Building medical physics capacity in East Africa to reduce

Building medical physics capacity in East Africa

to reduce radiation toxicities and manage

radiotherapy care for cancer treatment

July 3, 2018

Stephen Avery, Ph.D., FAAPMAssociate Professor of Radiation Oncology

Director, Medical Physics Graduate Program

2

The Evolution of Radiation Therapy

1920’s

The investigation of x-ray radiation for patient therapy moved into the clinical routine in the early 1920s.

1895

As early as 1897, it was concluded that x-rays could be used for therapeutic as well as diagnostic purposes

Marie Curie published the "Theory of Radioactivity."

1911

Wilhelm Conrad Röentgendiscovers x-rays

1890 - Arthur Goodspeedproduced radiograph at UPenn

3


Radioactive cobalt-60 was discovered by Glenn T. Seaborg and John Livingood at the University of California -Berkeley in the late 1930's.

1930’s

1950’s

The cobalt machine was developed in Canada. It was the first available megavoltage cancer therapy machine.

1940’s

Van de Graaff begins commercialProduction of 2 and 2.5 MeV machines

4


High resolution IMRT

Multileaf Collimator

Dynamic MLC

and IMRT

1960’s

1970’s

1980’s1990’s 2000’s

Cerrobend Blocking

Electron Blocking

Blocks were used to reduce the dose to normal tissues

MLC leads to 3D

conformal therapy

which allows the

first dose escalation

trials.

Computerized IMRT

introduced which

allowed escalation of

dose and reduced

compilations

Functional

Imaging

IMRT Evolution

evolves to smaller

and smaller subfields

and high resolution

IMRT along with the

introduction of new

imaging technologies

The First Clinac

Computerized 3D CT

Treatment Planning

Standard Collimator

The clinac reduced complications compared to Co60

5


Beyond 2000’s

Proton Therapy

Photodynamic Therapy

6

Projected Needs in LMICs-2020

Datta et al. IJROBP 2014

7

Projected Needs in LMICs-2020

8

Radiation Therapy … a Key Element

Main methods of cancer treatment

Surgery

49%

WHO 2016

Chemo-therapy

11%

Radiotherapy 40%

9

Projected Staffing Needs

Staff Number to

be trained

Radiation

Oncologists30,000

Medical

Physicists22,000

Radiation

Therapists78,000

September 2015

Additional staff needed

globally in low-to-middle-

income countries by 2035

Minimum education: Graduate degree plus

2-year residency

10

Radiation Machines in Africa

By courtesy of Dr. Surbhi Grover

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16%

84%

Distribution of 293 Radiation Machines in Africa

By courtesy of Dr. Surbhi Grover

12

Global Evolution

13

Building Capacity from Palliative to Curative Cure

Healthcare Infrastructure

IAEA, WHO

Education and Training

Research

Industry

Advocacy

Ministers of Health

Funding Agencies

Academia

14

Multiple Enriching Organizations

>35 RT enriching org’s1

• Professional societies

• Volunteer organizations

• Gov’t Organizations

• NGOs

Coordination is crucial!

• … but how?

Multiple world-wide partnering organizations 1 Van Dyk & Meghzifene, Semin Radiat Oncol 27:124-135; 2017

By courtesy of Jake Van Dyk

15

Building Capacity from Palliative to Curative Cure

Healthcare Infrastructure

IAEA, WHO

Education and Training

Research

Industry

Advocacy

Ministers of Health

Funding Agencies

Academia

16

17

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What to do?

Partnerships and collaborations

• MPs in HICs and LMICs

– Education programs

– Training programs

○ Residency

○ Continuing education

– Joint on the job mentoring support

○ Locally

○ Remotely

– Development of user friendly on-line education and training

materials

19

Factors Impacting Training in LMICs

Local desire in LMICs for MP mobilization

Basic infrastructure allowing MP mobilization

Resources available for MP mobilization

Local individuals

• Seeking MP expertise advancement

Collaboration and partnering

• Through enriching organizations

Clear understanding of local circumstances

• By mentors and collaborating organizations

20

What we hope to accomplish?

Medical Physics

education and training

programs in Tanzania

• Master’s degree program

• Short education courses

Regional Training Hub

21

MUHAS

22

UPenn Medical Physics Program History

2000 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Original Medical

Physics Master’s

program established

Stephen Avery, PhD

becomes Director

Post-Graduate Certificate in

Medical Physics receives

CAMPEP accreditation

Jarod Finlay, PhD

becomes Director

CAMPEP

reaccreditation

approved until 2020

Kate Spillane, PhD

becomes Director of

revised MMP program

First cohort enrolls in revised

MMP program through College

of Gen. Studies (now LPS)

