Brachytherapy 12 (2013) 615e621

Brachytherapy practice across Canada: A survey of workforceand barriers

Jim Rose*, Pierre-Yves McLaughlin, Conrad B. FalksonDepartment of Oncology, Queen’s University, Kingston, Ontario, Canada

ABSTRACT PURPOSE: To determine the current use of

Received 4 Febru

accepted 21 August 2

* Corresponding a

25 King Street West, K

2631; fax: þ613-548-

E-mail address: j

1538-4721/$ - see fro

http://dx.doi.org/10

brachytherapy, characteristics of the brachytherapyworkforce, and barriers to development and maintenance of brachytherapy programs acrossCanada.METHODS AND MATERIALS: A survey was designed to inquire about the use of brachyther-apy and was sent to all Canadian radiation oncologists.RESULTS: Of the 116 respondents, we identified 80 radiation oncologists from 33 of 41 respond-ing centers who currently or in the past have practiced brachytherapy. Responses were receivedfrom 30% overall and 80% of provinces. Approximately 58% of the respondents treat in one sitewith brachytherapy, whereas 12% treat in three or more sites. Gynecologic (GYN) and genitouri-nary are the most commonly treated sites (49% of respondents). For all sites, there was a large rangein the number of patients treated with brachytherapy by each radiation oncologist per year (i.e.,cervix: 1e50). Approximately 49% of the respondents have discontinued practicing brachytherapyfor a certain site, most commonly head and neck (28%), GYN (25%), and bronchus (24%). Themost common reasons include reassignment or lack of a local program. The most common reasonswhy brachytherapy is not used for sites other than GYN and prostate include lack of infrastructureand insufficient training of radiation oncologists rather than insufficient patient numbers or lack ofevidence for a benefit of brachytherapy.CONCLUSIONS: Within its limitations, our study suggests a mismatch between demand andavailability of brachytherapy programs across Canada. In light of finite resources, a rationalapproach to investment in brachytherapy is needed and this must be based on a formal audit of bra-chytherapy demand and use. � 2013 American Brachytherapy Society. Published by Elsevier Inc.All rights reserved.

Keywords: Brachytherapy; Survey of practice patterns; Barriers; Workforce; Canada

Introduction

In 2012, therewill be an estimated 186,400 new diagnosesof cancer (excluding nonmelanoma skin cancer) made inCanada (1). The incidence of new cases of cancer in Canadais increasing owing to the increasing age and size of the pop-ulation (1). Radiotherapy is an important modality of cancertreatment and remains underused in Canada. Approximately39% of patients in Ontario currently receive radiotherapy atsometime during their illness. This is below the recommen-ded 48% benchmark for radiotherapy utilization established

ary 2013; received in revised form 8 May 2013;

013.

uthor. Department of Oncology, Queen’s University,

ingston, Ontario K7L 5P9, Canada. Tel.: þ613-544-

1355.

rose2007@gmail.com (J. Rose).

nt matter � 2013 American Brachytherapy Society. Publis

.1016/j.brachy.2013.08.008

by the Cancer Quality Council of Ontario (2). Up to 20% ofthe patients in Ontario experience longer than recommendedwait times to start radiotherapy (3). There are a number offactors, including lack of resources and training, whichmay contribute to this.

The use of brachytherapy and the brachytherapy work-force in Europe and Latin America have previously beenstudied (4e6). There have been some studies investigatingthe patterns of practice and utilization of brachytherapy incancer of the cervix in North America (7, 8). We wereunable to identify any studies examining the barriers todevelopment and maintenance a brachytherapy program.Specifically, there have been no Canadian studies investi-gating the use of brachytherapy for non-gynecologic(non-GYN) and non-prostate tumors.

The purpose of this study is to determine the current useof brachytherapy, characteristics of the brachytherapy

hed by Elsevier Inc. All rights reserved.

616 J. Rose et al. / Brachytherapy 12 (2013) 615e621

workforce, and the barriers to development and mainte-nance of brachytherapy programs across Canada.

Methods and materials

Canadian radiation oncologists were identified using theCanadian Association of Radiation Oncology directory (9),individual cancer center directories, and provincial collegedirectories. The target population included all Canadianradiation oncologists, regardless of whether they practicebrachytherapy.

