Medical Student Rotations
Director of Education: Neha Vapiwala, MD, Assistant Professor of Radiation Oncology
Associate Director of Medical Education: Cordelia Baffic
Education Officer for Trainees
: Abby Berman, MD, Resident Physician
Visiting Medical Students
Thank you for your interest in enrolling as a visiting student in Radiation Oncology at the Perelman School of Medicine at the University of Pennsylvania. Please click on the links below to find out more information about the program and our application process. Note that this application is only for U.S. and Canadian Medical Students.
Perelman School of Medicine Visiting Students
Radiation Oncology Elective Course Description
This is a brief summary of what we hope you will get out of your elective rotation in the Department of Radiation Oncology. We hope that you will learn the fundamentals of cancer care. You will see how radiation oncologists work closely with medical oncologists, surgical oncologists, nutritionists, and a wide variety of specialties to provide multidisciplinary cancer treatment. You will find in radiation oncology that our daily interaction with patients is quite intense. Whether it is before, during, or after their course of radiation therapy, patients become well-known to you and to the department.
Most importantly, we expect that you perfect your ability to take a focused patient history and do a thorough physical examination. Depending on your assigned radiation oncology service, you will learn the art of various cancer-specific physical exams, including proper lymph node, head and neck, and female pelvic exams. We want you to learn about the natural history, treatment, and prognosis of the cancers you see. Sometimes the goal of treatment is cure, but other times palliative. To guide your reading, please see recommended books and references at the end of this handout. We do want you to learn about how we try to set up radiation fields and what our concerns are for normal tissues, although we do not want you to focus too much on the technical aspects of radiation.
Finally, a word on professionalism. Please dress in appropriate clothes as you would on any clinical rotation. Please, no scrubs (unless you are going to the operating room). Likewise, the department expects that all personnel will conduct themselves in a professional manner that optimizes patient care as well as student teaching. If anyone behaves inappropriately, we expect you to bring this to our attention promptly.
Here are the goals and expectations of the rotation:
- To understand the role of radiation therapy in the treatment of cancer.
- To learn more about the general principles of oncology, including:
- Basic Science of Oncology
- Diagnostic workup and staging of cancer
- Tumor boards and deciding on a cancer treatment plan.
- The administration of treatment for cancer
- The supportive medical care of the cancer patient, particularly outpatient care
- To observe the specialized procedures of radiation therapy for cancer, including
To work closely with one attending who sees 1-2 disease sites. In order to maximize interaction between student and faculty, you will be assigned to work with one primary attending (and his/her resident, where applicable) for the entire 4-week rotation. When that attending is out of the office or has an academic day, you should spend time with your pre-assigned secondary attending.
- General simulation and treatment of common radiation therapy fields.
- Planning and administration of CT-planned external beam radiation therapy.
- Planning and administration of brachytherapy (optional).
- Intraoperative photodynamic therapy (optional).
To give a presentation on a topic of your choice. A requirement of the rotation is a 10-15 minute powerpoint-based presentation on any topic of your choice. The topic should be discussed with and approved by your primary attending and should be oncology-related. It should answer a clinical question, and should not specifically be a talk about your research. You are also encouraged to seek guidance from any of the residents. For example, the talk can be based on a particularly interesting case that you observed during the rotation, or it can be a general overview on a particular new drug, treatment method, or rare oncologic entity. Generally, the best talks will cover 2-3 primary literature articles in good detail. The talk is typically followed by a question and answer period. You should plan on having no more than 10-12 powerpoint slides. A handout corresponding to the talk is optional but generally preferred.
To attend tumor boards and conferences. You are expected to attend:
- Your primary attending may want you to work on clinic notes
- Consultations: For all consultations, you should gather the pertinent information (radiology, path reports, operative reports, etc.) prior to seeing the patient.
- Follow-Up Visits and On-treatment Visits: You will see and examine the patient together with the resident/attending. You will assist the resident in obtaining pertinent information (e.g. lab or radiology results; updating the patient’s medication list; scheduling tests or appts with other M.D.s).
- Simulations, Dosimetry, and Setups: You will observe the attending and resident in the technical aspects of radiation oncology. You are expected to help in gathering the pertinent information (e.g. radiology studies) necessary for these procedures. You may be quizzed about anatomy and oncology during these procedures, but is not expected that you perform any of these technical procedures. If feasible, you should work with your attending and/or resident on contours for simulations.
- When you have free time, you should spend time with dosimetrists, therapists or with a different attending doing consults or OTVs. The expectation is that you spend at least one half-day with dosimetrists and one half-day with therapists on the treatment machines during your rotation. If you have free time, call Abby Milby (215-900-7257) and she will set you up with dosimetry or one of our treatment machines.
