Minjmaa Minjgee, MD, National Cancer Centre, MONGOLIA IAEA/RCA RAS/6/040 Project Planning Meeting on “Improvement in Quality of Radiotherapy for Frequent Cancers in the Region” Mumbai, India, March 2005 Minjmaa Minjgee, MD, National Cancer Centre, MONGOLIA

Mongolia, NCCM 1.56 million sq.km territory Relatively small number of people: 2.4 million (Oct 2001) The National Cancer Centre (NCCM) is only place in the field of Radiotherapy in the country The distances from some regions to the capital are very large (sometimes more than 1600 km). It would be necessary to enlarge existing radiotherapy centre and to build up at least one more centre in the west of Mongolia Aiming to reach status of centre of competence in future

NCCM The reported cancer incidence in Mongolia is about 160 new cases per 100.000. Necessary to ensure a specific treatment for about 3500 cancer patients per year Demand to treat about 2000 patients per year by Radiotherapy and Chemotherapy.

Structure of malignant neoplasms (annual statistics of the NCC, Ulaanbaatar 2001) 8% 6% 2% 1% 38% 19% 16% 10% Liver Others Stomach Lung Oesophagus Cervix uteri Breast Ovary

Structure of malignant neoplasms mortality (annual statistics of the NCC, Ulaanbaatar 2001) 45% 17% 14% 10% 9% 3% 1% Liver Stomach Others Lung Oesophagus Cervix uteri Breast Ovary

Cancer stages at diagnosis in Mongolia, 2003 (annual statistics of the NCC, Ulaanbaatar) Localization G Abs % St I abs St II St III St IV Total abs % Esophagus M F 169 161 4.8 4.5 6 33 191 100 330 9.3 Stomach 316 9.0 1 36 263 185 485 13.8 Lung 273 90 7.7 2.6 5 26 206 126 363 10.3 Cervix uteri 278 7.9 40 39 180 19 Others 1128 927 32.1 26.6 1113 718 2055 58.7 1872 1639 53.3 46.7 91 319 1953 1148 3511

Survival of cancer patients after diagnosis in 2003 (annual statistics of the NCC, Ulaanbaatar 2003) Localization G abs % Years of survival Total <1 1-2 3-4 5-10 >10 Esophagus M F 184 146 8.1 6.4 119 162 34 14 1 330 Stomach 391 217 17.3 9.6 196 223 117 70 2 608 Liver 642 435 28.5 19.3 331 502 164 76 4 1077 Lung 246 106 10.9 4.7 91 174 62 23 352 Cervix uteri 1009 44.8 189 218 270 253 79 Others 869 1176 16 21.6 493 831 380 22 102 341 2332 3089 100 1419 2110 1027 458 190 5421

IAEA TC projects which were implemented in Mongolia MON 6/ 006: Upgrading of Radiation Services in Mongolia RAS 6/ 027: QA programme MON/6/011: Development of QA Program in Radiotherapy and improvement of radiotherapy services in Mongolia

Factors affecting Quality of Radiotherapy lack of proper dosimetry system lack of proper therapy procedures, by available therapy units lack of perfect staff performance high patients’ workload, etc., and led to some radiological incidents.

Achievements Basic principles and rules of radiation protection and safety have been carefully evaluated before implementation of the basic QA programme and are now on an acceptable level Basic dosimetric problems connected with the beam calibration were solved and first attempts to introduce basic QA procedures for therapy machines and for treatment procedures were suggested. (IAEA project MON/6/006) Next step was preparation of written QA programme and its partial implementation within the department (IAEA project MON/6/011

QA programme Written protocol of QA program covered following main areas: clinical policies treatment planning and delivery a quality control programme for therapy units and equipment performance maintenance programmes radiation protection and safety aspects investigative procedures for accidental medical exposures etc

Priorities To implement fully developed QA programme in radiotherapy for improvement of radiotherapy services within the department and in the country To introduce new treatment methods and features, like individual patient’s shielding To introduce individual immobilization of patient during the treatment To introduce in vivo dosimetry for improvement of QA of treatments To introduce individual treatment planning for brachytherapy treatments

Actions which have to be done for solving basic problems full implementation of existing QA programme in the radiotherapy and next extension of service in the centre. to strengthen the internal quality audit to apply QA programme on up to date therapy machines to replace a simulator with the modern one to provide the centre with a basic mould room tools for production of an individual shielding and immobilization tools. train the staff

