History of Radiotherapy & Infrastructure in India

History & Infrastructure of RT in
India
Dr.Rakesh Jadhav
• Radiation Oncology is the branch of medicine
that uses various types of radiation to treat
and control cancer.
• The foundation of radiation oncology is based
on the interaction between matter and
energy.
Beginning with the discovery of
x-rays
by Wilhelm Roentgen in 1895.
1896
“Henry Becquerel, a French physicist accidently

discovered radioactivity. Uranium caused black spot on
photographic film”
Courtesy- Dr.S.K.Shrivastava
1898
“The various reasons we have just enumerated lead us
to believe that the new radioactive substance contains a
new element to which we propose
to give the name of RADIUM”
…was announced by Marie and Pierre Curie at the

meeting of the Academy of Science in Paris on December 26, 1898.
It took another 45 months, however, before the Curies were able to prepare
a tiny amount of pure radium and determine its atomic weight to be 226.
India
• In India, use of X ray in the treatment of various
diseases including cancer started in the 192Os.
• Radiotherapy in the beginning of 194Os, with 60-and

lOO KV X rays used by radiologists who were practicing
the combined specialty.
• Establishment of at least four radium institutes in the four
corners of the country as early as the beginning of the
1940s.
1. The radium institutes in Patna.
2. The radium institutes in Agra.
3. The Bernard Institute of Radiology in Madras.
4. Medical college of Lahore (now in Pakistan)
• Main centers providing radiation treatment for benign
and malignant diseases and were developed inside the
medical college hospitals.
Int. J. Radiation Oncology Eiol. Phys.. Vol. 36. WI. 4. pp. 945-947, 1996.
• Dr. K. M. Rai (Madras), Dr. P. K.Haldar (Agra), Dr.
J. P. Sinha (Patna), and Dr. M. L. Aggarwal
(Amritsar) were specially trained in the handling of
radium and use of x-ray therapy in the United
Kingdom.
• Upon their return from UK they developed the clinical
practice of radiotherapy in India.
• A few personnel trained exclusively in radiotherapy
joined the Indian scene. The first among them were
Dr. Siddiqui and Dr. A. D. Singh, who were trained
in England and were awarded the Fellowship of the
then Faculty of Radiologists (now known as the
Royal College of Radiologists, London).
• Dr. Siddiqui joined the Bernard Institute of Radiology
at Madras.
• Dr. Soloman Padam Singh at Vellore, Dr. A. D.
Singh at Chandigarh, and Dr. Urmil Sharma in Delhi
during early 1960s.
• They strengthened the radiotherapy facilities in
combined departments of radiotherapy with 250-KV
machines.
• Dr. Saroj Gupta (Calcutta), Dr. B. D. Gupta (Delhi),
and Dr. M. Krishnan Nair (Trivandrum) returned to
India after receiving exclusive training in radiotherapy
in the middle and latter part of 1960s with the
degrees of Fellow of the Faculty of Radiologists,
London.
• This group of trained personnel started independent
disciplines (as far as functioning of radiotherapy is
concerned) in the four coners of India and gave
radiotherapy a new direction.
• They have contributed immensely to modern
radiotherapy as a clinical discipline.
• The trend continued with the addition of more
specialists. Notable among them are Dr. K. A.
Dinshaw and Dr. Arvind Kulkami, who subsequently
developed full-fledged departments in their hospitals
as independent disciplines.
• In 1970s Medical degree exclusively in radiotherapy
was started in three institutions in the country,
namely, the PGI,Chandigarh; the AlIMS, New Delhi;
and the Medical College, Trivandrum.
• This was indeed a definite step forward, and was the
fruition of efforts by Prof. B. D. Gupta at Chandigarh
and Prof. M. Krishnan Nair at Trivandrum.
• The efforts of Dr. Urmil Sharma of the AIIMS, New
Delhi, and Dr. K. A. Dinshaw at the Tata Memorial
Hospital, Mumbai, are equally important contributions
to the clinical practice and progress of radiotherapy
in India.
• The first medical degree in radiotherapy graduated
from the Postgraduate Medical Institute, Chandigarh,
in 1972.
Photograph of Sieman's Stabilapan.
orthovoltage therapy, or
deep therapy machine.
• The evolution of radiotherapy in India has mostly
followed the western pattern in general, since we are still
depending on the imported machines.
• In the early 50's only deep X-ray units operating in the

