Radiation oncologists' scope of practice and role in cancer management in Australia, New Zealand, and Singapore: Are we clinicians or technicians?

To evaluate the scope of practice and role in cancer management for radiation oncologists in Australia, New Zealand, and Singapore (ANZ).


Introduction
Radiation oncology, along with surgical and medical oncology is one of the classic oncology disciplines.The specialty has made significant advances in being recognised as an independent entity, internationally.In the United States, it is no longer called" therapeutic radiology" and locally, radiation oncology has an independent faculty within the Royal Australian and New Zealand College of Radiologists (RANZCR) with a robust specialty training program and examinations producing specialists who are recognised in their own right. 1,2et one might ask how far we have actually come.Patients often confuse us with radiologists and even medical students have reportedly confused us with radiation therapists. 2 How often does one hear a patient say "I'm seeing my oncologist after you", referring to their medical oncologist.Although we have our own Faculty, we still remain part of the College of Radiologists.
Our scope of practice, according to our Faculty defines us as . ... "part of a multidisciplinary team contributing to all aspects of the management of cancer patients. .." 3 But how true is this?Are we leaders in cancer management for our patients or do we just provide radiation therapy at the request of referring clinicians?Are we satisfied with our current role?
If we are not performing our perceived 'optimal' role what are the factors behind this and is there anything we can do to rectify this?
A recent study in the United States (US) revealed that radiation oncologists often simply provided radiation therapy at the request of their referrers. 4Despite 82.5% believing that their role was to provide a comprehensive opinion on cancer managementthe reality was that this was reported as happening only 39% of the time. 4Radiation oncology was regarded as a "downstream" specialty with much less influence than our surgical and medical oncology colleagues. 4e have endeavoured to ascertain the role of radiation oncologists in Australia, New Zealand, and Singapore in the management of cancer patients by a survey of radiation oncologists practicing in these countries.We sought to analyse the scope of practice and the roles performed in cancer management.This information was thought to be helpful in analysing whether our current training program prepares radiation oncologists for the roles held once the fellowship is obtained and whether changes are required to ensure this occurs.The College also sought this information to explore whether advocacy was required to support radiation oncologists in performing roles they feel are appropriate for their training within overall cancer management for their patients.

Survey development
The questions were developed by the principal author (JL) with the help of another author (MJ) and checked and approved by the Royal Australian and New Zealand College of Radiologists, Faculty of Radiation Oncology Economic and Workforce Committee (GA).
It was estimated that it would take 5 min to complete the survey.Most of the questions were close-ended with two or several options allowed.However, it was thought important to provide some free text answers to allow further clarification of why an opinion was held.
The survey was conducted on Survey Monkey and was sent to all active radiation oncologists in Australia, New Zealand, and Singapore (ANZ) listed on the RANZCR's database, with a weekly email reminder over the 10week period.
Only practicing radiation oncologists were emailed this survey.Descriptive statistics and frequencies were produced for categorical and scaled variables.p-Values for relevant variables were calculated and p-values <0.05 were considered statistically significant.Data analysis was conducted using Microsoft Excel and p-values were calculated using IBM SPSS Statistics for Windows.

Results
The RANZCR's membership database identified 448 eligible members.A total of 242 responses were received, giving a response rate of 54%.Using the information stored in the database analysis showed no obvious differences between responders and non-responders.

Demographics
The majority of respondents were from New South Wales (25.2%), followed by Victoria (19.8%) and then Queensland (17.4%).All geographical locations had respondents.Most respondents were male (56.4%) with the most common age bracket 45-54 (32.6%).The most common work setting was the city public hospital (42%), followed by a mixture of city public hospital and private practice (21.8%) and then the regional public hospital (12.2%).The most common length of experience revealed practicing radiation oncologists had been practicing for over 20 years (32.4%),followed by the 10-20-year time period (28.2%).A large majority of radiation oncologists spent over 50% of their time on patient care and were subspecialists (60.7%).Eighty-six percent of respondents worked at least 30 h per week.Regarding the average number of patients receiving radiation therapy per day, the most common response was the 10-20 patient category (44.9%), followed by the 0-10 category (26%).Four respondents (1.8%) treated between 50-60 patients each day.Multidisciplinary meeting participation occurred for 97.4% of respondents.The demographic and other data are summarised in Tables 1 and 2.

