The Impact on Peer Mentorship After Implementation of a Competency-Based Residency Curriculum in Canadian Radiation Oncology Training Programs

Abstract

Purpose

Peer mentorship provides professional and personal support between physicians with similar experiences and levels of training. While peer mentorship has shown to benefit academic success and professional growth, little data has examined contextual factors, such as curricular change, that may affect the quality of these relationships. This study aims to explore the impact of a new, nationwide radiation oncology (RO) residency curriculum, known as competence by design (CBD), on peer mentorship experiences between Canadian RO residents.

Methods and Materials

A qualitative study, with a social constructivist approach, was conducted with 2 groups of Canadian RO residents. The first were those in the academic year before CBD implementation (non-CBD cohort), and the second were those in the inaugural year of CBD (CBD cohort). Semistructured 1-on-1 interviews were conducted to explore experiences of peer mentorship as it related to curriculum change. Interviews were transcribed and analyzed with deductive and inductive methods until data saturation.

Results

Between April and December 2021, 14 participants (6 non-CBD and 8 CBD residents) from 8 out of 10 eligible English-speaking RO training programs across Canada participated. Three major themes were identified: (1) the CBD cohort identified fewer opportunities for peer mentorship, with specific concerns regarding new evaluation processes and uncertainty about the later stages of training; (2) there was minimal impact on specialty-specific learning; and (3) peer mentorship thrived when occurring as spontaneous in-person interactions.

Conclusions

Inaugural residents of a CBD curriculum perceived fewer opportunities for peer mentorship. There were specific concerns about new evaluative processes, though this did not affect specialty-specific learning. Peer mentorship was most impactful as informal and in-person interactions. Our findings suggest that unintended consequences of curriculum change may be mitigated by improving communication about new training objectives and increasing opportunities for informal interactions between residents.

Introduction

The transmission of knowledge through peer mentorship is an important way for residents to navigate and succeed in their postgraduate training. Peer mentorship establishes a relationship in which a trainee within a similar level of educational training (eg, residency) provides guidance to another trainee and supports acclimatization to a new educational environment.1, 2, 3 Peer mentorship has also been linked to improvements in academics, psychosocial well-being, communication, stress management, and achievement of professional goals.4, 5, 6, 7, 8 Mentorship relationships between peers have been seen as fundamental to program success,⁹ with benefits observed in multiple specialties including radiology,¹⁰ family medicine,⁹ and pediatrics.¹¹ The aforementioned benefits of peer mentorship have also been associated with successful implementation of new educational curricula and practices in medical schools and residency.12, 13, 14, 15, 16 However, no studies, to our knowledge, have examined the potential for curriculum change to disrupt peer mentorship relationships. The objective of our study, therefore, was to explore the impact of a new, nationwide residency curriculum on peer mentorship experiences of Canadian radiation oncology (RO) residents.

Peer mentorship may be of particular relevance in the training of oncology residents as it may provide a medium to address self-identified learning gaps in postgraduate oncology training.^17,18 Within RO, mentorship has been shown to be beneficial through all stages of training. Hirsch et al described the positive impacts of mentorship among medical students in choosing RO as a specialty and productivity in RO-related research,¹⁹ while Croke et al demonstrated that RO residents value a culture of receiving and providing advice among each other.²⁰ Mentorship remains a key element as trainees transition to attending physicians. Within North America, 62% of academic radiation oncologists reported using peer mentoring,²¹ and those that had an academic/scientific mentor had more publications, more citations, and longer careers.²² Furthermore, a recent review examining mentorship within a residency program suggested that those who engage in peer mentorship, compared with traditional formal mentorship programs between faculty and trainees, felt more comfortable asking for academic, professional, and personal advice.²³ Altogether, this suggests that fostering peer mentorship early in RO training programs is beneficial, that the benefits extend over the course of one's career, and that it would be prudent to encourage these interactions throughout training and beyond.

In 2019, RO residency programs across Canada implemented a new residency curriculum, known as competence by design (CBD), that replaced the previous time-based model of residency education.^24,25 The new CBD curriculum, implemented by the Royal College of Physicians and Surgeons of Canada, aims to identify and assess competencies and learning objectives during all stages of residency training in a more concrete, real-time, and objective manner. It allows for more depth and breadth in skills assessments and contrasts with the previous time-based model that assumed increased/prolonged exposure correlated with improved competency. For RO, the CBD curriculum included the creation of new stage-specific skills assessments (known as entrustable professional activities [EPA]), a shorter amount of time spent on non-RO clinical rotations, and writing of the Canadian RO Specialist Exam 1 year earlier than prior. Therefore, CBD implementation provided a unique opportunity to examine peer mentorship in a cohort of residents that did not have access to senior peers within the same curriculum.

