Developing Innovative, Robust and Affordable Medical Linear Accelerators for Challenging Environments

Harnessing progress in radiotherapy for global cancer control

The pace of technological innovation over the past three decades has transformed the field of radiotherapy into one of the most technologically intense disciplines in medicine. However, the global barriers to access this highly effective treatment are complex and extend beyond technological limitations. Here, we review the technological advancement and current status of radiotherapy and discuss the efforts of the global radiation oncology community to formulate a more integrative 'diagonal approach' in which the agendas of science-driven advances in individual outcomes and the sociotechnological task of global cancer control can be aligned to bring the benefit of this proven therapy to patients with cancer everywhere.

Failure modes and downtime of radiotherapy LINACs and multileaf collimators in Indonesia

BACKGROUND AND PURPOSE

The lack of equitable access to radiotherapy (RA) linear accelerators (LINACs) is a substantial barrier to cancer care in low- and middle-income countries (LMICs). These nations are expected to bear up to 75% of cancer-related deaths globally by 2030. State-of-the-art LINACs in LMICs experience major issues in terms of robustness, with mechanical and electrical breakdowns resulting in downtimes ranging from days to months. While existing research has identified the higher failure frequency and downtimes between LMICs (Nigeria, Botswana) compared to high-income countries (HICs, the UK), there has been a need for additional data and study particularly relating to multileaf collimators (MLCs).

MATERIALS AND METHODS

This study presents for the first time the analysis of data gathered through a dedicated survey and workshop including participants from 14 Indonesian hospitals, representing a total of 19 LINACs. We show the pathways to failure of radiotherapy LINACs and frequency of breakdowns with a focus on the MLC subsystem.

RESULTS

This dataset shows that LINACs throughout Indonesia are out of operation for seven times longer than HICs, and the mean time between failures of a LINAC in Indonesia is 341.58 h or about 14 days. Furthermore, of the LINACs with an MLC fitted, 59 . 02 - 1.61 + 1.98 $59.02_{ - 1.61}^{ + 1.98}$ % of all mechanical faults are due to the MLC, and 57 . 14 - 1.27 + 0.78 $57.14_{ - 1.27}^{ + 0.78}$ % of cases requiring a replacement component are related to the MLC.

CONCLUSION

These results highlight the pressing need to improve robustness of RT technology for use in LMICs, highlighting the MLC as a particularly problematic component. This work motivates a reassessment of the current generation of RT LINACs and demonstrates the need for dedicated efforts toward a future where cancer treatment technology is robust for use in all environments where it is needed.

Collaboration, the force that makes the impossible possible

Over the last three decades, the landscape of cancer treatment with radiotherapy has never stopped improving. ENLIGHT – the European Network for Light Ion Hadron Therapy – has been an active participant in the huge changes that have taken place, in particular in Europe. At the end of the 90s when I arrived at CERN, it appeared clear that an improvement in communication, sharing and exchange, while keeping a common goal, was needed to bring together international experts from accelerator physics, imaging, medical physics, radiobiology and clinical medicine. ENLIGHT network was most aptly launched at CERN, since CERN is renowned as a place for global collaboration. The network has come a long way since the kick-off meeting at CERN in 2002 when only about 70 specialists from different disciplines took part and continues to grow and flourish with now over 1000 participants, accounting for over 100 institutions, from around 40 countries around the globe.

Surveying the Challenges to Improve Linear Accelerator-based Radiation Therapy in Africa: a Unique Collaborative Platform of All 28 African Countries Offering Such Treatment

