The Educational Impact of Web-based Platforms for Therapeutic Radiology in Sub-Saharan Africa

Methods and Materials: A 2-hour real-time video didactic lecture and demonstration of the left parotid tumor contouring on axial CT images was delivered using the ProKnow system and a video conferencing software. Participants were granted week-long access to practice contouring of the left parotid volume after the session. Effectiveness of the remote training was evaluated with a self-assessment questionnaire administered before and after the training. Areas of competence assessed included: (i) ability to identify anatomic structure on axial CT; (ii) ability to contour a parotid volume; (iii) ability to delineate tissues; (iv) dose-volume histogram evaluation (DVH); (v) plan evaluation; (vi) port film evaluation; (vii) cone-beam CT evaluation (CBCT). A comparative statistical analysis was undertaken to evaluate for significant changes in the average self-competence score for the various competency areas before and after intervention. The post-class survey also contained questions to determine the acceptability of the ProKnow system for training and imageguided radiotherapy planning among the participants and their access to the necessary internet services.


Introduction
The use of ionizing radiation for cancer treatment has undergone extraordinary development in the past century propelled by advancements in medical imaging (1,2).An inherent goal of radiation therapy is to deliver a large enough dose to the tumor to eradicate all cancer cells or to palliate symptoms, while minimizing injury to normal tissue.Integration of imaging modalities such as computed tomography (CT), magnetic resonance (MR) imaging, and positron emission tomography (PET) into the radiation treatment planning process has set a high standard for more precise delineation of target and accurate radiation volumes (1,2).Thus, a radiation oncologist is expected to have a comprehensive understanding of radiologic anatomy, as well as a functioning knowledge to interpret a variety of imaging modalities to delineate and deliver high-quality radiation treatment.However, formal radiology and anatomic contouring training opportunities are lacking in many low and middle-income countries (LMICs), as there is a shortage of radiologists and radiation oncologists with the expertise (3).
In recent times, prospects of bridging the training gap through international collaborations with organizations, institutions, and experts in developed countries have sparked global health interest among radiology and radiation oncology residents (4)(5)(6)(7)(8).However, a common issue expressed at global health summits, seminars and symposia is that people want to participate in global health but do not know how.Often, specialist physicians eager to impart knowledge and skills are limited by the cost and time-space barrier (9).This points to the need for a platform for facilitating participation, converting this upsurge in interest into greater concerted action and impact (10).
One possible platform model discussed at the American Association of Physicists in Medicine conference is the successful collaboration-driven model of Harvard Catalyst, which fosters a culture of collaboration in 31 Harvardaffiliated institutions, hospitals, and community partners.A similar platform could integrate the above key elements with information and communication technology (ICT) in an optimal way to catalyze high-impact global health collaborations (10).
In 2016, we implemented the Global Health Catalyst (GHC) at Harvard Medical School, which would incorporate components covering activities in cancer care, research, and education, and involve institutions from both developed countries and LMICs.In 2018, Global Health Catalyst worked with several stakeholders to develop and assemble advanced information and communication tool (ICT) platforms that could supplement training and ease the clinical burden of health professionals in LMICs (11)(12)(13).So far, a constellation of web-links and software toolbox for global cancer care and training is available on a web-portal known as eCancer4all (14), designed to be a premier comprehensive cancer center on the cloud for global health.
An integral component of eCancer4all is cancer imaging and internet-based programs for both the training and practice of contouring and tumor delineation in radiation planning.Contouring is a process in radiotherapy simulation that entails defining the borders of normal organs with intent to produce a clinical target volume (CTV), an area corresponding to disease risk and organ exclusion.Tumor delineation entails the process of defining and outlining tumor boundaries by the physician, radiologist, or radiation oncologist for effective and targeted radiation therapy.Radiation therapy follows a step-by-step process.The first step is an initial consultation, where the radiation oncologist discusses treatment options with a referred patient and a treatment plan is adopted.The second step is the simulation, where the clinician outlines or maps the exact area to be treated through a contouring and tumor delineation exercise.A CT scan or other imaging technique, such as PET or MRI, is used to verify the anatomy and ensure the accuracy of the area of the body to be treated with radiation.If needed, immobilization devices such as a face mask or a leg mold will be made at this time.The third stage is treatment planning.At this time, the radiation oncologist works with dosimetrists and medical physicists to creates a unique plan of treatment considering the diagnosis, the type of radiation machine that will be used, the amount of radiation needed and the number of treatments to be given.The fourth stage is the radiation treatment process, which could take weeks.Finally, patients usually have follow-up appointments after the treatment.
The simulation process requires a mastery of the anatomy and imaging modality used.Web-based radiotherapy contouring platforms such as eContour (15), EduCase (16), Anatom-e (17), and ProKnow (18) presently function as supplemental resources for residents in training and all practitioners desiring continuous medical education on refresher cases for therapeutic radiology.Randomized trials in the United States, Europe, and Russia have shown these programs to be as effective as traditional didactic lectures aimed at teaching and testing radiation oncology contouring skills (19)(20)(21)(22).However, the capacity for such platforms to address the need for contouring training and clinical practice of tumor delineation in low-resource regions is yet to be explored.

