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Implementing IMRT on Non-MLC machine and eChart in Manual Operation Clinic - A Zambian Experience

2020; Elsevier BV; Volume: 108; Issue: 3 Linguagem: Inglês

10.1016/j.ijrobp.2020.07.2502

1879-355X

Lewis Banda, Ernest Chanda, C. Chintala, Mulape Kanduza, Kennedy Lishimpi, Dorothy Lombe, Susan Msadabwe, Catherine Mwaba, Augustine Mwale, Barbara Chanda M'ule, Phanny Nankonde, A. Sinalume, S Chang,

Advances in Oncology and Radiotherapy

MLC-IMRT and electronic chart are not available at the Cancer Diseases Hospital of Zambia and many RT clinics in Low- and Middle-Income Countries. Tremendous resources and time are needed to bring digital technologies to LMIC on large scale. We report our initial experience of implementing a recyclable compensator-IMRT and eChart by a social enterprise in the US at CDH. We evaluated the feasibility and quality of the US developed solutions in a LMIC clinic setting. CDH has 1 LINAC and 2 cobalt machines, all without MLC. The social enterprise startup and the government of the Republic of Zambia signed a memorandum of understanding to bring the solution to Zambia. The solution includes software (treatment planning software PLUNC and a novel eChart that is designed for manual operation clinics), hardware (milling machine and compensator fabrication materials), service (commissioning and local network setup), and training (software, QA, and procedures). The training includes both weekly remote trainings and two onsite trainings to CDH physicists, radiation oncologists, and RTTs. IMRT commissioning service for Primus Linac is provided by the startup. The training also includes CDH staff teaching each other, a crucial step for CDH to make the solution its own. CDH found two PLUNC features are particularly useful. One is Plan Comparison that allows CDH to compare plans (i.e., a 3D and an IMRT) and make a sensible decision on which plan to use. Other is Plan Robustness Test that calculates the cumulative dosimetry of a n-fraction treatment course. An estimated patient setup uncertainty model that reflects CDH practice is used to compute the Plan Robustness to determine if the IMRT plan is safe to use. Our RTTs found the color-coding approach (each block and compensator pair labeled with a unique color dot) easy to use in daily treatments and the compensator fabrication and QA procedures easy to follow to constantly produce high quality compensators. We have done initial testing of eChart, a new product for clinics that use paper charts. PLUNC users' exports to the eChart treatment prescription, machine parameters of each fields, DRRs of setup and treatment fields, isodose distribution, DVHs, plan goal sheet, and other information. The eChart is not linked to CDH analog treatment machines that we operate manually. The eChart makes it easier for RTT to deliver high quality care to patients. The eChart automatically highlights the field to be treated for RTTs to program the treatment machine, records the actual MU/time delivered provided by RTT, computes the delivered total dose so far, and highlights any deviations. Both eChart and PLUNC run on a server and are available to oncologists, physicists, RTTs via CDH computers. It is feasible to use non-MLC machines to deliver IMRT and evaluate pros and cons of IMRT for each patient in Zambia. Echart benefits patient safety and workflow in manual operation clinics. The training a trainer approach ensures local knowledge retention.