Essence of Importing Technology in Diagnosis and Treatment of Cancer

Suresh Poudel

The success of any development effort of a country depends on its ability to absorb the outcomes of modern technology. This is true for all facets of economic and social activities. Generally developing countries lack such capacity. Often this lacking is due to inadequate infrastructure, human capital, finance, commitment of leaders and their willingness to do so. It is an undeniable fact that for setting a country into a path of development, it should focus on development of science and technology.

Experiences of developed countries show that they were once a fertile land for technologies.  Most of them are yet working hard to develop new technologies. Only those countries which have invested heavily in science and technologies are progressing leaps and bounds. They have been benefitted by their home made and imported technologies. Technology is the application of knowledge to practical purpose which ultimately innovates the way of performing task assuring a better outcome in what we do. As a developing country, it might not be possible for Nepal to invest heavily on development of science and technology; however it shall prepare itself to build capacity to absorb the recent outcomes of scientific development.

Since last century we have been using different machines in disease diagnosis and treatment. These machines are the outcomes of dedicated research and investments. Similarly ionizing radiations have been used for diagnosis and treatment of diseases. To improve the precision of diagnosis and treatment, the producers of such machines are using the recent and exotic research findings.  This has made the use   of such machine is expensive.

Regarding Cancer diagnosis and treatment, in recent years, there has been a huge development in the techniques of imaging and therapy. In imaging conventional X-Rays, Mammography, Angiography, Ultra-sonogram (USG) have been used for quite long. Magnetic Resonance Imaging (MRI), Computed Tomography (CT), SPECT, PET Scans machines are proving themselves as reliable machines for disease diagnosis.

Similarly radiotherapy has come a long way from the days when the treatment was started with X-ray tubes, Van de Graff generators and betatrons and cobalt-60 teletharapy units. Today we are using moderns LINACS and modern Brachy therapy machines. As special techniques in radiotherapy Stereotactic irradiation, Total Body Irradiation(TBI), Total Skin Electron Irradiation(TSEI), Intra Operative radiotherapy(IORT), Endo rectal Irradiation, Conformal Radiotherapy and Intensity Modulated Radiotherapy (IMRT), Image Guided Radiation Therapy (IGRT), Respiratory Gated Radiation Therapy(IGRT), PET/CT fused images, proton therapy and higher nuclide therapy at our avail although the use of most of them by a common patient has been limited by cost and shortage of manpower who has skills on using them. In addition, there are many equipments, chemicals and accessories used in medicines.

The price of these machines is generally high for the obvious reasons that they are the result of huge investment and dedicated efforts. But a mankind cannot stay away from being benefitted from such grace of human efforts. Many developing countries lack such services for the limitation of their resource. Nevertheless Governments of these countries should not make an excuse for high price to import such technologies to their country. They should find the ways to import these technologies to their country and hence start building a necessary infrastructure including skills and manpower to do that.  This will help every Nepali citizen to do cancer diagnosis and treatment at home than going abroad. This will help a country to assure the right of every citizen for health.

The writer is a member of Bangladesh Medical Physics Society (BMPS) and student of Gono University, Savar, Bangladesh.

On Occasion of 2nd International Day of Medical Physics

Suresh Poudel

On November 7, this year Medical Physicists around the world are going to celebrate 2^nd International Day of Medical Physics (IDMP) to mark the birth date of Marie Sklodowska- Curie, the pioneer researcher on radioactivity, who was born on the same day in 1867. The theme of IDMP 2014 is “Looking into the Body: Advancement in Imaging through Medical Physics.”  

Last year on the same day, to mark 1^st IDMP, a Symposium was organized at B. P. Koirala Memorial Cancer Hospital (BPKMCH), Bharatpur, Chitwan, Nepal. It had been a successful event. Nepalese Association of Medical Physicists (NAMP) is the professional organization of/for Nepalese Medical Physicists. NAMP is small in terms of its membership subscription. Nevertheless it has been an important organization to further the role of medical physicists in national context and in international arena. NAMP is a member of International Organization of Medical Physicists.

