Scholarly article on topic 'Improving Quality and Access to Radiation Therapy- An Iaea Perspective'

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Abstract of research paper on Economics and business, author of scientific article — May Abdel-Wahab, Eduardo Zubizarreta, Alfredo Polo, Ahmed Meghzifene

The International Atomic Energy Agency (IAEA) has been involved in radiation therapy since soon after its creation in 1957. In response to the demands of Member States, the IAEA׳s activities relating to radiation therapy have focused on supporting low- and middle-income countries to set up radiation therapy facilities, expand the scope of treatments, or gradually transition to new technologies. In addition, the IAEA has been very active in providing internationally harmonized guidelines on clinical, dosimetry, medical physics, and safety aspects of radiation therapy. IAEA clinical research has provided evidence for treatment improvement as well as highly effective resource-sparing interventions. In the process, training of researchers occurs through this program. To provide this support, the IAEA works with its Member States and multiple partners worldwide through several mechanisms. In this article, we review the main activities conducted by the IAEA in support to radiation therapy. IAEA support has been crucial for achieving tangible results in many low- and middle-income countries. However, long-term sustainability of projects can present a challenge, especially when considering health budget constraints and the brain drain of skilled professionals. The need for support remains, with more than 90% of patients in low-income countries lacking access to radiotherapy. Thus, the IAEA is expected to continue its support and strengthen quality radiation therapy treatment of patients with cancer.

Academic research paper on topic "Improving Quality and Access to Radiation Therapy- An Iaea Perspective"

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Seminars in

RADIATION ONCOLOGY

Improving Quality and Access to Radiation Therapy- An Iaea Perspective

May Abdel-Wahab, Eduardo Zubizarreta, Alfredo Polo, Ahmed Meghzifene

Joel E. Tepper, MD Editor

Normal Tissue Tolerance in Stereotactic Body Radiation Therapy

www.eLsevier.com^ocate/enganabound

PII: S1053-4296(16)30060-1

DOI: http://dx.doi.org/10.1016/j.semradonc.2016.11.001

Reference: YSRAO50572

To appear in: Seminars in Radiation Oncology

Cite this article as: May Abdel-Wahab, Eduardo Zubizarreta, Alfredo Polo and Ahmed Meghzifene, Improving Quality and Access to Radiation Therapy- An Iaea Perspective, Seminars in Radiation Oncology,

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IMPROVING QUALITY AND ACCESS TO RADIATION THERAPY- AN IAEA PERSPECTIVE May Abdel-Wahab*, MD, PhD, Eduardo Zubizarreta, MD, Alfredo Polo, MD,

Ahmed Meghzifene, PhD Division of Human Health, Department of Nuclear Sciences and Applications International Atomic Energy Agency (IAEA) P.O. Box 100, 1400 Vienna, Austria

Corresponding author

Address first proofs and reprints requests to May Abdel-Wahab, MD, PhD at P.O. Box 100, 1400 Vienna, Austria. E-Mail: M.Abdel-Wahab@iaea.org

Conflict of interest: none. Abstract

The International Atomic Energy Agency (IAEA) has been involved in radiation therapy since soon after its creation in 1957. In response to the demands of Member States, the IAEA's activities relating to radiation therapy have focused on supporting low and middle income countries to set up radiation therapy facilities, expand the scope of treatments, or gradually transition to new technologies. In addition, the IAEA has been very active in providing internationally harmonized guidelines on clinical, dosimetry, medical physics and safety aspects of radiation therapy. IAEA clinical research has provided evidence for treatment improvement as well as highly effective resource sparing interventions. In the process, training of researchers occurs through this program. In order to provide this support, the IAEA works with its Member States and multiple partners worldwide through several mechanisms.

In this article, we review the main activities conducted by the IAEA in support to radiation therapy. IAEA support has been crucial for achieving tangible results in many low and middle income countries. However, long-term sustainability of projects can present a challenge, especially when considering health budget constraints and the brain drain of skilled professionals. The need for support remains, with more than 90% of patients in low income countries (LIC) lacking access to radiotherapy. Thus, the IAEA is expected to continue its support and strengthen quality radiation therapy treatment of cancer patients.

1. Introduction

The International Atomic Energy Agency (IAEA) has had, for over 30 years, several projects that aim to enhance quality, safety and access to radiation therapy practice world-wide \ The aim of this paper is to give an overview of some of the IAEA activities that contribute to the safe and effective implementation of radiation therapy. This is not meant to be an exhaustive review, but rather an introduction to the breadth of services and activities in radiation therapy. Essential elements to ensure success within a country include a supportive political environment, an appropriate professional milieu with a trained workforce with the needed technical expertise, as well as dependable sources of financial support. New and innovative programs are needed to improve outcome and reduce the inequities in cancer care. The IAEA, through its different programs, and upon requests by its current 168 Member States 2, can support national services that offer safe and effective access to quality radiotherapy treatment 3.

2. Historical background

The IAEA was created in 1957 with an initial 56 Member States 2 in response to hopes and fears that resulted from the discovery of nuclear energy 4. In the same decade, radiotherapy was expanding

tremendously in many countries, supported by the rapid development of Co-60 teletherapy technology. Although the potential benefits associated with the use of Co-60 teletherapy were already recognized, the IAEA and the World Health Organization (WHO) soon identified the need to support its implementation in many Low and Middle Income Countries (LMIC) as well as the need to standardize radiation dosimetry worldwide to ensure consistent, effective and safe delivery of radiotherapy treatments. For example, the IAEA supported countries of Latin America to replace the use of radium in the treatment of uterine cancer by the safer and more reliable radioisotope caesium-137.