Radiation therapy is a critical component for curative and palliative treatment of cancer and is used in more than half of all patients with cancer. Yet there is a global shortage of access to this treatment, especially in Sub-Saharan Africa, where there is a shortage of technical staff as well as equipment. Linear accelerators (LINACs) offer state-of-the-art treatment, but this technology is expensive to acquire, operate and service, especially for low- and middle-income countries (LMICs), and often their harsh environment negatively affects the performance of LINACs, causing downtime. A global initiative was launched in 2016 to address the technology and system barriers to providing radiation therapy in LMICs through the development of a novel LINAC-based radiation therapy system designed for their challenging environments. As the LINAC prototype design phase progressed, it was recognised that additional information was needed from LMICs on the performance of LINAC components, on variables that may influence machine performance and their association, if any, with equipment downtime. Thus, a survey was developed to collect these data from all countries in Africa that have LINAC-based radiation therapy facilities. In order to understand the extent to which these performance factors are the same or different in high-income countries, facilities in Canada, Switzerland, the UK and the USA were invited to participate in the survey, as was Jordan, a middle-income country. Throughout this process, LMIC representatives have provided input on technology challenges in their respective countries. This report presents the method used to conduct this multilevel study of the macro- and microenvironments, the organisation of departments, the technology, the training and the service models that will provide input into the design of a LINAC prototype for a LINAC-based radiation therapy system that will improve access to radiation therapy and thus improve cancer treatment outcomes. It is important to note that new technology should be introduced in a contextual manner so as not to disrupt existing health systems inadvertently, especially with regards to existing staffing, infrastructure and socioeconomic issues. A detailed analysis of data is underway and will be presented in a follow-up report. Selected preliminary results of the study are the observation that LINAC-based facilities in LMICs experience downtime associated with failures in multileaf collimators and vacuum pumps, as well as power instability. Also, that there is a strong association of gross national product per capita with the number of LINACs per population.

Mobilising stakeholders to improve access to state-of-the-art radiotherapy in low- and middle-income countries

In an ongoing effort to improve access to state-of-the-art radiotherapy in low- and middle-income countries (LMICs), a joint symposium was organised by the non-governmental, non-profit organisation Medical physicists in diaspora for Africa e.V. (MephidA e.V.) in collaboration with the Germany-based Cameroon-German medical doctor’s association (Camfomedics e.V.) and the Harvard-based Global Health Catalyst summit. The goal of the symposium was to discuss the technical and structural challenges faced in African LMIC settings, re-evaluate strategies to overcome the shortfall of radiotherapy services and ameliorate the situation. The meeting brought together industry partners, including radiotherapy machine vendors and dosimetry solution providers, alongside public health, oncology and medical physics experts. This paper summarises the deliberations and recommendations based on the ongoing efforts including the use of information and communication technologies towards the provision of expert knowledge and telemedicine, the use of solar energy to avoid power outages and the use of high-end technology for enhanced quality assurance. We also present the experiences on the first linac installation at the Rwanda Military Hospital, the challenges faced in this LMIC as well as the patient’s demography, reflecting the reality in most sub-Saharan LMICs.

Capturing Acquired Wisdom, Enabling Healthful Aging, and Building Multinational Partnerships Through Senior Global Health Mentorship

The undeniable benefit of mentorship by experience senior mentors can meaningfully increase the breadth of their experience and contributions to society as well as address the dire inequality in global health. This model captures wisdom lost to retirement, enables opportunities for purposeful lifespan, underpins sustainable health care systems, and has the potential for building multinational partnerships.

Achieving flexible competence: bridging the investment dichotomy between infectious diseases and cancer

Today's global health challenges in underserved communities include the growing burden of cancer and other non-communicable diseases (NCDs); infectious diseases (IDs) with epidemic and pandemic potential such as COVID-19; and health effects from catastrophic 'all hazards' disasters including natural, industrial or terrorist incidents. Healthcare disparities in low-income and middle-income countries and in some rural areas in developed countries make it a challenge to mitigate these health, socioeconomic and political consequences on our globalised society. As with IDs, cancer requires rapid intervention and its effective medical management and prevention encompasses the other major NCDs. Furthermore, the technology and clinical capability for cancer care enables management of NCDs and IDs. Global health initiatives that call for action to address IDs and cancer often focus on each problem separately, or consider cancer care only a downstream investment to primary care, missing opportunities to leverage investments that could support broader capacity-building. From our experience in health disparities, disaster preparedness, government policy and healthcare systems we have initiated an approach we call flex-competence which emphasises a systems approach from the outset of program building that integrates investment among IDs, cancer, NCDs and disaster preparedness to improve overall healthcare for the local community. This approach builds on trusted partnerships, multi-level strategies and a healthcare infrastructure providing surge capacities to more rapidly respond to and manage a wide range of changing public health threats.