Bridge over troubled water: The experience of Turkey to access … · 2018-05-07 · Bridge over troubled water: The experience of Turkey in providing high-quality nationwide radiotherapy

Bridge over troubled water: The experience of Turkey in providing

high-quality nationwide radiotherapy service

Yavuz ANACAK

Access to high quality care: challenges and possible solutions SESSION 13A

Ege University School of Medicine Izmir - Turkey

Turkey: Main indicators of an upper-middle income country

History of Radiotherapy in Turkey

• The medical use of radiation arrived to Turkish soil very early • 1897: One year after the Roentgen’s discovery locally

produced x-ray tubes were used for diagnostic purposes in Medical School of Istanbul

• 1897: Earliest use of x-rays to detect bullets and schrapnels in war wounds

Nevsali Afiyet, page 226, 1897


• 1898 – the first radiology book in Turkish was published

Röntgen Şu’â’âtı ve Tatbikat-ı Tıbbiye ve Cerrahiyesi, 76 pages, 1898


• Turkey is among the first countries in the World having a radiotherapy service!

• Prof.Cemil Topuzlu published his experience with radiotherapy on 30 patients in 1 January 1904 at Gazette Medicale d'Orient

History of Radiotherapy in Turkey • 1923 - Republic of Turkey • 1930s - The rise of Nazism, German intellectuals and scientists

seek refuge in Turkey • 1933 - University reform

Paul Hindemith Carl Ebert Rudolf Belling

Clemens Holzmeister

Ernst Reuter

Alexander Rüstow

Einstein letter to Ataturk

Prof.Friedrich Dessauer in Turkey 1934 -1937

• Prof. Dessauer was a physicist, a philosopher, a socially engaged entrepreneur, a journalist and a member of the parliament. He was imprisoned by the Nazis when they came to power for his opposition to Hitler.

• He was released at request of the Turkish government, who invited him to the University of Istanbul, where he was made chair of the Radiology Institute.

• Dessauer is the father of the «Modern Radiotherapy» in Turkey

Çapa Institute of Radiology and Biophysics Today’s «Istanbul University Oncology Institute»

• The institute became one of the leading cancer institutes worldwide, where new equipment used and new techniques were developed, such as rotational chair technique for TBI

1930-1995 • Very few improvements until

1990s • Radiotherapy was limited to 6-

7 major towns • Only cobalts, 1-2 linacs, 2-3

brachy systems • Less than 30 radiation

oncologists, less than 20 physicists

• No standartization for education, training and practice

Radiation Oncology in Turkey 1930-2017 Period of stagnation followed by booming

1995-2017 • Open-economy • Booming of radiation oncology • Public and private investments • Radiotherapy departments in

almost all cities • Modern linacs replaced

cobalts completely • İncrease in the number of staff • Projects on standartization of

education, training and practice

• National cancer control plan • Turkish Society for Radiation

Oncology

Public university

Private centers & universities Min.of Health

135 radiotherapy centres in 40 towns More centers in planning & construction

Radiation Oncology in Turkey in 21st Century Radiotherapy Centers

Radiation Oncology in Turkey in 21st Century Teletherapy Machines

• Heterogenous distribution throughout the country

• 54 centers operate with single machine

• Fragmentation of the services

• High-tech machines with inadequate staffing

• Replacement of the aging machines is a problem

• Maintenance quality is not good

Goksel F et al. Asian Pacific Journal of Cancer Prevention, Vol 12, 2011

Radiation Oncology in Turkey in 21st Century Radiation Oncology Manpower

148.000 new cancers/year 90.000 needs radiotherapy

IAEA guidelines for infrastructure and manpower

Lievens Y et al. Radiotherapy staffing in the European countries: Final results from the ESTRO-HERO survey. RadiotherOncol (2014),

Radiation Oncology in Turkey in 21st Century Radiation Oncology Manpower

Radiation Oncology in Turkey in 21st Century Projection to 2023 (Centennial of the Republic)

2023 Population 82.000.000 Population +45 27.800.000 – 33,8% Cancer incidence (1.000) 3-3,2 New cancers/year 245.000-265.000 Need for radiotherapy 170.000-185.000

From the report: Restructuring the Oncology Services in Turkey 2010-2023

Staffing needs in 2023 • RO: 850-925 • MP: 425-462

350 – 400 radiation oncologists and 200-250 medical physicists should be trained until 2023

Radiation Oncology in Turkey in 21st Century Aproaching shortage of radiation oncologists

More than 100 radiation oncologists will retire in 10 years!

Radiation Oncology in Turkey in 21st Century Radiation Oncology Training

• Radiation oncologist • 5 year training in university centers • Core curriculum is prepared, but not officially endorsed yet • Quality is variable among centers

• Medical physicist • 2 years MSc degree is required - B.Sc degree is prerequisite • No core curriculum yet • Quality is variable among centers

• RTT • 2 year associate’s degree – no further training available • No core curriculum • Quality is variable among centers

• 800 members • Radiation Oncology core

curriculum • V.2.0. updated June 2013

• Resident’s log-book • Courses • National Congress • Educational grants • Board certification

Competence triangle of TUKMOS based on 7 main fields of competence

Radiation Oncology in Turkey in 21st Century Turkish Radiation Oncology Society (TROD)

Training Courses • 6 week-end and 3 pre-congress

courses in 2017 • Hands on e-contouring-ASTRO • Basic Radiation Physics • Radioimmunotherapy • Clinical Radiobiology • Treatment Planning & Plan

Evaluation • Lung cancer

• Post-ASTRO meeting


National Radiation Oncology Congress • Every second year

• 13th UROK will be in 2018 • 3 pre-congress courses • 10 teaching sessions • Panels & sessions on education and

training

• National Cancer Congress in-between • TROD is a partner together with medical

oncology and pediatric oncology


• Annually • 1 year eduation abroad for 3 young members (15.000 euro/each) • 3 months eduation abroad for 4 young members (3.750 euro/each) • 20-25 grants for ESTRO courses


Proficiency exams • What do we evaluate?

• Competence which yields on • Cognitive domain

(How?)Exam blueprint, web based question bank, 100 MCQs, quality review, Nedelsky standard setting

• Skills / attidute domain (How?)Exam blueprint, question templates, 10 stations OSCE (150 mins), Modified Angoff standard setting (expert consensus on minimum acceptable level for each station)


Practical Exam Objective Structured Clinical Examination-OSCE


•15 minutes duration for each station

Radiation Oncology in Turkey in 21st Century Objective Structured Clinical Examination-OSCE

Starting… nervous moments… Critical reading an article…


Room for patient communication… Outside…


Big brother is listening… And watching you…


From one station… To another…


Contouring… Plan evaluation…


Teachers smiling… 2.5 hours passes quickly…


It’s over… everybody seems relaxed…


Candidates discuss the exam with teachers…


Teachers evaluate…


Happy end …. Not for everybody


Results

• Athough Turkey has a long history of radiotherapy, services still has the problems common to middle-income countries • Problems in manpower - availability and training

• Problems in countrywide distribution of infrastructure

• Infrastructure and quality of radiotherapy is improving

• Guidelines and minimum requirements for manpower and infrastructures should be prepared

• Training should be standartised

• TROD is a major player especially in training

• Planning of future is required – current national cncer control plan of the MoH needs revision

Conclusions

Thank you for your attention!

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Bridge over troubled water: The experience of Turkey to access … · 2018-05-07 · Bridge over troubled water: The experience of Turkey in providing high-quality nationwide radiotherapy