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Over the past decades, Brachytherapy (BT) has been facing a progressive decline in Italy, even though there are many signs of a renewed interest thanks to new technologies, with a growing number of publications.
The development of new dedicated devices, the progressive incorporation of 3D image-based guidance and real-time planning has allowed improved accuracy of applicator positioning and target delineation.
With these advances, the increased level of complexity in BT procedures has led to the need of specific training, as it requires complex and advanced technical skills.
Possible reasons for BT underutilization include fewer patients having access to BT due to referral patterns and insufficient training of radiation oncology residents.
To promote knowledge and empowerment amongst physicians, the Interventional Radiotherapy Study Group (SG) of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) encouraged outreach efforts to address the utilization and efficacy of BT for different types of tumors, including advocacy for treatment guidelines and educational programs for both physicians and patients alike.
In 2016 the AIRO-SG conducted a survey in Italian Radiation Oncology Centres regarding the status of BT infrastructure, the availability of BT equipment, the type of services offered and care patterns in Italy.
Questions focused on the number and model of BT units, treatment planning systems, how many physicians were engaged in BT, how many patients were treated with BT and how many treatments and to which tumor sites were delivered annually in the radiation oncology centre.
Almost half of centres did not deliver BT treatments or delivered less than demanded apparently because of lack of skilled personnel and multi-disciplinary teams or the need to update equipment.
In 2017 all the Italian radiation oncology schools’ directors were involved in a web survey, which included questions on the teaching of BT. The results evidenced a wide heterogeneity in the learning activities available to trainees in BT across the country, even if in Italian legislation BT practical teaching is included among the minimum requirements for the accreditation of radiation oncology schools. In particular, the types of practice to which trainees were exposed varies significantly among different schools.
The opportunity of a geographically well-distributed network of learning sites organized by the residential schools as well as establishing centers of excellence to augment BT training has been imagined and the creation of specific post-specialization training courses for already certified radiation oncologists interested to acquire more complex knowledge and specific expertise in BT was promoted.
The AIRO-SG has fostered the inclusion of BT as a treatment option when clinically indicated, promoting the publications of systematic review and clinical interdisciplinary guidelines in collaboration with other AIRO study groups and other scientific societies, such as the Italian Association of Radiation Therapy and Medical Physics Technologists (AITRO) and the Italian Association of Medical Physics and Health Physics (AIFM).
To increase the role of research in the field of interventional radiotherapy the AIRO-SG promoted a national and international network for dedicated research and big data sharing supporting the COBRA (COnsortium for BRachytherapy data Analysis) project.
Active support to a more accurate knowledge and re-discovery of BT among colleagues, institutional representatives and patients should be pursued promoting different form of communication and awareness campaigns. The term “interventional radiotherapy” was introduced in the name of the study group to better explains the effective operational aspects of the technique. A task force was created within the study group for the development of patient specific booklets (both paper and web-based), educational videos or animations.
Decreasing reimbursement for BT and increasing disparity between Italian National Health Service reimbursements for BT compared with competing treatment modalities, such as IMRT and SBRT, have still more negatively affected the utilization of BT. Probably an alternative payment model with an equalized reimbursement level may reduce this potential bias of treatment selection.
Modern interventional radiotherapy still remains an important tool for the management of cancer patients to be integrated with other therapeutic strategies and the AIRO-SG will promote different strategic interventions to increase its use in different interdisciplinary settings.