Methods and Materials

Study participants

Following ethics approval from the institutional review board and authorization from Canadian residency program directors, 2 cohorts of Canadian RO residents from 10 eligible English-speaking programs and across all 6 provinces with training programs were invited to participate via email. One English-speaking training program in Ontario from Queen's University implemented CBD before 2019 and was therefore excluded from the study.²⁶ The first cohort included the last group of residents before CBD implementation (hereafter non-CBD group) who entered residency in July 2018, while the second cohort included the inaugural year of CBD residents (hereafter CBD group) who entered residency in July 2019. The groups were chosen as the non-CBD group would conceivably have the greatest number of peers within the same curriculum from whom to receive peer mentorship, while the inaugural CBD group would have no peers and could therefore highlight the impacts of CBD implementation on peer mentorship.

Study design

This was a qualitative study guided by social constructivism, a social learning theory that holds that individuals are active participants in the creation of their own knowledge.²⁷ Social constructivism suggests that successful teaching and learning is heavily dependent on interpersonal interaction and discussion.²⁸ As peer mentorship often happens through social interactions, this study sought to explore how the implementation of CBD might influence peer mentorship.

A purposive sampling strategy was employed and an invitation to participate in this study was sent via email to all eligible RO residency program directors, who subsequently informed residents in the CBD group and non-CBD group as described above. Respondents were then contacted by the principal investigator for a one-time, one-on-one semistructured interview lasting between 30 to 45 minutes to permit in-depth discussion of individual experiences and insights on peer mentorship as it related to the curriculum change. Before their interview, participants reviewed and signed a consent form outlining the study goals, risks, and benefits of participation and for collection of data via confidential audio recording and anonymized transcription. Interview questions were created by the principal investigator (DM) and reviewed with coinvestigators, comprised of medical education experts (MG, JP, PAI, JC), RO residency program directors (SL, JA), and practicing radiation oncologists (SL, JA, PAI, MG, JC). The interview guide is presented in Fig. E1. The interview guide included 11 questions that first started broadly by exploring each participant's personal experiences with mentorship and progressively focused more on their peer mentorship experiences as it related to CBD implementation. Interviews were conducted with a comparative and iterative approach to allow the interview guide to evolve as themes arose and to invite more participants as needed. For example, earlier iterations of the interview guide did not specifically mention the concurrent impact of the COVID-19 pandemic on peer mentorship, but this was incorporated after a few participants identified it as such. Interviews were continued until no new information was emerging and saturation was achieved adequately along the dimensions of study aim, sample specificity, established theory, quality of dialogue, and analysis strategy.^29,30

Data analysis

Interviews were recorded and transcribed verbatim with removal of identifying information using professional transcription services. The principal investigator (DM) then ensured accuracy of the transcripts. Recordings and data were kept in secure electronic servers and were only accessed by study investigators. Thematic content analysis was carried out by 2 independent researchers. The principal investigator (DM) first performed thematic analysis independently as described below and reviewed the generation of each theme with a coinvestigator to reduce bias and ensure agreement of data interpretation. NVivo qualitative software version 11 was used to manage data and to facilitate independent data coding. Using an abductive approach, recurring concepts were grouped as codes, and those with corresponding relationships ultimately yielded themes describing the research findings. All themes generated were then discussed and reviewed with the entire research team through collaborative analysis to enhance comprehensiveness and to ensure final agreement. The meaning and implications of the generated themes were also discussed to improve credibility before yielding a conceptual analysis.

Ethical considerations

The study protocol and interview guide were reviewed and approved by the research ethics board at the University Health Network in Toronto, Ontario (REB approval number 20-6042). Participation in the study was completely voluntary, and all participants provided written informed consent. Participants received a gift card to thank them for their participation after the interview. This project was supported financially by a Research, Education, Advocacy and Direct Service grant from the American Association for Cancer Education.

We acknowledge that the principal author (DM) was an RO resident in the CBD curriculum from the time of project conceptualization to manuscript publication. All coauthors were also immersed in CBD as residency program directors, educational leaders, or practicing radiation oncologists working and evaluating residents under the CBD model. We acknowledge that each author's personal lived experience of CBD varies and we were aware to remain as neutral as possible and set aside personal views or experiences when discussing interview questions, data analysis, and generation of themes.