Arts & Sciences approves

expansion and redirection

of MMP program for


MMP program receives


American Board of

Radiology (ABR) new

eligibility rules

Med Phys residency

Match established

Taoran Li, PhD

becomes

Associate Director

Program ends at LPS;

transfer plans created

CAMPEP: Commission on Accreditation of Medical Physics Educational Programs

Stephen Avery, PhD

becomes Director

23

Student & Alumni Success2018 Match Results

(6 of 7 students )

86%

57%

Resident Matching Results

24

Harvard University – Global Health Catalyst Summit

25

Harvard University – Global Health Catalyst Summit

26

The Education Team

Ocean Road Cancer

Institute

• Dr. Julius Mwaiselage

• Dr. Khamza Maunda

Muhimbili University

• Dr. Twalib Ngoma

University of

Pennsylvania

• Stephen Avery, PhD

Harvard University

• Wilfred Ngwa, PhD

27

Clinical Priorities

Updated RAPHEX Exams

28

Course on QA for radiation therapy

29

Survey of faculty/staff in LMICs

30

Grant submission – R21

AIM 1. Develop the practical USA-Africa Radiation Oncology Core

(PROC) through a co-mentored research/training based program in

radiological sciences.

• Establish a research-based MSc. Degree Program in medical physics at MUHAS.

Research co-mentors will include faculty from the USA and Africa. The program will

enhance the ability of trainees to develop, implement and conduct low-cost

radiation medicine technologies.

• Partner with Ocean Road Cancer Institute to create a program, for cervical cancer

patients, which automatically identifies pathologically enlarged lymph nodes on

non-contrast simulation CT images. This program would be used for radiation

treatment planning in low-resource environments where diagnostic imaging isn’t

readily available.

AIM 2. Develop and test a virtual USA-Africa ICT-powered Radiation

Oncology Core (IROC). This ICT-powered core facility/platform will

provide imaging and radiation oncology quality assurance (QA) services

and provide a Radiation Oncology Incident Learning or error reporting

system that is voluntary and confidential.

31

Lesson Learned from funding opportunities

Study Section does not have anyone with a background in

Radiation Oncology.

• Some comments…

– “It is imperative that the PIs demonstrate that the Ocean Road

Cancer Institute has been equipped with Varian linear

accelerators, a CT-simulator as indicated in 2018.”

– “Who are the faculty teaching at MUHAS for the 7 of the 14

courses? This is risky.”

– “It is still unclear how many students and from what countries are

enrolled per year.”

– “The application does not consider a Python platform instead of a

MATLAB platform since the open source aspects of Python may

make the IROC components more expandable.”

No funding opportunities for education programs with a

foreign component (i.e. R25)

Consider Foundation grants• Prospective foundations with a history of investment in east African health include Bill and

Melinda Gates, Rockefeller, Ford, Doris Duke, Carnegie, the Union for International Cancer

Control and the Abbott Fund.

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Code Instructor Course NameTheory/Seminars Practical/Clinical Total

Hours Credits Hours Credits Hours Credits

Semester 1: 28.7 Credits

GA 605 MUHASAnatomy and Physiology for Medical

Physicists132 13.2 300 30.0 432 43.2

ER 600 MUHASEpidemiology, Biostatistics and

Research Methodology57 5.7 15 1.5 72 7.2

GB 605 UPenn/Harvard Radiation Physics 66 6.6 66 6.6 132 13.2

GC 605 MUHAS Medical Imaging Fundamentals 33 3.3 33 3.3 66 6.6

EE 600 MUHAS Bioethics 57 5.7 15 1.5 72 7.2

Total 443 19.7 331 7.2 774 77.4


RB 605 MUHAS Radiobiology 55 3.5 60 1.5 115 5.0

HE 600 MUHAS Education Principles and Practices 40 4.0 60 6.0 100 10.0

GD 605 UPenn/Harvard Radiation Dosimetry and Protection 88 8.8 90 9..0 178 17.8

GE 605 MUHASPhysics of Diagnostic Imaging and

Interventional Radiology 110 11.0 90 9.0 200 20.0

GF 605 UPenn/HarvardPhysics of Radiation Oncology and

Radionuclide Therapy110 11.0 90 9.00 200 20.0

Total 145 14.5 625 62.5 793 79.3


GG 605 ORCI/VARIAN Clinical Training 20 2.0 492 49.2 512 51.2

RR 699 ALLDissertation Module1: Proposal

Writing and Ethical Clearance0 0 225 22.5 225 22.5

Total 20 2.0 717 71.7 772 77.2


GH 605 ORCI/VARIAN Clinical Rotation 0 0 400 40.0 400 40.0

RR 699 ALL

Dissertation Module 2: Data

Collection and Analysis, Dissertation

writing and submission

0 0 325 32.5 325 32.5

Total 0 0 725 72.5 725 72.5

Grand Total 608 36.2 2398 213.7 3064 306.4

MUHAS Curriculum

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Physicists132 13.2 300 30.0 432 43.2






