External Beam Radiotherapy Techniques —
Training activity: 15

Details

Produce and critically appraise routine treatment plans for a range of patients covering different anatomical sites

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• 3D-CRT
• Inverse planned techniques including rotational and step and shoot IMRT techniques
• Clinical optimality of treatment plan
• Dose prescriptions
• Relevant legislation and guidelines

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

• What does success look like for producing and critically appraising routine treatment plans? What are the criteria for a clinically acceptable and optimal treatment plan e.g., dose coverage, OAR sparing, deliverability? How will you evaluate the plan’s quality, considering patient-specific needs and treatment goals across various anatomical sites?

• What is your existing knowledge of treatment planning algorithms, dose calculation, plan optimisation, and evaluation metrics e.g., DVHs? What challenges might you face in optimising plans or identifying suboptimal areas, and how will you approach refining them? When should you seek expert advice on complex planning scenarios or challenging appraisals? How do you feel about the creative and critical aspects of treatment planning?

• Which specific skills in treatment planning software, dose-volume histogram analysis, or critical thinking for plan appraisal do you aim to develop? What insights do you hope to gain regarding the trade-offs in plan optimisation and the factors influencing clinical acceptability across different patient cases?

• Have you reviewed feedback from previous planning exercises or considered different planning techniques that might be relevant? What important information, such as clinical prescriptions, patient images, and departmental planning guidelines, should you review?

In action

• You make a note of anything that feels surprising or different from what you anticipate, such as:
  • Difficulty in achieving prescribed dose coverage to target volumes while respecting OAR constraints.
  • Unexpected hot or cold spots in the dose distribution.
  • The treatment planning system (TPS) optimiser failing to converge or producing unusual results.
  • Challenges in ensuring the plan is clinically deliverable with available machine capabilities.
• You consider how this specific experience compares with previous experiences of similar activities. Is this complexity inherent to the anatomical site or patient presentation?
• How do you react to the unexpected development?
  • Do you respond appropriately e.g., do you modify beam angles, energies, or optimisation objectives?
  • Do you adapt or change your approach to plan design or evaluation e.g., re-evaluating constraints, exploring alternative techniques?
  • Does it affect your ability to undertake the activity independently e.g., do you recognise the need to discuss trade-offs with a senior clinical scientist or oncologist?
• Do you find it difficult to adapt? Do you feel confident in your ability to manipulate the TPS and understand dose distributions?
  • Does it affect your confidence in your critical appraisal skills of treatment plans?
  • Do you feel positive you can reach a successful conclusion, creating a high-quality plan?
• You identify how you work within your scope of practice to address the unexpected development. Do you ensure the plan is robust and meets clinical requirements? What are you learning in the moment as a result of the unexpected development e.g., the impact of specific planning parameters, strategies for balancing competing objectives, or the limitations of planning algorithms.

On action

• Begin by summarising the key points of your experience producing and critically appraising routine treatment plans for various anatomical sites. Consider specific events, actions, or interactions which felt important during plan production and appraisal, including your own feelings at the time. Include any ‘reflect-in-action’ moments where you adapted to the situation as it unfolded during plan production and appraisal.

• Identify what learning you can take from this experience of creating and appraising treatment plans e.g., what strengths did you demonstrate? What skills and/or knowledge gaps were evident? Compare this experience against previous engagement with similar treatment planning activities – were any previously identified actions for development achieved? Has your practice improved in creating and appraising treatment plans? Identify any challenges you experienced during plan production or appraisal and how you reacted to these e.g., did this affect your ability to deal with the situation? Were you able to overcome the challenges? Identify anything significant about this activity of producing and appraising treatment plans e.g., did you need to seek advice or clarification regarding plan optimisation or evaluation? Or did you need to escalate to ensure that you were working within your scope of practice? Acknowledge any changes in your own feelings now that you are looking back on the experience of producing and appraising treatment plans.

• Identify the actions / ‘next steps’ you will now take to support the assimilation of what you have learnt from this activity e.g., what will you do differently next time you produce or appraise a treatment plan? Has anything changed in terms of what you would do if you were faced with a similar plan production or appraisal situation again? Do you need to practise any aspect of plan production or appraisal further?

Beyond action

• Have you reviewed the actions you identified for improvement from your prior reflections on this activity? For instance, did you aim to enhance your efficiency in planning, your ability to optimise plans, or your skills in critically assessing plan quality e.g., dose to OARs, PTV coverage? Have you completed these actions, and are you ready to demonstrate this improved capability? Has analysing these with others deepened your understanding of planning algorithms, dose constraints, or clinical priorities?

• Consider how this collective learning will support you in preparing for observed ‘in-person’ assessments, especially those focused on treatment planning. Reflect on how your practice in plan production and critical appraisal has developed and evolved. Do you now more adeptly identify suboptimal plans, potential planning errors, or situations where a plan falls outside your scope of practice, requiring senior review or modification?

Relevant learning outcomes

#	Outcome
# 3	Outcome Apply appropriate guidance, regulations and codes of practice to ensure patient safety in all elements of practice.
# 6	Outcome Develop and appraise external beam radiotherapy treatment plans for clinical use.
# 7	Outcome Practice effectively as part of a multidisciplinary team.