1. 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

2. 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

3. NCCM
The reported cancer incidence in Mongolia is about 160 new cases per
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.

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. Thank you for attention.