Clinical practice
The large majority of radiation oncologists often managed symptoms of toxicities associated with radiation therapy (96%), and cancer-related symptoms (86%), and wrote narcotic and analgesic prescriptions (76%).Over half of respondents were often involved in palliative care (57%), just under half were often prescribed noncytotoxic systemic therapy (45%), and were involved in inpatient admissions (41%).Some of the other services provided included on-call management of patients presenting to the emergency department including new diagnoses; prescription of chemotherapy and immunotherapy; and management of other comorbidities such as blood pressure and diabetes; and genetic counselling (see Figure 1).
When it came to being comfortable in providing services, 91% felt comfortable with the management of symptoms and toxicities associated with radiation therapy, 85% with the management of cancer-related symptoms, 81% with narcotic prescriptions, 69% with palliative care, 67% with inpatient admissions and 61% with prescriptions of non-cytotoxic systemic therapy (see Table 3).
Just over 20% (20.3%) of respondents wanted to expand their services with subspecialty systemic treatment, in-patient care, palliative care, brachytherapy for gynaecology patients, and radiopharmaceuticals among the choices (see Table 4).
However, for those who were unable to expand the clinical practice, the major reasons were insufficient time (34.8%)insufficient training (14.2%), inter-specialty political difficulties (12.1%), and lack of support from the organisation (11.8%).

Radiation oncologist's role in patient care
Respondents were asked about their role in patient management with over half (56.4%) Indicating they had an overall management role and almost 20% (19.4%) providing an opinion on radiation therapy only.Less than 1% provided radiation therapy at the request of the referring physician, but nearly a quarter (23.3%) had a combination of the above.Three-quarters of those reporting the combination were involved in both overall cancer management and providing an opinion on radiation therapy, but not providing radiation therapy at the request of the referring clinician.

Ideal role of radiation oncologists in patient care
Radiation oncologists were asked what they thought was their ideal role in patient care.Just over 80% thought they should be involved in overall management which included not just an opinion on radiotherapy, but also other treatment options including systemic therapy surgery and surveillance.Just under 20% thought they should provide an opinion on radiation therapy only and <1% thought they should provide radiation therapy at the request of the referring clinician.Subspecialists (83.3%) were more inclined than generalists (74.7%) to think they should be involved in overall management (p < 0.001), but there were no significant differences according to practice type (public city vs. private city vs. mixture city).When respondents were asked if their actual role matched their ideal role the large majority answered in the affirmative (87.3%).However, there was a significant difference between those in city public hospitals (86.2%) mixture of private practice and public hospitals (94%) and those in city private practice (69.6%) (p < 0.001).Radiation oncologists in Tasmania (57.1%) were less likely to answer in the affirmative, but the numbers were small.Subspecialists thought their ideal role and actual role matched more commonly than did generalists (88.2% vs. 85.1%, p < 0.001).For those where the actual role did not match the ideal role, the main reasons were referring clinicians relied solely on a radiation therapy opinion; referring clinicians would be alienated if a different opinion was provided and would change subsequent referrals; and, the medical oncologist provided the overall management plan including the indications for radiation therapy (see Table 5).
When the radiation oncologist was not providing an opinion on overall cancer management, the most common scenario was decision-making by a combination of other disciplines (but excluding radiation oncology) (66.3%).However, there were reports of decisionmaking by single disciplines with the most common being the medical oncologist (15.5%) and the referring clinician (14.9%) (see Radiation oncologists reported that in their opinion they were perceived as an independent clinician (83.1%) by the large majority of clinician colleagues, but a substantial minority (16.9%) felt they were perceived as a provider of radiation services, effectively functioning more as a technician.
The large majority of respondents (77.7%) thought that current radiation oncology training enabled radiation oncologists to have an opinion on overall management.For those who answered in the negative, exposure to medical oncology with rotation during training and modification of the curriculum would improve this situation were the most common answers.This might enable radiation oncologists to feel more comfortable in providing an opinion on overall management (see Table 7).
Over 90% (90.6%) of respondents were satisfied with their current role in overall management.For those who were not satisfied the most common reason was being perceived as a technician and just a provider of radiation services.The large majority of respondents (86.6%) routinely ordered scans, blood tests, biopsies, and other investigations prior to treatment with a small minority having no role (4.0%) and relying on other clinicians (9.4%).
Radiation oncologists were also asked what they thought the role of radiation oncologists should be within the cancer management team.The large majority (86.6%) thought they should function as part of a multidisciplinary team.The minority (12.9%) thought the radiation oncologist should be the overall leader of the team, with practically no respondents thinking the role should be restricted to being only a provider of radiation therapy (0.4%).Over half of those who thought radiation oncologists should be leaders within the cancer management team had been practicing for over 20 years.

