Radiation Oncology in Oman: Current Status and Future Challenges.

Oman is a high-income Middle Eastern country. Over the past 50 years, the country's health care system has undergone revolutionary changes to meet the health care needs of its population, driven by high oil and gas revenues. It currently has a very efficient universal health care system. There are 2 linear accelerators in the country and 6 radiation oncologists. A new cancer research center is currently under construction. The major challenge that could affect the delivery of radiation therapy in the future is sustenance of the health care achievements in view of a growing population and the reliance on public funding for health care delivery.

[Report on current status of Hungarian radiotherapy]. / A magyar sugárterápia jelenlegi helyzetének bemutatása.

The purpose of the study is to report the status of Hungarian radiotherapy (RT). In the 13 centers 84 radiation oncologists, 19 residents, 66 physicists and 231 radiotherapy technologists work, and 40 megavoltage units (38 linear accelerators, 2 cobalt units) are in use. HDR afterloader is available in all and CT-simulator in all but one centers. In 2017 33,024 patients received RT, 22,236 were irradiated with MV beams, 1,406 with BT and 9,382 with orthovoltage X-ray. Main indications for BT were gynecological tumors (75%), HDR prostate implants were performed in 3 centers. Due to the recent infrastructural developments the number of patients receiving modern RT increased, but in order to fulfil the international recommendations additional linear accelerators have to be installed along with the replacement of the out of date equipment. From professional point of view further developments are warranted in Budapest.

Taking Stock: The Canadian Association of Radiation Oncology 2017 Radiation Oncologist Workforce Study.

PURPOSE: To identify and report radiation oncologist (RO) workforce demographics, clinical workload trends, and equipment inventory in Canada. METHODS AND MATERIALS: The Canadian Association of Radiation Oncology (CARO) distributed an online survey to RO administrative leaders at 47 Canadian cancer centers providing radiation therapy services from June to December 2017. The survey queried RO staff demographics, clinical workload, and equipment inventory from 2014 to 2016. RESULTS: The response rate was 98% and represented 46 of 47 centers for analysis. In 2016, 510 ROs were in practice, with 98 ROs (19.2%) having <1.0 full-time equivalent (FTE) clinical work activities because of administration, research, or part-time employment. Most ROs worked full-time (92.0%), were affiliated with a university (77.5%), and worked in communities with a population >200,000 (84.9%). Approximately half (52.3%) were ≥46 years old. The male-to female ratio was 1.5:1 or higher in all regions of Canada except for Quebec, where there was no gender gap. Part-time employment was more common among female ROs (P < .01). Although FTE staff levels rose steadily between 2014 (456.3) and 2016 (475.8), an increase in patient workload resulted in a rise in the average annual consults per FTE-RO (from 257 to 267). Over a 2-year period, there were 63.5 FTE-recruitments and 44.0 FTE-departures (18.3 FTE-retirements; 25.7 FTE-migration) for a net gain of 19.5 RO-FTEs. An 8.4% increase in FTE staffing to 516 RO-FTEs in 2019 is anticipated, with 22 ROs expected to retire by 2019. There were 251 megavoltage linear accelerators across Canada, with most (39.8%) located in Ontario. Approximately one-fifth (20.7%) of these were older than 10 years and operating beyond the equipment's recommended life span. CONCLUSIONS: The Canadian RO workforce demonstrated incremental growth, but rising annual caseloads suggest that radiation therapy demand outpaced RO supply gains. Government funding is required to replace aging equipment in Canada.

Quality of radiotherapy services in post-Soviet countries: An IAEA survey.

BACKGROUND: The quality of radiotherapy services in post-Soviet countries has not yet been studied following a formal methodology. The IAEA conducted a survey using two sets of validated radiation oncology quality indicators (ROIs). METHODS: Eleven post-Soviet countries were assessed. A coordinator was designated for each country and acted as the liaison between the country and the IAEA. The methodology was a one-time cross-sectional survey using a 58-question tool in Russian. The questionnaire was based on two validated sets of ROIs: for radiotherapy centres, the indicators proposed by Cionini et al., and for data at the country level, the Australasian ROIs. RESULTS: The overall response ratio was 66.3%, but for the Russian Federation, it was 24%. Data were updated on radiotherapy infrastructure and equipment. 256 radiotherapy centres are operating 275 linear accelerators and 337 Cobalt-60 units. 61% of teletherapy machines are older than ten years. Analysis of ROIs revealed significant differences between these countries and radiotherapy practices in the West. Naming, task profile and education programmes of radiotherapy professionals are different than in the West. CONCLUSIONS: Most countries need modernization of their radiotherapy infrastructure coupled with adequate staffing numbers and updated education programmes focusing on evidence-based medicine, quality, and safety.