- Conferences relevant to the service to which you are assigned.
- Abramson Cancer Center Grand Rounds at 8 AM on Wednesdays (TRC Auditorium).
- Resident didactic conferences from 7 to 8 AM on Thursdays and from 7 or 8 AM to 11 AM on Fridays (sometimes starting at 7 AM, schedule can be found by typing “radoncsharepoint” into the internet browser bar). They are located in TRC-2 west.
- Weekly medical student teaching sessions at a time TBD.
- Weekly “Chart Rounds” at noon on Fridays in the board room on the CC level of PCAM.
- Optional: Weekly PROPS (Proton Prioritization Committee) where we review the potential upcoming cases for proton beam therapy. This meeting is in TRC- 2 West on Mondays at 8:45 AM.
- If you find yourself with downtime, there are almost always site-specific conferences occurring during the day, so ask one of the residents or attendings, and he or she will be happy to suggest a conference. Here is a list of the weekly conferences:
- Tumor Board: Wednesday, 1:30 PM, PCAM 2 West conference room
- Chart Rounds: Friday, 10:30 AM, PCAM CN Proton conference room
- Tumor board: Fourth Tuesday of the month, 7:00 AM, Urology Conference Room on TRC-3
- Chart Rounds: Fridays, 11:00 AM, TRC-2 Conference Room
- Tumor Board: Wednesday, 5:00 PM, PCAM 1 West Penn Lung Center Conference Room
- Chart Rounds: Thursday, 9:00 AM, PCAM CN Dosimetry Conference Room
- Pediatrics: Please touch base with pediatrics resident prior to going to any of these conferences.
- Chart rounds: Tuesday, noon, PCAM CN Proton conference room
- Proton Triage Conference: Tuesday, 7:30 AM, CHOP Wood 4330
- Neuro-Oncology Tumor Board: Wednesday, Noon, Colklet Translational Research Building, 4th floor
- Solid Tumor Board: Thursday, 3 pm, Wood 6th floor
- Tumor Board: Monday, 8:00 AM, PCAM 3 West conference room
- Chart rounds: Tuesday, 8:00 AM, PCAM CN Dosimetry Conference Room
- Tumor Board: Thursday, 8:00 AM, BRB 252
- Chart Rounds: Wednesday 7:00 AM, PCAM CN Dosimetry Conference Room
- Skull Base Conference periodically, but this is a variable time and location. Discuss with Dr. Lustig if you would like to go.
- Tumor Board on Bone Marrow Transplant, Tuesday, 1:00 PM, PCAM 2 West conference room
- Head and Neck
- Tumor board: Thursday, 1:00 PM, Silverstein 5 Conference Room
- Chart Rounds: Thursday, 2:00 PM, TRC-2 Conference Room
Grading (Honors, High Pass, Pass, Fail, Incomplete):
The attending(s) who have worked with the student will report back to the course directors with written comments on the student’s clinical performance, quality of the student's conference presentation, and a tentative grade.
Highly motivated students interested in a career in Radiation Oncology should be prepared to submit a short article to Oncolink, the University of Pennsylvania’s Internationally recognized cancer web site. This can be a version of the student’s brief handout that he/she did for the conference, or another "interesting" case of the month. See www.oncolink.upenn.edu.
The department offers opportunities for clinical and/or basic science research for highly motivated students interested in a career in radiation oncology. In general, the one-month rotation of RO300 is not sufficient time to design and implement even a simple research project. However, separate 1-2 month rotations in radiation oncology focusing on clinical research projects are available (Radiation Oncology 400). These are can either be clinical projects or basic science projects. Some laboratory and/or clinical research positions in the department offer students a modest stipend. * If you would like to participate in research of any nature, please let Cordy Baffic know and she will direct you to the correct person.*
Suggested Reading for RO 300: Residents should be able to locate a copy of the suggested reading for you to borrow.
- Hansen: Handbook of Evidence Based Radiation Oncology (Springer)
- Haffty: Handbook of Radiation Oncology, Basic Principles and Clinical Protocols (Jones and Bartlett) *We have copies for you to sign out and borrow for the duration of your rotation in the resident room*.
- AJCC Cancer Staging Manual (7th Edition)
The staging manual is important for anyone who is interested in any field of oncology. Copies are available at many locations throughout the dept.
