Speaker
Description
Introduction:
Nepal is a landlocked country around thirty million inhabitants. For decades, Cobalt-60 machines have been the workhorses of radiotherapy in low- and middle-income countries (LMICs) like Nepal. Their affordability, relative ease of use, and lower maintenance needs made them the go-to technology for providing essential cancer treatment. In recent years, the field of medical physics has witnessed significant advancements in radiation therapy technology, with linear accelerators (linacs) emerging as a preferred choice for delivering precise and targeted radiation doses. However, the transition from traditional cobalt-60 machines to linacs poses unique challenges, especially in underdeveloped healthcare settings like Nepal. This article delves into the issues, challenges and considerations surrounding this transition and explores potential solutions for a successful integration.
- Infrastructure Challenges:
One of the primary hurdles in adopting linacs in LMICs countries is the lack of infrastructure. Linear accelerators require a stable power supply, specialized treatment rooms, and intricate shielding to ensure the safety of both patients and healthcare professionals. In Nepal, where the healthcare infrastructure is still evolving, there is a discernible need for substantial investments in facility upgrades. Initiatives to build and retrofit radiation therapy centers must be undertaken with careful planning and consideration of available resources. The retrofitting of the cobalt-60 bunker to accommodate the new 6 MV linac is imperative, necessitating additional shielding due to the existing cobalt-60 bunker. Similarly, a stable and high-voltage power supply was a requisite during this process. - Competent and Skilled Human resources:
Transitioning to new technology necessitates a skilled workforce capable of operating and maintaining highly sophisticated equipment. In Nepal, where specialized academic and training programs for medical physicists and radiation therapists is limited. Investing in comprehensive education initiatives is crucial. Collaborations with international institutions, online training programs, and mentorship programs can help bridge the knowledge gap and ensure a competent workforce capable of utilizing linacs effectively. - Regulatory Compliance:
The Radioactive Substances (Utilization and Regulation) Act of 2020 mandates the establishment of an independent regulatory authority, a requirement that Nepal has yet to fulfill with a competent and independent body. The adherence to international standards and regulations is paramount for the safe and effective utilization of radiation therapy equipment. In underdeveloped countries such as Nepal, the establishment and enforcement of robust regulatory frameworks become indispensable, ensuring that linear accelerators (linac) adhere to stringent quality and safety standards.
Implementing ongoing quality assurance programs, conducting regular equipment audits, and fostering continuous education are vital components of a successful transition that prioritizes patient safety. It is crucial for Nepal to expedite the establishment of an independent regulatory authority to align with international best practices and facilitate the safe deployment of radiation therapy technologies. - Collaboration and Partnership:
International partnerships with developed countries and organizations such as the International Atomic Energy Agency (IAEA) and the US DOE Office of Radiological Security (ORS) present invaluable opportunities for expertise, resources, and technology transfer. Collaborative efforts between international support groups, healthcare providers, governmental bodies, and community leaders are pivotal in fostering a positive perception of advanced radiotherapy technologies. Engaging in these partnerships facilitates the exchange of knowledge and best practices, enabling Nepal to leverage the experience and advancements of developed nations. Such collaboration not only enhances the capabilities of healthcare providers but also contributes to the establishment of robust frameworks for the safe and efficient utilization of advanced radiotherapy equipment. It is through these cooperative endeavors that Nepal can progress towards achieving international standards in medical physics and radiation protection. - Financial Implications:
The financial burden associated with the acquisition and maintenance of linear accelerators can pose significant challenges. The initial investment in procuring the equipment, combined with ongoing expenses for maintenance, training, and infrastructure development, can strain the limited budgets of underdeveloped healthcare systems. To address these financial challenges, innovative financing models and international collaborations, including partnerships with organizations like the International Atomic Energy Agency (IAEA), become essential.
In the context of our institution, substantial expenditures were incurred for the decommissioning and disposal of disused cobalt-60. The process involved intricate paperwork, intricate security measures, and logistical challenges in transporting the disused source. Exploring cost-effective and sustainable solutions, supported by international collaborations, can mitigate the financial implications associated with the integration of advanced radiotherapy technologies into the healthcare system. - Unforeseen Circumstances:
The transition period coincided with the unprecedented challenges posed by the Covid-19 pandemic, impacting the installation process of the acquired equipment in Kathmandu. The delay was exacerbated by the absence of a safe and secure location for the equipment container at our institution, necessitating its placement in a nearby facility for almost two years. During this time, the local supplier was responsible for ensuring the secure storage of the equipment.
Upon the eventual arrival of engineers for installation after the resolution of pandemic-related issues, an unforeseen complication emerged – water leakage inside one of the containers. This setback led to the engineers aborting the installation process. Adding to the challenges, the local supplier had failed to continue the insurance coverage for the equipment. Resolving this matter between the supplier company and the local agent took an additional year. Ultimately, the manufacturing company agreed to provide a brand new linear accelerator.
This experience underscores the importance of vigilant monitoring, anticipating challenges, and implementing a strategic and multidimensional approach as circumstances evolve. It highlights the necessity of developing sustainable financing models to ensure the long-term operation and maintenance of linac, recognizing that unforeseen circumstances may require adaptability and resilience in the implementation of advanced medical technologies.
Conclusion:
The transition from Cobalt-60 to linear accelerator in LMICs is undeniably a formidable challenge, but it also signifies an unparalleled opportunity to enhance cancer care for millions of patients. Meticulously addressing these challenges through a strategic and multidimensional approach empowers LMICs to overcome hurdles and capitalize on the clinical advantages of linac, ultimately delivering improved radiotherapy services to their citizens. Crucially, the decision to transition should be tailored to the unique needs and resources of each healthcare setting, emphasizing a case-by-case basis. A well-planned and coordinated approach is instrumental in ensuring a successful transition that not only benefits patients directly but also strengthens the overall cancer care infrastructure in LMICs. Experience has underscored the paramount importance of vigilant monitoring, anticipating challenges, and adopting a strategic and adaptable approach as circumstances evolve. This underscores the necessity of developing sustainable financing models for the long-term operation and maintenance of linac, acknowledging the potential for unforeseen circumstances that demand adaptability and resilience in the implementation of advanced medical technologies. Nepal, by addressing infrastructure limitations, financial constraints, workforce training, regulatory compliance, and community engagement, can pave the way for a successful integration of modern radiation therapy technology. International collaborations, knowledge-sharing initiatives, and a steadfast commitment to improving healthcare infrastructure will play pivotal roles in ensuring equitable access to advanced cancer treatment in the region.
