"third world" radiation oncology

[defthaiku]

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Anybody know of ways to get involved with sharing the technology of radiation oncology with developing countries? For instance with a short-term international rad onc elective/rotation?

 

[napoleondynamite]

I spent a summer in Ghana (West Africa) working with radiation oncologists and doing research. This was something I sought out and organized myself. There may be more formal experiences elsewhere. To my knowledge, there are only three African nations with radiotherapy available to cancer patients: Ghana, Nigeria and South Africa. Anyway, I had a phenomenal experience. It was like going back in time 50 years as they only have Cobalt machines. But it also helped me to understand our field in a new way because I could see where we've come from (treating in 2 dimensions!).

 

[3dtp]

Anybody know of ways to get involved with sharing the technology of radiation oncology with developing countries? For instance with a short-term international rad onc elective/rotation?

There are many ways to do this. I have personally been instrumental in advancing the art in developing countries. I repaired the only CT scanner in Ethiopia some years ago. Hopefully they have a better one by now.

I was also asked and stepped in to install the second CT scanner in Kazakhstan as a volunteer. While there, I traveled to the Cancer Hospital (subject, I think of Solzenhitzen's The Cancer Ward). For me it was Co-60 on a pedestal. (This means AP - PA without immobilization) They had just started installing the first gantry based Co-60 machine. They used a russian treatment planning system and since the CT scanner was not then operational everything was plain film with wet processing. I'm not sure how good the treatment planning system was, but the hand calcs I did with it seemed to match the timer calcs it came up with. Everything there was SSD calcs at that time.

I also spent half a year teaching in Kosovo, primarily radiologic physics and basic equipment repair skills at the university level. We designed a curriculum which would bring people to the level of a basic radiologic technician so that the Kosvar's would be able to maintain their own equipment without depending on charity from the EU.

So, there are many things that can help. One thing that does not help, is to "donate" junk equipment that is obsolete for a tax write off. I can't tell you how much stuff I had to tell missionaries to throw away because it was a.) unreliable b.) unrepairable c.) unsafe d.) too expensive to maintain or outside of the abilities of the nationals to maintain and repair. By donating non-working equipment, it discourages the nationals and convinces them that the US makes poor equipment.

That being said, there is a need for people to help advance the arts in developing countries. I have worked with a couple of companies who will pre-qualify the equipment or, if you have some ideas in this regard, please feel free to drop me a message and I can tell you how to make sure that good stuff is going over there before someone pays for a container and all manner of political work to ship something over that just plain won't work well in the local environment. I have set up a program to do this which begins with an inspection of the equipment and full electronics and physics pre-quals. This will save the missions groups lots of headaches, and make the nationals a bit more comfortable with our gifts.

 

[3dtp]

Societies that are interested and have occasional opportunities are some of the following

Christian Medical And Dental Association, Bristol, TN
International Aid, Spring Lake, Michigan
International Organization of Medical Physics, Vienna

These organizations occasionally get called to see if there is someone available to help out, but the opportunities with them are relatively rare.

Most of the groups I've been hooked up with (as a free lancer, long before and during med school), have been through personal contacts, or a friend of a friend who knew someone who knew...

My first involvement was at a national meeting where I gave a talk on an unrelated subject and was buttonholed after the talk by someone who asked me to help.

But, you've given me an idea. I'm in the process of interviewing right now and perhaps I can help set up a clearinghouse of people who are interested in doing mission workk/donating time to help advance the art in less advantaged countries. If I do this it will likely be in cooperation with one of the above groups.

 

[turkleton]

Do you fella's think that's its the greatest utilization of resources to advance radiation onc in developing countries? I know I'm probably asking the wrong crowd... but to a non rad onc physician interested in international health, that seems a huge allocation of resources- I am presuming establishing the infrastructure for a properly functioning facility for your field requires quite an investment- in locations where basic health needs are still unmet. I'm not saying that you shouldn't cure cancer in Africa... to me, it seems like taking care of basic vaccinations, treatable infections, and basic surgeries are the first priority. Thoughts?