- Bethesda Handbook for Clinical Oncology
- DeVita: Cancer: Principles and Practice of Oncology
This book has chapters on each type of malignancy, e.g. breast cancer, lymphomas, lung cancer, head and neck cancer, cervical cancer and prostate cancer. This textbook is available at the med school library or in multiple locations throughout the radiation oncology dept. (residents’ room, etc.).
- The results of major large randomized trials in oncology that may be of interest to medical students are usually published in the New England Journal of Medicine, Lancet, or the Journal of Clinical Oncology. These journals occasionally have good review articles on important topics in oncology as well. The major journal specific to the field of radiation oncology, International Journal of Radiation Oncology Biology Physics, is also an excellent journal but often highly technical.
Fundamentals of Radiation Oncology
Steps involved in Clinical Radiation Therapy
- Consultation, including decision to irradiate
- Pre-radiation workup, including staging, dental evaluation, nutritional assessment
- Simulation, including immobilization of the area to be irradiated
- Dosimetry (Calculation of radiation dose to tumor and normal structures)
- Setup or final quality assurance planning session
- Radiation Treatments, including on-treatment visits by the physician(s)
- Conedown(s) --- if applicable ---- : Repeat of steps 3 through 6
- Post-radiation follow-up visits
Examples of Indications for Radiation Therapy
- Definitive Radiotherapy alone for early larynx cancer.
- Preoperative Radiotherapy prior to resection of a low-lying rectal cancer.
- Postoperative Radiotherapy after mastectomy for locally advanced breast cancer.
- Palliative Radiotherapy for a massive incurable lung cancer causing pain/bleeding
- Benign (rarely used) Radiotherapy to prevent coronary artery restenosis after PTCA.
Different Radiation Therapy Dose Fractionation Schedules
(1 cGy = 1 rad = approximately the radiation dose absorbed in getting a typical CT scan)
- Conventional Radiotherapy 180-200 cGy/day, 5 days/wk to 6600-7200 cGy; no planned interruptions
- Accelerated Hypofractionated Radiotherapy 250-300 cGy/day, 5 days/wk to 5000-5400 cGy; no planned interruptions
- Non-accelerated Hypofractionated Radiotherapy 250-300 cGy/day, 3-4 days/wk to 5000-7000 cGy; no planned interruptions
- Split course Radiotherapy 200-300 cGy/day, 5 days wk to 6000-7200 cGy; 1-2 wk break in the middle of therapy
- Hyperfractionated Radiotherapy 110-125 cGy b.i.d., 5 days wk to 7000-8000 cGy; no planned interruptions
- Accelerated Hyperfractionated Radiotherapy 140-160 cGy b.i.d., 5 days wk to 6600-7200 cGy; usually requires 1-2 wk break in the middle of therapy
- Accelerated, Concomitant Boost Radiotherapy 180-200 cGy/day, 5 days wk to 3500-4500 cGy followed by 150-180 cGy b.i.d. "conedown" boost radiotherapy to 6600-7200 cGy; no planned interruptions
- Continuous Hyperfractionated Accelerated Radiotherapy 120-180 cGy b.i.d or t.i.d. 7 days wk to 5000-5400 cGy; no planned interruptions
The Four "R’s" of Radiation Biology
- Repair: Cells repair DNA damage from radiation in between radiation fractions (doses). Larger radiation doses, radiation sensitizers (e.g. concurrent chemotherapy) partly overcome repair.
- Redistribution: Cells "redistribute" from radioresistant phases (e.g. S phase) of the cell cycle to more radio-sensitive cell cycle phases (e.g. M phase) in between radiation fractions Hyperfractionated radiotherapy (increased number of XRT fractions increases the probability of cells being in M phase during a treatment).
- Reoxygenation: Cells may go from a hypoxic (and thus radioresistant) environment to a well-oxygenated state as a course of treatment proceeds Hyperfractionated radiotherapy; hypoxic cell sensitizers; carbogen or hyperbaric oxygen during XRT.
- Repopulation: Cells may respond to the death of adjacent cells by "accelerated repopulation" Accelerated radiotherapy kills off cells before they gain the opportunity to repopulate.
Glossary of Terms Related to Radiation Therapy
- Adjuvant: Generally refers to postoperative therapy. However, chemotherapy given after "definitive" radiotherapy would also be considered adjuvant.
- Blocks: Thick shields made of a lead-like alloy which can be shaped for each patient to "block" portions of their anatomy that would otherwise fall into the radiation field. In the treatment of head and neck cancer, for example, every attempt is made to block as much CNS tissue as possible.
- Brachytherapy: radiotherapy given in the form of radioactive sources placed directly into or around a patient’s tumor. This may be given interstitially (sources imbedded directly into tissue) or intracavitary (sources laid into a cavity such as the nasopharynx.
