By Shoukat Ali, Sr. Medical Physicist and RSO at Aga Khan University Hospital, Nairobi
Surgery, chemotherapy and radiotherapy are the standard treatment options for all types of cancer. As a part of the treatment options, radiotherapy plays an important role in the management of cancer treatment. Approximately 50% of cancer patients require radiotherapy at one point or another during their course of treatment. The LINAC with highly energetic x-ray beams are used for this purpose. Various types of LINACs are commercially available with a wide range of specifications. Purchasing a linear accelerator is a difficult task and requires a huge budget. Additionally, it is crucial to carefully consider which machine will meet the hospital’s needs in the current and the long run. In this article I will emphasize on the key points that are crucial for choosing a better linear accelerator for a radiotherapy department.
What types of treatment will you offer?
First and foremost, it’s crucial to specify what services will be offered and the available funding. The department will provide either standard treatment or specialized treatment like SBRT/SRS, or both. The overall cost of the machine’s will also depend on specifications, the more the specifications, the costlier it will be.
Financial analysis and available budgets
It’s challenging to purchase the machine within the available budget. To make it easy, request the vendor to provide a competitive quotation with the breakdown of prices for the various parts. If the available budget is less, the technical team will recommend removing optional items to reduce the cost of the equipment. Detailed financial analysis is very important for any private organization before planning to start radiotherapy setup because it requires huge investment. Majority of government hospitals have established radiation therapy departments because of the availability of resources and funding. Public and private partnership initiatives are also a good option to meet high budgets.
What staff and expertise is required?
Radiation oncologists, medical physicists and technologists are the main team members of a radiotherapy department. Their qualification and experience are different from each other and thus have unique specialties. Therefore, before selection of the machine, there should be an assessment of the clinical experience of existing staff i.e. sufficient to provide the services with the new technology or the need to hire experienced staff. The hiring of new staff will also increase the budget.
Availability of a machine room
A large room with suitable shielding is needed to install a high energy LINAC. However, if the hospital does not have much space to install the machine, then there are alternative solutions to take into consideration, such as single energy with internal shielding. Furthermore, If the hospital already has a machine installed in a room and wants to replace it with a new one, then it would be necessary to check either if the new one will be installed in an existing bunker or require some modification. Alteration in a bunker is always not a good option so try to select a machine which will not require any significant room alteration.
Need for backup with identical machines
Having a backup of similar machines in the radiation oncology department provides a significant benefit. Since LINAC is a highly complex machine, there is always a chance that it will break down. If the department has twin machines, they can quickly and efficiently move patients from one to the other without any treatment delay. It is advisable to prevent treatment gaps once radiation therapy begins.
Deciding on the company and latest brands
It is commonly observed that many hospitals purchase a complicated machine without justification. Any machine may be finalized after deliberation and expert advice from an experienced team. Almost more than 95% of radiotherapy patients require conventional treatment and only 3 to 5% patients require specialized treatments. There are many LINAC’s of different companies that are commercially available and have the same specifications. However, it has been noted that hospitals solicit feedback from other hospitals that have experience working with a particular company. Furthermore, it has been noted that customers often buy a LINAC from the same vendor that has already installed larger quantities in a country.
What Treatment planning system (TPS) and Oncology information system (OIS) will be used?
Each company has its own TPS and OIS. However, for integration and seamless operation, the majority of hospitals often acquire TPS and OIS from the same company. The TPS and OIS of different companies have some restrictions and are not entirely integrated with LINACs. The free and paid licenses that will be used for treatment optimization and routine workflow would pay close attention when buying a TPS and OIS. The third party TPS and OIS are also a nice alternative to consider, but again, careful thought would be needed.
What quality assurance is to be used?
Medical physicists should decide which quality assurance tools are necessary for the LINAC to function properly. Choose the best tools to meet your needs from the many phantom and ion chambers that are commercially available. Similarly, when choosing immobilization devices, it’s important to keep the department’s goal in mind.
Servicing services of the linac
Radiotherapy machines are extremely sophisticated. These may be dependent on other devices like UPSs and chillers. In case of a failure of any item, the LINAC will not be functional. Therefore, it is important to evaluate the number of trained engineers of the company and their history of serving other hospitals. Also coordinate with other hospitals and collect feedback about the company and their services.
What to consider in drafting contracts and agreements?
The contract should be very clear and written in detail about every aspect of the individual items, warranty and then signed after mutual understanding. Anything which is mutually agreed on should be captured and signed in the contract.
It is recommended to form a task force with a medical physicist, radiation oncologist, biomedical engineer, radiation therapy technologist, department manager, and IT expert. The involvement of the purchase and construction department is also important in the whole purchasing process. The task group meets once a week or more frequently as necessary for urgent consultations. Additionally, selecting the machine is a group decision as opposed to an individual one. As a result, each person’s input is valuable and helps with decision-making.