In the area of radiation dosimetry, around I9605, a small group of medical physicists working at the IAEA formulated and launched a program aimed at assisting radiotherapy in Latin America where ionizing radiation was extensively used in medicine at that time. In order to assess the therapeutic doses delivered to the patients, the IAEA organized a dose inter-comparison with selected radiotherapy hospitals by mail using Thermo-luminescent dosimeters 6. This proved to be of utmost importance in the following decades. It soon became clear that a critical issue was the absence of dosimetry laboratories in those areas of the world. In fact, the IAEA noted that, even in many industrialized countries, such national dosimetry services with a direct link to the international measurement system did not exist.

As a result of these findings, a Network of Secondary Standards Dosimetry Laboratories (SSDLs) was established jointly by the IAEA and the WHO in 1976 5. From only eight SSDLs in in 1976, the Network now includes 82 laboratories in 67 Member States. To strengthen its support, the IAEA established a central laboratory in Seibersdorf to support the development and international standardization in radiation dosimetry and provide dosimetry services to Member States that have no access to such services. Through the calibration services, the IAEA provides a link to the international measurement system through its reference dosimetry system within the framework of the Mutual Recognition Arrangement of the International Committee for Weights and Measures. In addition to calibration

services, the IAEA provides dosimetry verification services both for SSDLs and for end-user institutions engaged in radiotherapy and radiation protection. These verification services aim at supporting the Member States to check the integrity of their dosimetry standards and implementation of dosimetry protocols in radiotherapy hospitals. The primary beneficiaries of these activities are hospital patients undergoing medical procedures involving radiation, hospital staff and the general public that benefit from improved dosimetry practices. In addition to radiation dosimetry, the IAEA has also supported the establishment or upgrading of many radiotherapy centers in many low and middle income countries. With an investment of nearly €300 million in cancer and radiotherapy projects throughout the world, the IAEA support has been instrumental in improving access to radiotherapy treatments in many countries.

Establishing new radiotherapy facilities is a long process and requires strong governmental support. It involves staff training (2-5 years), facility planning and construction, equipment specification, equipment procurement, installation, acceptance testing and commissioning, registration and licensing, developing protocol and procedures including quality control programs 7.

3. Current radiation therapy status

Only five out of ten cancer patients needing radiotherapy in LMIC have access to treatment 8. The situation is worse in low income countries (LIC) where access is only 10% and 74% of the population lives on less than US$ 2 per day 9, 10. There are 28 countries in Africa without a single radiotherapy machine and an average gross national income (GNI) per capita of US$ 410 8. Many of these countries have a high incidence of malaria and human immunodeficiency virus (HIV), high child mortality, low life expectancy, lack of infrastructure and basic services, and the expenditure in health per capita is in some cases 100 times lower than in European countries 11. But as child mortality is decreasing and the fight against infectious diseases is better organised, the cancer problem begins to be visible.

Figure 1 presents the existing and needed machines in 2013 and the needs for 2035 according to income groups and figure 2 shows the gap between actual and needed machines in LMIC in 2013 divided by IAEA regions. The assumption in figure 1 was that treatment machines work 12 hours, while for the calculation in figure 2 the machines only run for 10 hours 3, 8. Figure 3 shows current radiotherapy coverage for assumed 12 hours machine daily utilization 12.

Existing-needed machines per income group

Number of machines h-iNiUj^uim^iDOiiO oooooooooa oooooooooo ooooooooooo

HIC U-MIC L-MIC LIC

■ Existing 2013 8911 3145 1014 62

■ Needed 2013 8300 4128 2252 624

□ Needed 2035 9205 7358 3909 1266

Figure 1. Existing and needed machines in different income groups in 2013 and 2035 (based on data from 3)

Existing-needed machines per region in LMIC

6000 tn £ 5000 IE m 4000 rtj E H- 3000 o £ 2000 A E 3 1000 z 0

Africa Asia and the Pacific E j rope-Central Asia Latin America

■ Existing 2013 278 2541 527 875

□ Needed 2013 981 5684 713 1170

Figure 2. Existing and needed machines in LMIC in different regions in 2013 (based on data from 8).

Figure 3. Current radiotherapy coverage for assumed 12 hours machine daily utilization (based on data from Dirac12).

4. IAEA activities to address the needs 4.1 Education and Training

Radiation therapy is a complex process, which is carried out by a multi-disciplinary team of health care professionals composed of a radiation oncologist, a medical physicist and a radiation therapy technologist (RTT) or radiation therapist. The roles and responsibilities of these professionals have been defined in previous IAEA guidelines 7, and are based on knowledge, skills and competencies, which are acquired through academic education and clinical training programs followed by a certification and registration process. However, such highly specialized education programs exist only in a limited number of low and middle income countries. Even when available, such programs are usually not comprehensive and often lack critical components. For example in the field of medical physics, the current requirements for the qualification of medical physicists vary largely throughout the world. This variation was confirmed by the results of two large scale surveys made by the European Federation of Organizations of Medical Physics (EFOMP) in 2006 and the IAEA in 2010-201113. The largest discrepancy corresponds to huge variations in clinical training programs across different countries. Their duration varies from non-existing to a four year requirement. Graduates of such programs (MSc or PhD level) with no clinical training are not clinically qualified to work in a hospital environment without direct supervision. Taking these findings into account, the IAEA, in consultation with medical physics professional societies, decided to establish internationally harmonized criteria on the minimum recommendations for academic and clinical training of medical physicists. The IAEA guidelines 13 were endorsed by the International Organization for Medical Physics and the American Association of Physicists in Medicine. They are now used to achieve common standards of competence in medical physics worldwide.