- cGy (centigray): A modern basic unit of radiotherapy dose; 1 cGy = 1 rad. One cGy = 100 ergs per gram of absorbed energy.
- Cobalt-60 therapy: A form of external beam radiotherapy in which the source of radiation is not x-rays, but gamma rays emitted from a machine containing radioactive Cobalt-60.
- Conedown: Shrinking the field size sometime during the course of radiotherapy, to take advantage of the decreasing size of tumor during treatment and to minimize the amount of toxicity of treatment. For example, a patient may begin radiotherapy with a 15 x 15 cm field and then have a conedown midway through treatment to a 10 x 10 cm field.
- Conformal Radiotherapy: The use of extremely sophisticated imaging studies and dosimetry to design radiation fields that "conform" precisely to the shape of a patient’s tumor. Conformal radiotherapy usually uses smaller "safety margins" around a patient’s tumor, a larger number of fields, and less prophylactic radiotherapy of clinically uninvolved lymph node areas.
- Consolidative: Refers to radiotherapy given after a maximal or complete response to chemotherapy, as is often done in the treatment of lymphomas.
- Course: A series or program of radiation treatments or fractions with a specific goal in mind for a patient, e.g. a seven-week course of daily radiotherapy to the lung for attempted cure.
- Definitive: Refers to radiotherapy given with the intention of cure without radical surgery. May be given with other non-surgical treatment such as chemotherapy.
- Dosimetry: The process of optimizing the radiotherapy fields and dose by calculating the radiation dose to be received by a tumor and/or normal tissues in a radiation field(s). Physicists and "dosimetrists" work with the radiation oncologist in comparing possible radiation treatment plans with the goal of maximizing the radiation dose to the tumor while minimizing dose to normal tissue, often requiring sophisticated computer programs. Dosimetry can be described as the radiotherapy version of pharmacokinetics.
- External beam radiotherapy (x-ray therapy): radiotherapy given from a machine (usually a linear accelerator) which produces a high-energy x-ray beam which is then aimed at a patient’s tumor and/or suspected tumor areas.
- Field: An area at which a radiotherapy beam is directed, usually described as a rectangular shape, in cm (e.g. 10 x 14 cm). "Blocks" are often used to further customize the shape of a field. A single fraction of radiotherapy may include multiple fields, typically two to four.
- Fraction: A single radiation therapy session, usually given over one to three minutes. A fraction may consist of one or multiple "fields," and any dose, as prescribed by the radiation oncologist. Most courses of radiotherapy involve one fraction per day, Monday through Friday, over one to seven weeks, although an infinite number of possible fractionation schedules are possible.
- Gy (Gray): The SI modern basic unit of radiotherapy dose; 1 Gy = 100 cGy = 100 rad. One Gy = 1 Joule per kilogram of absorbed energy.
- Hyperfractionation (see also fraction): The delivery of two or more radiation fractions per day, generally given with a four or more hour interval between fractions.
- Neoadjuvant: Generally refers to preoperative therapy. However, chemotherapy prior to "definitive" radiotherapy would also be considered neoadjuvant.
- Palliative: Refers to therapy given with the goal of relieving distressing symptoms, without any anticipated effect on survival.
- Prophylactic: Refers to radiotherapy given to a site at which there is no known tumor but which is considered to be at high risk for harboring occult "microscopic" disease, such as lymph node areas.
- Rad: Basic unit of radiotherapy dose; terminology has now changed to the S.I. units (cGy and Gy). 1 rad = 1 cGy (See Gray).
- Radiation Therapy Oncology Group (RTOG): A National Cancer Institute-sponsored multicenter clinical trials cooperative group which performs studies related to radiation therapy, including many lung cancer studies.
- Radiosensitizers: Drugs or other treatments which increase the cellular response to radiotherapy. Many chemotherapeutic drugs have radiosensitizing properties.
- RTOG: See Radiation Therapy Oncology Group.
- Safety Margin: A margin of "normal-appearing" tissue which is added onto the visible tumor area for the purposes of radiation planning. Typically 1.5-2 cm in all dimensions is added, to account for microscopic extension of tumor cells and the possibility of slight patient motion during treatment.
- Simulation: A detailed planning session for radiation therapy, which "simulates" but does not actually deliver a radiation treatment. Simulation consists of immobilization of the patient in an appropriate position for radiation therapy, marking the patient’s skin, localizing the area to be treated under fluoroscopy, taking radiographs of the area to be treated, and taking measurements of the patient’s contour for dosimetry purposes.