Location-allocation model for external beam radiotherapy as an example of an evidence-based management tool implemented in healthcare sector in Poland.

BACKGROUND AND PURPOSE: External beam radiotherapy (EBRT) is one of three key treatment modalities of cancer patients. Its utilisation and outcomes depend on a plethora of variables, one of which is the distance a patient must travel to undergo the treatment. The relation between distance and utilisation is clearly visible in Poland. At the same time no strategic investment plan is observed. This work proposes a method of resolving these two issues. MATERIALS AND METHODS: We propose a mixed-integer linear programming model that aims to optimise the distribution of linear accelerators among selected locations in such a way that a patient's journey to the nearest EBRT is as short as possible. The optimisation is done with observance of international guidelines concerning EBRT capacity. With the use of proposed theoretical framework, we develop a national, strategic plan for linear accelerator investments. RESULTS: According to model assumptions decentralisation of EBRT, together with new equipment purchases, is required to ensure optimal access to EBRT. CONCLUSIONS: The results were incorporated into Healthcare Needs Maps for Poland. The plan based on the results of this study, implemented by 2025, should deal with the most pressing concerns of Polish EBRT.

Infrastructure and equipment for radiation oncology in the Spanish National Health System: analysis of external beam radiotherapy 2015-2020.

PURPOSE: Planning for radiation oncology requires reliable estimates of both demand for radiotherapy and availability of technological resources. This study compares radiotherapy resources in the 17 regions of the decentralised Spanish National Health System (SNHS). MATERIALS AND METHODS: The Sociedad Española de Oncología Radioterápica (SEOR) performed a cross-sectional survey of all Spanish radiation oncology services (ROS) in 2015. We collected data on SNHS radiotherapy units, recording the year of installation, specific features of linear accelerators (LINACs) and other treatment units, and radiotherapeutic techniques implemented by region. Any machine over 10 years old or lacking a multileaf collimator or portal imaging system was considered obsolete. We performed a k-means clustering analysis using the Hartigan-Wong method to test associations between the gross domestic regional product (GDRP), the number of LINACs per million population and the percentage of LINACs over 10 years old. RESULTS: The SNHS controls 72 (61%) of the 118 Spanish ROS and has 180 LINACs, or 72.5% of the total public and private resources. The mean rate of LINACs per million population is 3.9 for public ROS, and 42% (n = 75) of the public accelerators were obsolete in 2015: 61 due to age and 14 due to technological capability. There was considerable regional variation in terms of the number and technological capacity of radiotherapy units; correlation between GRDP and resource availability was moderate. CONCLUSION: Despite improvements, new investments are still needed to replace obsolete units and increase access to modern radiotherapy. Regular analysis of ROS in each Spanish region is the only strategy for monitoring progress in radiotherapy capacity.

Is Africa a 'Graveyard' for Linear Accelerators?

Linear accelerator downtimes are common and problematic in many African countries and may jeopardise the outcome of affected radiation treatments. The predicted increase in cancer incidence and prevalence on the African continent will require, inter alia, improved response with regard to a reduction in linear accelerator downtimes. Here we discuss the problems associated with the maintenance and repair of linear accelerators and propose alternative solutions relevant for local conditions in African countries. The paper is based on about four decades of experience in capacity building, installing, commissioning, calibrating, servicing and repairing linear accelerators in Africa, where about 40% of the low and middle income countries in the world are geographically located. Linear accelerators can successfully be operated, maintained and repaired in African countries provided proper maintenance and repair plans are put in place and executed.

Cobalt, linac, or other: what is the best solution for radiation therapy in developing countries?

The international growth of cancer and lack of available treatment is en route to become a global crisis. With >60% of cancer patients needing radiation therapy at some point during their treatment course, the lack of available facilities and treatment programs worldwide is extremely problematic. The number of deaths from treatable cancers is projected to increase to 11.5 million deaths in 2030 because the international population is aging and growing. In this review, we present how best to answer the need for radiation therapy facilities from a technical standpoint. Specifically, we examine whether cobalt teletherapy machines or megavoltage linear accelerator machines are best equipped to handle the multitudes in need of radiation therapy treatment in the developing world.

