tumours to heat

Modern Trends /Recent Advances

Advancements in Radiation Oncology:

Virtual Simulation: Principle, CT Simulation, TPS based virtual simulation, Differences,
Merits and Demerits, Practical considerations

Others:
i. Anti angio-genic factors , Angiogenesis & carcinogenesis
ii. Monoclonal Antibodies - MABs & NIBs
iii. Essentials of Genomics:
 Genomes,
 Signal translation
 Immunology
 Cytogenetic, cell cycle
 Apoptosis
 Invasion and metastasis
Iv. Gene Therapy
v. Molecular therapy,
vi. Cancer vaccines.
Vii others

34
STASTISTICAL BASIS FOR PLANNING AND INTERPRETATION OF

CLINICAL TRIALS
 Advantages & disadvantages
 Retrospective & Prospective studies
 Controlled & uncontrolled trials
 Single blind & double blind studies
 Phase I,II & III trials
 Ethics (Helsinki declaration/Good clinical practice)

PLANNING A TRIAL
 Establishing objectives – short term and long term
 Determining the appropriate criteria
 Establishing grounds for inclusion and exclusion of patients
 Determining how many treatment schedules are to be completed
 Determining the treatment schedules and any appropriate modifications
 Determining the method of allocation of treatment; the allocation ratio and the
method and timing of randomization
 Determining what measures are to be taken, how they will be taken, who will take
them, at what times (s) and where they will be recorded.
 Designing, the appropriate forms of documentation
 Determining the proposed duration of the trial, either in terms of a fixed closing
date, or the entry of a predetermined number of patients.
 Establishing conditions under which the trial may be terminated earlier than
planned & procedures for detecting these conditions.
 Re-assessing the proposed trial in terms of ethics, appropriateness to the short &
long terms objectives, feasibility & the availability of resources.
 Writing the protocol
 Running a pilot study

35
 TEACHING SCHEDULE

1 Basic clinical training should rest on day to day working in care of both in & out
patients, day care chemotherapy, radiotherapy treatment planning (both manual &
TPS) and execution, training in Quality assurance of therapeutic and allied
equipments. The common tumors should be discussed at length in the teaching ward
rounds. Each individual should present and discuss the respective case problems.
2 There should be intra and inter departmental meeting for discussion the
Uncommon / interesting cancer cases.
3 In addition to above the following are suggested as some of the activities to impart
clinical training & skills:-

 Didactic teaching- once a week

 Subject seminars - once a week
 Case presentation - once a week
 Journal club - once a week
 Interdepartmental conferences- once a week
 In depth clinical presentation by individual – minimum desirable of at least
15 session per year.
4 Attending various accredited scientific meeting -CME/Symposia/conference- 30
hours.
5. Training in patients’ record keeping, hospital based and city tumor registry system,
cancer notification and WHO recommendations on improving follow up.

Research Training
Collection of information related to advances in medicine from various sources (use of
library, multimedia, internet etc.) their interpolation and application.
Teaching
1. Undergraduate clinical demonstration of minimum 3 sessions
2. Demonstration and teaching for nursing students.
3. Patient /Public education talks and preparation of multi-media presentation, material,
articles, lectures, pamphlets & books.

36
 POSTGRADUATE TRAINING

Standard Requisite
Teaching
Administration

Standard Requisite

I. Basic Sciences
II. Clinical Sciences
III. Research

I. Basic Sciences: Minimum undergraduate level training in anatomy, physiology,

biochemistry microbiology, pathology & pharmacology relevant in clinical practice, in
addition to specific emphasis on basic genetic and molecular biology related to tumor
and clinical oncology.

