METHODS
Questions were sent to 141 centers to evaluate the number of devices, technical specifications, date of
manufacture and the number of radiation oncologists, medical physicists, and radiotherapy technicians
by Turkish Medical Physics Association. The responses from the centers were analyzed by region and
compared with the situation in other countries.
RESULTS
The data collected in the study are from December 2019. The rate of radiotherapy devices in Turkey according
to population is estimated to be 3.14 megavoltage (MV) external devices per 1 million people.
The distribution is not homogeneous in all regions. The highest value is 4.59 in the Central Anatolia
region, and the lowest is 0.78 in the Eastern Anatolia region. For each MV device, on average, there are
1.58 specialists in medical physics.
CONCLUSION
Our study has shown that Turkey has made significant progress in terms of radiotherapy equipment and
workforce in the past decade. Nevertheless, although Turkey did not reach the standards of high-income
European countries, it is comparable to middle-income countries.
Keywords: Radiotherapy equipment; Turkey; workforce
Since 1982, the European Organization for Research
and Treatment of Cancer-Radiation Oncology
Group (EORTC-ROG) has launched a quality assurance
program to establish standards for the participation
of member centers in clinical trials involving
radiotherapy and to check the consistency of data. In
1989, EORTC-ROG created a survey and developed it
over the years. Between December 2005 and October
2007, 98 active EORTC-ROG member organizations
from 19 countries completed the report online and
provided survey responses. According to the results
of this study, a total of 197.000 patients (an average
of 2016 patients per center) were treated in 98 centers
per year. The number of patients per radiation oncologist,
radiation physicist, and radiotherapy technician
was 258, 420, and 107, respectively. The average annual
number of patients per treatment device was 488 and
1117 for a CT simulator/classic simulator.[
The project "Radiation Therapy for Cancer" was
launched in 2003 by the European Society for Radiotherapy-
Quantitation of Radiation Therapy Infrastructure
and Staffing (ESTRO). The aim of the project was
to gather information and to provide general guidelines
for infrastructure and personnel across Europe. In this
study, countries were divided into three groups as low
(<$3000), medium ($3000-$10.000), and high (more
than $10,000) according to their annual national income
levels. Survey questions were sent to all countries, and
the responses were evaluated according to the income
groups. Forty-one countries (93.2%), representing 99%
of the European population, responded. The principles
of the linear accelerator and the number of staff were
present in approximately 40% of the countries.[
Today, there is a need for objective data on cost and
cost-effectiveness against ever-increasing maintenance
costs. For this reason, ESTRO launched the Health
Economics in Radiation Oncology (HERO) project to
develop a knowledge base model for health and economic
evaluation of radiation treatments at the European
level.[
Although it is easy to obtain statistical information in
countries with high annual income, for example, Europe,
it is not easy in low- and medium-income countries.
Grover et al.[
The current status of radiotherapy facilities, the diversity
of devices, the number of medical physicists, radiation
oncologists and radiotherapy technicians, and
their comparison with the situation in other countries
are essential for establishing plans for the future. This
study by the Turkish Medical Physics Association aimed
to determine the number of devices in radiotherapy,
their technical characteristics, and the workforce in radiotherapy
as well as to compare the current status of
Turkey with the situation in other countries of the world.
Turkish population is 83.154 million by December
2019. The incidence of cancer will be 3-3.2 per 1000
people, which means that there will be 245.000-265.000
new cancer patients.[
The number of centers (CN), linear accelerators
(LA), TomoTherapy systems (TT), CyberKnife systems
(CK), GammaKnife systems (GK), intraoperative devices
(IORT), brachytherapy devices (BRT), and CT
simulators in Turkey were determined by region. Megavoltage
(MV) devices include LA, TT, CK, and GK, do not include IORT and BRT devices. The number of
MV devices per 1 million population and the number
of 1 MV devices for 450 new patients were determined.
The number of radiation oncologists, medical physicists,
and radiotherapy technicians in radiotherapy
were determined and compared with results from the
international literature.
In radiotherapy, radiation oncologists, medical
physicists, and radiotherapy technicians constitute the
essential workforce; the summary for Turkey is shown
in Table
Table
LA: Number of linear accelerators; TT: Number of TomoTherapy
systems; CK: Number of CyberKnife systems;
GK: Number of GammaKnife systems; BRT: Number of
brachytherapy units.
MV: Megavoltage; RO: Radiation oncologist; MP: Medical
physicist; RTT: Radiotherapy technician.