Results

Study participants

Invitations were sent to 34 eligible residents (19 non-CBD and 15 CBD). Between April and December 2021, 14 respondents consented, and interviews were conducted with 6 non-CBD residents (32% response rate) and 8 CBD residents (53% response rate), at which point no new themes were identified and no further interviews were conducted. There was adequate sex representation (8 female, 6 male), and the majority of participants (71.4%) were between the ages of 25 and 29 years. Participants represented 8 out of 10 eligible English-speaking RO residency programs across Canada. Participant demographics are summarized in Table 1.

Table 1.

Study participant demographics and characteristics

Characteristic	N (%), Total	N, CBD	N, Non-CBD
Age (y)
25-29	10 (71.4)	6	4
30-34	4 (28.6)	2	2
Sex
Female	8 (57.1)	4	4
Male	6 (42.9)	4	2
Other	0 (0)	0	0
Residency curriculum
CBD	8 (57.1)	-	-
Non-CBD	6 (42.9)	-	-
School of RO residency (City, Province)
University of British Columbia (Vancouver, BC)	2 (14.3)	2	-
University of Calgary (Calgary, AB)	1 (7.1)	-	1
University of Manitoba (Winnipeg, MB)	1 (7.1)	1	-
McMaster University (Hamilton, ON)	1 (7.1)	1	-
University of Toronto (Toronto, ON)	6 (42.9)	2	4
University of Ottawa (Ottawa, ON)	1 (7.1)	1	-
McGill University (Montreal, QC)	1 (7.1)	1	-
Dalhousie University (Halifax, NS)	1 (7.1)	-	1
Previous medical school training
Canadian medical school	12 (85.7)	8	4
International medical school	2 (14.3)	0	2

Abbreviations: AB = Alberta; CBD = competence by design; MB = Manitoba; NS = Nova Scotia; ON = Ontario; QC = Quebec; RO = radiation oncology.

Thematic analysis

Three distinct themes emerged following data analysis: (1) Inaugural residents of CBD described fewer opportunities for peer mentorship, with concerns around new assessment activities and later stages of residency training; (2) There was minimal impact on specialty-specific learning; and (3) Peer mentorship thrived as spontaneous in-person interactions. Within theme 1, residents expressed different experiences depending on if they were in the CBD or non-CBD group, highlighting the potential for curriculum change to disrupt peer mentorship relationships. Themes 2 and 3, however, did not demonstrate this difference between the 2 cohorts. Each theme is discussed in further detail below.

Theme 1: The CBD Cohort Identified Fewer Opportunities for Peer Mentorship, With Particular Concerns About New Evaluation Processes and the Later Stages of Residency Training

When asked if participants had sought out the mentorship of their peers throughout residency, all participants reported that they engaged in and even relied on peer mentorship for support. However, while non-CBD residents largely endorsed no impact on their own peer mentorship from the curriculum change, CBD residents expressed a lack of peer mentors who had adequate knowledge and experience to help guide them.

P08 (CBD): “You kind of feel like you're on your own because nobody really understood what CBD was, so you have to kind of mentor yourself.”

P14 (CBD): “Usually we look to our senior residents, but they are not on the CBD program. So if we have any questions, they can't answer.”

Despite being in a different curriculum, non-CBD residents still expressed a desire and willingness to help but were hesitant about whether the advice they previously received would be applicable in the new CBD era.

P05 (non-CBD): “Some specific advice pertains to the specific timeline that [non-CBD] are working with and I can't really help with [CBD] residents.”

P10 (non-CBD): “I think the approaches to ‘doing well’ may differ based on the curriculum to some degree.”

In addition to fewer opportunities for peer mentorship, CBD residents expressed a lack of mentorship and guidance with new evaluation processes introduced with the new curriculum. Residents acknowledged that curriculum change is associated with a transition period and new learning curve for staff and residents alike, but felt it was largely a personal endeavor, with the burden placed on the resident to solely navigate this new process.

P02 (CBD): “The main gap is mainly based around the new assessments rather than clinical work. You don't really have anyone to ask about getting them done – there's hardly anyone who understands what they're about […] it's my passing that's at stake so, not that [staff] don't care, but it's just on me to take on extra work to get all these evaluations.”