A 21-item electronic questionnaire (in both officiallanguages, namely English and French, Appendix 1) wasdesigned to inquire about the use of brachytherapy incancer centers across Canada (10). The questions focusedon specific applications of brachytherapy at each center,the training of individuals who practice brachytherapy,time spent on brachytherapy, number of sites treated,and number of patients treated per year by each radiationoncologist. An e-mail message with a link to the question-naire was sent to all participants with a followup e-mailsent. All respondents agreed to allow their anonymousresponses to be used for research purposes. Questionnaireswere anonymous and analyzed by individual respondent(11).

Table 1

Proportion of radiation oncologists treating each disease site with bra-

chytherapy and number of patients treated per brachytherapist per year

(n5 65)

Disease

site

Number

treating (%) Subsite

Number

treating (%)

Number of patients

treated/y

Median Range

Gyne 32 (49) Uterine 32 (49) 30 1e125

Cervix 32 (49) 15 1e50Vulva 13 (20) 6 1e30

GU 32 (49) Prostate 31 (48) 35 7e200

Other GU 6 (9) 6 1e30GI 9 (14) Esophagus 9 (14) 3 1e10

Rectum 2 37 3e70

Other GI 4 5 4e5

Lung 13 (20) Bronchus 13 (20) 7 1e50Lung 1 3 1e5

Other 17 (26) Breast 9 (14) 15 2e50

Skin 8 (12) 6 1e15

Head/Neck 3 6 1e12Eye 1 9 9

Sarcoma 1 2 2

Gyne5 gynecologic; GI5 gastrointestinal; GU5 genitourinary.

Results

Of the 41 Canadian radiation oncology centers, wereceived responses from 33 (80%), which represented 116of 389 individual responses to e-mails. A total of 80 respon-dents (69%) currently practice brachytherapy or have doneso in the past and 66 currently practice brachytherapy. Wereceived responses from centers in each province excepttwo (one Atlantic and one Prairie). A total of 30 (91%)of responding centers have clinical brachytherapyprograms. All centers with a clinical brachytherapyprogram have high-dose-rate brachytherapy, 57% havelow-dose-rate brachytherapy (including permanent seedimplants and all other applications/isotopes), and 10% usepulsed-dose-rate brachytherapy.

Workforce

The age of radiation oncologists currently practicingbrachytherapy was analyzed using the c2 test and they werefound to be younger than either those who have never prac-ticed brachytherapy or who have discontinued the practice( p!0.01). A total of 29% of the respondents practicingbrachytherapy received no special training outside resi-dency. Approximately 48% received training in the formof mentorship outside of a brachytherapy fellowship.Around 43% have done a fellowship with 5% doinga fellowship for more than 1 year. Approximately 38% haveengaged in continuing medical education courses such as

the American Brachytherapy Society Prostate or Gyne-cology courses. Only 4% have done a sabbatical as partof their training.

Physicians were polled as to which disease sites theytreat with brachytherapy defining disease sites as GYN,genitourinary (GU), gastrointestinal (GI), lung, and other(breast, skin, head and neck, eye, and sarcoma). A totalof 58% of the respondents treat one site, 29% treat twosites, 8% treat three sites, and 5% treat four sites. TheGYN and GU are the most common sites treated by radi-ation oncologists who practice brachytherapy (Table 1).Less commonly treated sites include lung, GI, and othersites including breast, skin, head and neck, eye, andsarcoma.

The number of patients treated with brachytherapy ineach disease site by each radiation oncologist demonstratesa large range. The median number of patients treated withbrachytherapy per year by radiation oncologists is highestfor prostate (35) and lowest for esophagus (3), lung (3),and sarcoma (2, Table 1). On average, radiation oncologistswho practice brachytherapy spend 20% of their time perweek on brachytherapy-related activities (range, 1e80%,Fig. 1).

Barriers to initiation/maintenance of a comprehensivebrachytherapy program

A total of 49% of those who practice brachytherapy havediscontinued treatment in at least one disease site. The mostcommon disease sites discontinued include head and neck,cervix, uterine, bronchus, and esophagus (Fig. 2). The mostcommon reason for giving up the practice of brachytherapyin a certain area was being reassigned to treat other diseasesites (67%) followed by lack of a program at their center

Fig. 1. Time spent per week in brachytherapy-related activities (n5 66).