Discussion
This survey was undertaken not only to assess the current scope of practice for radiation oncologists in Australia, New Zealand and Singapore, but also to assess their actual role, their self-assessed perceived role, and their ideal role within the cancer management team.Scope of practice as defined by health services is "the extent of an individual's clinical practice within a particular organisation or facility based on their credentials as well as the needs and capability of the organisation to support the requested clinical scope of practice." 5his survey was performed to evaluate the scope of practice beyond patient evaluation and delivery of radiation therapy, assessing other components of cancer care provision.
To explore these other components of cancer care we questioned respondents regarding provision of symptom control, The fact that radiation oncologists manage radiation toxicity, and cancer symptoms and prescribe narcotics is unsurprising.However, the prescription of narcotics and analgesics by 76% might be perceived as lower than expected.This may reflect the case mix of radical/ palliative patient care; however, one might expect nearly all radiation oncologists to have some fundamental knowledge to write prescriptions.Indeed, this is reflected in the curriculum with emphasis on the importance of gaining skills in symptom control with frequent fellowship examination questions seeking to assess competence in this area.
Palliative care is listed on the RANZCR scope of practice but with only 57% of respondents reporting often being involved and 69% feeling comfortable, one might question whether additional training such as a formal trainee rotation, focused work-based assessments in palliative care of patients or post qualification teaching is required.
Inpatient admissions have been a recent controversial issue for the accreditation of trainees.Some centres do not allow radiation oncologists admitting rights which has made the demonstration of compliance with Accreditation Standards more challenging for these training centres.These centres have needed to demonstrate inpatients are managed appropriately and trainees are receiving the appropriate training even if they are under a non-radiation oncologist bed card.The ability to manage inpatients was seen as core to practice and centres are required to demonstrate trainees have sufficient exposure to inpatient management in order to achieve accreditation.If trainees do not have adequate exposure to inpatient management, it would be difficult to expect competence as a consultant.The fact that over 80% of respondents feel responsible for the overall management of cancer patients and 77.7% feel that the current training enables them to have an opinion on overall management (Table 7) should strengthen this stance for current training programs.
The prescription of non-cytotoxic systemic therapy is more likely to be reported by those who subspecialise in these cancer types.
Activities such as the prescription of chemotherapy, and specialist genetic counselling do not fall into the current radiation oncology scope of practice.However, radiation oncologists may be involved in the discussion of chemotherapy and genetic counselling with their patients, and competency with interpreting oncology radiology would be considered core for practice and training.
A comparison with our US colleagues in the scope of practice reveals many similarities although the provision of genetic counselling occurred in, one-third of their respondents, and 10% prescribed medical marijuana. 4ur US colleagues conducted "masterclasses" in some of these areas to help gain sufficient expertise.
It should be noted that a significant majority of our respondents (80%) had no desire to expand the current scope of practice with reasons given very similar to our US colleagues. 4t is important to be preparing fellows well to adapt to an ever-changing/ dynamic specialty.It was reassuring to note the large majority of respondents felt that radiation oncology training did not limit their role in cancer management.The minority did not feel preparation was adequate however, the survey did not explore this further.
A significant reason for performing this study was to evaluate our role in cancer management.The fact that <1% provided radiation therapy at the request of the referring clinician is reassuring and compares favourably with our US colleagues where one-quarter of their respondents provided radiation therapy at the request of the referrer. 4"The difference between our study and the US one is shown in that, although both US and ANZ radiation oncologists thought the ideal practice was to provide a comprehensive opinion on cancer management or give an opinion on radiation therapy, 87% of our respondents actually found this matched their actual practice compared to <20% of our US colleagues. 4t is unlikely that there is a single reason for this disparity.It may reflect a different practice culture.This is supported by 96% of US practitioners wanting to be the leaders in cancer management compared to 13% of ANZ radiation oncologists.Nearly 90% of ANZ respondents preferred to be part of a multidisciplinary team without one specialty dominating.Of course, there are many other differences between ANZ and US practice (private vs. public mix, employment contracts, student debt repayments, etc) that could result from this apparent competition between specialists (and potential dissatisfaction from radiation oncologists).There may also be a difference in the way the term "leader" is defined with variations between the countries and individual survey respondents that reflect cultural attitudes beyond medicine-for example a leader being defined as a single dominant figure as opposed to multiple leaders bringing their collective wisdom to the council.Such nuances are beyond the scope of this survey.Finally, it should be recognised that questions about leadership are inevitably worded differently between surveys so cross comparison should be done cautiously.