200 - 400 kV range were available for teletherapy; the
quality and the depth dose of these units were very poor.
• The radiotherapy facilities in all the institutions,
especially in the radium institutes, were provided by
60 KV. - 100 KV.
• Later on, deep x-ray therapy units and radium,
specially procured by these institutions with grants
from private sources, thus marking the beginning of
the new era in brachytherapy.
• These radium institutes were under the direct
supervision and in charge of the professor and head
of the department of radiology.
This is a commercial model of the
cobalt-60
cancer therapy unit designed by Harold
Johns.
Made by Atomic Energy of Canada, Ltd.,
Ottawa, Ontario, Canada
Canada Science and Technology Museum
First used to treat a patient on 8 November

1951.
Photograph of
137
Cs unit with Lucite cone attached.
A CAESIUM 137 TELETHERAPY UNIT FOR USE AT

A SOURCE-TO-
SKIN DISTANCE OF 35 CM
By H. E. JOHNS et ai. University of Toronto, Canada
• The first cobalt-60 teletherapy unit (Eldorado A) was commissioned
at the Cancer Institute, Chennai-600 020 in 1956.
• One of the first isotope teletherapy units was a Theratron Junior

installed in the Tata Memorial Hospital, Bombay, in 1958.
• By 1965, 19 institutions possessed either cobalt or caesium

teletherapy units.
• 10 years later this number had grown to 49 centres.
• By 1978, 57 departments had telegamma units and another 6

centres awaited their first cobalt machines representing a total of 63
departments in all.
J Cancer Res Ther - March 2005 - Volume 1 - Issue 1

• Of 44 stationary units, 10 used caesium sources and 34 used
cobalt.
• Of the latter, 17 were Eldorado units (mainly gifted under the

Colombo plan) and 17 were double-headed Janus units
(manufactured in India) with fixed vertical beams.
• The majority of the 50 rotational units were Theratron 60’s or

Gammatrons, although a new rotational cobalt unit was being
manufactured by Elpro International at Pune.
• Most of the stationary units had been installed since 1970.

• 66 radiotherapy departments with megavoltage
equipment were located in 52 towns and cities.
• Total of 96 teletherapy units served India’s needs,

roughly one machine per six million population.
• It was noticeable that the south of India (Kerala and

Tamil Nadu) and the northern states (Uttar
Pradesh,Haryana including Delhi and Punjab) were
served by 26 radiotherapy departments and a total of 38
machines.

• These five states covered 17% of India’s land surface
was served by 40% of radiotherapy departments and
40% of the machines.
• In the other regions, the four central states of the Deccan
(Madhya Pradesh, Maharashtra, Orissa and Andhra
Pradesh) had a combined population of 160 million.
Twenty radiotherapy departments, with a total of 27
telegamma units, were situated in 15 towns and cities.
• In this region 26% of India’s population was served by
30% of the radiotherapy centres and 30% of the
teletherapy resources.

• Cancer Institute, Chennai developed first telecaesium unit in
collaboration with Atomic Energy Establishment, Trombay (AEET) in
1962.
• The International General Electric Company developed a cobalt-60
teletherapy unit (Gammarex) in 1970's.
• Cancer Institute made another attempt in the 1990's to develop a
cobalt unit but had to be discontinued due to lack of financial
support.
http://mohfw.nic.in/WriteReadData/l892s/pg80to86-85846667.pdf
• Despite recognition of radiotherapy as a separate clinical
speciality by the Indian Medical Council as long ago as
1972, the emergence of independent radiotherapy
departments was slow, partly because insufficient funds
were available for creating new specialist posts.
• The Indian Radiological Association had 1500 members
of which 150 were involved in radiotherapy either full-
time or combined with diagnostic duties.
• In 1977- Association of Radiation Oncologists of India
• (AROI) was established.

• Most universities still offered a combined M.D. to their
post-graduates although the move to separate the two
courses was gathering momentum.
• Each year, 10-15 post-graduates qualified with an M.D.
in radiotherapy and a much larger group qualified with a
combined therapy/diagnosis M.D.

• The development of medical physics in India began in
the late 1950’s, following the launching of the atomic
energy programme.
• It became clear that the implementation of the
countrywide radiation safety programme was impossible
without properly trained staff in hospitals using ionising
radiations.
• In 1962 the Division of Radiological Protections, Bhabha
Atomic Research Centre (B.A.R.C),Bombay, with the
support of the WHO, established a one-year post-
graduate diploma course in radiological physics
recognised by the university of Bombay.

• Fifteen candidates were accepted each year and up to
the beginning of 1976, 212 trainees had completed this
course under W.H.O., I.A.E.A. or Colombo plan aided
schemes.
• The number of hospitals having medical physicists at the
beginning of 1975 was 42.
• The total number of medical physicists working in
radiotherapy departments was 64, a likely
underestimate.