 

[Mulletfluf]

Do you fella's think that's its the greatest utilization of resources to advance radiation onc in developing countries? I know I'm probably asking the wrong crowd... but to a non rad onc physician interested in international health, that seems a huge allocation of resources- I am presuming establishing the infrastructure for a properly functioning facility for your field requires quite an investment- in locations where basic health needs are still unmet. I'm not saying that you shouldn't cure cancer in Africa... to me, it seems like taking care of basic vaccinations, treatable infections, and basic surgeries are the first priority. Thoughts?

To be honest, I can see your arguement. However, most of the donated equipment is older (i.e too old to be of use in US) but in good working order. Thus the only cost is getting the equipment shipped. Procedures are very basic and largely palliative. Chances are if you don't have the resources to afford new equipment you also don't have robust screening measures in place.

I know a physicist who has donated old physics equipment to a third world rad onc clinic and its made a huge difference in their center. A little goes along way!

 

[napoleondynamite]

You know, there is a lot that can be done in developing nations without necessarily donating equipment too.. The group I worked with in Ghana had equipment, but was starving to have visiting faculty from the US. They were very excited about research, but didn't really have any idea where to begin. Keep in mind, their training was not in large, academic centers with heavy focus on evidence-based medicine. Anyway, they often spoke about how they would love to turn their treasure-trove of information and patients into tangible research, but just lacked the resources, and in some cases the know-how to get it done. I think a lot can be done by just developing relationships with new radonc programs in the developing world. But I also admire the extraordinary efforts others are going to to secure donated equipment and I'm sure that in the right circumstances, this is also an enormous blessing to certain areas of the world.

 

[3dtp]

To be honest, I can see your arguement. However, most of the donated equipment is older (i.e too old to be of use in US) but in good working order. Thus the only cost is getting the equipment shipped. Procedures are very basic and largely palliative. Chances are if you don't have the resources to afford new equipment you also don't have robust screening measures in place.

I know a physicist who has donated old physics equipment to a third world rad onc clinic and its made a huge difference in their center. A little goes along way!

I beg to differ here.

Older equipment that is in good working order may be of some use in these countries, but the cost of shipping and import duties may make this equipment unimportable. Unfortunately, a lot of old junk has been donated, tax writeoffs taken and well meaning groups paid the freight only to get equipment in the third world that flat out doesn't work or is unreliable.

In addition, there are some companies that abandon support for and orphan equipment. I can't tell you how many times I've run into this situation. For the record, GE is one of the worst. They wanted to charge me a large fortune for the technical manuals for the scanner I worked on. Their solution: buy a brand new one. Right. These folks can't afford the power to run the things.

Granted, donating a water phantom or a chamber/electrometer in good working order will help a lot, but the underlying reality is that a lot of equipment is donated that is unsuitable.

What I have found in the field are things like ultrasound units without transducers, transducers with cracked crystals (useless), ct scanners with bad computer disks (obsolete and unreplaceable), old x-ray generators that require frequent (like daily) tinkering to keep the energy/mAs accurate, mammography machines that are dangerous and unusable in the US because of the image quality/radiation dose, ie absolutely no way to meet MQSA requirements.

Please, if you are thinking about donating equipment that you consider obsolete, check with International Aid (Billy Tenenty is the contact there), and make sure that a.) the donation is suitable, b.) the donation is serviceable and c.) the field can support and maintain the equipment with the resources that are available.

 

[3dtp]

Do you fella's think that's its the greatest utilization of resources to advance radiation onc in developing countries? I know I'm probably asking the wrong crowd... but to a non rad onc physician interested in international health, that seems a huge allocation of resources- I am presuming establishing the infrastructure for a properly functioning facility for your field requires quite an investment- in locations where basic health needs are still unmet. I'm not saying that you shouldn't cure cancer in Africa... to me, it seems like taking care of basic vaccinations, treatable infections, and basic surgeries are the first priority. Thoughts?

You are correct. These should be and are a first priority.

But, let's look at a huge problem in Africa. Cervical cancer in the US is usually caught at a very early stage, mostly in the HSIL/ASCUS/AGUS stage, where it is easily cured, primarily due to paps.