P03 (CBD): “We now have new evaluations that [non-CBD] have never had to do, so trying to talk to somebody ahead of us, you know, they might not have the same expectations or mindset that we currently do.”

A second area of concern with CBD residents revolved around the RO specialist certification examination administered by the Royal College of Physicians and Surgeons of Canada (colloquially known as the Royal College exam). Before CBD implementation, the examination was conducted in the spring of Postgraduate Year 5 (PGY5: the final year of RO residency), with a 4- to 6-week gap between written and oral components. However, with the implementation of CBD, the written component is scheduled to be written 1 year earlier in the spring of PGY4, with the oral component taking place 6 months later. Throughout our interviews, CBD residents consistently expressed concerns of not having resident peers from whom to receive mentorship on study strategies and consolidation of knowledge, given that this high-stakes examination is occurring 1 year earlier.

P08 (CBD): “No resident has had to write their Royal College in PGY4 […] so nobody can really help you prepare for a Royal College [exam] in 4 years when nobody else has gone through that same experience.”

P06 (CBD): “[non-CBD] will say ‘you don't need to know this right now’ but in my head I think, if I am writing Royal College in fourth year, maybe I do need to know it now.”

Although these concerns about the Royal College examination were consistent among CBD residents, an underlying sense of teamwork did arise. Though CBD residents would be the first to “lead the charge,” being “the only people going through it also facilitates being more connected to your colleagues” (P03, CBD). This sense of solidarity was also expressed when discussing the potential hurdles that CBD residents would have to face, such that it's “easier when you share the burden with someone at the same level as you” (P14, CBD).

In addition, CBD residents also expressed uncertainty about what the academic year in PGY5 will entail, given that the Royal College examination will have been completed already. Currently, PGY5 is designed as transition to practice, whereby residents act as a junior attending physician under supervision for roughly 9 to 12 months. However, several CBD residents expressed thoughts on whether PGY5 could serve as a pseudofellowship year instead. Some also discussed the potential implications of the earlier examination on employment opportunities now that residents are Royal College certified earlier in residency.

Theme 2: Despite Curriculum Change, There was Minimal Impact on Specialty-Specific Learning

With regards to mentorship specific to training and learning in RO, residents in either curriculum endorsed no significant disruptions as a result of CBD implementation. CBD residents attributed this to the fact that the oncology knowledge, management decisions, and treatment/contouring techniques within RO do not change, and that the curriculum change is simply a different manner in which those skills are delivered, learned, and evaluated. Non-CBD residents agreed with this sentiment and as a result felt comfortable mentoring those in the CBD cohort on RO-specific skills and described a sense of mutualism and teamwork among residents.

P07 (CBD): “The skills that [non-CBD residents] are expected to learn are the same skills that I am, they're just evaluated in a different way.”

P01 (non-CBD): “We still talk about similar Rad Onc things. Our main interaction is determined by where [CBD residents] are in their training program and where I am, and what we can offer each other.”

Theme 3: Regardless of Curriculum, Peer Mentorship Thrived as Spontaneous In-Person Interactions

Respondents in both non-CBD and CBD curricula expressed that peer mentorship often occurred and thrived as informal and serendipitous social interactions, largely based on being in the same physical vicinity or when undergoing similar clinical experiences.

P06 (CBD): “Whenever I have any questions or concerns about anything […] I would just look around and see who's in the room […] or use our group chat and usually someone answers me. It's pretty ad hoc and informal.”

P09 (non-CBD): “With COVID, if you don't see each other much, and you're a small program like Rad Onc, I think not being able to communicate with residents in-person hinders being able to strengthen the relationships between them.”

Residents in both curricula expressed that the challenges of the COVID-19 pandemic significantly hindered the ability to pursue peer mentorship in a similarly meaningful prepandemic way. These challenges included minimal in-person interactions, working virtually, and being redeployed to other departments.

Discussion

In our pan-Canadian study examining the impact of a new CBD curriculum on RO resident peer mentorship, we identified 3 major themes: (1) Inaugural residents of a new competency-based curriculum described fewer opportunities for peer mentorship with concerns around new assessment activities and the later stages of residency training (namely an earlier sitting of the Royal College examination); (2) There was minimal impact on specialty-specific learning; and (3) Peer mentorship thrived as spontaneous in-person interactions. To our knowledge, this is the first study of its kind to examine the impact that a systems-level curriculum change can have on mentorship during residency training.