• The Association of Medical Physicists in India formed in
1976 had a membership of 194, including 68 working at
B.A.R.C. and 20 working abroad. The remaining 106
members were mostly hospital physicists and members
of the newly founded Indian Academy of Medical
Physicists.
• The scarcity of trained radiographers was an obvious
weakness of Indian radiotherapy at that time.
• There were training schemes offered at around 10
centres in India, comprising a blend of academic course
work and practical apprenticeship.

• Estimate based on one radiographer and one X-ray
assistant for each machine gives a total of approximately
200 individuals.

Linear Accelerators (“Linacs")
• The history of particle accelerators for ion beams is often
described in association with the development of
cyclotrons, primarily due to their wide-spread use in the
medical field.
• Ion linear accelerators ("linacs") were developed in
parallel with the cyclotron and other circular accelerators.
• While Lawrence and Livingston designed the first small
cyclotron in 1930.
• R. Wideröe had already published a paper in 1928 on his
results from an rf powered linear accelerator.
LINAC-3
ADVANCES IN MEDICAL LINEAR ACCELERATOR TECHNOLOGY
LINAC-3
• In mid 1950’s Linear Accelerators now popularly known
as LINAC’s are evolved with the earlier advent of
microwave power tube such as Klystron developed
during the Second World War.
• These linacs were in the range of 4 – 8 MeV.
• In 1952 , microwave electron based linear accelerators

which have made possible modern radiotherapy
treatment of tumors with mega voltage x rays.
LINAC-3
• The first one was at
HAMMERSMITH
HOSPITAL,
operational with 8MV
built by metropolitan
Vickers.
• In 1953 the first
medical linear
accelerator (Linac)
treated its first
patient, in London.
LINAC-3
• In 1956 Henry Kaplan
utilized the linear
accelerator used by the
physicists of Stanford, a
fighting tool against
cancer. 2 year old boy with
a retinoblastoma.
LINAC-3
• In 1960 the first 360 degree isocentric Linac was
developed at Varian and transported to UCLA.
• In 1972, Fessender explored how to create linear

accelerator that delivered their punch to tumour cells
through two types of radiation.
• Working with the Varian Medical Systems Inc of Palo

Alto, his group helped the first machine that combined
both x-rays and electron treatment.
LINAC-3
First commercial 360º
isocentric
accelerator : the Varian
Clinac 6 (ca 1960)
LINAC-3
Linear Accelerators History India
• First linear accelerator was installed at the Cancer
Institute, Chennai-20 in 1976.
• Jivan-Jyoti Linear accelerator developed by PGI
Chandigarh in around1992.
• High end machines

• Tomotherapy- 3
• Cyberknife – 2
• Protons – To be install at
1. ACTREC, Navi Mumbai.
2. New Delhi
• The Tata Memorial Hospital inaugurated on February
28, 1941
• Initially commissioned by the Sir Dorabji Tata Trust.
• The Indian government’s ministry of health took over the
Tata Memorial Hospital in 1957.
• In 1962 the administrative control of Tata Memorial
Centre (Tata Memorial Hospital and the Cancer
Research Institute) was handed over to the department
of atomic energy.
• The Tata Memorial Hospital and Cancer Research
Institute merged as the two arms of the Tata Memorial
Centre (TMC) in 1966
43
EVOLUTION OF TELETHERAPY AT THE TATA MEMORIAL HOSPITAL
1941 Deep X-ray Therapy 200kV (2)
1959 Telecocalt (Theratron Junior)
1963 Deep X-ray Therapy 300kV
1965 Telecobalt (Theratron-60)
1972 Telecobalt (Janus), Telecaesium (Gammatron)

1979 Telecobalt (Gammerex-R)
1980 Linear Accelerator- (Mevatron-12)
1981 TPS (TP-11-AECL),; Mould room facility
1982 Linear Accelerator (Clinac-6/100) ; Simulator (Therasim-780 AECL)
1984 TPS (Somados)
1985 Telecobalt (Alcyon & Theratron-780)
1987 Telecobalt (Theratron-780C)
1990 Simulator – C-Arm
1994 Linear Accelerator (Clinac-2100C Dual Energy)