Total 443 19.7 331 7.2 774 77.4









Total 145 14.5 625 62.5 793 79.3





Total 20 2.0 717 71.7 772 77.2



RR 699 ALL




0 0 325 32.5 325 32.5

Total 0 0 725 72.5 725 72.5

Grand Total 608 36.2 2398 213.7 3064 306.4

MUHAS Curriculum

34





Physicists132 13.2 300 30.0 432 43.2






Total 443 19.7 331 7.2 774 77.4









Total 145 14.5 625 62.5 793 79.3





Total 20 2.0 717 71.7 772 77.2



RR 699 ALL




0 0 325 32.5 325 32.5

Total 0 0 725 72.5 725 72.5

Grand Total 608 36.2 2398 213.7 3064 306.4

MUHAS Curriculum

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Projects which benefit LMICs

Courtesy of Laurence Court, MD Anderson

Auto Contouring tools for cervical cancer

AVUS for treat of liver cancerMLC for Co-60 treatments

Courtesy of Chandra Sehgal, UPenn

36

Acoustic Imaging/Range Finding Techniques

Ultrasound:

Transmit sound then receive reflections

Thermoacoustics/Photoacoustics:

Transmit electromagnetic radiation, then

receive generated acoustic signal

+++

Protoacoustics/Ionoacoustics:

Irradiate with protons, then receive

generated acoustic signal

Transducer

37

History of proton acoustics

1980 1990 2000 2010

Harvard

Brookhaven

ITEP ITEP

Uppsala

Tsukuba, JapanLMU (Munich)

Stanford (sim.)

Indiana (sim.)

Penn

Oregon

Medical Physics

Physics

Sulak et al. Nucl. Instr. Meth. 161 (1979) 203-217 Hayakawa et al. Rad. Onc. Invest. 3 (1995) 42-45

Assmann et al. Med. Phys. 42 (2015) 567-574

1957

predicted

Turkey(sim)

UW

38

Physics of protoacoustics

Phantom

Hydrophone

2

2

0 0

( ) ( ), ( )* ' ' ' sin

4 '

s

p

c E z E sp t E t d d

C t

r r r

r r

t1*c

t2*c

1. K C Jones A Witztum, C M Sehgal and S Avery, Phys. Med. Biol. 59 (2014)

2. Xu M and Wang L, Rev. Sci. Instrum. (2006)

39

Effects of pulse width

40

Detector comparison

41

A. Tobias, Non-destructive testing, 1976

Source localization-Triangulation technique

In an isotropic plate

Acoustic

source

Sensor#1

Sensor#2

Sensor#n

Triangulation

algorithm

OU

TP

UT

t1

t2

tn

Source

Sensor 1 Sensor 2Sensor 3

42

12

3

4

5

Accelerometer

Source localization-Triangulation technique

43

Proton radiation therapy room with Vibrometer

44

Examples of Thermoacoustic Techniques

Patch et al., PMB 60 (2015) 689-708

Thermoacoustic CT

•imaging of excised human prostate

•1.4 MHz

X-ray Acoustic CT

•imaging of lead bar in chicken breast

•10 MV medical linear accelerator

Xiang et al., Med Phys 40 (2013) 010701

Photoacoustic Imaging

•in vivo imaging of mouse melanoma

•584 and 764 nm laser

Zhang et al., Nature Biotech 26 (2006) 848-851

45

Prompt Gamma Spectra Measurement

46

Prompt Gamma Spectra from Tissue

47

Compton scatter camera

“Polaris” – CdZnTe Compton camera system Zhong He et al, University of Michigan

Passive scattering

proton beam nozzle MDACCLogical 3-stage CC simulated

using Geant4Permission from Dennis Mackin (MDACC)

48

SOE 2-D proton pencil beam

Dose and gamma origins from Monte Carlo

49

Slide courtesy of

Holger Wirtz

50

GEANT4 Monte Carlo

51

Radiation Oncology / Physics Collaboration

Physics Department Detector G

Detector/electronics design &

signal

processing in Physics

Department

Detectors fabricated at CERN

Medical Physics Divison

Radiation Oncology Department

Proton Beam in PCAM

Monte Carlo simulation with

GEANT4

52

Lessons Learned

Can be done in less time

Do not be too rigid on timelines

Limit scope of projects

Physical presence has more impact

then distance learning

Build and maintain trust

Regular Communication

53

Keys to Success

1. Work with an existing relationship

2. Develop MOU early

3. Establish government recognition of Medical

Physics profession

4. System designed around regional needs with

regional expertise

5. Publish results

6. Funding Opportunities for Global Health

education

54

Quote

“The delicate balance of mentoring

someone is not creating them in your

own image, but giving them the

opportunity to create themselves.”

Steven Spielberg

55

Thank you for the invitation!!

Documents

Building medical physics capacity in East Africa to reduce