The IAEA has also produced syllabi for the education of radiation oncologists, endorsed by The European Society for Radiotherapy and Oncology (ESTRO) and the American Society for Radiation Oncology (ASTRO), radiotherapy nurses, and two versions of syllabi for radiation therapists 14, 15.

The IAEA activities include the development of training material such as handbooks 16, an online training resource for radiotherapy professionals, and competence-based clinical training guides 17. In addition, the IAEA organizes national, regional or inter-regional training courses and workshops. For example, during the past 5 years, the IAEA has organized about 60 training courses and workshops and 4 interregional workshops for health care professionals working in radiation therapy. To ensure that the training programs organized by the IAEA meet the needs of the radiotherapy professionals, the contents are decided in consultation with national or regional representatives from member states and professional societies participating in IAEA projects. IAEA training courses and workshops include an important component of hands-on work and aim at building knowledge in a specific area or focus on implementation of a specific technique, such as tumor volume contouring, radiosurgery, brachytherapy techniques, the use of in-vivo dosimetry for checking treatment delivery, commissioning of new equipment or implementation of dosimetry codes of practice. In addition to human capacity building, participation in IAEA courses and workshops strengthens networking by bringing together experienced radiotherapy professionals from developing and LMIC. Furthermore, the IAEA supports continuous professional development through its Technical Cooperation (TC) projects. Under relevant projects, fellows from LMIC are supported to get specific training in a suitable institution abroad for periods ranging from a few months to one year to enhance previous training or de-novo training of two years (RTTs and physicists) to 4 years (radiation oncologists). In addition, IAEA has an extensive e-learning platform that supports activities through the Human health campus 18 and VUCCnet 19. In addition,

Afronet, a virtual tumor board with 9 participating African countries is also available to support activities 20. Many of the above resources can be found online.

4.2 Research and development activities

4.2.1 Overview

The rapid advances in the field of radiation therapy in the past decades threaten to increase the existing gaps in the access and availability of radiation oncology technologies between LMIC and other technologically advanced countries. LMIC face unique challenges, from inadequate financial resources to fund technology and support clinical research, to the lack of robust educational plans and training infrastructure for physicians, physicists, and technologists to ensure the sustainability of the practice.

The IAEA supports research and development of practical applications of atomic energy for peaceful purposes throughout the world and fosters the exchange of scientific and technical information as well as exchange of scientists. The IAEA's Coordinated Research Activities (CRAs) have been designed to contribute to the fulfilment of this mandate by stimulating and coordinating research by institutes in IAEA Member States in selected nuclear-related fields, such as radiation therapy. The CRAs are normally implemented through Coordinated Research Projects (CRPs) which bring together national research institutes (normally 5-15) in both developing and developed Member States. This occurs within a well-defined operational framework for research. Research, technical and doctoral contracts and research agreements are awarded to institutes in Member States to allow completion of research work under these CRPs. The IAEA may also respond to proposals from institutes for participation in the research activities under individual research contracts not related to a CRP. Coordinated Research Activities are a gateway for researchers in Member States to access a neutral platform of controlled quality clinical research where a full range of projects (from pre-clinical to phase III trials, health economics trials, patterns of care, and cost-analyses http://cra.iaea.org/cra/explore-crps) can be discussed and actions

planned. Funding research to improve health globally fulfil the IAEA commitment to international development while also exploring research questions of relevance that would be difficult to address otherwise.

The IAEA has built a substantial Global Health research portfolio, reinforcing the leadership of the Agency in key areas of radiotherapy, nuclear medicine, and medical physics. The research results are freely available worldwide for use by all its Member States. Without the Agency's support, such research would not be available in many LMIC.

Since 1959, when CRAs were initiated (the first CRP started in 1960), the IAEA has funded these activities with a total of €159 million. During the last ten years (2004 - 2014), the total budget for CRAs was about €70 million, with €19 million dedicated to the Human Health program. In 2014, the total budget assigned to CRAs for the entire IAEA fields of activities was €6.7 million. One hundred and eight Member States participated in 131 CRPs. The Human Health program managed 31 of these CRPs, funded with €1.7 million (25% of the total).

Since 1999, Doctoral CRPs were introduced to help create a one to one relationship between research agreement holders, research contract holder (a PhD or other equivalent advanced degree) and the training program at the contract holder's institution. Doctoral CRPs pair a host institution from a LMI country with an agreement institution from a developed country in a doctoral program, to foster impact on medical services, teaching and research in LMIC. Under the Human Health program, 172 research contracts, 16 technical contracts and 16 doctoral contracts were awarded in 2014. The clinical research portfolio included in CRPs in radiation therapy includes several thematic areas such as: comparative effectiveness, resource sparing, quality assurance (QA) and patient safety, patterns of care, and innovation and emerging issues and applied radiobiology). In the field of medical physics, the CRP topics include testing of a dosimetry code of practice for new technologies using small photon fields,

developing dosimetry audit methodologies for advanced radiation therapy techniques and QA in breast screening.