II. Clinical Sciences:

(Radiotherapy, Chemotherapy and related discipline):

Theoretical background including recent advances is prerequisite for clinical training of

PG’s –

2. Become competent in taking patient’s history of illness and able to identify

Possible etiological/predisposing factors.
3. Should develop skills to interpret and elicit various physical signs and to arrive at
a probable diagnosis and to decide on cost effective diagnostic procedures.
4. Carryout usual clinical interventions in the management of oncology patients like
FNAC, pleural aspiration, abdominal paracentesis, bone marrow aspiration,
Central venous lines and biopsy etc.
5. Acquainted with basic methodological & interpretation of various diagnostic tests
and procedures.

37
 6. Seminars, symposia, reviews, ward round & post graduate interactive group
discussion should constitute methodology of their training.
7. Able to provide palliative and terminal care for cancer patients.

III Research: A post graduate student pursuing the specialty of radiotherapy-

 Should have knowledge of the basic scientific methodology, statistical basis and
cancer epidemiology
 Should be able to devise, prepare and carry out research project ‘individually’.
 Should be able to decide the relevance of any study/analysis on the subject
 Should develop a skill to present data in the form of research paper at
conference / symposia/CME etc.
 Should know the basic concepts of Indexing and international classification of
disease, tumor registry systems, department tumor registry. The student should
also know about the UICC, IACR system for Methodology of follow up and
patient retrieval system that forms the foundation of clinical research follow up
based expertise.

Teaching
a. Should be well versed with method of teaching using audio-visual aids
b. Should be able to conduct demonstration and teaching for under graduate students
c. Should be able to collect, compile and present the material and data for scientific and
public lectures pertaining to radiotherapy and oncology.

Administration
A post graduate student should be involved in managing the day to day affairs related to
patient treatment, care, academics, and research. He/she must have knowledge of
planning and setting up an oncology department, interaction with government machinery
and other agencies , experience of National Cancer Control Programme.cts of training,
academic, patient care & research.

SCOPE OF TRAINING

38
 - Clinical training
- Clinical procedures
- Research training
- Teaching

Clinical Training
Posting
1. Major tenure of posting should include care of inpatients, out patients, day care,
isolation, special clinics, terminally ill patients and maintenance of case records for both
in & out patients
2. Linear Accelerator
3. Simulator
4. CT simulator
5. Brachytherapy LDR/MDR/HDR/PDR
6. Computerized TPS
7. Mould room
8. Medical physics lab
9. Others

III Following support department posting is also desirable: -

1. Pathology
2. Radio diagnosis
3. Nuclear Machine
4. Gynecology, GI surgery, Otorhinolaryngology, Neurosurgery and Pulmonary
Medicine.
5. Molecular Oncology and genetics

39
 CLINICAL POSTINGS

Rotations Postings

1st Year

 Clinical Oncology (In-patient ward and special clinics)

 Radiation Physics
 Pathology and Radiation Pathology, Cell biology and Radiobiology
 Diagnostic Radiology
 Cancer Epidemiology and Statistics
 Cancer Research and Laboratory methods

2nd Year

 Clinical Oncology & Critical Care (In–patient ward & special clinics)
 Radiation Physics
 Palliative Care
 Medical Oncology including Haemato-oncology
 Targeted /Biological Therapies
 (In-patient ward and special clinics)
 Mould room and Immobilization devices
 Simulator and Teletherapy machine posting
 Brachytherapy

3rd Year

 Radiation Oncology (Inpatient ward and special clinics)

 Clinico pathological meetings / morbidity and mortality and medical audits
 Recent Advances
 Peer reviewed /Indexed journal based studies

40
BIOSTATISTICS AND RESEARCH METHODOLOGY

1. Sampling –Random sampling, purposive sampling, advantages of sampling,

various methods of sampling (Simple random, systemic, stratified, cluster,
multistage and multiphase), sampling error, on-sampling error.

2. Descriptive statistics-Arithmetic mean, Median, Mode and standard error,

coefficient of variation.

3. Graphics presentation of date-Bar diagram, histogram frequency curve, line

graph, pie chart

4. Normal distribution-Definition and properties /Confidence interval, Basic concept

of testing of hypothesis, p-value, power of the test.