1997 TMS (Helax)
1998 Simulator (Ximatron)
1999 Linear Accelerator (2100CD), TPS (Cadplan), Body Frame
2000 Telecobalt (Elite-80); mMLC (BrainLab); Networking R&V (Varis)
2002 Linear Accelerator (Clinac-6EX)); CT-Sim. & VS (Emotion); Dosimetry (Blue Phantom,
Film, Brain Scan)
2005 TPS (Eclipse); in vivo multi-channel Real Time Dosimetry; TLD dosimeter
44
2006 Telecobalt (Equinox); PET based planning (Advantage Sim)
Sr. No. Type/ Equipment Models Year of commissioning
Tomotherapy 2009
Trilogy 2009
1 Linear Accelerator Clinac6EX 2002
Clinac2100CD 1999
Clinac2100C 1994
Equinox 2006
Elite 80 2000
2 Telecobalt
Th-780C 1987
Th-780 1984
Eclipse 2005
Cadplan 1999
3 Treatment planning
PLATO 1994
BrainLAB 1999
4 Simulator Ximatron 1999
5 CT Simulator Somatom Emotion 2002
6 HDR Brachytherapy Micro-Selectron 1994
7 LDR Brachytherapy Selectron 1984
Dosimetric Equipment
Radiation Field Analyser Blue Phantom 2002
TLD System Rexon 2005
8 Electrometers with various Ion
Unidos, NE 2000
chambers
In-vivo Dosimetry System DPD-12 2005
Film Dosimetry System Omni-Pro IMRT 2002
• Indian Cancer Research Centre (ICRC), which
was established in 1952 in Parel, Mumbai, under
the purview of the Ministry of Health,
Government of India.
• In 1966, ICRC was renamed the Cancer

Research Institute (CRI) and amalgamated with
the Tata Memorial Hospital.
• The ACTREC project was conceptualized by the
DAE in November 1983.
• During the period 1985-1987, DAE acquired a

huge 60 acre plot of land from CIDCO in Navi
Mumbai, the newly developing city across the
harbour, and it was decided to set up a much
larger institute on this campus.
• The foundation stone for this campus - the
Advanced Centre for Treatment, Research and
Education in Cancer (ACTREC), located near
the foothills of the Sahyadri mountain ranges in
Kharghar, Navi Mumbai, was formally laid in May
1997 by Dr. R. Chidambaram, Chairman, AEC
and Secretary, DAE.
• In August 2002, in its 50th year, CRI moved in
toto from Mumbai to Navi Mumbai to become the
basic research wing of ACTREC.
• In December 2002, CRI celebrated its Golden

Jubilee, with the pledge to 'not remain content'
with its stature and recognition worldwide as the
premier Indian institute conducting research on
cancer
1920
Madame Marie Curie
discovered radium in
1896.
Just two years later, a vial
of radium salt was placed
on the breast of a
woman with cancer, and
the tumor was observed
to shrink.
This was the first use of
interstitial brachytherapy.
Dr. Keynes' technique of

inserting radium 1920.
1914
In 1914, Stevenson and Joly

improved the technique.
Using pure radium sulphate, thus

manufacturing the first radium
“needles” made from steel or
platinum.
Dr Failla at Memorial Hospital,

collected radon gas in tiny glass
tubes that were then inserted into
tumours and left there indefinitely..
1901-1950
• Pierre Curie studied the effect of radiation
•1900: Friedrich Walkoff & Friedrch Giesel (Germany) radiation burn

•1901: Dr Henri Danlos & Paul Bloch, French doctor (St Louis
Hospital,Paris) 0.39 Gm Radium treated lupus skin lesion& Dr Robert Abbe,
Surgeon (St Lukes & Memorial Hospital, New York) used radium for patients
•1903-1950: Margaret Cleves (Ca Cervix), Hugh Young (Ca Prostate),
Geoffrey Keynes (Ca Breast)
• 1960: After-loaders (E. Henschke)
•1990: Imaging – CT, MRT
• 2000: Advanced computerized - 3D presentations
• 2005: Robotic delivery of prostate seed
Mile stones - Brachytherapy
1896 – Becquerel - Radioactivity
1898 – Madam Curie / Pierre Curie - Radium
1903 – Nobel Prize for Curie’s & Becquerel
1903 – First successful case of malignancy basal cell carcinoma of face
1920 – Patterson & Parker tables for Radium
1920 – Paris system of IC Rx / Stockholm System
1934 – Manchester System
1953 – Tod & Meridith point A & B defined
1957 – Ir–192 in implants
1960 – Preloaded applicators Stockholm, Paris & Manchester
1960 – After-loading applicator - Henchke / Fletcher-suit
1962 – First Remote after-loading machine
1965 – Paris system – Interstitial
1970 – Co-60 HDR
1985 – HDR Ir-192
2000 – 3D Brachy planning, CT/MR Compatible appl., Inverse planning
• The brachytherapy facilities in India at the beginning of
1975 were as follows:
• The total stock in curies (Ci) of brachytherapy sources in
India at the beginning of 1975 was as follows: Radium
18 Ci, Cobalt 10 Ci + 20 Ci and Caesium 1.2 Ci.
• The 20 curies of cobalt listed apart relates to the