Table 2

Reasons for giving up practice of brachytherapy for a certain disease site

Reason %

Reassigned to other sites 67

No program at center 23

Lack of evidence/other treatments preferred 20

Not enough patients 10

617J. Rose et al. / Brachytherapy 12 (2013) 615e621

(23%, Table 2). Lack of evidence for benefit from brachy-therapy or preference for other treatments was the reasonfor five respondents. Lastly, three respondents cited nothaving enough patients to treat as the reason for discontin-uing treatment of a certain disease site with brachytherapy.

Table 3 lists the reasons why brachytherapy is not usedfor non-GYN or non-prostate sites. The most commonreasons include lack of infrastructure, insufficient radiationoncologist training, and lack of cooperation from otherspecialties (i.e., anesthesia and gastroenterology). The leastcommon reasons include too few patients and lack ofsupport from fellow radiation oncologists.

Discussion

In Canada, the provision of radiotherapy is directed bynonprofit provincial regulatory bodies (such as Cancer CareOntario) that receive operating funds from the provincialgovernments. The provincial governments also providefunding for hospital/cancer center infrastructure and reim-bursement for physician services through single-payer

Fig. 2. Number of radiation oncologists who have given up practicing

brachytherapy for a certain disease site (n5 80). HN5 head and neck;

GU5 genitourinary; Gyne5 gynecologic; GI5 gastrointestinal.

health insurance. As such, the provision of radiotherapyin Canada is centralized into provincial networks of cancercenters that form the monopoly provider of cancer care foreach province. This system was designed to optimizeaccess to services and minimize costs by eliminatingunnecessary duplication of services (12, 13). Although effi-cient, this system has proven unable to meet increasingdemands for radiotherapy across Canada (14, 15). Thepurpose of this study was to examine the provision of bra-chytherapy, workforce, and barriers to development andmaintenance of brachytherapy programs across Canada.This information is essential to provide a rational basisfor policy development in the future.

In this study, it seems that resource limitations, both interms of infrastructure and human capital, are significantbarriers to development and maintenance of comprehensivebrachytherapy programs in Canada. Among the reasons fornot having a brachytherapy program in sites other thanprostate and GYN, insufficient infrastructure (40%) wasthe most common answer. Lack of radiation oncologisttraining (38%) and lack of support from nononcologyspecialties (24%, i.e., anesthesia and gastroenterology)were also commonly reported, indicating that humancapital may also be a limiting resource. In contrast, lessfrequent reasons included lack of evidence to supporta benefit (five respondents) and too few patients to treat(three respondents), indicating that radiation oncologistsperceive both a benefit and a demand for brachytherapy.This suggests that a larger and more efficient investmentin infrastructure and human capital may be required tomatch brachytherapy program development with demand.This finding is similar to the work of AlDuhaiby et al.(16) who did a 5-year longitudinal survey of the availabilityand barriers to intensity-modulated radiotherapy (IMRT)

Table 3

Reasons why brachytherapy is not used for sites other than gynecology and

prostate

Reason %

Lack of infrastructure 40

Insufficient radiation oncologist training 38

Lack of cooperation from other specialties 24

Insufficient radiation therapist training 16

Costebenefit ratio does not favor a program 12

Lack of evidence of a benefit 12

Insufficient nurse training 2

Too few patients 2

Brachytherapy done at another center 2

No support from fellow radiation oncologists 2

618 J. Rose et al. / Brachytherapy 12 (2013) 615e621

and stereotactic radiosurgery in Canada. The mostcommonly cited barriers to implementation of an IMRTprogram were recruitment and training of skilled personnel.For stereotactic radiosurgery, lack of infrastructure was themost common barrier to program implementation.

The median number of patients with cervical cancertreated per radiation oncologist per year in our study is15, which is similar to the results of a Canadian study byPearce et al. (7), who found that the median number was10e20. Eifel et al. (8) found that patients with cervicalcancer treated at centers with low numbers (#2 patientsper year) are more likely to have protracted courses of treat-ment and receive lower doses. For cervical cancer, theAmerican Brachytherapy Society has suggested that centerstreating low numbers of patients should refer to largercenters with more experience (17). In our study, the mediannumber of patients treated per year per oncologist waslower for subsites such as esophagus (median5 3) andbronchus (median5 7) compared with subsites such asprostate (median5 35) and cervix (median5 15). InCanada, it may not always be feasible to refer these patientsto other centers as many are elderly or receiving palliativetreatment and travel is a significant burden. However, finiteresources place necessary limitations on the availability oftreatments and these issues must be balanced.