Optimal location of radiation therapy centers with respect to geographic access.

PURPOSE: To develop a framework with which to evaluate locations of radiation therapy (RT) centers in a region based on geographic access. METHODS AND MATERIALS: Patient records were obtained for all external beam radiation therapy started in 2011 for the province of British Columbia, Canada. Two metrics of geographic access were defined. The primary analysis was percentage of patients (coverage) within a 90-minute drive from an RT center (C90), and the secondary analysis was the average drive time (ADT) to an RT center. An integer programming model was developed to determine optimal center locations, catchment areas, and capacity required under different scenarios. RESULTS: Records consisted of 11,096 courses of radiation corresponding to 161,616 fractions. Baseline geographic access was estimated at 102.5 minutes ADT (each way, per fraction) and 75.9% C90. Adding 2 and 3 new centers increased C90 to 88% and 92%, respectively, and decreased ADT by between 43% and 61%, respectively. A scenario in which RT was provided in every potential location that could support at least 1 fully utilized linear accelerator resulted in 35.3 minutes' ADT and 93.6% C90. CONCLUSIONS: The proposed framework and model provide a data-driven means to quantitatively evaluate alternative configurations of a regional RT system. Results suggest that the choice of location for future centers can significantly improve geographic access to RT.

Technetium-99m -- new production and processing strategies to provide adequate levels for SPECT imaging.

The most important radioisotope for use in Nuclear Medicine is (99m)Tc, supplied in the form of a (99)Mo/(99m)Tc generator. After the supply crisis of (99)Mo starting in 2008 the availability of (99)Mo became a worldwide concern. The purpose of this work is to do a brief story of the availability of (99)Mo in the world followed by an overview of the production routes of (99)Mo and the generators technology.

Japanese structure survey of radiation oncology in 2007 with special reference to designated cancer care hospitals.

BACKGROUND AND PURPOSE: The structure of radiation oncology in designated cancer care hospitals in Japan was investigated in terms of equipment, personnel, patient load, and geographic distribution. The effect of changes in the health care policy in Japan on radiotherapy structure was also examined. MATERIAL AND METHODS: The Japanese Society of Therapeutic Radiology and Oncology surveyed the national structure of radiation oncology in 2007. The structures of 349 designated cancer care hospitals and 372 other radiotherapy facilities were compared. RESULTS: Respective findings for equipment and personnel at designated cancer care hospitals and other facilities included the following: linear accelerators/facility: 1.3 and 1.0; annual patients/linear accelerator: 296.5 and 175.0; and annual patient load/full-time equivalent radiation oncologist was 237.0 and 273.3, respectively. Geographically, the number of designated cancer care hospitals was associated with population size. CONCLUSION: The structure of radiation oncology in Japan in terms of equipment, especially for designated cancer care hospitals, was as mature as that in European countries and the United States, even though the medical costs in relation to GDP in Japan are lower. There is still a shortage of manpower. The survey data proved to be important to fully understand the radiation oncology medical care system in Japan.

Survey of the availability and use of advanced radiotherapy technology in the UK.

AIMS: To determine the availability of intensity-modulated radiotherapy (IMRT) treatment in the UK and to assess the magnitude of the shortfall in terms of patient treatments. In addition, the availability of image-guided radiotherapy (IGRT) was also reviewed. MATERIALS AND METHODS: A survey was carried out between July and September 2008 of the use of advanced technology in radiotherapy. RESULTS: In total, 50 centres responded out of the 58 National Health Service centres canvassed, representing about 89% of patients treated in the UK. Forty-six centres had at least two machines capable of IMRT and 26 centres had at least one machine capable of IGRT. Thirty-two centres were carrying out forward-planned IMRT and 18 centres were carrying out the more complex inverse-planned IMRT. In all, 38 centres (76% of respondents) were offering either forward- or inverse-planned IMRT to some of their patients. All the centres with IGRT capability were using IGRT for at least some of their patients. Respondents were asked to list the total number of radical and palliative patients being treated according to the treatment site. Forty-two per cent of respondents took the option to list the total number of radical and palliative patients only. Based on these data, 10.7% of radical patients are currently being given forward-planned IMRT, mainly for breast cancer (18.6% of such patients) and 2.2% of radical patients are being given inverse-planned IMRT, mainly for prostate (7.5% of such patients) and head and neck cancer (6.7% of such patients). Whereas at present only 18 centres are able to treat with inverse-planned IMRT, 45 centres expected to be able to do so by 2010. Respondents were asked to estimate the percentage of patients who should be given IMRT for each site and this was used to estimate the shortfall in IMRT provision. CONCLUSIONS: Based on the consensus of opinion, 32% of radically treated patients should receive inverse-planned IMRT and 22% forward-planned IMRT, making a total of 55%. In fact, 2% receive inverse-planned IMRT and 11% the less complex forward-planned IMRT. Thus, with an estimated 75,948 radical treatments being carried out with megavoltage radiotherapy, the professional opinion is that 41,421 of patients would benefit from treatment with IMRT. In fact, only 9775 were so treated in 2008; a shortfall of 32,497 patients treated instead with conventional radiotherapy.

