Abstract:
Aim: To assess helical tomotherapy (TOMO) current clinical application and practice in mainland China. Materials and methods: Data were collected for all TOMO units clinically operational in mainland China by 30 April 2016, including (a) the distribution of installation and staffing levels; (b) types of cancers treated; (c) utilisation efficiency; (d) quality assurance; (e) maintenance; (f) optional features; and (g) satisfaction levels. The data were collected as a census and analysed qualitatively and quantitatively. Results: As of 30 April 2016, 23 TOMO units were used clinically by 22 hospitals in mainland China. In the same period, 22,558 cancer patients were treated. For TOMO units with more than a year of clinical utilisation, a median of 378 cases were treated annually per machine. The median daily operation was 10·5 hours, and treatment headcount was 38·3 patients. The median service outage rate was 2·6%, and the most common cause was malfunction of the multi-leaf collimator. In terms of overall satisfaction levels, 3 hospitals were very satisfied, 16 were satisfied and 3 considered their satisfaction level as average. Findings: The overall operation of TOMO is good, but there are some problems due to running at full capacity, lack of clinical efficacy research and insufficient quality assurance regulations. Introduction Helical tomotherapy (TOMO; Accuray Incorporated, Sunnyvale, CA, USA)1,2 is a relatively new modality with integrated treatment planning and delivery hardware for radiation therapy treatments.3 The TOMOdelivery system consists of a 6-MV linear acceleratormounted on a computed tomography (CT)-like ring gantry. Therapeutic radiation is delivered using a rotating fan beam that is modulated by a multi-leaf collimator (MLC) system while the patient moves through the gantry in the longitudinal direction.4 The therapy combines intensity-modulated radiation therapy treatment delivery and megavoltage CT (MVCT) imaging capabilities to integrate the treatment planning, patient set-up and treatment process. TOMO’s clinical application is extensive; not only can it treat head and neck (HN) tumours with anatomical complexity5 and chest– abdomen tumours6,7 with proximity to vital organs at risk (OARs), but it can also be used to treat brainmetastases,8 craniospinal tumours,9 central nervous system tumours10 andmultiple tumours in different locations of the body. TOMO was first introduced in mainland China in 2007. Information on its long-term clinical application is therefore somewhat incomplete. Moreover, there is a shortage of surveys of TOMO’s current application status both domestically and abroad. Here, we report the results of a survey examining the utilisation and management of TOMO clinical programmes in mainland China and the level of user satisfaction with the technology. Our aim was ultimately to promote radiation treatment capabilities and developments in China, overall. Methods The survey examined hospitals in mainland China that commenced treatments with TOMO before 30 April 2016. The survey covered China’s 31 provinces, municipalities and autonomous regions. Hong Kong, Macau and Taiwan were excluded. The survey stages were as follows: (1) initial planning of the survey’s content; (2) finalization of the content based on discussions with experts in hospitals equipped with TOMO, including the distribution of installation and staffing levels, types of cancers treated, utilisation efficiency, quality assurance, maintenance, optional features and satisfaction levels; (3) sending the survey questionnaires to each hospital by e-mail, where designated staff members completed and https://doi.org/10.1017/S1460396919000062 Downloaded from https://www.cambridge.org/core. IP address: 54.70.40.11, on 24 Jan 2020 at 06:07:34, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. returned the surveys; (4) examining, cross-checking, normalising and standardising the data, as well as establishing a database; and (5) collecting the data through a census and analysing the data qualitatively and quantitatively. Results Distribution of installation and staffing levels From the first TOMO installation in September 2007 to date, 22 hospitals in mainland China have installed 23 TOMO units for clinical application. Figure 1 presents the cumulative numbers of TOMO units installed by year. After the first introduction in 2007, no additional TOMO units were introduced until 2011. Since then, several new installations have occurred each year, with a peak of seven installations in 2015. At the end of 2015, there were a total of 1,931 linear accelerators that conducted radiation therapy in mainland China,11 which puts TOMO’s percentage at 1·2%. Table 1 displays basic information on the TOMOunits installed in mainland China, including geographical location, the category and function of the corresponding hospital, the number andmodel of the equipment, and the start date