A balance between availability of brachytherapyservices and cost must be struck to ensure high-qualityradiotherapy treatments. The Royal College of Radiologistsin the United Kingdom has developed guidelines for thedevelopment of brachytherapy services to ensure thedelivery of high-quality brachytherapy (18). In summary,to determine whether a brachytherapy service is justifiedin a particular network several factors must be taken intoaccount, including demand for the service, number ofpatients needed to maintain expertise, cost-effectiveness,and the place of such a service in the research and develop-ment of brachytherapy. A recommendation was also madeto maintain minimum case loads both at the network andclinical oncologist level. For interstitial prostate, it is rec-ommended that each clinical oncologist perform at least 5implants per year. For low throughput techniques, such asendobronchial or head and neck, it is recommended thateach oncologist attend or perform at least five proceduresper year. In Canada, it seems that some radiation oncolo-gists are performing fewer procedures than recommendedin the United Kingdom (Table 1). This study was nota formal audit of numbers of patients treated so we cannotmake firm conclusions about minimum case loads. None-theless, similar national or provincial guidelines are neededto provide a rational basis for the planning and delivery ofhigh-quality brachytherapy in Canada. This must be basedon a formal national or provincial audit of brachytherapydemand and usage.

Despite the low numbers of patients treated per year forsome sites, there seems to be a centralization of brachyther-apy practice among Canadian radiation oncologists. Most

radiation oncologists practicing brachytherapy (58%) inCanada treat only one disease site and less than 10% treateither three or four disease sites. It may be that the use ofbrachytherapy by most Canadian radiation oncologistsreflects interest in a specific tumor site, rather than in bra-chytherapy in general.

We have also found that significant numbers of radiationoncologists in Canada have discontinued treating one ormore disease sites with brachytherapy. A total of 12% ofradiation oncologists surveyed have discontinued brachy-therapy practice altogether. In addition, 20e25% have dis-continued practicing brachytherapy in head and neck,cervix, uterine, bronchus, or esophagus. The top tworeasons included being reassigned to other disease sites(67%) or not having a program at their center (23%). Thissuggests a mismatch between demand and availability ofbrachytherapy programs, as only four respondents indicatedpersonal preference as a reason for reassignment to otherdisease sites (data not shown). We did not specifically askwhy oncologists were reassigned away from brachytherapyat their centers and we therefore cannot draw firm conclu-sions about the reasons for this or if there has been a corre-sponding decrease in the demand for brachytherapy.Nonetheless, reassignment of a physician who practicesbrachytherapy to a disease site not requiring brachytherapyrepresents an inefficient use of trained individuals. Thepractice of brachytherapy requires specialized skills andknowledge that are not universally taught at the residentlevel. In our study, 71% of those practicing brachytherapyhave received training beyond residency for this. We fearthat the specialized training of these physicians may beundervalued and unrecognized as they are assigned to non-brachytherapy disease sites. With this comes the risk ofa deficit in brachytherapy-trained physicians who are moredifficult to replace than those who have a strictly nonbra-chytherapy practice.

In comparison with Europe, the general practice of bra-chytherapy in Canada has some similarities. On average,Canadian radiation oncologists practicing brachytherapyspend 20% of their time on brachytherapy-related activities,compared with an average of 29.5% for Europe (4). Themost common tumor subsites treated in our study seemedto be GYN and prostate, which is similar to Europe[GYNd66.9% of all brachytherapy, prostated8.1% (19)].In Europe, subsites such as bronchus (5.2% of all brachy-therapy), head and neck (3.2%), and breast (7.3%) aretreated but much less frequently than GYN (19), whichseems similar to Canadian practice. It is difficult to makedirect comparisons between this study and the practice inEurope because this was not a formal audit of number ofpatients treated.