'GAP' in radiotherapy services in Australia and New Zealand in 2009.

AIM: In this study we estimated (a) the number of linear accelerators required in Australia and New Zealand to achieve a 52.3% treatment rate; (b) the 'GAP' between the actual and required number of linear accelerators; c) the number of persons not treated (PNT), premature deaths (PD) and years of life lost (YLL) as a result of the 'GAP'; and (d) to review the actions being taken by health jurisdictions in Australia and in New Zealand to address the 'GAP' and reach the 52.3% treatment rate. MATERIAL AND METHODS: The actual number of fully staffed and operating linear accelerators (A) in Australian and New Zealand was obtained from a survey of radiotherapy facilities in December 2009. The required number of linear accelerators (R) was calculated from the projected cancer incidence figures for 2009 and was based on 1.6 linear accelerators being required per 1000 new cancer patients. The 'GAP' in Radiotherapy services (G) was R minus A. The maximum treatment capacity (MTC) was the ratio of A over R multiplied by 52.3%, assuming that all linear accelerators were operating at 100% capacity. As each linear accelerator can treat 331 new patients each year, the number of new cancer PNT is G x 331. The estimated 5-year survival benefit from radiotherapy is 16%, and the average survival for all patients receiving radiotherapy (radical and palliative) is 0.76 year. Hence, the number of PD attributed to the 'GAP' is PNT x 16%, and the YLL to cancer is PNT x 0.76. A literature search and local knowledge of health department Radiotherapy Plans in all jurisdictions were used to determine the action being taken to achieve a 52.3% treatment rate. RESULTS: In 2009, the 'GAP' was 50 linear accelerators in Australia and the MTC was 38%, the same as it was in 1999, but there has been an increase in PNT each year from 7419 in 1999 to 16,550 in 2009, and PD each year increased from 1187 in 1999 to 2649 in 2009, and YLL each year increased from 5638 in 1999 to 12,585 in 2009. In New Zealand in 2009, the 'GAP' was nine linear accelerators and the MTC was 38%. An estimated 3310 persons did not receive radiotherapy in 2009 in New Zealand, and as a result, there were 523 PD and 2266 YLL. The review showed that new and replacement machines were being installed in all jurisdictions in Australia and in New Zealand. Only Victoria and Queensland have a Radiotherapy Plan beyond 2010, but both have underestimated the projected cancer incidence. CONCLUSION: Urgent action is needed by health departments and governments on both sides of the Tasman to improve access and equity to this essential cancer treatment. There is merit in the Baume Report recommendation of establishing a national body to oversee radiotherapy services in all jurisdictions in Australia. A similar central body should also be considered for New Zealand.

Japanese structure survey of radiation oncology in 2007 based on institutional stratification of patterns of care study.

