1. Radiation Oncology at the Border: Dónde Estamos? Lars Ewell, PhD Assistant Professor, Department of Radiation Oncology, University of Arizona College of Medicine lewell@email.arizona.edu Border Health Viscount Suites Hotel 10/28/05, Tucson AZ

2. Radiation Oncology at the Border: Dondé Estamos? I.Introduction II.Radiation Oncology III.Radiation Oncology en Los Estados Unidos IV.Radiation Oncology en Mexico V.Equipment Costs VI.Accidents VII.Future in Both Countries VIII.Conclusion 2

3. Introduction Goal of radiation therapy is to kill cancerous cells, while sparing normal tissue. Radiation therapy can be either curative, or palliative. In contrast to diagnostic procedures, therapeutic doses are high. 5000 cGy vs 10 cGy (CAT scan). 3

4. Radiation Oncology en Los Estados Unidos In the US in 1995, 41% of the 1,252,050 newly diagnosed cases of cancer were treated with radiation. These radiation treatments relieved suffering and extended the lives of the patients being treated. Along with early diagnosis, radiation treatments contributed to a 1.1% decrease in annual cancer death rates from 1993 through 2002 1. 1) Edwards et al., Journal of the National Cancer Institute, Vol. 97, No. 19, 1407-1427, October 5, 2005 4

5. Radiation Oncology en Los Estados Unidos 2) Radiation in Medicine - A Need for Regulatory Reform, K. Gottfried and G Penn editors, National Academy Press, Washington DC, 1996. 2 5

6. Radiation Oncology en Los Estados Unidos 2 6

7. Radiation Oncology en la Universidad de Arizona Hospital http://www.rad-onc.arizona.edu/ ~ 60 Patients Cada Dia 5 Attending Physicians, 5 Residents 3 (4) Physicists (Físicos Médicos) Dosimetrists, Therapists, Nurses, Administrators 3 machines: Elekta SLi, Siemens S2 and Novalis Brainlab Brachytherapy: Permanent Prostate Seed, Eye Plaque (ocular melanoma), High Dose Radiotherapy (HDR) Pinnacle Treatment Planning System Marconi 5,000 CAT Scan 7

8. Radiation Oncology en Los Estados Unidos: Agencies/Regulations Nuclear Regulatory Commission (NRC): Regulates reactor produced radio-nuclides used in radiotherapy. American Board of Radiology (ABR): Provides board certification for physicians and physicists. Radiological Physics Center (RPC): Provides quality assurance for radiotherapy physics equipment. 8

9. Radiation Oncology en Mexico Comisión Nacional de Seguridad Nuclear y Salvaguardias (CNSNS): Provides for regulation of radiotherapy in Mexico (see http://www.cnsns.gob.mx/index.htm ). Currently, there are 83 facilities licensed by the CNSNS to perform radiotherapy. Closest is perhaps in Hermosillo (none in Nogales). 9

10. United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) report, Appendix D: Medical Radiation Exposure (year 2000). Four different categories for countries depending on how many physicians per population. Mexico – II:  < Mexico < Radiation Oncology en Mexico 10

11. Diagnostic Equipment: –1996, US: 6,800 CAT scanners, 3,500 MRI scanners. –1996, Mexico: 56 CAT scanners, 2 MRI scanners. Radiation Oncology en Mexico Radiotherapy Equipment: –1996, US: 1,893 Linear Accelerators, 504 Co. –1996, Mexico: 24 Linear Accelerators, 92 Co. 11

12. Radiation Oncology en Hospital Oncológico del Estado de Sonora en Hermosillo 2004 2 radio-oncológos, 3 físicos médicos, 6 técnicos en radioterapia, 1 ingeniero en electrónica 2 machines: GE Saturno 41 y Cobalto 60 Theratronics GE VERASIM II Simulator (diagnostic) Braquiterapia: HDR with GammaMed plus 12

13. Radiation Oncology en Hospital Oncológico del Estado de Sonora en Hermosillo 2004: Treatment 127 Tumor Maligno de la Mama 106 Tumor Maligno del Cuello del Útero 48 Tumor Maligno de Bronquios y Pulmón 30 Tumor Maligno del Sistema Nerviso Central y Medula Espinal 29 Tumor Maligno de Prostata 13

14. Radiation Oncology: New Equipment Costs New Varian Clinac 600C: Single 6MV photon energy, no electrons, no MLC - $USD 650,000 New Varian Trilogy: Two photon energies, electrons, MLC (IMRT), OBI - $USD 3,500,000 New MDS Nordion 60 Co basic: 1MV photon energy, no MLC - $USD 400,000 New MDS Nordion 60 Co Equinox: 1MV photon energy, MLC - $USD 900,000 14

15. Radiation Oncology: Used Equipment Costs Varian 600C: Single 6MV photon energy, no MLC - $USD 175,000 Varian 2100C: Two photon energies, electrons - $USD 250,000 CT Scanners: From $USD 75,000 to $500,000+ for multislice systems 15

16. Radiation Oncology: Accidents In April, 2005, it was discovered that 77 patients that had been treated for brain tumors at the H. Lee Moffitt Cancer & Research Institute in Tampa Florida had received ~50% overdose of radiation 3. A physicist had miscalibrated the machine and this resulted in the overdose. Error was caught when the RPC conducted a routine calibration check of the Novalis Brainlab linear accelerator. 3) Hemingway-Johnson, ‘Patients Given Too Much Radiation’, Tampa Tribune, April 2, 2005. 16

17. Radiation Oncology: Accidents In early 2001, it was discovered that a number of patients treated in Panama had been given excessive radiation 4. The Treatment Planning System (TPS), RTP/2 Multidata System Version 2.11, used to calculate the amount of radiation to deliver had a bug in it. Depending on the direction (clockwise or counterclockwise) of contour drawn, the TPS would either account for the block, or not. Error discovered when radiation oncologists noticed an excessive number of cases of diarrhea. 4) ‘Investigation of an Accidental Exposure of Radiotherapy Patients in Panama’, IAEA, August 2001. 17

18. Radiation Oncology: Future Intensity Modulated Radiation Therapy (IMRT) Image Guided Radiation Therapy (IGRT) Adaptive Therapy En Mexico, Mas CAT Scans, Mas MRI scans 18

19. Conclusion By studying border health, there is much to be learned in the field of Radiation Oncology. This will continue to be an important area of study in the years to come. There are substantial benefits to be gained, both north and south of the border. 19

20. Acknowledgment Dr. Jose Benjamin Arroyo Acosta Angela Enciso, Drs. Tom Cetas, Chris Watchman Carlos Caballero 20