Requirements and Implementation of a Lung SBRT Program in a Developing Country: Benefits of International Cooperation

Evolving practice in global healthcare: Remote physics support for low- and middle-income countries

The COVID-19 pandemic has disrupted traditional onsite support for radiotherapy clinics in low- and middle-income countries (LMIC). Clinics there have struggled to commission new techniques and receive onsite training for their staff. We sought to evaluate whether an offsite approach could fill this gap at a clinic in Jordan by requesting a clinical audit and attempting to commission volumetric modulated arc therapy (VMAT). Over 13 months, a consultant provided remote support for a radiotherapy center that had already obtained treatment equipment and licenses. The consultant began by conducting a virtual audit, using a remote login to the center's R&V and TPS, to identify any gaps in the clinical workflow. Suggestions for improving the clinical workflow were proposed, and change implementation was tracked through emails, social media apps, and video conferencing. An extensive table outlined the commissioning process, including all measurements to be done. Social media apps and shared documents were used to track measurements and analysis. The lack of person-to-person interaction in this new remote-support ecosystem created conflicts; we have highlighted some of these, as well as their resolution and the lessons learned from them. The virtual audit identified gaps categorized as machine QA, treatment plan review, and treatment delivery processes. Following the implementation of the proposals, motion management was added, and machine QA became more comprehensive. VMAT was commissioned using the reports of the AAPM and the IAEA. The main challenges for remote support were time difference, establishing an appropriate form and frequency of communication, tone of voice used in messages, and buy-in from local staff. This evolving practice will enable medical physicists to use modern, multimodal remote communication pathways to effectively transfer knowledge to centers in LMICs. The audit-proposal-improvement pathway for remote support can be incorporated to help others while avoiding the pitfalls we faced.

Successful Development of a Competency-Based Residency Training Program in Radiation Oncology: Our 15-Year Experience from Within a Developing Country

One of the main challenges of delivering high quality of care to cancer patients in developing countries is the lack of well-trained radiation oncologists. This is a direct cause for the lack of residency programs coupled with lack of resources. This article describes and details establishments of a successful and sustainable radiation-oncology residency program in our country. The program has been in operation for 14 years and has trained and graduated radiation oncologists who are now working in various countries. The curriculum of the 4-year residency program, fashioned according to American College of Radiologists (ACR) recommendations, includes site-specific clinical rotations and didactic lectures in clinical oncology, radiobiology, medical physics, statistics, and epidemiology. It also includes a component of advanced clinical experience in the form of 3-month externship at one of collaborating centers outside the country. Evaluation of the residents is conducted annually via written exams and 360° feedback. Residents also sit for the formal certification exam in radiation oncology from the national Medical Council. The exam consists of 2 written exams and one oral. As a form of benchmarking residents' knowledge, they are required to sit for the ACR examinations held annually and conducted in Amman in tandem. The program has successfully trained and graduated 28 residents, who now work as consultant radiation oncologists locally and abroad. Each resident has gone through a structured training that includes exposure to a Western-style patient-management culture, enhancing the breadth and width of their clinical experience. The residency program, initiated in a developing country, underwent many challenges, yet it overcome all obstacles and resulted in a successful training of competent radiation oncologists serving the region.

History and Current State of Radiation Oncology Services and Practice in Jordan

Radiation therapy (RT) for patients with cancer in Jordan began with a small individual effort and has now grown to be one of the most prominent treatment centers in the Middle East. Currently, there are 4 different centers that provide RT not only for the people of Jordan but also for citizens of other neighboring Arab countries. Because Jordan is a developing country, it still faces problems with the insufficient number of RT machines available and their supporting staff (physicists and technologists among others). In this article, we shed light on the history and current status of radiation oncology in Jordan and discuss the challenges we face.

Enhancing value of quality assurance rounds in improving radiotherapy management: a retrospective analysis from King Hussein Cancer Center in Jordan

PURPOSE

The quality assurance (QA) chart rounds are multidisciplinary meetings to review radiation therapy (RT) treatment plans. This study focus on describing the changes in RT management based on QA round reviews in a single institution.

MATERIALS AND METHODS

After 9 full years of implementation, a retrospective review of all patients whose charts passed through departmental QA chart rounds from 2007 to 2015. The reviewed cases were presented for RT plan review; subcategorized based on decision in QA rounds into: approved, minor modifications or major modifications. Major modification defined as any substantial change which required patient re-simulation or re-planning prior to commencement of RT. Minor modification included treatment plan changes which didn't necessarily require RT re-planning.

RESULTS

Overall 7,149 RT treatment plans for different anatomical sites were reviewed at QA rounds. From these treatment plans, 6,654 (93%) were approved, 144 (2%) required minor modifications, while 351 (5%) required major modifications. Major modification included changes in: selected RT dose (96/351, 27%), target volume definition (127/351, 36%), organs-at-risk contouring (10/351, 3%), dose volume objectives/constraints criteria (90/351, 26%), and intent of treatment (28/351, 8%). The RT plans which required major modification according to the tumor subtype were as follows: head and neck (104/904, 12%), thoracic (12/199, 6%), gastrointestinal (33/687,5%), skin (5/106, 5%), genitourinary (16/359, 4%), breast (104/2387, 4%), central nervous system (36/846, 4%), sarcoma (11/277, 4%), pediatric (7/251, 3%), lymphoma (10/423, 2%), gynecological tumors (2/359, 1%), and others (11/351, 3%).

CONCLUSION

Multi-disciplinary standardized QA chart rounds provide a comprehensive and an influential method on RT plans and/ or treatment decisions.