Matthew Beckett, MD, MSc
The World Health Organization (WHO) and the International Atomic Energy Agency (IAEA) have collaborated to publish new technical guidance on procurement of radiotherapy equipment for treatment of cancer. These guidelines aim to help contextualize equipment selection for the country, health care system, and facility in which it will be used, with emphasis on safety, quality assurance, and sustainability. The intended audience of this document includes clinical radiation oncologists; medical physicists and biomedical engineers; and professionals in information technology, finance, and governance in cancer-control centers.
In 2020, the global cancer burden exceeded 19 million new cases and 9 million deaths.1 WHO estimates2 an increase to 22 million new cases and 13 million deaths annually by 2030. Lung cancer is the most commonly diagnosed cancer in men, the third most common in women, and the greatest cause of cancer deaths in both sexes.1 As approximately two-thirds of lung cancers are attributable to tobacco smoking, lung cancer incidence generally mirrors the worldwide rise of tobacco use. Incidence is therefore rising in many low- and middle-income countries, where tobacco use has been widespread for several decades, at faster rates than in high-income countries, where tobacco use has plateaued or has started to decline.3 Despite its persistently high fatality rate, the prognosis of lung cancer is improving because of advances in our capabilities for prevention, early detection, and multidisciplinary treatment regimens. Among these lifesaving treatments is radiotherapy. However, capacity for radiotherapy currently varies significantly within and between countries.
May Abdel-Wahab, MD, PhD, FACR
Radiotherapy is a cornerstone of evidence-based multidisciplinary cancer care. It is estimated that radiotherapy is indicated for approximately 50% of cancer patients for either curative or palliative treatment.4-7 In high-income settings, when utilized optimally, radiotherapy provides significant population-level local control and overall survival benefits.7 There is a potential role for radiotherapy in lung cancer at all stages, either in the form of stereotactic treatments for early-stage tumors; concurrently or in sequence with systemic therapies for locally advanced tumors; or for palliative purposes in cases of advanced, incurable disease. Advancements in technology and expertise have made highly conformal stereotactic therapies an excellent option for small tumors when surgery is not possible. Similarly, these same principles have been applied to stereotactic treatment of brain metastases in an effort to avoid the toxicities of whole-brain radiotherapy. Even conventional fractionation schemes, when utilizing intensity-modulation technology, can improve efficacy and spare patients toxicity by maximizing dose to the tumor while minimizing dose to crucial organs at risk. For this to be possible, a radiation oncology department requires certain technological and human resources, including appropriately selected and maintained equipment and a multidisciplinary team to coordinate its use for delivery of care.
It is in this spirit that the WHO and IAEA guidelines have been assembled. These specifications are an update of a previous version released by the IAEA in 2008. As the global cancer burden grows, it is necessary that the capacity for radiotherapy be expanded worldwide, requiring tailoring to the local and regional contexts in which these efforts are undertaken. The updated document is therefore broad in its scope. This document includes coverage of procurement, maintenance, and life cycle for equipment involved in both external beam radiotherapy (EBRT; including linear accelerators and Cobalt-60 technology) and brachytherapy. Necessary components of EBRT and brachytherapy programs are discussed in terms of health care system capacity. Medical imaging equipment, such as that for CT simulation, is also addressed, as well as software for treatment planning.
Maintenance of safety and quality are essential for staff, patients, and members of the public, and therefore International Electrotechnical Commission (IEC) and International Organization for Standardization (ISO) standards for safety and emergency preparedness practices are discussed in detail. This provides crucial information for infrastructure planning of cancer-control centers and the design of routine policies and procedures to be undertaken by various radiation medicine professionals. Hand-in-hand with assurance of safety is assurance of quality, and therefore processes for maintaining high-quality treatment delivery are also reviewed. The aforementioned are described systematically as they apply to each particular equipment item.
A skilled and knowledgeable multidisciplinary team is necessary for establishment and ongoing administration of a radiotherapy service. This large team includes groups for project management, clinical implementation, and technological implementation and therefore consists of a broad range of professionals including radiation oncologists, medical physicists, nurses, radiation therapists, biomedical engineers, radiation safety officers, administrators, information technologists, and others. These roles may vary depending on geography or health care system and whether the intended goal is establishment of a radiotherapy service or expansion of an existing one. Necessary tasks and responsibilities are therefore reviewed in detail with these various possible contexts in mind, as are the expected education and qualifications for each of these professional roles.
Implementation of high-quality radiotherapy services has its challenges. All of the undertakings described herein require financial and on-the-ground government support; unfortunately, cancer care is simply not a high priority for many governments. This applies to the procurement of both equipment and human resources, as some countries and regions have limited capacity to educate, train, and retain the broad array of professionals integral to a radiotherapy service. Nongovernmental and international organizations are therefore often involved to make ends meet when governments are unable. Ensuring meaningful access to radiotherapy services will be different under various health care systems, as many systems strike unique balances between public and private sectors. Thorough, evidence-based understanding of a particular health care system is an important part of establishing or expanding a radiotherapy service, in order to identify challenges, resources, and stakeholders and to develop contextualized solutions.
In an effort to provide comprehensive guidance for all elements of radiotherapy administration, these guidelines are cross-referenced where appropriate with other relevant publications by the IAEA. The IAEA and WHO continue to support member states in their pursuit of high-quality, accessible, sustainable, and safe use of nuclear technology for cancer treatment through training, education, research, and guidance. It is through coordination, collaboration, and commitment that we will be able to rise to the challenge of the growing worldwide cancer burden.
References:
- 1. [World cancer fact sheet]. International Agency for Research on Cancer 2020. March 2021. https://gco.iarc.fr/today/data/factsheets/populations/900-world-fact-sheets.pdf
- 2. McGuire S. World Cancer Report 2014. Adv Nutr. 2016;7(2):418419.
- 3. Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209-249.
- 4. Baskar R, Lee KA, Yeo R, Yeoh KW. Cancer and radiation therapy: Current advances and future directions. Int J Med Sci. 2012;9(3):193-199.
- 5. Tepper JE, Foote RL, Michalski JM, eds. Gunderson and Tepper’s Clinical Radiation Oncology. 5th ed. Elsevier; 2021.
- 6. Delaney G, Jacob S, Featherstone C, Barton M. The role of radiotherapy in cancer treatment: Estimating optimal utilization from a review of evidence-based clinical guidelines. Cancer. 2005;104(6):1129-1137.
- 7. Hanna TP, Shafiq J, Delaney GP, Vinod SK, Thompson SR, Barton MB. The population benefit of evidence-based radiotherapy: 5-Year local control and overall survival benefits. Radiother Oncol. 2018;126(2):191-197.