5. Test of significance-t test, test of proportion, chi-square test, concept of analysis

of variance

6. Study design-Descriptive studies, analytical studies. Observational studies,

experimental studies, prospective studies, retrospective studies, odds ration,
relative risk, attributable risk percent, population attributable risk percent.

7. Correlation and regression-Simple correlation, linear regression, concept of

multiple regression.

8. Survival analysis-Life table, survival analysis , K-M Methos, Cox regression ,log
ran K test

9. Sample size determination-Basic concept , sample size determination of

estimating proportion and mean

10. Clinical trials in cancer research –Basic concept

 Biostatistics, Research Methodology and Clinical Epidemiology

 Ethics
 Medico legal aspects relevant to the discipline
 Health Policy issues as may be applicable to the discipline

41
THESIS PROTOCOL & THESIS
The candidates are required to submit a thesis at the end of three years of
training as per the rules and regulations of NBE.

Guidelines for Submission of Thesis Protocol & Thesis by candidates

Research shall form an integral part of the education programme of all

candidates registered for DNB degrees of NBE. The Basic aim of requiring the
candidates to write a thesi protocol & thesis/dissertation is to familiarize him/her
with research methodology. The members of the faculty guiding the
thesis/dissertation work for the candidate shall ensure that the subject matter
selected for the thesis/dissertation is feasible, economical and original.

Guidelines for Thesis Protocol

The protocol for a research proposal (including thesis) is a study plan, designed
to describe the background, research question, aim and objectives, and detailed
methodology of the study. In other words, the protocol is the ‘operating manual’
to refer to while conducting a particular study.

The candidate should refer to the NBE Guidelines for preparation and
submission of Thesis Protocol before the writing phase commences. The
minimum writing requirements are that the language should be clear, concise,
precise and consistent without excessive adjectives or adverbs and long
sentences. There should not be any redundancy in the presentation.

The development or preparation of the Thesis Protocol by the candidate will help
her/him in understanding the ongoing activities in the proposed area of research.
Further it helps in creating practical exposure to research and hence it bridges
the connectivity between clinical practice and biomedical research. Such
research exposure will be helpful in improving problem solving capacity, getting
updated with ongoing research and implementing these findings in clinical
practice.

Research Ethics: Ethical conduct during the conduct and publication of research
is an essential requirement for all candidates and guides, with the primary
responsibility of ensuring such conduct being on the thesis guide. Issues like
Plagiarism, not maintaining the confidentiality of data, or any other distortion of
the research process will be viewed seriously. The readers may refer to standard
documents for the purpose.

The NBE reserves the right to check the submitted protocol for plagiarism, and
will reject those having substantial duplication with published literature.

42
PROTOCOL REQUIREMENTS

1. All of the following will have to be entered in the online template. The
thesis protocol should be restricted to the following word limits.

 Title : 120 characters (with spacing) page

 Synopsis [structured] : 250-300
 Introduction : 300-500
 Review of literature : 800-1000
 Aim and Objectives : Up to 200
 Material and Methods : 1200-1600
 10-25 References [ICMJE style]

2. It is mandatory to have ethics committee approval before initiation of the

research work. The researcher should submit an appropriate application to
the ethics committee in the prescribed format of the ethics committee
concerned.

Guidelines for Thesis

1. The proposed study must be approved by the institutional ethics

committee and the protocol of thesis should have been approved by NBE.

2. The thesis should be restricted to the size of 80 pages (maximum). This

includes the text, figures, references, annexures, and certificates etc. It
should be printed on both sides of the paper; and every page has to be
numbered. Do not leave any page blank. To achieve this, following points
may be kept in view:

a. The thesis should be typed in 1.5 space using Times New

Roman/Arial/ Garamond size 12 font, 1” margins should be left on
all four sides. Major sections viz., Introduction, Review of Literature,
Aim & Objectives, Material and Methods, Results, Discussion,
References, and Appendices should start from a new page. Study
proforma (Case record form), informed consent form, and patient
information sheet may be printed in single space.
b. Only contemporary and relevant literature may be reviewed.
Restrict the introduction to 2 pages, Review of literature to 10-12
pages, and Discussion to 8-10 pages.
c. The techniques may not be described in detail unless any
modification/innovations of the standard techniques are used and
reference(s) may be given.
d. Illustrative material may be restricted. It should be printed on paper
only. There is no need to paste photographs separately.