4.2.2 Impact of the CRAs:

The impact of the CRAs in the field of Human Health is varied and far-reaching. It is not unusual to find that such activities are the first of their kind in a given country and thus are instrumental in building capacity in radiation therapy research in Member States. The participating researchers can act as a nidus or core group with expertise that can support future research activities within the country. In addition, the program allows provision of opportunities for scientists and institutions in Member States to conduct research that would not otherwise be possible. The benefits, however are not limited to support in navigating the processes involved in research, but includes access to specialized researchers in various fields and close contact with networks of experienced researchers world-wide. This latter benefit can support sustainability of future efforts as well. In addition to benefits to individuals, institutions or countries, the research program can provide significant benefits in terms of well-thought out trials that can lead to greater resource sparing, leading to decrease in unnecessary visits to hospitals, and enhancing patient comfort, while freeing resources to increase treatment capacity. One example of this is the glioblastoma trial 21 which demonstrated that frail elderly patients can be spared longer radiation therapy courses with no significant decrement. Another trial showed that a brachytherapy boost did not improve the results when added to external beam radiation in advanced nasopharyngeal cancer 22. Other potential benefits include training in the techniques and providing evidence to support the use of certain technologies in targeted diseases. One example is research examining the role of stereotactic body radiotherapy (SBRT) in hepatocellular carcinoma through a randomized trial that compares transcatheter arterial chemoembolization (TACE) with SBRT. Such a trial will not only allow training on the technique for participating radiation oncologists, but will also allow the use of a novel

liver QA phantom and will bring together leaders in the field with other colleagues to enhance their networks and provide a forum for continued future collaboration.

The mechanism can also be used to enhance safety and efficiency by training in contouring and assessing the effect of this training (e.g. CRP E33039: Improving Radiotherapy Treatment Planning for Patients with Nasopharyngeal Carcinoma in LMI countries). Other trials can optimize collaboration between related disciplines (e.g. PET-CT based lung cancer treatment planning trial) 23, 24 to allow the optimal use of imaging in radiation oncology practice. For example, the PET/CT study is comprised of two components. The first, CRP E13042, focuses on the diagnostic aspects of introducing 18F-FDG PET/CT for RTP including quality control, acquisition and processing protocols, and imaging analysis and interpretation. The second component of the study, CRP E33038, concentrates on the PET/CT utilization for the tumor volume determination and on the clinical outcomes of such treatment approach. PET/CT for radiation therapy treatment planning will be introduced and implemented for patients with stage III A/B NSCLC in participating centers that are suitably equipped but were previously unable to implement this technology.

In addition, by virtue of the wide spectrum of countries involved and LMIC involvement, there is a possibility of generating evidence-based guidelines relevant to these countries. Furthermore, there are many opportunities for developing unique perspectives in public/global health and health economics, supported by tools such as the Directory of Radiotherapy Centers (DIRAC) 12. Currently major efforts are underway to further streamline the various processes within the clinical research program.

4.3 Technical cooperation

The IAEA Technical Cooperation (TC) Program is a delivery mechanism in which IAEA recipient Member States can propose national projects in different fields of activity, including human health, food and agriculture, hydrology, nuclear power and safety, etc. These projects are usually designed for a two to

five year cycle and include training of professionals, advice from international experts, and occasionally the supply of cost-shared equipment. National projects have proved to be extremely useful not only for the establishment of the first radiotherapy facility in many countries (e.g. Ethiopia, Ghana, Mongolia, Namibia, Uganda, Yemen, Zambia) but also to begin local training of professionals, upgrade of services or to introduce modern techniques. There are also regional projects mostly dedicated to training and capacity building in the four IAEA regions: Europe, Asia and the Pacific, Africa, and Latin America. The annual budget of the TC program is around €100 million, and human health projects represent about 25% of the total expenditure. Over the last 30 years, the IAEA has invested more than 270 million in cancer-related projects.

The ideal process of starting radiation therapy services where they don't exist begins with a feasibility study, a medium-long term plan, and the establishment of the first basic radiation therapy department, including training abroad of the team. The radiation safety regulatory infrastructure should be in place to ensure implementation of all requirements for the safe use of the imaging and treatment modalities. Once the department has reached an appropriate level of competence, local educational programs for RTTs, radiation oncologists, and medical physicists should be implemented. The possibility of training, at least partially, locally new professionals will enable a third phase of expansion of the facility or establishment of new centers. This complex process requires a strong commitment of all parties, including the government, to ensure sustainability and later expansion of the services, which typically can take up to ten years. The medium-long term plan for radiation therapy, done at the beginning of a project, should include these three phases.

Regional projects include several countries from the same region and focus mainly on human capacity building. Their activities include regional training courses and workshops and expert services. The thematic of these projects usually addresses and accompanies the technological evolution in the region.

4.4 Quality and safety

4.4.1 Quality Assurance in radiation therapy

Over the years, then IAEA has been involved in quality assurance and safe radiotherapy 1 published multiple guidelines on quality assurance programs and quality control procedures to support safe and effective patient treatment in radiation therapy. These reports give general guidance on the establishment of quality assurance programs 7, as well as specific guidance on quality control procedures 25, 26. Several national radiation safety regulations have also incorporated specific requirements on the implementation of QA programs in radiation therapy. The implementation of QA programs is expected to lead to better outcomes, as demonstrated by a recent literature review 27. In order to investigate further this topic, the IAEA launched in 2013 a coordinated research project aiming at establishing whether there is a link between the quality assurance effort and the accuracy achievable, as measured by independent end to end phantom tests. A future phase could then provide additional evidence that more accurate radiotherapy translates into improved clinical outcomes. The methodology and results of this coordinated research project will be published soon after it is completed at the end of 2017.