In this study, we conducted a collaborative e-contouring training initiative between radiation oncologists in the United
States and Sub-Saharan Africa using the ProKnow system as a platform.We then evaluated the effectiveness of this program with pre-and post-intervention questionnaires that assessed changes in the participants' self-confidence in their skills to contour and analyze contours of a normal left parotid gland.Using the same questionnaire method, we further evaluated the prospects for implementing the e-platform for training residents in low-resource countries.

Methods and materials
We conducted a 2-hour live video lecture and training on contouring the left parotid gland on axial CT images.The lecture was delivered remotely from Boston, Massachusetts using PowerPoint slides, a live GoToMeeting video connection, with live contouring demonstrations using the ProKnow system.ProKnow TM (short for "profound knowledge") is a cloud-based system founded in 2016, specifically designed for quality anatomical contouring and data management.Its analytical modules ensure contouring accuracy, quantify and study plan quality metrics, identify best practices, and ultimately correlate tumor contouring methods and modalities with patient outcomes (18).GoToMeeting is an online desktop-sharing program for video conferencing.The amount of bandwidth that GoToMeeting uses depends on the features that are being used per session.Screen sharing and computer audio during a PowerPoint presentation with multiple slides typically require a bandwidth of 40Kbps (0.004Mbps), while webcam sharing requires an average of 700 Kbps (0.7 Mbps) (23).In general, a session requiring all three features will require at least 1 Mbps of bandwidth.Less bandwidth will still work, but the session performance may suffer because of it.More bandwidth provides a superior user experience (23).
Invitation requests were sent via a mass email to all radiation oncologists (RO), medical physicists (MP), and therapy radiographers (TR) in Nigeria, Tanzania and Cameroon using our database, developed with the support of various professional societies in each country.Participants who registered were granted access to attempt and practice parotid gland contouring using ProKnow software during and after the scheduled session.The scope of the lecture included: a review of the parotid gland, its anatomy and tissue types; identification of the axial slice range (superior and inferior borders); a step-by-step contouring guide on the axial images; a review of special considerations for parotid radiation therapy, such as its sensitivity to radiation; and landmark studies that guide treatment dose.The didactic lecture was followed by a demonstration of tumor contouring with a left parotid case imported into the ProKnow system.Participants were granted week-long access to practice contouring of the left parotid volume after the session.Figure 1

Statistical Analysis
Self-competence before and after training were self-reported and converted to a scoring metric, and a general average score for each component was calculated as a summation

Radiotherapy Contouring Resources in Sub-Saharan Africa
Twenty-one participants reported on the resources used to guide contouring and tumor delineation (see Table 1 2).