43
 3. Since most of the difficulties faced by the residents relate to the work in
clinical subject or clinically-oriented laboratory subjects, the following
steps are suggested:
a. The number of cases should be such that adequate material,
judged from the hospital attendance/records, will be available and
the candidate will be able to collect case material within the period
of data collection, i.e., around 6-12 months so that he/she is in a
position to complete the work within the stipulated time.
b. The aim and objectives of the study should be well defined.
c. As far as possible, only clinical/laboratory data of investigations of
patients or such other material easily accessible in the existing
facilities should be used for the study.
d. Technical assistance, wherever necessary, may be provided by the
department concerned. The resident of one specialty taking up
some problem related to some other specialty should have some
basic knowledge about the subject and he/she should be able to
perform the investigations independently, wherever some
specialized laboratory investigations are required a co-guide may
be co-opted from the concerned investigative department, the
quantum of laboratory work to be carried out by the candidate
should be decided by the guide & co-guide by mutual consultation.

4. The clinical residents are not ordinarily expected to undertake

experimental work or clinical work involving new techniques, not hitherto
perfected OR the use of chemicals or radioisotopes not readily available.
They should; however, be free to enlarge the scope of their studies or
undertake experimental work on their own initiative but all such studies
should be feasible within the existing facilities.

5. The DNB residents should be able to freely use the surgical

pathology/autopsy data if it is restricted to diagnosis only, if however,
detailed historic data are required the resident will have to study the cases
himself with the help of the guide/co-guide. The same will apply in case of
clinical data.

6. Statistical methods used for analysis should be described specifically for

each objective, and name of the statistical program used mentioned.

General Layout of a DNB Thesis:

 Title- A good title should be brief, clear, and focus on the central theme of
the topic; it should avoid abbreviations. The Title should effectively
summarize the proposed research and should contain the PICO elements.

44
 Introduction- It should be focused on the research question and should
be directly relevant to the objectives of your study.

 Review of Literature - The Review should include a description of the

most relevant and recent studies published on the subject.

 Aim and Objectives - The ‘Aim’ refers to what would be broadly achieved
by this study or how this study would address a bigger question / issue.
The ‘Objectives’ of the research stem from the research question
formulated and should at least include participants, intervention,
evaluation, design.

 Material and Methods- This section should include the following 10

elements: Study setting (area), Study duration; Study design (descriptive,
case-control, cohort, diagnostic accuracy, experimental (randomized/non-
randomized)); Study sample (inclusion/exclusion criteria, method of
selection), Intervention, if any, Data collection, Outcome measures
(primary and secondary), Sample size, Data management and Statistical
analysis, and Ethical issues (Ethical clearance, Informed consent, trial
registration).

 Results- Results should be organized in readily identifiable sections

having correct analysis of data and presented in appropriate charts,
tables, graphs and diagram etc.

 Discussion–It should start by summarizing the results for primary and

secondary objectives in text form (without giving data). This should be
followed by a comparison of your results on the outcome variables (both
primary and secondary) with those of earlier research studies.

 Summary and Conclusion- This should be a précis of the findings of the

thesis, arranged in four paragraphs: (a) background and objectives; (b)
methods; (c) results; and (d) conclusions. The conclusions should strictly
pertain to the findings of the thesis and not outside its domain.

 References- Relevant References should be cited in the text of the

protocol (in superscripts).