The IAEA offers also dosimetry services to countries that have no national dosimetry infrastructure. These dosimetry services are an important technical component of QA programs to ensure traceability of all measurements to the international System of Units and also to verify adequate implementation of dosimetry protocols in radiation therapy clinics. The IAEA services include the calibration of national dosimetry standards maintained by national calibration laboratories as well postal dose verifications to ensure proper calibration of radiotherapy beams in countries that have no such capabilities. This postal dosimetry service checks approximately 600 clinical beams per year. Since the service has started in 1969, it has checked a total of more than 4500 radiotherapy beams in approximately 2000 hospitals. Follow-up actions on results outside the acceptance limit support the radiotherapy centers to resolve

the deviation, thus preventing further mistreatment of patients. The TLD program is implemented through a close collaboration between the IAEA and WHO (Pan American Health Organization, PAHO, in Latin America). A comprehensive QA program supports the IAEA dose quality audit program. The long-term impact on the improvement of the results with time is significant, as highlighted in Figure 4 which shows the trends of the fraction of the results that are within the 5% acceptance limit.

1.0 J 0.9 'E 0.8

M 0.7 0)

& J ^ ^ ^ # ^ ^ V* V*

Figure 4. Improvements of medical dosimetry with time as a result of the IAEA/WHO hospital TLD dose verification program. The dashed black line shows the trend as a result of the first postal TLD check. The solid black line shows the improvement as a result of follow-up when the first exposure is outside of the 5% acceptance criterion.

As part of a comprehensive approach to QA in radiation therapy, an independent external audit is highly recommended to review the quality of practice and advice on improvement. To ensure a harmonized approach to QA audits, the IAEA developed the concept of a "Comprehensive Audits of Radiotherapy Practices: A Tool for Quality Improvement, Quality Assurance Team for Radiation Oncology (QUATRO)", which was published in 200828. The objective of QUATRO is to review and evaluate the quality of all of the components of the practice of radiotherapy at an institution, including its professional competence, with a view to quality improvement. A multidisciplinary team, comprising a radiation oncologist, a

medical physicist and a radiotherapy technologist, carries out the audit. Until now, the IAEA has conducted about 70 audit missions worldwide.

4.4.2 Radiation Safety and Security

In addition to its mandate to support the use of peaceful nuclear techniques in many areas such as health, the IAEA has also an important role in the development of safety standards and in providing its support for their implementation in Member States. The IAEA safety standards reflect an international consensus on what constitutes a high level of safety for protecting people and the environment from harmful effects of ionizing radiation. They are established in consultation and cooperation with the competent organs of the United Nations and with specialized agencies, such as the WHO. One of the most widely recognized IAEA safety standards is the International Basic Safety Standards (BSS) 29. To strengthen patients and workers' safety in radiation therapy, the recently revised BSS includes, among other requirements, specific reference to QA, traceability of measurements and the need to use a dosimetry code of practice. Furthermore, specific requirements are given on the qualifications and skills of the members of the radiation therapy team (radiation oncologist, medical physicist and therapy radiographer).

In December 2014, the IAEA expanded activities to help support the development of a nuclear security culture in medical institutions requesting assistance on the secure use of radioactive sources. The institutions are assisted in the methodology of self-assessment of nuclear security culture, and understanding of the key elements underlying a strong nuclear security culture and security risks associated with radioactive sources. This allows institutions to take responsibility for ensuring the security of radioactive sources and to effectively counteract related threats and risks.

4.5 Inter-Agency Collaboration

The design, planning and implementation of activities in radiation therapy require collaboration between several regional and international organizations, professional bodies and specialized institutions, non-governmental organizations as well as governmental authorities. In order to foster information exchange with other institutions and improve coordination at national, regional and international level, the IAEA has established several formal collaborations with these important stakeholders through memoranda of understanding and practical arrangements.

4.5.1 Collaboration with UN organisations

The IAEA and the WHO collaborate on the human health program through a memorandum of understanding. The IAEA-WHO collaboration on medical dosimetry is also formally included in an agreement signed by both organizations to setup the IAEA/WHO Network of Secondary Standards Dosimetry Laboratories.

The IAEA, in collaboration with other UN agencies like the International Agency for Research on Cancer (IARC) and the WHO offers an assessment tool ("integrated missions of PACT" intended to assess a Member State's readiness to develop and implement a long term radiation medicine infrastructure and capacity building plan, including the relevant safety, regulatory and quality assurance requirements, within the framework of a National Cancer Control Plan. The mission team assesses the Member State's radiation medicine infrastructure and human resource circumstances, examines existing and future plans related to cancer services (including radiation oncology), and advises on priority actions to address the issues that have been identified. A detailed mission report containing the findings, analysis, conclusions and recommendations is submitted to the Ministry of Health of the requesting Member State. Upon the receipt of the report, a "Short to Medium Term Action Plan" is expected to be created by the Ministry of Health, leading to project proposals, multidisciplinary assistance packages and

identification of potential sources of funding for the established priorities, helping also in the planning of the country's cancer-related technical cooperation projects.

