Original Research Article Board-certified specialty training program in radiation oncology in a war-torn country: Challenges, solutions and outcomes Layth Mula-Hussain a,⇑ , Akhtar N. Shamsaldin b , Muthana Al-Ghazi c , Hawzheen Aziz Muhammad d , Shada Wadi-Ramahi e , Rabbie K. Hanna f , Abdulla Alhasso g a Physician in Radiation Oncology, Cross Cancer Institute – University of Alberta, Edmonton, Alberta, Canada b Consultant Medical Physicist, Ministry of Higher Education and Scientific Research, Sulaimani, Kurdistan, Iraq c Clinical Professor & Director of Medical Physics, Department of Radiation Oncology, School of Medicine – University of California – Irvine, Orange, CA, USA d College of Medicine – University of Sulaimani, Sulaimani, Kurdistan, Iraq e Biomedical Physics Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia f Wayne State University School of Medicine and Henry Ford Health System, Detroit, MI, USA g Consultant Clinical Oncologist, The Beatson West of Scotland Cancer Centre, Glasgow, Scotland, UK article info Article history: Received 31 May 2019 Revised 11 August 2019 Accepted 15 August 2019 Available online 19 August 2019 Keywords: Radiation oncology residency War-torn nation Developing country Iraq abstract Background: Residency programs leading to board certification are important for safe and competent Radiation Oncology (RO) practice. In some developing nations, there is a gap in this field. This work addresses the experience that was accomplished to establish such a program in Iraq despite all the chal- lenges that faces a country under war. Methods: Descriptive report of challenges faced in a developing country that is still reeling from war, the steps taken to overcome these challenges and outcomes after graduation of two classes. Results: After over 18 months of prerequisite technical and logistical preparations, a group of local and external faculty members were invited to establish the required syllabus of a structured RO residency program in Iraq. It is comprised of a total of 100 post-graduate academic credits over a 48-months period after clinical internship. First year evaluations included regular practical assessments; seven in-house papers covering RO, cancer and radiation biology, medical physics, radiological anatomy and diagnostic oncology, tumor pathology, onco-pharmacology, and medical statistics, research methodology, and can- cer epidemiology, followed by a comprehensive examination. Subsequent evaluations were on an annual bases with enrollment in the American College of Radiology In-Training examination in RO. Final assess- ment included logbook and skills’ reviews, graduation thesis or peer-review publication, two-papers’ written examination, and an exit practical examination. Conclusions: Given the political, economic and social difficulties in post-war Iraq, it was a major challenge to establish a residency program in RO. Despite the significant difficulties, the first residency program leading to board certification in RO was successfully started in Iraq. The new specialists will help in addressing the shortage of radiation oncologists in the country. Ó 2019 The Author(s). Published by Elsevier B.V. on behalf of European Society for Radiotherapy and Oncology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). 1. Background Radiation Oncology (RO) is the discipline of clinical medicine that uses ionizing radiation, either alone or in combination with other modalities, for the treatment of patients with malignant diseases (mostly) or non-malignant conditions (occasionally). This specialty can be practiced as an independent oncology specialty or may be integrated into the broader medical practice of clinical oncology with the use of systemic therapies to enhance the effec- tiveness of radiation in a multi-modality setting [1]. In Iraq, the first establishment of radiotherapy services dates back to the 1920s when the Radiology Institute was established in Baghdad [2]. This institute was the only place in Iraq that was offering diagnostic and therapeutic radiation services until the late 1950s, when a deep X-ray therapy unit was installed in Mosul in 1959. The establishment of the Oncology and Nuclear Medicine https://doi.org/10.1016/j.ctro.2019.08.002 2405-6308/Ó 2019 The Author(s). Published by Elsevier B.V. on behalf of European Society for Radiotherapy and Oncology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). ⇑ Corresponding author. E-mail addresses: LMulaHussain@AOL.com (L. Mula-Hussain), akhtar_samand@ yahoo.fr (A.N. Shamsaldin), malghazi@uci.edu (M. Al-Ghazi), hawzheen.a@gmail. com (H.A. Muhammad), salramahi92@kfshrc.edu.sa (S. Wadi-Ramahi), rabbie. hanna@me.com (R.K. Hanna), abdulla.alhasso@ggc.scot.nhs.uk (A. Alhasso). Clinical and Translational Radiation Oncology 19 (2019) 46–51 Contents lists available at ScienceDirect Clinical and Translational Radiation Oncology journal homepage: www.elsevier.com/locate/ctro