 Appendices -The tools used for data collection such as questionnaire,

interview schedules, observation checklists, informed consent form (ICF),
and participant information sheet (PIS) should be attached as appendices.
Do not attach the master chart.

45
Thesis Protocol Submission to NBE

1. DNB candidates are required to submit their thesis protocol within 90 days
of their joining DNB training.

2. Enclosures to be submitted along with protocol submission form:

a) Form for Thesis Protocol Submission properly filled.
b) Thesis Protocol duly signed.
c) Approval letter of institutional Ethical committee. (Mandatory, non
receivable of any one is liable for rejection)

Thesis Submission to NBE

1. As per NBE norms, writing a thesis is essential for all DNB candidates
towards partial fulfillment of eligibility for award of DNB degree.
2. DNB candidates are required to submit the thesis before the cut-off date
which shall be 30th June of the same year for candidates appearing for
their scheduled December final theory examination. Similarly, candidates
who are appearing in their scheduled June DNB final examination shall be
required to submit their thesis by 31st December of preceding year.
3. Candidates who fail to submit their thesis by the prescribed cutoff date
shall NOT be allowed to appear in DNB final examination.
4. Fee to be submitted for assessment (In INR): 3500/-
5. Fee can be deposited ONLY through pay-in-slip/challan at any of the
Indian bank branch across India. The challan can be downloaded from
NBE website www.natboard.edu.in
6. Thesis should be bound and the front cover page should be printed in the
standard format. A bound thesis should be accompanied with:
a. A Synopsis of thesis.
b. Form for submission of thesis, duly completed
c. NBE copy of challan (in original) towards payment of fee as may be
applicable.
d. Soft copy of thesis in a CD duly labeled.
e. Copy of letter of registration with NBE.

7. A declaration of thesis work being bonafide in nature and done by the

candidate himself/herself at the institute of DNB training need to be
submitted bound with thesis. It must be signed by the candidate
himself/herself, the thesis guide and head of the institution, failing which
thesis shall not be considered.

The detailed guidelines and forms for submission of Thesis

Protocol & Thesis are available at
www.natboard.edu.in.thesis.php.

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LOG BOOK

A candidate shall maintain a log book of operations (assisted / performed) during

the training period, certified by the concerned post graduate teacher / Head of
the department / senior consultant.

This log book shall be made available to the board of examiners for their perusal
at the time of the final examination.

The log book should show evidence that the before mentioned subjects were
covered (with dates and the name of teacher(s) The candidate will maintain the
record of all academic activities undertaken by him/her in log book .

1. Personal profile of the candidate

2. Educational qualification/Professional data
3. Record of case histories
4. Procedures learnt
5. Record of case Demonstration/Presentations
6. Every candidate, at the time of practical examination, will be required to
produce performance record (log book) containing details of the work done by
him/her during the entire period of training as per requirements of the log
book. It should be duly certified by the supervisor as work done by the
candidate and countersigned by the administrative Head of the Institution.
7. In the absence of production of log book, the result will not be declared.

47
Leave Rules
1. DNB Trainees are entitled to leave during the course of DNB training as per the
Leave Rules prescribed by NBE.
2. A DNB candidate can avail a maximum of 20 days of leave in a year excluding
regular duty off/ Gazetted holidays as per hospital/institute calendar/policy.
3. MATERNITYLEAVE:
a. Afemale candidate is permitted a maternity leave of 90 days once during
the entire duration of DNB course.
b. The expected date of delivery (EDD) should fall within the duration of
maternity leave.
c. Extension of maternity leave is permissible only for genuine medical
reasons and after prior approval of NBE. The supporting medical
documents have to be certified by the Head of the Institute/hospital where
the candidate is undergoing DNB training. NBE reserves its rights to take
a final decision in such matters.
d. The training of the candidate shall be extended accordingly in case of any
extension of maternity leave being granted to the candidate.
e. Candidate shall be paid stipend during the period of maternity leave. No
stipend shall be paid for the period of extension of leave.
4. Male DNB candidates are entitled for paternity leave of maximum of one week
during the entire period of DNB training.
5. No kind of study leave is permissible to DNB candidates. However, candidates
may be allowed an academic leave as under across the entire duration of training
program to attend the conferences/CMEs/Academic programs/Examination
purposes.
DNB COURSE NO. OF ACADEMIC LEAVE
DNB 3 years Course (Broad & Super Specialty) 14 Days
DNB 2 years Course (Post Diploma) 10 Days
DNB Direct 6 years Course 28 days