Cathetron installed in Indore in 1973.
• A second Cathetron was commissioned at the Cancer

Hospital and Radium Institute, Hyderabad, in 1978.
EVOLUTION OF BRACHYTHERAPY AT TATA MEMORIAL HOSPITAL
1941 Radon Seeds
1960 Preloaded Cesium137/Cobalt-60 capsules
1962 Gold-192 grains
1972 Manual after-loading Cobalt-60

1976 Cesium-137 tubes (BARC)
1979 Cesium137 tubes/needles (Amersham)
1981 Selectron LDR/MDR – Cs-137
Manual after-loading & Iridium-192 wire implants
1987 microSelectron LDR – Ir-192
1994 microSelectron-HDR, TPS – PLATO
1999 microSelectron-HDR control console & PLATO up-gradation
2003 microSelectron console up-gradation
2005 PLATO up-gradation. Sunrise workstation, MRI comp.
applicator
2006 Digitally networked C-Arm in OT
2008 USG in OT, use MRI volume delineation
58
Cancer in India
Current scenario (2000-10)
• 800,000 new cases, 2,500,000 prevalent cases

• 550,000 cancer deaths/year, Relatively young cancer population
• 2/3 rd of cancer patients need Radiotherapy (RT) i.e. 5,00,000
patients /year – A proven and effective modality.
•Only 1/3rd of these estimated patients actually receive RT due to
major shortfall in number of therapy units and urban-centric
distribution of centres.
• Interesting paradox, small %ge – afford anything including latest

high-end RT, majority cannot afford, social & ethical dilemmas
• Only 30-40% of these patients actually receive RT
• Same/less in similar countries, Some parts of Africa and Asia –
not even 1 machine. Courtesy – Dr.Rakesh Jalali
Lancet Oncol 2006; 7: 584–95
Lancet Oncol 2006; 7: 584–95
Lancet Oncol 2006; 7: 584–95
• Radiation therapy facilities have been inadequate and
disproportionate to tackle the emerging problem of
cancer cases in the developing world.
• With the projected rise of new cancer cases in
developing countries from 5.4 million in year 2000 to 9.3
million by 2020.
• Radiotherapy facilities would be insufficient to deliver
the basic radiotherapy care for cancer patients in the
near future.
Niloy Ranjan Datta

Additional Professor and Head, Department of Radiotherapy,
a SGPGI, Lucknow, India
1962-1986 — 76 Telecobalt units (> 20 years old)
1987-1991 — 35 Telecobalt units (> 15 years old)
Pre 1991 LA — 12 units (>15 years old)
76/260 Telecobalt units outdated and old: Need to be

decommissioned
12/69 LA units outdated and old: Need to be

decommissioned
National Cancer Control Programme Task Force Reports for XIth plan
Projected Shortfall in RT Equipment / Manpower (2001-2010)
RT Recomm. Scaled down Required for Existing, in Shortfall
Equipment / West (Per requirement in whole the country
Manpower million people) India (per million country
people)
Teletherapy 4 1.5 1500 450 1050

Simulator 1 0.5 500 200 300
TPS 1 0.5 500 230 270
Brachytherapy 1 0.5 500 150 350
(Remote)
Radiation 4 1.5 1500 1000 500
Oncologist
Medical 4 1.5 1500 700 800
Physicist
Radiotherapy 6 2.0 2000 1000 1000
Technologist
BHABHATRON
Telecobalt Machine, BHABHATRON, Mumbai
Dept of Atomic Energy and Tata Memorial Centre (ACTREC)

Bhabhatron
Fully Conformed to IEC 601-1 technical specifications
• Source head 15,000 Ci

• Collimator FS 0x0 cm to 35x35 cm , rotation + 90
• Couch Isocentric with vert/long/lat/rot motion
• Couch top Conformal carbon fibre table top
• Beam modifiers Wedges, Breast cone, Blocks
12
10
Over 1000 patients treated from Jan’08-July’10
8
6
% downtime
4
2
0
Jan Feb Mar Apr May Jun Jul Aug Sep Down time: 3% (2009) Courtesy – Dr.Rakesh Jalali
• 16 machines installed and
functional so far
• Low cost: Bhabatron – less
than 200,000 USD
• 1 In Vietnam
• 1 in Nigeria
• Cobalt also important along
with LA
• MLC also being installed
India donates Bhabhatron
to Vietnam (IAEA-PACT programme)
Courtesy – Dr.Rakesh Jalali
Linear accelerator programme
Linear Accelerator
• 1st LA, October, 2006, 6 Units SIDDHARTHA
now, Wardha, India Dec 06
• 6MV and 10 MV
• Electrons and MLC
• Cost, likely to be <1 million USD
• Similar models / initiatives
Courtesy – Dr.Rakesh Jalali