Cervical cancer in Africa is usually caught in an advanced stage due to the lack of the early and available primary care. This leaves radiation as one of the only treatments, be it curative or palliative. And, using tradiational methods (LDR brachytherapy using Cs-137 sources with 30 year half lives), reusable applicators the cost of equipment and treatment are relatively reasonable.

Again, looking at external beam radiotherapy, I agree that bringing a linear accelerator into a hospital where a washing machine is a big step forward is probably not an ideal use of resources.

But, if you consider the concept of using a Co-60 machine with cerrobend blocking, using the treatment machine to simulate or using a conventional x-ray or flouro unit, this can be highly cost effective in treating or palliating cancer. If manufacturers were willing to fit a Co-60 unit with a modern multileaf collimator using the higher reliability systems we have today, I think this would be useful. A Co-60 unit requires modest to no maintenance other than routine monthly inspections that can be easily and economically done and a source change every 5-8 years. I wish accelerators where that easy to maintain and keep in calibration.

So, I think that cancer, like ID, OB and basic primary care should be treated and although the resources are not there to set up a modern western style center, there are economic solutions that will permit bringing the care to the unfortunate of these nations. On the other hand, I saw my first case of osteomalacia due to malnutrition in Ethiopia, and I wondered what I was doing there.

 

[napoleondynamite]

Hey 3dtp,

When I was in Ghana the Cobalt-60 they were using had not had a source change in 15 years b/c they could not afford it 😱 Any idea how much something like that costs? If it were a reasonable endeavor, I'd love to try to raise the dough for them..

 

[3dtp]

Hey 3dtp,

When I was in Ghana the Cobalt-60 they were using had not had a source change in 15 years b/c they could not afford it 😱 Any idea how much something like that costs? If it were a reasonable endeavor, I'd love to try to raise the dough for them..

Excellent idea.

Haven't the foggiest on the costs. Most of the Co-60 units were AECL units and AECL is still, as far as I know, producing replacement sources. They are in Mississauga, Ontario. There are probably a few other manufacturers of Co-60 units but I'm not aware of them. You might try the IOMP (International Organization of Medical Physics). The other place to check is with Imami''s group at Loyola. They (at least they did in the not so distant past) used Co-60 units and their physicists might have a handle on source change costs. Most likely the unit manufacturer will insist on doing the source changeout so that accountability for the old source can be maintained, but as always, your mileage may vary.

If I get a chance and run into someone who knows, I'll get you a rough idea of the costs. Any idea who manufactured the Ghana unit?

 

[IndyXRT]

Hey 3dtp,

When I was in Ghana the Cobalt-60 they were using had not had a source change in 15 years b/c they could not afford it 😱 Any idea how much something like that costs? If it were a reasonable endeavor, I'd love to try to raise the dough for them..

The going rate for a source change on a Gamma Knife is hundreds of thousands of dollars, but that's for 201 small sources. I'm not sure what it would cost for one larger source.

 

[3dtp]

The going rate for a source change on a Gamma Knife is hundreds of thousands of dollars, but that's for 201 small sources. I'm not sure what it would cost for one larger source.

This is correct, if the GK can be reloaded in the field at all. Leksell, at least in some of the older of the more recent designs could not field-reload them at all, thus requiring them to be sent back to Uppsaala. I'm not sure if they completely solved this problem, but I do know that Pitt had to "exchange/upgrade" at least one unit when the sources were highly depleted and I think the Detroit GK had to do the same with their original unit. And the operative words here are "hundreds of thousands ," plural!

I've asked a few buddies who are sort of in the know on this, and no one really knows for sure, off the top of their head, but most of these guesses are in the $60-$90K range for a Co-60 source change. They are not sure whether that includes disposal of the decayed source or not.

 

[blkprl]

Hey 3dtp,

When I was in Ghana the Cobalt-60 they were using had not had a source change in 15 years b/c they could not afford it 😱 Any idea how much something like that costs? If it were a reasonable endeavor, I'd love to try to raise the dough for them..

Were you able to raise any money?

 

[Carotenoid]

I know someone who did gyn rad onc in Honduras with these folks: http://chicago2011.asco.org/ASCODailyNews/InternationalCancerCorps.aspx