48
6. Under normal circumstances leave of one year should not be carried
forward to the next year. However, in exceptional cases such as
prolonged illness the leave across the DNB training program may be
clubbed together with prior approval of NBE.
7. Any other leave which is beyond the above stated leave is not permissible
and shall lead to extension/cancellation of DNB course.
8. Any extension of DNB training for more than 2 months beyond the
scheduled completion date of training is permissible only under extra-
ordinary circumstances with prior approval of NBE. Such extension is
neither automatic nor shall be granted as a matter of routine. NBE shall
consider such requests on merit provided the seat is not carried over and
compromise with training of existing trainees in the Department.
9. Unauthorized absence from DNB training for more than 7 days may lead
to cancellation of registration and discontinuation of the DNB training and
rejoining shall not be permitted.
10. Medical Leave
a. Leave on medical grounds is permissible only for genuine medical
reasons and NBE should be informed by the concerned
institute/hospital about the same immediately after the candidate
proceeds on leave on medical grounds.
b. The supporting medical documents have to be certified by the Head
of the Institute/hospital where the candidate is undergoing DNB
training and have to be sent to NBE.
c. The medical treatment should be taken from the institute/ hospital
where the candidate is undergoing DNB training. Any deviation
from this shall be supported with valid grounds and documentation.
d. In case of medical treatment being sought from some other
institute/hospital, the medical documents have to be certified by the
Head of the institute/hospital where the candidate is undergoing
DNB training.

49
 e. NBE reserves its rights to verify the authenticity of the documents
furnished by the candidate and the institute/hospital regarding
Medical illness of the candidate and to take a final decision in such
matters.
11.
a. Total leave period which can be availed by DNB candidates is
120+28 = 148 days for 6 years course, 60+14=74 days for 3 years
course and 40+10 = 50 days for 2 years course. This includes all
kinds of eligible leave including academic leave. Maternity /
Paternity leave can be availed separately by eligible candidates.
Any kind of leave including medical leave exceeding the
aforementioned limit shall lead to extension of DNB training. It is
clarified that prior approval of NBE is necessary for availing any
such leave.
b. The eligibility for DNB Final Examination shall be determined strictly
in accordance with the criteria prescribed in the respective
information bulletin.

50
EXAMINATION

FORMATIVE ASSESSMENT

Formative assessment includes various formal and informal assessment

procedures by which evaluation of student’s learning, comprehension, and
academic progress is done by the teachers/ faculty to improve student
attainment. Formative assessment test (FAT) is called as “Formative “as it
informs the in process teaching and learning modifications. FAT is an integral
part of the effective teaching .The goal of the FAT is to collect information which
can be used to improve the student learning process.

Formative assessment is essentially positive in intent, directed towards

promoting learning; it is therefore part of teaching. Validity and usefulness are
paramount in formative assessment and should take precedence over concerns
for reliability. The assessment scheme consists of Three Parts which has to be
essentially completed by the candidates.

The scheme includes:-

Part I:- Conduction of theory examination

Part-II :- Feedback session on the theory performance
Part-III :- Work place based clinical assessment

Scheme of Formative assessment

Candidate has to appear for
CONDUCT OF THEORY
PART – I Theory Exam and it will be
EXAMINATION
held for One day.
FEEDBACK SESSION ON Candidate has to appear for
PART – II THE THEORY his/her Theory Exam
PERFORMANCE Assessment Workshop.
After Theory Examination,
WORK PLACE BASED
PART – III Candidate has to appear for
CLINICAL ASSESSMENT
Clinical Assessment.