Global Action Plan for the prevention and control of non-communicable diseases

After fifty years focusing on the management of communicable diseases the global health community is now becoming aware of the major challenge of chronic and non-communicable diseases (NCDs), including cancer. In May 2013, the World Health Assembly endorsed the WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020. The Global Action Plan provides Member States, international partners and WHO with a road map and menu of policy options which, when implemented collectively between 2013 and 2020, will contribute to progress on key global indicators to be attained in 2025, including a 25% relative reduction in premature mortality from NCDs by 2025.

UN Interagency Task Force on the Prevention and Control of NCDs (UNIATF)

The UN Interagency Task Force on the Prevention and Control of NCDs (UNIATF) was established by the UN Secretary-General in June 2013 to "coordinate the activities of the relevant United Nations funds, programs and specialized agencies and other intergovernmental organizations to support he implementation of the World Health Organization Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013-2020" (paragraph 2 of Economic and Social Council resolution 2013/12 of 22 July 2013) 30. The IAEA participates actively in the UN Interagency Task Force. Currently there are two joint projects that aim to increase access to cervical cancer prevention, control and monitoring services:

• The Integrated IAEA-IARC-WHO Joint Project on Cancer Control:

The Joint Project will provide technical assistance to governments in about seven selected countries. These countries will act as hubs to disseminate experience to neighbouring countries.

• Joint United Nations Global Program on Cervical Cancer Prevention and Control: The objective of the collaboration is for UN agencies to work together to increase access to cervical cancer prevention, control and monitoring services as an entry point for other types of cancer in low- and middle- income countries. It will build on the expertise and experience of several UN agencies with regards to cancer prevention and control, including the successes and lessons learned from over 30 years of IAEA technical expertise in implementing radiotherapy programs and radiation medicine in LMIC. The country-wide coordinated activities will be initiated in 3 countries from 3 different regions, with plans for further expansion to 7-9 countries in the future.

4.5.2 Collaboration with the Union for International Cancer Control (UICC)

The IAEA has been a key supporter of the Global Task Force on Radiotherapy for Cancer Control (GTFRCC) whose mandate was to identify the need for global deployment of radiation therapy infrastructure to a reasonable standard and to identify an investment framework to close this equity divide. The purpose of the GTFRCC was "...to unite the cancer community to reduce the global cancer burden, to promote greater equity, and to integrate cancer control into the world health and development agenda." The GTFRCC report quantifies coverage of radiotherapy services worldwide and by country and analyzed factors precluding access to radiotherapy services. It also includes new estimates for the future burden of cancer to 2035 and the projected demand for radiotherapy services by country and globally from 2015 to 2035, to ascertain the scale-up of radiotherapy services needed. Economic models have also been defined to better understand the conditions needed for the delivery of high-quality radiotherapy services in low-income and middle-income countries. Finally, the GTFRCC has proposed a call for actions based on 5 strategic axes to reduce the gaps 3.

4.5.3 Collaboration with professional societies

The IAEA maintains close collaboration with many professional societies, which are active in radiation therapy, radiation biology, dosimetry and medical physics. The collaboration includes consultations with relevant numerous scientific committees and task groups of professional societies on the development of new guidelines, training material and codes of practice. For example in the field of dosimetry, the international code of practice on radiotherapy dosimetry 31 is endorsed by the European Society of Radiotherapy and Oncology, while the IAEA guidelines on roles and responsibilities and education and clinical training requirements for medical physicists 13 are endorsed by the International Organization for Medical Physics as well as the American Association of Physicists in Medicine. The endorsement of IAEA guidelines by international and regional professional societies facilitates their adoption at the national level, avoids duplication of efforts and contributes to worldwide harmonization of procedures.

5. Impact of projects

An important role of the IAEA is to promote the safe and effective use of nuclear techniques. Additionally, the IAEA is a key player in supporting countries to set up radiotherapy programs in low and middle income countries in all regions. The radiotherapy needs are evident world-wide, especially in Africa, 32 and the IAEA offers support world-wide. For example, the IAEA has supported Zambia, through several technical cooperation projects, to establish their first radiation therapy department in 2008. The IAEA provided advice on the planning and building of the centre and supported the purchase of the equipment (linear accelerator, Cobalt-60 machine, a conventional simulator, a 3-D treatment planning system, and a High Dose Rate brachytherapy unit). The IAEA also supported the training of the radiation therapy team in South Africa. The government was highly committed and took the necessary measures to retain all trained professionals in the country. The centre became operational in 2008, and in the next 5 years incorporated another cobalt machine, an additional high dose rate brachytherapy unit , a CT simulator, a magnetic resonance imaging unit, and constructed a new building to expand the oncology

guards including teaching facilities. Training programs for RTTs and radiation oncologists were established in 2012 and 2014, respectively. The country is now planning the establishment of satellite centers to improve access to radiotherapy treatment.

Sustainability is difficult to attain in many low and middle income countries, due to insufficient funding and brain drain of human resources. The initial effort of establishing a radiotherapy centre and training professionals is not always followed by a continuous commitment to ensure maintenance of the equipment, additional training and continuous professional development, and further expansion of the radiation therapy services.

The involvement of the IAEA in different regions through regional technical cooperation projects has in some cases facilitated the establishment of regional professional societies or specialized professional groups such as the African Group for Radiation Oncology (AFROG). In those cases, the IAEA not only supported the training and continuous professional development but also serves as a hub for networking between radiation therapy professionals within the region.