Although International Labor Organization (ILO) has listed medical physicists as health professions, it is the least heard profession in Nepal. Many of us even when we are in medical professionals do not know who medical physicists are and what exactly they do. So it has been urgent to make everyone clear about the role of Medical Physicist in Healthcare, particularly in diagnosis and therapy of cancer.

Medical Physicists are basically the physicists who apply their knowledge of physics to medicine. On the occasion of 2^nd IDMP, I found it relevant to highlight the role of Medical Physicists in medicine. According to American Association of Physicists in Medicine (AAPM) many medical physicists are heavily involved with responsibilities in areas of diagnosis and treatment, often with specific patients. These activities take the form of consultations with physician colleagues. Medical physicists play a vital role and often leading role on medical research team. Their activities cover wide frontiers, including such key areas as cancer, heart disease, and mental illness. In cancer, they work primarily on issues involving radiation, such as the basic mechanisms of biological change after irradiation, the application of high energy machines to patient treatment, and the development of new techniques for precise treatment. Similarly in teaching often medical physicists have faculty appointments at universities and colleges, where they help train future medical physicists, resident physicians, medical students, and technologists who operate the various types of equipment used to perform diagnosis and treatment.

Besides in hospitals, medical physicist is generally responsible for specification, acceptance, commissioning, calibration and Quality Assurance of all radiotherapy equipment; radiation measurement of beam data; calculation procedures for determination and verification of patient doses; physics content of treatment planning and patient treatment plans; supervision of therapy equipment maintenance, safety and performance; establishment and review of QA procedures, radiation safety and radiation protection in the radiotherapy department. Besides they have important roles in education and research.

To conclude, medical physicist is an important member of cancer diagnosis and treatment team. S/he is a person who conducts scientific research on physics and medicine and also does teaching and deals with radiation protection and safety issues inside and outside the hospitals.

The writer is a student of Gono University, Savar, Dhaka, Bangladesh and a member of Bangladesh Medical Physics Society(BMPS)

त्यो कस्तो पोखरी ?

Suresh Poudel

त्यो पोखरी 

पानी भरी छ

मुहान देखी टुटी-टुटी सम्म
पाइप बिछैएको छ

तर  पानी ओरली Jhardaina

निर्मल भनेर झायली पिटाइएको छ

सबैको हो भनि pratinidhi

माछा( भ्यगुत) रखिएको छ

दामी रैन्बो ट्रौट्

कत्ले, भातरलक्,

स्यङि, जुङे

बाम्, 

बुदुन, झिङे

 र अरु अमुक अमुक्

माछा( भ्यगुत) haru

त्यो पोखरी 

मुहानबाट तल पानी 
झार्ला झारला जस्तो

देख्दा भिरलो 

पाईप बिछएको 

टुटी टुटी म पानी झार्छ

 भनेर झ्याल्ली पिटाएको छ

थरी थरी (६०१) माछ!(भ्यगुत) सज!एको 

तर पानी आल्झिएको,

 त्यो anautho euta पोखरी कस्तो ?   

हासेरै बच्ने इछ्या मेरो

आफ्नो मुटु आफैलाई

किन आज वोझ भयो

खुशी भन्ने चिज 

झन ब्रहमन्ड्को खोज भयो

हासेरै बच्ने इछ्या मेरो

निमेशमै टुटी गयो

आफ्नै आखाको नानी आज

सन्सार छेक्ने पर्द बन्यो

मान्छेहरु को भिड भित्र

एउटा मान्छे एक्लो पर्‍यो

निस्टुरिले साथ छोडिदिदा झनै

समाजले उस्को सेखी झार्यो

हृद्य को सनो टुक्र

मलाई छादी कहाँ गयो

मन्छे मन्छेको को यो  शहर

मलाई वने सुन्ने भयो

Suresh Poudel

Dhaka, Bangladesh

Towards Building a National Infrastructure in Radiation Safety

After being the member of IAEA in 2008, Nepal has been receiving the extended technical co-operation from the IAEA. Currently, a draft Nuclear Law has been prepared and approved by the Council of Ministers (16/09/2011) and is under the review of the Nepal Law Commission. Developing and establishing the national infrastructure is one of the major co-operation areas which Nepal and IAEA have agreed upon. Safe Use of Radiation is the primary aim of this co-operation.