PURPOSE: To evaluate the ongoing structure of radiation oncology in Japan in terms of equipment, personnel, patient load, and geographic distribution to identify and improve any deficiencies. METHODS AND MATERIALS: A questionnaire-based national structure survey was conducted from March to December 2008 by the Japanese Society of Therapeutic Radiology and Oncology (JASTRO). These data were analyzed in terms of the institutional stratification of the Patterns of Care Study. RESULTS: The total numbers of new cancer patients and total cancer patients (new and repeat) treated with radiation in 2007 were estimated at 181,000 and 218,000, respectively. There were 807 linear accelerator, 15 telecobalt, 46 Gamma Knife, 45 (60)Co remote-controlled after-loading, and 123 (192)Ir remote-controlled after-loading systems in actual use. The linear accelerator systems used dual-energy function in 539 units (66.8%), three-dimensional conformal radiation therapy in 555 (68.8%), and intensity-modulated radiation therapy in 235 (29.1%). There were 477 JASTRO-certified radiation oncologists, 826.3 full-time equivalent (FTE) radiation oncologists, 68.4 FTE medical physicists, and 1,634 FTE radiation therapists. The number of interstitial radiotherapy (RT) administrations for prostate, stereotactic body radiotherapy, and intensity-modulated radiation therapy increased significantly. Patterns of Care Study stratification can clearly identify the maturity of structures based on their academic nature and caseload. Geographically, the more JASTRO-certified physicians there were in a given area, the more RT tended to be used for cancer patients. CONCLUSIONS: The Japanese structure has clearly improved during the past 17 years in terms of equipment and its use, although a shortage of personnel and variations in maturity disclosed by Patterns of Care Study stratification were still problematic in 2007.

[First results of the federal quality assurance group ("Arztliche Stelle") in radiotherapy in baden-württemberg: part 1]. / Erste Ergebnisse der Qualitätssicherung durch Arztliche Stellen in der Radiotherapie am Beispiel Baden-Württemberg: Teil 1.

PURPOSE: To evaluate the structure quality (medical staff, linear accelerators, and patients) of radiotherapy units based on the clinical audits by the "Arztliche Stelle" (this institution is based on federal German law) in Baden-Württemberg. MATERIAL AND METHODS: External audits (performed by at least two radiation oncologists, one radiation physicist, and a member of the administration) of recently completed charts by designated reviewers using appropriate checklists developed by the federal task group ("Arztliche Stelle") were used. RESULTS: In the interval from 2005 to 2007, 60 linear accelerators in 24 radiotherapy units served a population of approximately 10.7 million inhabitants (178,000 inhabitants/linear accelerator). 28,210 people with malignant tumors were treated in these units in 2007. These patients were served by 127 radiation oncologists, 83 radiation physicists, and 235 technologists. The ratio of patients irradiated annually to staff would become 222 (range 85-400) for a radiation oncologist, 339 for a radiation physicist (range 170-538), and 120 for a technologist (range 48-189). In five of seven departments (71%), new staff was employed following the recommendations of the auditors. CONCLUSION: Clinical audits by the "Arztliche Stelle" are highly effective to evaluate the structure quality of radiotherapy units. Based on these audits realistic data for staff requirements were gained. Making use of these data, guidelines for average minimum personnel necessary for good patient care were calculated. Personnel requirements may vary related to specific needs (teaching, research) of the treatment program and should be accounted for when discussing with the administration. The recommendations of the auditors of the "Arztliche Stelle" resulted in the new employment of additional staff.

A 'Catch Up' Plan for radiotherapy in New South Wales to 2012.

In New South Wales (NSW) from 1996 to 2006, only 34-37% of newly diagnosed cancer patients were treated with radiotherapy instead of the 50% proposed by NSW Health in Radiotherapy Plans released in 1991, 1995 and 2003. As a consequence, over 50 000 cancer patients were not treated and has resulted in the estimated premature death of over 8000 patients and over 40 000 years of life lost. In 2008, there were 42 linear accelerators in NSW rather than the 62 recommended. Based on cancer incidence projections, NSW will require 69 linear accelerators in 2012--a shortfall of 27 linear accelerators. Already 15 linear accelerators have been approved. NSW Health has funding for seven extra linear accelerators, and eight extra linear accelerators are to be funded by the private sector. To make up the shortfall, a 'Catch Up' Plan is proposed for an additional 12 linear accelerators by the end of fiscal year 2012. This is estimated to cost $200 million over 4 years for one-off establishment costs for buildings and equipment plus $50 million per year for recurrent operating costs such as staff salaries. The 'Catch Up' Plan will create five new departments of radiation oncology in country hospitals and three new departments in metropolitan hospitals. These will be in addition to those already approved by NSW Health and will markedly improve access for treatment and result in an improvement in cancer survival. This significant increase in departments and equipment can only be achieved by the creation of an NSW Radiotherapy Taskforce similar to that proposed in the Baume report of 2002, 'A vision for radiotherapy'. Even if the 'Catch Up' Plan bridges the gap in service provision, forward planning beyond 2012 should commence immediately as 76 linear accelerators will be required for NSW in 2015 and 81 linear accelerators in 2017.