For CRAs, the main impact of the projects is capacity building of local and interdisciplinary teams in the area of research and development. In addition, new methodologies are also compared and tested through the CRAs. For example, through a CRP on the development of quality audits for radiotherapy dosimetry for complex treatment techniques, the methodologies developed within the project were tested through a series of pilot and multi-national studies. In the final stage, the national audit networks participating in the CRP incorporated these methodologies in their national audit programs, after having adapted the audit procedures to their national conditions. The results and methodologies developed within this CRP have enhanced radiation dosimetry expertise in participating countries. The knowledge gained has provided improved confidence for the dosimetry audit networks to introduce audits for more complex technologies and treatments. The ultimate beneficiaries are the patients undergoing complex

radiotherapy procedures who are expected to receive improved quality treatment. The participants have produced a number of scientific publications presenting the research results achieved within the CRP.

6. Future needs and directions

According to a recent analysis on the future needs for radiation therapy 8, more than 50% of patients requiring radiotherapy in LMIC do not have access to treatment. The situation is even more dramatic in low income countries, where the proportion is higher than 90%. In terms of teletherapy equipment, the analysis shows that the 4300 machines are available in LMIC whereas 7000 additional units would be needed 9. This situation is expected to improve in the coming years, but still a large proportion of patients with indication for radiotherapy will not have access to treatment in the near future. Another recent study 3 has also shown that that investment in radiotherapy not only enables treatment of large numbers of cancer cases to save lives, but also brings positive economic benefits.

The IAEA uses several mechanisms to support safe and effective implementation of radiation therapy. For a new centre, the IAEA provides published guidelines on planning and optimized layout of facilities, equipment, QA, staffing, and education and training. IAEA provides support for practical implementation through the supply of equipment, provision of expert services and fellowships for training of health care professionals. For existing centers, the IAEA provides educational material for continuous professional development, coordinated research opportunities for participation in clinical trials and testing of protocols and also supports the expansion or upgrade of the facilities for safe transitioning to new technologies. However, the IAEA support remains limited, due to its budget limitations. In order to maximize the impact of its activities in radiation therapy, the IAEA has established strong collaboration with multiple stakeholders and partners. Through this collaboration and increased awareness of health

authorities on the benefits and cost-effectiveness of radiation therapy, access and quality treatment are expected to improve in the near future.

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22. Rosenblatt E, Abdel-Wahab M, El-Gantiry M, Elattar I, Bourque JM, Afiane Mh, Benjaafar N, Abubaker S, Chansilpa Y, Vikram B, Levendag P: Brachytherapy boost in loco-regionally advanced nasopharyngeal carcinoma: a prospective randomized trial of the International Atomic Energy Agency. Radiation Oncology 2014, 9:1-11.

23. Konert T, Vogel W, MacManus MP, Nestle U, Belderbos J, Gregoire V, Thorwarth D, Fidarova E, Paez D, Chiti A, Hanna GG: PET/CT imaging for target volume delineation in curative intent radiotherapy of non-small cell lung cancer: IAEA consensus report 2014. Radiother Oncol 2015, 116:27-34.

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26. International Atomic Energy Agency: Development of Procedures for In Vivo Dosimetry in Radiotherapy. Vienna: IAEA; 2013.

27. Fairchild A, Straube W, Laurie F, Followill D: Does quality of radiation therapy predict outcomes of multicenter cooperative group trials? A literature review. Int J Radiat Oncol Biol Phys 2013, 87:246260.

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32. Abdel-Wahab M, Bourque JM, Pynda Y, Izewska J, Van der Merwe D, Zubizarreta E, Rosenblatt E: Status of radiotherapy resources in Africa: an International Atomic Energy Agency analysis. Lancet Oncol 2013, 14:e168-175.

http://cra.iaea.org/cra/explore-crps/all-opened-for-proposals.html http://cra.iaea.org/cra/explore-crps/all-active-by-programme.html http://cra.iaea.org/cra/explore-crps/all-completed-by-programme-5-yrs.html CRP Code,Title ,Programme,Start Date,Completed/expected Date:

CRPs completed since 2010 (CRPs completed before 2010 can currently only be seen without selecting a specific programme).

E13037 The Use of Sentinel Lymph Node in Breast, Melanoma, Head & Neck and Pelvic Cancers Human Health 2010-10-12 2013-11-22

E15020 Application of FDG-PET and Molecular Gene Profiling for Risk Stratification of Diffuse Large B-Cell Non-Hodgkin's Lymphoma in Different Ethnic Populations Human Health 2006-09-15 2012-12-31

E24015 Doctoral CRP on Quality Assurance of the Physical Aspects of Advanced Technology in Radiotherapy Human Health 2008-06-15 2015-01-15

E24016 Development of Quality Audits for Radiotherapy Dosimetry for Complex Treatment Techniques Human Health 2009-03-26 2013-01-28

E33025 Resource Sparing Curative Treatment in Breast Cancer Human Health 2005-10-01 2013-01-30

E33026 Clinical/Radiobiological Study on Viral-Induced Cancers' Response to Radiotherapy, with Comprehensive Morbidity Assessment Human Health 2006-09-15 2015-02-02

E33027 Improving Outcomes in Radiotherapy Using New Strategies of Treatment Delivery with Focus on Oesophageal Cancer Human Health 2006-12-15 2013-01-28

E33030 Altered Fractionation and Radio-Sensitisation in Head and Neck Cancer Radiotherapy Human Health 2008-10-30 2015-12-17