Suresh Poudel

For disease diagnosis and radiation therapy, ionizing radiation is used. So to comply with the aim of the co-operation, it is necessary to focus on the quality control and radiation safety at hospitals and workplace. Nevertheless Nepal does not have a clear record of the number of radiation health professionals (i.e. Radiologists, Oncologists, Medical Physicists, Technologists, Technicians, Radiographers, nurses and others). Also there is no official record about the exact number of the operating radiological facilities, number and types of diagnostic and therapy machines using ionizing radiation. Conditions of workplace are still unknown. Lately there has been some development towards the baseline study of radioactive sources, and other basic studies in this area. In July 2010, a report “Status of Radioisotopes in Nepal- A Survey for the preparation of Inventory” was published as an initiative towards archiving information about the radioisotopes in the country. It was a positive development to create a database of radioactive sources. This report has been crucial in documentation of radioactive sources.

Widmark et al(2012) performed another study titled “Occupational Radiation Exposure in Health Care Facilities” to show the picture of occupational radiation safety in Nepal . In this study it has been mentioned that there are 11 computed radiography units, 12 mammography units, 30 CT units and more than 900 X-ray units are in operation. And in therapy, one gamma camera, three brachy equipments, three linacs, three simulators, four cobalt-60 machines are in operation in 5 hospitals. One big private hospital will come in operation soon with some additional facilities like IMRT, and nuclear medicine unit. In another study, Lamsal (2012) wrote a report about his reflection of attending “International Workshop on Radiation Risk Communication in Pediatric Imaging”. This report is basically his personal experience of and learning from the conference. However, it has included the different facet of radiation safety in Nepal. Also the report has discussed about the problems of achieving the quality assurance in imaging and also tried to shed information on radiation safety issues in Nepal.

On the other hand, Nuclear Law will be effective only if it is properly designed and effectively implemented in its implementation stage. But in every step of its design and also in implementation phase, it needs an adequate supply of information and expertise. As there is limited number of study undertaken till date which may make the literature insufficient for proper outcome of the Law. It is very challenging for the government to design a sound Nuclear Law with limited information, literature, expertise and insight of the true situation of the country. But it should not stop it for bring the Law as it would provide the basic guidelines for the use of ionizing radiation in medicine.

There are separate professional organizations for each group of professionals. Nepalese Radiological organization such as Nepal Nuclear Society, Nepal Radiological Society, Nepal Radiologist Association, Nepalese Association of Medical Physicists, Nepal Radiological Technology Student’s Society can play vital role in creating the database of the respective radiological health professionals. What government can do with these organizations is to ask such them to regularly supply the required data, primarily about their numbers, skills, trainings etc. On other words, the situation of these professionals in health care market.

Likewise for creating the database of the equipment used in diagnosis and radiotherapy, government can call the diagnostic equipment user for the voluntary registration of their devices in its early stage and then go for the mandatory registration. Since the number of radiotherapy facilities is very few in number, it can conduct survey to generate the information about the situation of devices there. It can be the initial step towards accounting the equipment used in diagnostic and therapy.Personal dose monitoring is rarely done in diagnostic facility with an exception at some private hospital. However, it is performed in radiotherapy but there are challenges like shortage of monitoring device, calibration in time and dose reporting.  Even in the cases where the personnel have devices, s/he may lack skills to handle it due to lack of knowledge and training.

In this context it has been essential for the government to initiate the collection and hence preservation of data related to the radiation health professionals, equipment related to diagnostic and radio therapy, organize training, workshop, radiation safety awareness programs now and has to come up with a long term planning to ensure radiation safety in Nepal.  This will help to ensure quality control and safe use of ionizing radiation in Nepal.  And hence it will add a brick towards building a national infrastructure in Radiation Safety.

The writer is a member of Bangladesh Medical Physics Society and a student of Gono Bishwobidyalay,  Savar, Dhaka, Bangladesh.