• Attempts have been made by Sameer (Society for
Applied Microwave Electronics Engineering and
Research) who have developed an indigenous 4 MV
medical linear accelerator.
• 2 or 3 units have been installed.
• Further attempts are now being made to develop an
integrated medical linac system with 6 MV energy under
the national programme for deployment of indigenously
developed integrated medical LINAC for cancer therapy
a proposal under Jai Vigyan National Science and
Technology Mission.
Public Private Partnership
• Standing committee on radiotherapy development
program.
• The Public Private Partnership (PPP) model has
already been successfully implemented in many
government medical colleges in the country.
• Under this model the institution enters into an
agreement with a private firm (which provides
the radiotherapy facilities)
• This will help to increase the cancer care
facilities in the remote areas of our country.
Journal of Cancer Research and Therapeutics - April-June 2011 - Volume 7 - Issue 2

• Indian Government Planning to open 6 New
AIIMS at
1. Patna
2. Bhopal
3. Bhubaneswar
4. Jodhpur
5. Raipur
6. Rishikesh
Cancer registration in India
• Until 1964, information on cancer occurrence in
India was available from surveys.
• Initiation of population based cancer registries
started:-
1. Mumbai in 1964
2. Pune in 1973
3. Aurangabad in 1978
4. Ahmedabad & Nagpur in 1980
• Due to these registries availability of data on
cancer incidence on a continuous basis started.
• The boost for cancer registration in India was in
1982, through initiation of National Cancer
Registry Programme (NCRP) by Indian Council of
Medical Research.
• The NCRP began with three population based

1. Mumbai
2. Bangalore
3. Chennai
• Three hospital based registries at
1. Chandigarh
2. Dibrugarh
3. Trivandrum
• Further, expansion of NCRP saw the initiation
of urban population based cancer registries at
Bhopal & Delhi in 1987
• Rural population based cancer registries at
Barshi (Maharashtra) in 1987.
• A hospital based cancer registry functioned at
Chandigarh from 1982 till 1992.
• The data from cancer registries helped in highlighting the
magnitude and common sites of cancer in India, and was
useful in planning the National Cancer Control
Programme.
• Besides the above mentioned registries population
based cancer registries are also functioning at
1. Kolkatta,
2. Thiruvananthapuram,
3. Karunagapally (ruralKerala)
4. Ambillikai (rural Tamil Nadu).
Three – tier radiotherapy
service
• Primary radiotherapy centres:-
 based on population density equipped with a teletherapy
unit.
• Secondary radiotherapy centres:-
 to provide services for teletherapy, brachytherapy,
treatment simulation and planning.
Niloy Ranjan Datta

• Tertiary radiotherapy centre:-
 The state of art technology already existing
radiotherapy centre having reasonable infrastructure
which could be augmented to act as a tertiary
radiotherapy centre.
• These centres, could be effectively linked through
teleradiotherapy network.
• With 70% of the world’s cancer problem in the

developing world, that has just 5% of the world’s
resources.
Niloy Ranjan Datta
1. Primary radiotherapy centre (PRC)
2. Secondary radiotherapy centre (SRC)
3. Tertiary radiotherapy centre (TRC)
Niloy Ranjan Datta