The performance of the resident during the training period should be monitored
throughout the course and duly recorded in the log books as evidence of the
ability and daily work of the student

1. Personal attributes:
 Behavior and Emotional Stability: Dependable, disciplined, dedicated,
stable in emergency situations, shows positive approach.
 Motivation and Initiative: Takes on responsibility, innovative,
enterprising, does not shirk duties or leave any work pending.

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  Honesty and Integrity: Truthful, admits mistakes, does not cook up
information, has ethical conduct, exhibits good moral values, loyal to the
institution.
 Interpersonal Skills and Leadership Quality: Has compassionate
attitude towards patients and attendants, gets on well with colleagues and
paramedical staff, is respectful to seniors, has good communication skills.

2. Clinical Work:

 Availability: Punctual, available continuously on duty, responds promptly

on calls and takes proper permission for leave.
 Diligence: Dedicated, hardworking, does not shirk duties, leaves no work
pending, does not sit idle, competent in clinical case work up and
management.
 Academic ability: Intelligent, shows sound knowledge and skills,
participates adequately in academic activities, and performs well in oral
presentation and departmental tests.
 Clinical Performance: Proficient in clinical presentations and case
discussion during rounds and OPD work up. Preparing Documents of the
case history/examination and progress notes in the file (daily notes, round
discussion, investigations and management) Skill of performing bed side
procedures and handling emergencies.

3. Academic Activity: Performance during presentation at Journal club/

Seminar/ Case discussion/Stat meeting and other academic sessions.
Proficiency in skills as mentioned in job responsibilities.

FINAL EXAMINATION
The summative assessment of competence will be done in the form of DNB Final
Examination leading to the award of the degree of Diplomate of National Board in
Radiotherapy and Oncology. The DNB final is a two-stage examination
comprising the theory and practical part. An eligible candidate who has qualified
the theory exam is permitted to appear in the practical examination.

Theory Examination
1. The theory examination comprises of Three/ Four papers, maximum
marks 100 each.
2. There are 10 short notes of 10 marks each, in each of the papers. The
number of short notes and their respective marks weightage may vary in
some subjects/some papers.
3. Maximum time permitted is 3 hours.
4. Candidate must score at least 50% in the aggregate of Three/ Four
papers to qualify the theory examination.

52
 5. Candidates who have qualified the theory examination are permitted to
take up the practical examination.
6. The paper wise distribution of the Theory Examination shall be as follows:

Paper I:

 Basic Sciences related to the specialty(Anatomy , Physiology , General and

Systemic pathology, Clinical Oncology)
 Research Methodology
 Evidence Based Medicine ,Tumor Registry System and Follow up
Methodologies
 Quality Assurance in Radiotherapy (QART)
 Medical physics and medical dosimetery as applied to clinical
Radiotherapy.

Paper II:

Radiotherapy with combined and multi modality approach in relation to :

Urinary system, Genital tract, Breast, Respiratory system, Childhood

tumors, Head & Neck, Mediastinum, Hematepoietic system, Geriatric

Oncology.

Paper III:

 Radiotherapy with combined and multi modality approach in relation to :

Skeletal system, Soft Tissue systems, Reticulo-endothelial system, Central
nervous system, Skin, Gastro Intestinal system, Non malignant conditions.
 Details of practice of Cancer chemotherapy as applied to human
malignancies, Management of Comorbid condition and Consequences(
sequellae/side effects) of chemo radiation.
 Molecular and Genetic Oncology