Acceptance of Web-based Training Resource by Participants
ProKnow's web-based technology was well received by respondents.95% indicated the remote training session (Parotid volume) was relevant to their clinical practice and training; 100% indicated the web-based tool will be helpful to their professional development; 100% indicated that ProKnow was easy to navigate and use, and 100% indicated they would recommend the resource.Most respondents had access to strong or moderate internet connectivity to integrate the web-based tools in their clinical practice and training (see Figure 3).Only three respondents were neutral on internet connectivity, and this same number were neutral on affordability (see Figure 3).While the contouring resource for parotid tumor was relevant in the Sub-Saharan region, most respondents indicated contouring training for breast cancer, prostate cancer, and uteri-cervix were more pertinent to their clinical practice.

Discussion
Challenges to the delivery of radiotherapy services in developing countries are manifold.In a 2017 needs assessment using the Directory of Radiotherapy Centers (DIRAC) database maintained by the International Atomic Energy Agency, only 23 of 52 African countries have a radiotherapy unit, which provides coverage for only 36% of the patients in need of radiotherapy within the continent (28,29).Radiotherapy access is generally low in all LMICs, ranging from 2.3% to 98.8% (median 36.7)(29).In stark contrast, radiotherapy access is 92% and 195% in Europe and North America, respectively (28).The quality of care is also affected by the unavailability  Table 2. Pre-and-post-evaluation scores and analysis.
of skilled staff and inadequate imaging services.For example, in the absence of CTs, many radiation oncologists in LMICs are often forced to treat cancer patients using anatomic landmarks (21).This method is prone to a higher chance of an inaccurate target delineation, higher rates of recurrence, suboptimal care, and possible adverse events secondary to radiation toxicities (21).On the other hand, many LMIC cancer centers with facilities for imaging lack the expertise for tumor delineation in radiotherapy delivery.
Moreover, the growing transitioning of radiotherapy-based planning and care from 2-D to 3-D imaging in some LMIC centers makes the need for radiation oncology health professionals skilled in this area an imperative.However, global health collaboration to train oncology and radiology staff poses a challenge.These challenges mostly entail cost of travel, time, and distance.For example, the cost of training a team consisting of four radiation oncologists, three medical physicists, and seven radiation therapists is between €1,850,000 and €2,516,000 in Europe (30,31 Despite the small cohort of participants in this study, the potential impact of remote learning should not be underestimated.Our results are promising and should serve as a motivation to scale internet-based contouring resources for the global health terrain.

Conclusion
The is an example of parotid contouring by a Nigerian resident for the first time after the educational session.To evaluate the effectiveness of the training, a seven-question self-confidence assessment questionnaire was prepared and administered before and after the training.The questions assessed the participants' confidence in the necessary skills needed to contour a treatment plan.Areas of competence assessed included: (i) ability to identify anatomic structure on axial CT; (ii) ability to contour a parotid volume; (iii) ability to delineate tissues; (iv) dose-volume histogram evaluation (DVH); (v) plan evaluation; (vi) port film evaluation; (vii) cone-beam CT evaluation (CBCT).See Appendix 1 for pre-and post-training questionnaires.The post-class survey also contained questions to determine the acceptability of the ProKnow system for training and imageguided radiotherapy planning among the participants and their access to internet services.

Figure 1 .
Figure 1.First time contour of the left parotid of a participating resident.

Figure 2 .
Figure 2. Differences in self-assessment score before and after training session

Figure 3 .
Figure 3. Acceptance of web-based contouring tool and availability of internet bandwidth for their utility in Sub-Saharan Africa.

Table 1 .
Reported Radiotherapy Contouring Resources in Sub-Saharan Africaww It also opens a door of opportunity for trainees and residents in the United States and Europe to participate in impactful peer-to-peer education and twinning programs with LMIC oncologists and radiologists.
). Less attention has been paid to web-based remote training models due to global spread of computer and internet networks coupled with the development of multimedia platforms able to integrate any radiological imaging technique can provide valuable support for training in radiology and radiation oncology.Web-based interactive contouring atlases enable remote interactive learning on contouring activities.With adequate internet access, these tools are useful for training oncologists, radiologists, and other medical staff in developing countries.They can enable international collaboration, simulations, and self-directed learning.