Primary Referral Centre (Taluka /
District Hospital)
• Should provide routine RT services for 80% of standard
common cases
• ™No. of districts in the country: 600
• ™No. of centres needed if RT resources shared between
4 adjacent districts: 150
• ™No. or RT centres currently existing at the
Taluka/District Hospital level: 100
• 50 additional primary referral RT centres need to be
established
• 25 existing centres need to be equipped with
brachytherapy facilities
Mimimum RT requirements for
primary referral centre
 Teletherapy
· 1 Telecobalt unit with beam modifiers
 Brachytherapy
· 1 Manual low-dose rate / remote high-dose rate
brachytherapy unit
 Planning/Verification (Physics accessories for minimum
Quality Assurance)
· Secondary Standard Dosimeter
· Gamma Zone monitor
· Survey Meter (Ion chamber based)
 Optional
• · Treatment Planning System
Primary radiotherapy centre
• Located based on the population density to cater to the
needs of around 2 to 4 million population.
• could have just a teletherapy unit and be able to act as a
centre for delivery of teletherapy to patients of the
draining area.
• Treatment planning and simulation would have to be
carried out at the next higher centre.
• The centre could run outpatient services for both new
and follow up cases.
• PRC would have to get inputs and work in close
collaboration with the secondary radiotherapy centre
(SRC).
State wise distribution of primary referral centres
Secondary Referral Centre (Oncology
Wing of a Medical College)
• Should provide service and education/training
• ™No. of Govt. Medical Colleges in the country: 120
out of total 242
• ™No. of Govt. Medical Colleges with any RT facility
(mostly primitive): 40
• ™No of Teaching Institutes with MCI recognized PG
seats in RT: 28
• ™Immediate aim: Secondary referral RT centre -
every 2nd Govt. Medical College.
• 20 additional Medical Colleges need to be
equipped as secondary referral RT
centres.
• 25 existing Medical College RT
departments need to be upgraded.
Minimum RT requirements for a
secondary referral centre
 Teletherapy
• 2 Telecobalt units or 1 Telecobalt with beam
modifiers + 1 low energy LA
• with/without electrons
 Mould room facility
 Brachytherapy
• 1 High-dose rate brachytherapy system
 Planning
• Simulator or CT Simulator with Virtual Simulation
facility
 Treatment Planning System
 Verification (Physics accessories for
comprehensive QA)
• · Secondary Standard Dosimeter
• · Gamma Zone monitor
• · Survey Meter (Ion chamber based)
• Radiation Frequency Analyzer
 Optional
• · Dual Energy LA with electrons with multi-leaf
collimators (MLCs)
• · TPS with Inverse Planning module
Secondary radiotherapy centre
• Existing centres, many of which could lack in one or
more of the requirements of a basic radiotherapy centre.
• Ideally consist of both teletherapy and brachytherapy
units supported by simulator and treatment planning
system.
• These centres should be able to carry out the simulation
and treatment planning of patients from the PRC area
apart from those who directly attend these SRC centres.
• If patients requiring brachytherapy, these could be taken
care by SRC.
Tertiary Referral Centre (National
Centre & Regional Cancer Centres)
• Should provide service, education & research
(comprehensive cancer care)
• ™™™N
™o. of states in the country currently: 28
• No. of RCCs existing currently in the country:
25
• ™™™™™Each state should have at least minimum
one RCC.
Minimum RT requirements for an RCC
 Teletherapy
• 2 Telecobalt units or 1 Telecobalt with
beam modofoers + 1 low energy LA
with/without electrons
• 1 Dual energy LA with electrons & multileaf
collimators (MLCs)
• Mould room facility
 Brachytherapy
• 1 High-dose rate brachytherapy system
Minimum RT requirements for an RCC
 Planning
· Conventional Simulator or CT-Simulator with Virtual
Simulation
· 3-D TPS with Inverse planning module with networking
 Verification
• Electronic portal imaging device on LA
• Extensive physics accessories for comprehensive QA
I. Secondary Standard Dosimeter
II. Gamma Zone monitor
III. Survey Meter (Ion chamber based)
IV. Radiation Field Analyzer (RFA)
V. Film based dosimetry and Intensity map check facility
 Optional
• TPS with image fusion algorithms
• Automated compensator cutting & milling unit
• Stereotactic Radiotherapy/Radiosurgery System
• PET scanner with networking to TPS
• Image Guided Radiation Therapy (IGRT)
• Dose Guided Radiation Therapy (DGRT)
• Helical Tomotherapy.
Tertiary radiotherapy centre
• Could be the centre of excellence having state of art
technology to deliver “quality assured radiation therapy.”
• Should be equipped with high energy linear accelerator
and have facilities for conformal, stereotactic
radiotherapy, stereotactic radiosurgery and intensity
modulated radiotherapy supported by brachytherapy,
simulator, treatment planning systems and medical
physics support.
• Act as a referral centre for both SRC and PRC, co-
ordinate activities of PRC.
Linking PRC, SRC and TRC through
teleradiotherapy
• Qualitative and quantitative improvement in radiation
therapy management through teleconsultations.
• Availability of expert advice to all patients by
centralization of resources.
• Training of manpower through virtual class room
concept.
• Monitoring of multicentric clinical trials with a large
sample size with a lesser chance of patients getting lost
to follow up.
• Linked through either ISDN or satellite.
• Images can be transferred through the network,
treatment planning could be carried out at SRC could be
reviewed by TRC or those done at TRC could be
transmitted back to PRC or SRC for their
implementation.
Niloy Ranjan Datta

• International guidelines recommend one megavoltage
therapy equipment for every 1,20,000 population, for every 250
new patients providing about 6,250 treatments per year.
• India for a population of about 1,100 million, at the cancer

incidence rate of 70 per 100,000 population, 60% of them
requiring RT, we need about 1155 machines assuming a load
of 400 per treatment machine annually.
• Presently, there are only 400 tele-therapy machines, about