The first study on radiotherapy equipment and
workforce in Turkey was conducted in 2004 by Seyfettin
Kuter. According to their results, in 2002, the CN
was 50, the number of LA was 40, the number of Co-
60 devices was 48, the number of BRT was 19, and the
number of simulators was 53. Besides, there were 351
radiation oncologists, 98 medical physicists, and 271
radiotherapy technicians.[
Although the number of radiotherapy devices has
increased significantly over the past 8 years, it has only
achieved the criterion recommended by IAEA in Central
Anatolia and the Marmara Region. The numbers for the
other five regions do not meet this criterion and are far
from the average of 6 MV devices per 1 million population
in high-income countries. Istanbul, Ankara, Izmir,
Bursa, Antalya, and Adana are the top six most populous
cities in Turkey by constituting 37% of the population;
there are 5.1, 7.07, 4.12, 4.25, 3.58, and 4.91 MV devices
per 1 million populations, respectively, in these cities.
About 53% of the radiotherapy centers, 62.2% of the LA,
and almost all of the special devices (TT, CK, GK, and
IORT) are located in these cities.
The population is not the only method that determines
the standards for radiotherapy. There is also a method that determines the need considering annual
cancer patients. According to this reference, one MV
device is required for every 200-500 new radiotherapy
patients.[
Accurate determination of the target volumes and
critical structures is the first step for successful radiotherapy.
This is only possible when simulation is performed
with 3D CT. There are 147 CT simulation units
in Turkey. One CT simulator for each center was recommended
by the IAEA and ESTRO guidelines. However,
centers with three or more LAs are recommended
to have two CT simulators. In Turkey, the number of
CT simulators is sufficient. The number of patients
should not exceed 2400 for one CT simulator in a year.
[
In radiotherapy, radiation oncologists, medical
physicists, and radiotherapy technicians are the essential
workforce. While determining the need for radiotherapy devices and the required manpower, there are
different methods determined by taking into account
parameters such as population, number of patients,
and number of fractions.
Radiation Oncologists
Radiotherapy Technicians
Medical Physicists
The Institute of Physics and Engineering in Medicine
published a report in 2002 that made recommendations
to determine the minimum number of medical
physicists in the field of radiotherapy.[
A medical physicist called a health physicist by the
government in Turkey. According to law, a health physicist
is defined as a person who has a master"s degree in
one of the fields of radiotherapy, nuclear medicine, or
radiology after graduation. To become a medical physicist,
he/she is required to have a bachelor"s degree in
physics, a graduate degree in physics engineering and
nuclear energy engineering, and a master"s degree in
health physics. There are many health physics graduate
programs in Turkey. Some of them are in institutions
where there are no radiotherapy centers. These
students graduate by only taking theoretical courses.
Nothing prevents graduate programs from opening
in universities without clinical equipment. Students
who graduate from some programs can thus graduate
without the necessary practical training. In addition, it
is not recommended for a newly graduated person to
start working alone without the necessary experience
with an experienced specialist. EFOMP recommends
that a recently graduated medical physicist should
work with an experienced medical physicist for 5 years.
While trying to reach the required number of occupational
groups in radiotherapy, the quality of vocational
training should not be ignored. Unfortunately, the educational
quality of master"s programs in practical application
is not consistent in Turkey.
The ESTRO-HERO study revealed that the economic
conditions of countries did not affect the number
of radiation oncologists but did affect the number
of medical physicists and radiotherapy technicians.
[
There is one radiation oncologist for every 150-400
radiotherapy patients in the world. The range is very
wide. One radiation oncologist per 250 radiotherapy
patients on average is the accepted criterion.[
There must be a minimum of two radiotherapy technicians
for one device. This number may vary on the
defined workload; it should be considered that the procedures
for some techniques such as IGRT increase the
workload by repetitive steps of patient setups. There
were 600 radiotherapy technicians in Turkey in 2010.
[
In Turkey, the number of medical physicists working in
radiotherapy is 415. EFOMP recommends that a medical
physicist serves 400-750 patients annually and that
an average of 400 patients is eligible. A total of 425-462
medical physicists are needed for 170.000-185.000 new
radiotherapy patients in Turkey. Considering that there
are no assisting occupational groups planning treatment
such as dosimetrists and technologists in Turkey,
this number should be more than recommended. The
recommendation of two medical physicists per linear
accelerator is also widely accepted. In Turkey, the number
of medical physicists per MV devices is 1.58.
Peer-review: Externally peer-reviewed.
Conflict of Interest: All authors declared no conflict of interest.
Ethics Committee Approval: The decision was made in the board of directors of the National Medical Physics Association (No: 269, Date: 08/12/21). No biometric and biological materials belonging to humans and experimental animals were used in the study.
Financial Support: None declared.
Authorship contributions: Concept - H.B.B., S.G., B.Y.; Design - S.G., B.Y.; Supervision - H.B.B., S.G.; Funding - S.G., B.Y.; Materials - None; Data collection and/or processing - A.Ç., F.A.; Data analysis and/or interpretation - K.Y., T.O.G., S.G.; Literature search - F.A., K.Y.; Writing - H.B.B., S.G.; Critical review - H.B.B., S.G.