An Experience From ICMPROI-2014

By Suresh Poudel

2^nd International Conference in Medical Physics on Radiation Oncology and Imaging (ICMPROI-2014), held in Dhaka from 20^th -22^nd August, 2014 was an extraordinary experience for me. This conference was jointly organized by Bangladesh Medical Physics Society (BMPS), Association of Medical Physicists of India (AMPI), and Nepalese Association of Medical Physicists (NAMP). Virtually I was representing all of these three nations- Nepal as my motherland, Bangladesh as my place of study and also as a member of BMPS and India as my prospective place for postgraduate research.

With more than 300 delegates, national and international, it was an exotic event. Speakers were invited from International Atomic Energy Commission (IAEA), Asia-Oceania Federation of Medical Physicists (AFOMP), Secondary Standard Dosimetry Lab (SSDL), foreign Universities and Research Institutes. Delegates came from 23 nations. Mr. Abul Hassan Mahmood Ali, Hon’ble Foreign Minister, MP, Peoples Republic of Bangladesh was the chief guest and Dr. Ferdinand Von Weyhe, German Charge d’ Affairs for Bangladesh was a guest of Honor.

In this 3 days conference, I took an opportunity to host cultural program and other scientific sessions. NAMP president and organizing Vice President Mr. P P Chaurasia delivered a welcome speech and also presented his scientific paper on second day of the conference while Nepalese Oncologist Dr. Samir Sharma, co-chaired a scientific session. Another Nepalese delegate Mr. Shrawan Kumar presented his paper during a scientific session. 

Beside these regular formalities of any conference, this event has been vital for strengthening the relationship among the medical physicists in South Asia. Delegates from Pakistan, Srilanka, India, Bangladesh and Nepal were highlighted the importance of regional co-operation among the Medical Physicists and Medical Physics organization  for better and quality cancer treatment in this region.

This conference has brought together the Cancer experts, Oncologists, medical physicists, technologists, administrators, policy makers etc to engage on a discussion towards quality treatment of cancer in this region and the role of medical physics on it.

Particularly, the meeting between AMPI, BMPS and NAMP has been fruitful towards collaboration in knowledge sharing, accreditation Bangladeshi Medical Physicists by India etc.This conference has been crucial for digging up the issues related to radiation protection, quality assurance in radio diagnosis, radio therapy, nuclear medicine and recent development in biomedical Engineering. 

Participants emphasized the role of medical physicists in quality treatment delivery to the patients. They stressed that with the growing complexity of cancer treatment, the role of medical physicists has been increasing in radio diagnosis, radiotherapy and radiation protection. They informed their respective governments that International Labour Organization has recognized medical physicists are health professional basically involved in quality assurance of imaging and therapy, radiation protection, dosimetry, acceptance and commissioning of machines such as Medical Linacs, Brachytherapy Machines, Co-60 teletherapy machine, CT Scan machine, MRI etc. They are also involved in academics and research. Medical physics is basically the application of physics in medicine.

India is far ahead of its neighbors in Cancer treatment and radiation therapy. It has better infrastructure, advanced machines with large number of Oncologists, medical physicists, technologists and other related professional. It alone has around 1000 medical physicists working in different hospitals, universities, BARC, research institutes etc. Medical physics is taught in 8 different institutes in India. On the other hand, the number of oncologists, medical physicists and other radiation related health professional is very low in Bangladesh and Nepal. Bangladesh has around 30 and Nepal has 8 medical physicists till date.

Only Gono University offers Bsc and Msc Medical physics education in Bangladesh. Government hospitals have not yet  to create the posts for medical physicists in Bangladesh, Gono graduates are getting jobs in private hospitals, medical equipment companies, university and in research. Lately the government has shown interest to create post for medical physicists. Prof. Deen Mohd. Noorul Huq, Directorate general of Health Services, Ministry of Health and Family Welfare, Peoples’ Republic of Bangladesh said that the government would keep medical physics education and the role of medical physicists in top priority. It will be a step forward for BMPS in its effort to make Medical Physics a reputed profession in Bangladesh.

As Nepal has only 6 cancer centers with limited number of medical Linacs, Brachy Units, IMRT and other therapy and diagnostic equipment, it has not felt the pressure regarding the need of Medical physicists till date. However, with new cancer centers, modern equipment and necessity of precise radiation dose delivery, radiation protection issues in rise the medical physicists will grow in demand in Nepal. Also medical physics is not recognized as a intensive discipline in Nepal. No university offers intensive learning in medical physics except that it is taught as an optional paper for Msc Physics students in Tribhuvan University.