The equipment in the Department of Radiotherapy Manufacturer Supplier Installed Teletherapy unit Co-60 unit – GWGP-80 Nuclear Power Institute of China IAEA 1997 Co-60 unit – AGAT-S Russia Government 1982 Brachytherapy HDR, Co-60, GZP-6 1998 LDR, Cs-137, AMRA CIS biointernational, France C-arm x-ray machine Siemens, Germany 2002

The equipment in the Department of Radiotherapy Manufacturer Supplier Installed For treatment planning Simulator Nuclear Power Institute, China IAEA 1997 TPS- ROCS ROCS, USA For Dosimetry Standard imaging HDR 1000 plus wall chamber USA 1998 Universal dosimetry system UNIDOS PTW, Germany

External beam Radiotherapy Problems: The recommendation of 1 EBRT unit per 500 patients corresponds to the need of a total of 3 machines in the country GWGP-80 was repaired many times by the manufacturer, but there are still many problems which do not satisfy QA program (treatment coach, wedges, timer’s board, emergency button) The radioactivity of the source is too low (1100 Ci) (Jan 2005) Treatment time for one patient is very long and the number of patients which should be treated by RT is limited Radiotherapists work in 2 shifts until late evening

External beam Radiotherapy Problems solved: New Cobalt-60 machine will be in use from Jun 2005, which is sponsored by IAEA TC Project MON/6/011 The old Russian Co-60 machine will be replaced Radiotherapists will work in only one shift, so two radiotherapist could work together on one machine at same time

Brachytherapy Problems: The use of other sources is not suggested due to the difficulty with location and high costs Limited use for only gynaecological and esophageal cases The LDR unit has been used infrequently (5 patients per year) because of insufficient RTTs Radioactivity of the Co-60 source is too low (5.2 Ci in Jan 2005) Automatic afterloading function has been jammed many times Have an only one gynaecological applicator, doesn’t fulfill aseptic, antiseptic requirements

Brachytherapy Improvement From 2002 have started using C-arm mobile x-ray machine by Siemens (provided by IAEA TC project MON/6/011) for controlling the localization of the applicators.

Simulation and treatment planning Simulator had many technical problems (related to the lamp and generator, x-ray tube), has been repaired by the manufacturers not functioning since Nov 2003 because of detector failure new TPS- Theraplan plus hardware by Nucletron has been provided by IAEA TC project MON/6/011 in Feb 2005

Equipment needs in the near future Requirement Existing equipment Needed equipment A. Teletherapy 1. Co-60 machine 3 2 1 B. Brachytherapy 1. HDR 1 problematic 2. LDR - 3. Interstitial treatment C. Treatment planning 1. TPS 2. Simulator 1 not functioning

Equipment needs in the near future Requirement Existing equipment Needed equipment 3. Standard shielding block set 1 - 4. Mould room 5. Immobilization devices Very old and poor D. Dosimetry and radiation protection 1. Ionization chamber and electrometer 2 3 2. Phantom 2-3 3. Surveymeter - New

The future need on staff Requirement Existing at present Needed post A. Rad.oncologist 8 - B. Medical physicist 2-3 1 1-2 C. Radiotherapists 1. Senior RTT responsible for QA and rad.protection 2. Dosimetrist 3. 2 Co-60 EBRT machine 4-6 3 1-3 4. Brachytherapy 5. Simulator 6. Mould room technician D. Maintenance engineer 2 E. Nurse

Training of staffs Some doctors and physicists are trained abroad by the IAEA TC project No internationally certified national experts No special schools for radiotherapy for RTT-s and maintenance engineers RTT-s graduate just 3-6 months course for diagnostic x-ray technicians Mostly On the job training within the department under supervision of experienced staff

Training of staffs Continuing professional education - intradepartmental meetings - conference with major clinical departments - professional long and short term training Special training for new technologies and methods Radiation protection training are organized by the senior physicist and the specialist from Nuclear regulatory authority and confirm adequacy by testing and demonstration once a year

Training of staffs Suggestions Maintenance engineers to be trained in developed countries To invite foreign experts to train and sharing knowledge would be more effective way for RTTs

Thank you for attention.