There are some limitations to this study. We are missingrepresentation from two provinces and 20% of the cancercenters polled did not submit a response. Although ouroverall response rate was 30%, our intent was to identifyradiation oncologists who practice brachytherapy among

619J. Rose et al. / Brachytherapy 12 (2013) 615e621

the entire population of radiation oncologists. We suspectthat many of the nonresponders were those who did notpractice brachytherapy and did not feel the survey waspersonally relevant. In addition, volunteer bias may haveskewed our data toward academic or larger centers. Thus,the proportion of centers treating certain sites with brachy-therapy may be overestimated. Lastly, this is a retrospectivestudy and not a formal audit of brachytherapy practice,which raises the potential for recall bias. Our results,(Table 1) however, are similar to other studies (7), makingsignificant recall bias less likely.

Conclusion

This study represents a snapshot of Canadian brachy-therapy practice with attention to the workforce andbarriers to the development of brachytherapy programs.In Canada, resource limitations, rather than insufficientpatient numbers seem to be significant barriers to the devel-opment and maintenance of brachytherapy programs. Thissuggests a mismatch between demand and availability ofbrachytherapy programs across Canada. In light of finiteresources, a rational approach to investment in brachyther-apy is needed to deliver high-quality treatment. A nationalor provincial audit of brachytherapy demand and use isrequired to provide rationale for such an investment.

References

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Canadian Cancer Statistics 2012. Toronto, ON: Canadian Cancer

Society; 2012.

[2] Radiation Treatment Utilization; Cancer Quality Council of Ontario.

Available at: http://www.csqi.on.ca/cms/One.aspx?portalId5126935

&pageId5128123. Accessed October 22, 2012.

[3] Radiation Treatment Utilization; Cancer Quality Council of Ontario.

Available at: http://www.csqi.on.ca/cms/One.aspx?portalId5126935

&pageId5128165. Accessed October 22, 2012.

[4] Guedea F, Ellison T, Heeren G, et al. Preliminary analysis of the

resources in brachytherapy in Europe and its variability of use. Clin

Transl Oncol 2006;8:491e499.

[5] Guedea F, Ventura M, Londres B, et al. Overview of brachytherapy

resources in Latin America: A patterns-of-care survey. Brachytherapy

2011;10:363e368.[6] Guedea F, Venselaar J, Hoskin P, et al. Patterns of care for brachy-

therapy in Europe: Updated results. Radiother Oncol 2010;97:

514e520.

[7] Pearce A, Craighead P, Kay I, et al. Brachytherapy for carcinoma of

the cervix: A Canadian survey of practice patterns in a changing era.

Radiother Oncol 2009;91:194e196.

[8] Eifel P, Moughan J, Erickson B, et al. Patterns of radiotherapy prac-

tice for patients with carcinoma of the uterine cervix: A patterns of

care study. Int J Radiat Oncol 2004;60:1144e1153.

[9] Available at: http://www.caro-acro.ca. Accessed August 9, 2012.

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[11] Available at: http://www.gnu.org/software/pspp. Accessed October

8, 2012.

[12] Hayter C. Historical origins of current problems in cancer control.

Can Med Assoc J 1998;158:1735e1740.

[13] Mackillop W, Zhou S, Groome P, et al. Changes in the use of radio-

therapy in Ontario 1984-1995. Int J Radiat Oncol 1999;44:355e362.

[14] Mackillop WJ, Fu H, Quirt CF, et al. Waiting for radiotherapy in On-

tario. Int J Radiat Oncol 1994;30:221e228.

[15] Mackillop WJ, Zhou Y, Quirt CF. A comparison of delays in the treat-

ment of cancer with radiation in Canada and the United States. Int J

Radiat Oncol 1995;32:531e539.

[16] AlDuhaiby E, Breen S, Bissonnette JP, et al. A national survey of the

availability of intensity-modulated radiation therapy and stereotactic

radiosurgery in Canada. Radiat Oncol 2012;7:8.

[17] Nag S, Orton C, Young D, et al. The American Brachytherapy

Society survey of brachytherapy for carcinoma of the cervix in the

United States. Gynecol Oncol 1999;73:111e118.

[18] Royal College of Radiologists. The role and development of brachy-

therapy services in the United Kingdom. London, UK: Royal College

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survey. Clin Transl Oncol 2009;11:534e538.