of the clinical application. All of the TOMO units are distributed to top-level hospitals. In terms of hospital function, 13 are installed in polyclinics (including eight in military hospitals), and 10 are installed in oncology-specialised hospitals. Sixteen TOMO units have been in clinical use for more than a year by 30 April 2016. Regarding geographical distribution, these units are located in Beijing, Shanghai, Guangdong, Jiangsu, Hubei, Zhejiang, Liaoning, Shandong, Sichuan, Hunan, Fujian, Yunnan and Henan. Figure 2 displays the geographical distribution and the corresponding quantity across mainland China. Notably, there are six units installed in Beijing, accounting for 26·1% of all installations in the country. The 534 employees associated with TOMO units in mainland China consist of 172 radiation oncologists (including 61 senior staff), 57 medical physicists (including 7 senior staff), 128 therapists, 167 nurses and 10 engineers. Previous work reported that at the end of 2015, there were 52,496 employees and staff members Figure 1. Cumulative installations of TOMO in mainland China by year. Table 1. Basic information on TOMO units installed in mainland China Serial number Locations, province/city Types of hospital Model/number Starting date of clinical application 1 Beijing Polyclinic Hi Art/1 Sep. 2007 2 Yunnan/Kunming Polyclinic Hi Art/1 Feb. 2011 3 Shanghai Polyclinic Hi Art/1 Jun. 2011 4 Guangdong/Guangzhou Polyclinic Hi Art/1 Jul. 2011 5 Beijing Polyclinic Hi Art/1 Oct. 2011 6 Liaoning/Shenyang Polyclinic Hi Art/1 Nov. 2011 7 Jiangsu/Nanjing Polyclinic Hi Art/1 Jan. 2012 8 Beijing Polyclinic Hi Art/1 May 2012 9 Beijing Polyclinic Hi Art/1 Aug. 2012 10 Sichuan/Chengdu Oncology-specialised Hi Art/1 Aug. 2013 11 Beijing Oncology-specialised Hi Art/1 Nov. 2013 12 Sichuan/Chengdu Polyclinic Hi Art/1 Jun. 2014 13 Shandong/Jinan Oncology-specialised Hi Art/1 Sep. 2014 14 Guangdong/Guangzhou Oncology-specialised Hi Art/1 Oct. 2014 15 Jiangsu/Nanjing Polyclinic Hi Art/1 Mar. 2015 16 Zhejiang/Hangzhou Oncology-specialised Hi Art/1 May 2015 17 Beijing Polyclinic HD/1 Aug. 2015 18 Hubei/Wuhan Polyclinic HD/1 Oct. 2015 19 Liaoning/Shenyang Oncology-specialised HD/1 Nov. 2015 20 Henan/Anyang Oncology-specialised HD/1 Nov. 2015 21 Hunan/Changsha Oncology-specialised HD/1 Dec. 2015 22 Fujian/Fuzhou Oncology-specialised HD/1 Jan. 2016 23 Yunnan/Kunming Oncology-specialised HD/1 Arp. 2016 376 Zhiqiang Liu et al. https://doi.org/10.1017/S1460396919000062 Downloaded from https://www.cambridge.org/core. IP address: 54.70.40.11, on 24 Jan 2020 at 06:07:34, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. associated with radiation therapy in mainland China, including 15,841 radiation oncologists (4,824 senior staff), 3,294 medical physicists (562 senior staff), 8,454 therapists, 23,152 nurses and 938 engineers.11 TOMO staffing levels accounted for only 1·0% of these employees, corresponding to TOMO’s percentage of all radiation therapy equipment. The ratio of radiation oncologists to medical physicists among TOMO staffing levels in mainland China is 3:1, which surpasses the 4·8:1 at national level reported in the previous work,11 but remains lower than the United States ratio of 1·2:1.12–15 (Note: medical physicists in mainland China include dosimetrists and physicists, while in the United States, only physicists). Hence, it can be concluded that medical physicists are in high demand in mainland China, compared with the situation in developed countries. Types of cancers treated A total of 22,558 cancer patients by 30 April 2016 have received TOMO treatment in mainland China, including 18,186 primary tumour cases and 4,372 metastatic tumour cases. The top three primary tumour types treated with TOMO are nasopharyngeal carcinoma (19·2%), pulmonary cancer (16·0%) and other HN cancers (15·2%), together accounting for 50·4% of all primary tumour cases. The top three metastatic tumour types treated with TOMO are brain metastases (28·4%), lung metastases (17·5%) and liver metastases (10·5%), together making up 56·4% of all metastatic tumour cases (as illustrated in Figure 3). TOMO treatment covers a wide range of tumours and primarily focuses on complex tumours such as HN cancer and regular cases of pulmonary cancer. Utilisation efficiency Table 2 presents the average number of patients treated per year, the average hours of effective operation per day, the average treated patient headcount per day and the average treatment time per person. For TOMO units with over a year of clinical use, the average number of annual treatments is in the range of 365 ± 114 (median = 378, minimum = 162, maximum = 534); average daily operation time is within the range of 9·9 ± 2·6 (median = 10·5, minimum = 5·5, maximum = 14·0), average daily treatment headcount is within the range of 37·4 ± 10·2 (median = 38·3, minimum = 20·0, maximum = 50·0) and average treatment time per person is within the range of