Our Spanish colleagues also believe in the multidisciplinary contribution rather than a "star" performer, that is that "no single medical specialty should have a monopoly on cancer care". 6They in fact validated this at a conference which led to the Institutional Declaration for the Development of Multidisciplinary Cancer Care in Spain. 7There was a strong belief that the quality of cancer care depends on a team approach with health professionals who are willing to work collaboratively by contributing specialist input appropriately. 6eriodic reflection on the role of the radiation oncologist in cancer management is important as changes of practice for sound clinical reasons may have unintended consequences in team dynamics.For example, hypofractionation has led some of our US colleagues to believe that there is the potential for radiation oncologists to be perceived more as technicians rather than clinicians, given the reduced number of patient interactions compared to longer course treatments. 8he fact that 83% of respondents thought they were perceived as independent clinicians is reassuring.However, this means a significant minority were perceived as technicians.How does one overcome this problem?The US study has suggested open communication and collaboration with those outside the specialty to promote multidisciplinary teamwork, credibility and trust, and demonstrate the emphasis that radiation oncologists place on evidence-based medicine. 2owever, fundamental to all this lies the question "does our training allow us to be independent clinicians?"Those who answered negatively suggested changing the curriculum to a more clinical oncology focus, more exposure to medical oncology and other specialties, more advocacy and assertiveness, and even physician training.It should be realised, however, that the radiation oncology component of the curriculum is very comprehensive.Additional competencies require appropriate training and a more expansive curriculum, which may not be achievable or in fact desirable, in that it may detract from core training in radiation oncology.
Our United Kingdom colleagues, who are clinical oncologists (with both physician and radiation oncology postgraduate qualifications), routinely prescribe systemic therapy as well as radiation therapy.Not surprisingly, they faced a different dilemma than us.They gave more systemic therapy than their medical oncology and haematology colleagues and certainly were involved in the overall management of the patient. 9However, there was apprehension as to whether their radiation oncology skills could keep pace with all the radiation therapy developments. 9evertheless, they still preferred the broad clinical oncology model and believe that the clinical oncology specialty is "more than just radiation oncology."Unlike other countries, the specific practices within the UK likely make discussions about clinicians versus technicians redundant.
This study has several limitations.The response rate was 54% which is lower than previous workforce studies (over 70%), but an analysis of respondents and nonrespondents revealed no significant differences. 10,11,12It also compares favourably with the US study response rate. 2 One of the initial problems was that a large private provider of radiation oncology service in Australia did not receive the survey for a number of weeks because of technical issues and the impact of this on response rates is unknown.The survey structure had closed-type questions allowing specific options, this may have benefited from more free-text options in the questions to allow space for additional opinions.However, there were openended questions and free text comments were allowed at the end of the survey.The definition of "leader" within the cancer care team was not defined and this may have led to ambiguity in interpretation and variable responses.Although the survey itself was also thoroughly reviewed by the entire Economic and Workforce Committee, an independent radiation oncologist review may have assisted in the clarity of some questions Finally, the impact of the coronavirus pandemic is unknown.
In conclusion, this study has revealed a broad but expected scope of practice for ANZ radiation oncologists and the large majority provided an opinion on overall cancer management or radiation therapy with their ideal role matching the actual role.

Table 2 .
Response rate by country ‡Overseas refers to all respondents outside Australia and New Zealand.© 2023 The Authors.Journal of Medical Imaging and Radiation Oncology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Radiologists.
Fig. 1.Services provided by respondents.© 2023 The Authors.Journal of Medical Imaging and Radiation Oncology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Radiologists.

Table 3 .
Clinical Scope of practice -Services respondents were comfortable in providing Please note that the respondents could select more than one option.

Table 4 .
Percentage of respondents wishing to expand their scope of practice and desired services

Table 5 .
Respondents ideal and actual role in cancer management

Table 6 .
Total responses and responses by gender if the respondent was not providing an opinion on overall patient management, then who is the person responsible

Table 7 .
Total responses and responses by gender on whether current radiation oncology training enables radiation oncologists to have an opinion on the overall management of cancer patients © 2023 The Authors.Journal of Medical Imaging and Radiation Oncology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Radiologists.