Appendix 1

Survey questions

1. Please select one of the following that best describesyour age (in years):

A. 25e29B. 30e39C. 40e49D. 50e59E. 60 or older

2. In which cancer center do you primarily practice?3. What tumor sites do you currently treat (excluding

brachytherapy)?4. Which of the following applies to your brachytherapy

training:

A. No special training outside of radiation oncologyresidency

B. Fellowship (1 year or less)C. Fellowship (greater than 1 year)D. CME courses (i.e., American Brachytherapy

Society Gynecologic (GYN)/Prostate School)E. On the job trainingF. Other (please list)

5. Does your center practice brachytherapy?

A. YesB. No

If no, skip to question 9.

6. Which of the following does your center use?

A. IntracavitaryB. InterstitialC. Surface moldD. Intraluminal (e.g., endobronchial and esophagus)

620 J. Rose et al. / Brachytherapy 12 (2013) 615e621

E. Other (please list)F. Do not know

7. Which of the following does your center use?

A. High-dose rate (HDR)B. Medium-dose rateC. Low-dose rateD. Pulsed-dose rateE. ManualF. Other (please list)G. Do not know

8. What sites are treated with brachytherapy at yourcenter?

A. Head and neckB. CervixC. Uterine/endometrialD. GYN (other than cervix/uterine)E. ProstateF. Genitourinary (GU, other than prostate)G. LungH. EndobronchialI. EsophagusJ. RectalK. SkinL. BreastM. SarcomaN. Gastrointestinal (GI) other than esophagus or rectalO. Other (please list)P. Do not know

9. Do you currently/have you ever practicedbrachytherapy?

A. YesB. No

If no, skip to question 18.

10. What sites do you currently treat withbrachytherapy?

A. I do not currently practice brachytherapyB. Head and neckC. CervixD. Uterine/endometrialE. GYN (other than cervix/uterine)F. ProstateG. GU (other than prostate)H. EndobronchialI. LungJ. EsophagusK. RectalL. SkinM. BreastN. SarcomaO. GI other than esophagus or rectalP. Other (please list)

11. What sites have you treated in the past with brachy-therapy but no longer treat?

A. Not applicableB. Head and neckC. CervixD. Uterine/endometrialE. GYN (other than cervix/uterine)F. ProstateG. GU (other than prostate)H. EndobronchialI. LungJ. EsophagusK. RectalL. SkinM. BreastN. SarcomaO. GI other than esophagus or rectalP. Other (please list)

12. If you no longer treat patients with brachytherapy orif you no longer treat a specific site, why?

13. How many patients a year do you treat with brachy-therapy for each of the following sites?

A. Head and neckB. CervixC. Uterine/EndometrialD. GYN (other than cervix/uterine)E. ProstateF. GU (other than prostate)G. LungH. EsophagusI. RectalJ. SkinK. BreastL. SarcomaM. GI other than esophagus or rectalN. Other (please list)

14. What proportion of your time (as a %) is spent inbrachytherapy-related activities?

15. Does your center have a dedicated brachytherapyfellowship?

A. YesB. No

16. Does your center have a brachytherapy research orbrachytherapy clinical trial program?

A. YesB. No

17. List the sites for which you use the following imagingfor brachytherapy planning:

A. Clinical set-up onlyB. Plain films onlyC. UltrasoundD. CT

621J. Rose et al. / Brachytherapy 12 (2013) 615e621

E. MRIF. Positron emission tomography/CTG. Other (please list imaging modality and site)

18. Rate your level of confidence regarding your knowl-edge of the indications for brachytherapy for thefollowing sites (15 not confident, 25 some confi-dence, 35 complete confidence)

A. Head and neckB. CervixC. Uterine/EndometrialD. GYN (other than cervix/uterine)E. ProstateF. GU (other than prostate)G. EndobronchialH. LungI. EsophagusJ. RectalK. SkinL. BreastM. SarcomaN. GI other than esophagus or rectalO. Other (please list)

19. Does your center plan on starting an HDR brachy-therapy program in the next 5 years?

A. YesB. NoC. Already have oneD. Do not know

20. At your center, if brachytherapy is not used for sitesother than prostate and GYN, why not?

A. This question is not applicableB. Radiation oncologists not trainedC. Radiation therapists not trainedD. Insufficient funding for infrastructureE. Costebenefit ratio does not favor a brachytherapy

programF. Lack of co-operation or interest from other

specialties (i.e., GI, respirology, anesthesia)G. Lack of evidence to support a benefitH. Other (please list)

21. Do you consent to your anonymous responses beingused for research purposes?