53
Paper IV:

 Radiotherapy including radiobiology and radioactive isotopes

 Investigations

a) Practical Examination:
1. Maximum Marks: 300.
2. Comprises of Clinical Examination and Viva.
3. Candidate must obtain a minimum of 50% marks in the Clinical
Examination (including Viva) to qualify for the Practical Examination.
4. There are a maximum of three attempts that can be availed by a
candidate for Practical Examination.
5. First attempt is the practical examination following immediately after the
declaration of theory results.
6. Second and Third attempt in practical examination shall be permitted out
of the next three sessions of practical examinations placed alongwith the
next three successive theory examination sessions; after payment of full
examination fees as may be prescribed by NBE.
7. Absentation from Practical Examination is counted as an attempt.
8. Appearance in first practical examination is compulsory;
9. Requests for Change in center of examination are not entertained, as the
same is not permissible.
10. Candidates are required not to canvass with NBE for above.

Declaration of DNB Final Results

1. DNB final is a qualifying examination.

2. Results of DNB final examinations (theory & practical) are declared as
PASS/FAIL.
3. DNB degree is awarded to a DNB trainee in the convocation of NBE.

54
RECOMMENDED TEXT BOOKS AND JOURNALS
BOOKS

1. Liebelm and Philips text book of radiation oncology Richard T

Hoppe MD, FACR, FASTRO, Theodore Locke Philips MD, FACR, FASTRO, Mack
Roach III MD, FACR.
2. Perez and Brady’s Principles and Practice of Radiation Oncology
Edward C Halperin MD, MA, FACR, Carlos A Perez MD, Luther W Brady .
3. Cancer – Principles and Practice of Oncology Vincent T De Vita, Jr.
Theodore S, Lawarence, Steven A Rosenbergo, Stevven A.
4. Clinical Radiation Oncology Leonard L Gunderson, Joel E Tepper.
5. Bethesda Handbook of Clinical Oncology by Carmen J Allegra MD (Editor),
Jame Abraham MD (Editor), James L Gulley MD (Editor).
6. Handbook of evidence based radiation Oncology ,Dr. Eric K
Hansen, Dr, Mack Roach III.
7. Moss’s Radiation Oncology: Rational, Technique, Results (1994) William Thomas
Moss, and James Daniel Cox.
8. Text Book of Radiotherapy, Gilbert H Fletcher.
9. Treatment planning in Radiation Oncology Faiz M Khan.
10. Oxford Handbook of Oncology, Jim Cassidy, Donald Bissett, Roy A J Spence Obe.
11. The Physics of Radiation Therapy: Mechanisms, Diagnosis and Management by
Faiz M Khan.
12. The Physics of Radiology , Haold Elford Johns, John Robert
Cunningham.
13. Radiobiology for the Radiologist 6th Edition, Eric J Hall.
14. The Chemotherapy source Book 4th Edition, Michel C Perry.
15. Text Book of Medical Oncology 4th edition, Franco Cavalli, Stan B Kaye, Heine H
Hansen, James O Armitage, Martine J.
16. Surgical Oncology: Contemporary principles and Practice, K. I. Bland, John M Daly,
Constantine P Karakousis.
17. Basic Clinical Radiobiology, Edited by G Gordon Steel
18. Principles And Management of Cancer, Tejinder Kataria, Hemant Singhal,Dinesh
Chand Doval
19. Cancer Biology, Roger J.B.King,Mike W .Robins

55
20. Textbook of Radio Therapy by Dr Rath and Dr Mohanthy

JOURNALS

1. International Journal of Radiation Oncology, Biology, Physics.

2. Annals of Oncology
3. British Journal for Cancer
4. CA-A Cancer Journal for clinicians
5. Cancer
6. Cancer of clinical Oncology
7. Journal of Clinical Oncology
8. Journal of Cancer Research and therapeutics
9. Medscape Oncology
10. Seminars in Oncology
11. Seminars in Radiation Oncology
12. The Lancet
13. The new England Journal of Medicine
14. Radiotherapy and Oncology, Elsevier
15. Lancet Oncology-Elsevier
16. Acta Oncologica
17. Nature reviews Clinical Oncology
18. Natures Clinical Practice oncology

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