The mechanisms and benefits of peer mentorship are believed to stem from a smaller distance between participants’ social, professional and age level (relative to faculty-based mentoring), thus fostering so-called cognitive and social congruence.^5,7 However, the implementation of a curriculum change can disrupt peer mentorship interactions by increasing the distance between trainees in terms of the degree of shared learning experiences—a sentiment that was recognized and expressed by both CBD and non-CBD residents alike. Croke et al have described similar limitations, even between residents within the same curriculum.²⁰ This suggests that it may take several iterations of residents following a curriculum change until the once-new curriculum becomes the norm to reach previous levels of peer mentorship, though future studies will be needed to validate if this is indeed true. McLean also reports that trainees strongly value sharing the same learning experience and environment as their peers and often see it as a condition of providing and receiving mentorship.³¹ The perceived mismatch in curricula can strain mentorship relationships due to misunderstanding of curriculum-specific problems, including a lack of familiarity of assessment procedures,³¹ which is in keeping with our findings.

Huang et al examined near-peer interactions after a curriculum change at the medical school level. While they reported similar findings of fewer mentorship opportunities for those in a new curriculum, they found learners were not overtly concerned about the lack of near-peers within the same curriculum.³² This difference likely stems from how trainees learn at the medical school and residency level. Within medical school, students are learning the foundations of medicine (eg, anatomy, physiology, pharmacology) and therefore rely more heavily on course syllabi and textbooks,³³ which are not dependent or influenced by peer mentorship or curriculum change. However, residents tend to use more clinically oriented resources (such as clinical peers and specialists), with previous studies stressing the importance of the immersive and experiential aspect of residency training that involves a shift toward professional relationships with peers.^33,34 Huang et al also found that medical students often used their own previous academic successes to circumvent the lack of peer mentors.³² However, resident physicians generally learn on the job and often need to relearn and adapt to different hospital services, personnel, and organizational systems every few months. Furthermore, they must quickly become competent and independent with new responsibilities where they previously were always supervised (eg, placing orders, admitting and managing sick patients, performing procedures). Not only does this represent a stressful transition period, but the literature suggests that there is no previous training that can truly prepare new trainees for the lived experiences of residency.³⁴ As a result, peer mentors may serve as timely and necessary guidance to fill in these gaps of inexperience within residency training, but the extent to which mentors are able to do so seems to depend on a common learning environment. Based on our findings, we would recommend creating environments that foster spontaneity and in-person interactions, within which residents can engage in meaningful peer mentorship experiences. While curriculum change will likely disrupt peer mentorship to a certain degree, further studies examining various methods to minimize this before implementation would be beneficial.

CBD residents were particularly concerned about new evaluation processes resulting from curriculum change. These new evaluations are known as EPAs and are a major change associated with the CBD curriculum. CBD residents are assessed with EPAs more frequently (ie, several times weekly) to encourage longitudinal coaching interactions rather than a single all-encompassing evaluation based on achieving rotation-specific objectives at the end of a particular clinical rotation spanning several months. CBD residents expressed that staff physicians often had a poor understanding of EPAs and felt the burden was solely on themselves to complete them successfully. While we did not interview staff physicians, there are likely differences across RO residency programs on faculty development to get acquainted with EPAs. In general, though, the level of faculty apprehension toward CBD and EPAs may be a contributing factor that has been well documented in the literature.35, 36, 37, 38

There is also a described mismatch about whether faculty or residents should initiate an EPA,³⁹ but despite this difference of opinion, the burden of completing them appeared to fall on the shoulders of the resident. Residents may feel apprehensive toward EPAs if the perceived quality and timeliness of feedback delivered within them is negative, which was the case when CBD was implemented in an internal medicine training program.⁴⁰ This may be of relevance to RO training, where direct observation of resident performance has been described as the most challenging aspect of CBD to implement.⁴¹ Much of the day-to-day clinical work and contouring as a RO resident is done individually in real time, but often reviewed and evaluated after the fact. This delay may reduce the willingness and receptiveness of staff to complete EPAs, particularly if completing it is perceived to be time-consuming, burdensome, and disruptive to clinical workflow - all of which have been described in both RO and other specialties functioning under CBD.40, 41, 42, 43 One possible solution would be to increase the number of EPAs senior residents are allowed to complete for junior residents as the sole assessor. This would reduce the time burden for staff and allow residents in their transition to practice training stage to engage in formative assessments and coaching skills themselves. A similar approach was used in a CBD neurosurgical program, which showed that senior residents gave feedback 6 to 10 times more often and completed twice as many EPAs.⁴⁴