25% of them served more than 10 years needing urgent
replacements. Journal of Medical Physics, Vol. 34, No. 2, 2009, 63-5
Conclusion
• Recently in India, the rate of growth is about 25 machines per annum,
which is a very good indicator of fast growth of radiotherapy
infrastructure.
• We are far behind the goal
– Need for depth of penetration of facilities, and at the same
time more no of new high end state of art centers with
facilities
– Need for comprehensive cancer centers witrh all facilities –
RT Sx oncology Med oncology, Pall Care, Psycho oncol,
ocuupational and rehab, screening and prev, education
and awareness, research and development
• We are growing fast

• Future is definitely going to be ours…
Journal of Medical Physics, Vol. 34, No. 2, 2009, 63-5

A Tribute to Dr. KA Dinshaw
16 November 1943 – 26 August 2011
Thank You

History of Radiotherapy &amp; Infrastructure in India

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History of Radiotherapy &amp; Infrastructure in India

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History & Infrastructure of RT in

“Henry Becquerel, a French physicist accidently

…was announced by Marie and Pierre Curie at the

• Radiotherapy in the beginning of 194Os, with 60-and

• In the early 50's only deep X-ray units operating in the

First used to treat a patient on 8 November

A CAESIUM 137 TELETHERAPY UNIT FOR USE AT

• One of the first isotope teletherapy units was a Theratron Junior

• By 1965, 19 institutions possessed either cobalt or caesium

• 10 years later this number had grown to 49 centres.

• By 1978, 57 departments had telegamma units and another 6

J Cancer Res Ther - March 2005 - Volume 1 - Issue 1

• Of the latter, 17 were Eldorado units (mainly gifted under the

• The majority of the 50 rotational units were Theratron 60’s or

• Most of the stationary units had been installed since 1970.

• Total of 96 teletherapy units served India’s needs,

• It was noticeable that the south of India (Kerala and

J Cancer Res Ther - March 2005 - Volume 1 - Issue 1

J Cancer Res Ther - March 2005 - Volume 1 - Issue 1

J Cancer Res Ther - March 2005 - Volume 1 - Issue 1

J Cancer Res Ther - March 2005 - Volume 1 - Issue 1

J Cancer Res Ther - March 2005 - Volume 1 - Issue 1

J Cancer Res Ther - March 2005 - Volume 1 - Issue 1

J Cancer Res Ther - March 2005 - Volume 1 - Issue 1

J Cancer Res Ther - March 2005 - Volume 1 - Issue 1

• These linacs were in the range of 4 – 8 MeV.

• In 1952 , microwave electron based linear accelerators

• In 1972, Fessender explored how to create linear

• Working with the Varian Medical Systems Inc of Palo

• High end machines

1972 Telecobalt (Janus), Telecaesium (Gammatron)

1994 Linear Accelerator (Clinac-2100C Dual Energy)

• In 1966, ICRC was renamed the Cancer

• During the period 1985-1987, DAE acquired a

• In December 2002, CRI celebrated its Golden

Dr. Keynes' technique of

In 1914, Stevenson and Joly

Using pure radium sulphate, thus

Dr Failla at Memorial Hospital,

•1900: Friedrich Walkoff & Friedrch Giesel (Germany) radiation burn

• The 20 curies of cobalt listed apart relates to the

• A second Cathetron was commissioned at the Cancer

1972 Manual after-loading Cobalt-60

• 800,000 new cases, 2,500,000 prevalent cases

• Interesting paradox, small %ge – afford anything including latest

Niloy Ranjan Datta

1987-1991 — 35 Telecobalt units (> 15 years old)

Pre 1991 LA — 12 units (>15 years old)

76/260 Telecobalt units outdated and old: Need to be

12/69 LA units outdated and old: Need to be

Teletherapy 4 1.5 1500 450 1050

Dept of Atomic Energy and Tata Memorial Centre (ACTREC)

• Source head 15,000 Ci

Courtesy – Dr.Rakesh Jalali

Journal of Cancer Research and Therapeutics - April-June 2011 - Volume 7 - Issue 2

• The NCRP began with three population based

Niloy Ranjan Datta

• With 70% of the world’s cancer problem in the

Niloy Ranjan Datta

Niloy Ranjan Datta

• India for a population of about 1,100 million, at the cancer

• Presently, there are only 400 tele-therapy machines, about

• We are growing fast

Journal of Medical Physics, Vol. 34, No. 2, 2009, 63-5

History of Radiotherapy & Infrastructure in India

History of Radiotherapy & Infrastructure in India