Under this backdrop, it has been high time for Government of Nepal to formulate national radiation protection law, work out to establish medical physics department in hospitals using radiation particularly in Cancer Centers, run an intensive medical physics program in graduate level, help NAMP to conduct trainings, research, awareness and other programs.

The writer is the member of Bangladesh Medical Physics Society and student of Gono Bishwobidyalay, Savar Dhaka, Bangladesh.

My love Song

You will blush,
when I come nearby 
You will meltdown, 
when I Fix my eyes into ur eyes 
Your emotion will surge up, 
when u Know the whispering is mine 
You get tickled, 
when I Urge you to put ur hands on mine 
You will miss me Baby 
When I say U goodbye. 
You will cry baby 
when I Say u goodbye

So baby, 
I dont Wanna say U gooDbye 
I dont wanna say u goodbye 
I wanna see u blushing ...
..see you melting ....
..see your emotion surging ...
..see u tickling Baby, 
so baby, I wont say U goodbye

Suresh Poudel..

An Urge: To formulate National Radiation Protection Law

Few weeks ago, we got to read news about radioactive source container being lost on its way to Kathmandu from Chitwan. This news was unique but it was a subject of public concern for sure. Generally such issues are not viewed seriously in developing countries like Nepal. They are just overshadowed by the other issues like politics, and other common stuffs.

Nevertheless, this time it got a top priority on almost all national dailies for almost a week. Firstly they mentioned the loss of radioactive source container thus asking people to inform the concerned authority, if that source container comes into their notice. Secondly, two days after the first notice, to tell people that the container was found by a tea shopkeeper and was already handed over to a local police office in Kathmandu.

The first notice was not pleasing at all. It created a lot of fear of potential health hazards to the public. On newspapers, it was clearly mentioned that the source was being sent to Belgium as a regular process to get a new one. But it was sent via Courier service without a secure transportation arrangement. It illustrated the insufficient logistic management for the transportation of the source container. It seemed like the source handling was not given due priority by the authorities concerned during its transportation.

The material was used to treat cancer patients in Bharatpur Cancer Hospital, as a radioactive source for Brachytherapy Unit. Such radioactive materials if not sealed or expose an individual under unsafe condition can create different health problems ranging from skin reddening, erythema, cataract to deadly cancer and genetic aberration. Effects like skin reddening can be observed within an hour or days after exposure which we call early effects of radiation. While the effects like cancer might manifest in years or decades after exposure, which we call the late effect of irradiation.

In developed countries and in some other developing countries like India, they have clear code of practice for the transportation of radioactive sources. It has helped them for proper transportation management of the source containers. Such code of practice is generally recommended by agencies like IAEA and other national or regional organizations.Although Nepal became the member of IAEA in 2008, it lacks national rules and regulation regarding the handling and transportation of radioactive sources, which might have posed the challenges in source container transportation. The incident was typical of all possible mishandling of sources in future.

It is obvious that there was lacking in the transportation of the radioactive source container this time–firstly such serious issue should have been handled with greater care by the hospital administration. Secondly, it has already been too late to inform the general public about the effects of ionizing radiation at all situations because nowadays we are using ionizing radiation large and broad for varieties of purposes. Thirdly, the media which can play crucial role in creating awareness among people about the benefits and hazards of ionizing radiation in human health are found silent or not give due priority to this. Fourthly, Government of Nepal is not formulating a Radiation Protection Law although it has been years after it became member of IAEA. Finally our intelligentsia are not discussing and debating in such issues within the framework of national need.

Now the time has come to converge into the formulation and implementation of National Radiation Protection Laws, building a national infrastructure, creating awareness among people about the pros and cons of ionizing radiation, discussing and debating on the safety issues etc. If these things can be done, the safe use of radiation to benefit people can be assured.

The writer is a member of Bangladesh Medical Physics Society, and a student of Medical Physics, Gono Bishwabidyalay, Dhaka, Bangladesh.