CBD residents addressed concerns in writing the Royal College specialist examination 1 year earlier than previous non-CBD residents. CBD residents hoped to be adequately prepared for the examination, which is likely to occur given that our second theme found that specialty-specific learning was unaffected. However, one may argue that the accelerated timeline prevents additional time for knowledge consolidation pre-examination. As no CBD resident has completed the examination yet at the time of manuscript preparation, whether the earlier examination timing affects the pass rate or perceived competency of CBD residents remains to be seen. The first cohort of CBD RO residents completed the written component in March 2023, with the first iteration of the earlier CBD oral examination scheduled for October 2023.

Finally, both non-CBD and CBD residents endorsed that mentorship thrived in casual environments as informal interactions. Peer mentorship was largely based on proximity to one another, and interviewees did discuss that the COVID-19 pandemic had an impact on the peer mentorship experience. Many Canadian RO trainees experienced negative educational experiences from the pandemic,⁴⁵ so it is conceivable that peer mentorship also suffered during this time in RO, as it did in other disciplines.⁴⁶ The double hit of the curriculum change and COVID-19 may have disrupted peer mentorship to a greater extent compared with if CBD was implemented prepandemic. Remote mentorship was attempted in RO with mostly positive results,⁴⁷ although location was still found to be important to have sustainable relationships. Therefore, we would encourage programs to support more in-person opportunities for informal mentorship to occur rather than hoping that serendipitous interactions will be sufficient.

Our study has several strengths and limitations. First, the project underwent extensive planning and review with multiple investigators across Canada to minimize bias by geographic or institutional factors. The semistructured interview guide went through several iterations to minimize leading questions, implicit messages, or confusion. Interviews were done by a single investigator to ensure consistency and were reviewed iteratively with investigators to ensure transparency and consensus on analysis and data interpretation. Participants were from 8 out of 10 eligible RO residency programs, thus likely capturing an accurate representation of residents’ experiences across the country. However, given our purposive sampling method and that RO is a relatively small specialty, our findings may not be applicable to larger residency programs or to those where the day-to-day workflow is different (eg, inpatient medicine, surgical specialties). We also did not pursue further analysis to examine potential differences based on residency program size, and we did not include French-speaking residency programs (of which there are 2 in Canada). Finally, although competency-based medical education is a global phenomenon, our findings may not be applicable to institutions with different postgraduate medical training paradigms.

It is also important to note that almost the entirety of this study occurred during the COVID-19 pandemic, with participating RO residents and study investigators experiencing a variety of lockdown restrictions, clinical redeployments, and transition to virtual care. Given these unprecedented times, we made every effort to ensure interviews and discussions were within the scope of this study's focus and research question, although we acknowledge that experiences discussed by participants may have differed if the study were conducted in a prepandemic era.

Conclusion

To our knowledge, this is the first study to examine the impact of the recently implemented CBD residency curriculum on peer mentorship among Canadian resident physicians. Inaugural residents of CBD in RO cited fewer opportunities for peer mentorship, with specific concerns around new assessment activities and having to write their certification examination 1 year earlier. Peer mentorship was most impactful as spontaneous, informal, and in-person interactions. Our findings suggest that the unintended consequences of curriculum change on peer mentorship may be mitigated by allowing for increased informal activities among residents to foster these relationships. Further studies to reduce the perceived gap in the different learning environments would also be beneficial. Concerns about new assessments may be improved by more specific orientation and development activities for both residents and staff alike. Finally, while RO-specific learning remained unaffected, the outcome of an earlier certification examination remains unknown at this time.

Disclosures

David Y. Mak was the recipient of a 2020 Research, Education, Advocacy and Direct Service grant from the American Association for Cancer Education in support of this project that was used for transcription services. Additional support was provided by the Department of Radiation Oncology at the University of Toronto, Canada, in the form of provision of study materials, computer software, and support for conference presentations and attendance. Paris-Ann Ingledew is a section editor for the International Journal of Radiation Oncology, Biology, Physics. Meredith Giuliani is a member of the advisory board for AstraZeneca and Bristol-Myers-Squibb and is also a senior editor for the International Journal of Radiation Oncology, Biology, Physics. All other authors have no conflicts to declare.