E33031 Optimisation of Radiotherapy in Low Resource Settings: Paediatric Cancer Patients Human Health 2008-10-30 2014-08-06

E33032 Improving Outcomes in Radiotherapy using Novel Biotechnologies: Modification of Tissue Reactions and the Use of Stem Cell Therapeutics Human Health 2008-10-30 2012-11-15

E33033 Short Course Versus Standard Course Radiotherapy, in Elderly and/or Fragile Patients with Glioblastoma Multiform (GBM) Human Health 2009-02-04 2015-03-27

E33034 Resource-Sparing Curative Treatment for Rectal Cancer Human Health 2009-09-04 2015-11-26 Active CRPs (expected end date)

E12017 Standardizing Interpretation Criteria for Early Response Evaluation with 18f-FDG PET/CT in Paediatric Lymphoma Human Health 2013-07-04 2018-07-04

E13039 Enhancing Capacity for Early Detection and Diagnosis of Breast Cancer Through Imaging Human Health 2011-11-18 2016-11-18

E13042 Radiation Therapy Planning of Non-small cell lung cancer based on PET/CT. (Diagnostic component) Human Health 2014-05-29 2017-05-28

E24017 To Investigate the Relationship Between end to end Accuracy and Quality Assurance Extent and Depth in Radiotherapy Human Health 2013-06-04 2017-06-03

E24018 Development of Quality Audits for Advanced Technology (IMRT) in Radiotherapy Dose Delivery Human Health 2013-06-04 2016-06-03

E24021 Testing of Code of Practice on Small Field Dosimetry Human Health 2015-09-03 2018-09-02

E31006 Safety and Optimisation of Radiation Sterilization in Tissue Banking: Studies on Functional Properties of Irradiated Tissue Grafts Human Health 2010-03-18 2015-12-31

E31007 Instructive Surfaces and Scaffolds for Tissue Engineering Using Radiation Technology. (conducted jointly with F23030) Human Health 2014-04-04 2018-04-04

E33035 Resource Sparing Curative Radiotherapy for Locally Advanced Squamous Cell Cancer of the Head and Neck Human Health 2010-11-15 2018-11-14

E33036 Randomized Phase III Clinical Trial of Stereotactic Body Radiation Therapy versus Transarterial Chemoembolization in Hepatocellular Carcinoma Human Health 2014-05-29 2018-05-28

E33037 Evidence-Based Assessment of Radiotherapy Demand and Quality of Radiotherapy Services Human Health 2014-02-13 2017-02-13

E33038 Radiation Therapy Planning of Non-Small Cell Lung Cancer based on PET/CT (Radiation Oncology component) Human Health 2014-05-29 2018-05-28

E33039 Improving Radiotherapy Treatment Planning for Patients with Nasopharyngeal Carcinoma in Low and Middle Income Countries Human Health 2015-09-03 2018-09-28

E33040 Quality Assurance of Volumes Definition for Three-Dimensional Treatment Planning Human Health 2015-05-12 2018-05-11

E35008 Strengthening of "Biological dosimetry" in IAEA Member States: Improvement of current techniques and intensification of collaboration and networking among the different institutes Human Health 2012-02-10 2016-03-31

CRPs open for proposals

2109 Clinical applications of biodosimetry Human Health Planned

2117 Dosimetry in Molecular Radiotherapy for Personalized Patient Treatments Human Health Planned

2137 Modern radiotherapy techniques in cervical cancer Human Health Planned

2150 Use of PET-CT with Gallium-68 Labelled Prostrate Specific Membrane Antigen in the Diagnosis and Follow-up of Patients with Prostate Cancer Human Health Planned

2158 Comparison of Planar Multiple Gated Acquisition (MUGA) Scanning, Single Photon Emission Computed Tomography-MUGA and Echocardiography in the Evaluation of Chemotherapy Related Cardiotoxicity Human Health Planned

E12017 Standardizing Interpretation Criteria for Early Response Evaluation with 18f-FDG PET/CT in Paediatric Lymphoma Human Health Active 2013-07-04 2018-07-04

E13044 PET/CT in the Evaluation of Locally Advanced Breast Cancer Human Health New

E24021 Testing of Code of Practice on Small Field Dosimetry Human Health Active 2015-09-03 201809-02

E31007 Instructive Surfaces and Scaffolds for Tissue Engineering Using Radiation Technology. (conducted jointly with F23030) Human Health Active 2014-04-04 2018-04-04

E33035 Resource Sparing Curative Radiotherapy for Locally Advanced Squamous Cell Cancer of the Head and Neck Human Health Active 2010-11-15 2018-11-14

E33036 Randomized Phase III Clinical Trial of Stereotactic Body Radiation Therapy versus Transarterial Chemoembolization in Hepatocellular Carcinoma Human Health Active 2014-05-29 2018-05-28

E33039 Improving Radiotherapy Treatment Planning for Patients with Nasopharyngeal Carcinoma in Low and Middle Income Countries Human Health Active 2015-09-03 2018-09-28

E33040 Quality Assurance of Volume Definition for Three-Dimensional Treatment Planning Human Health Active 2015-05-12 2018-05-11

All CRPS including b4 2010

2051 Enhancing Capacity for Early Detection and Diagnosis of Breast Cancer Through Imaging Techniques Human Health

2053 Gated-SPECT in the Planning of Ischemia Guided PCI in STEMI Patients Human Health

2054 Strengthening the Role of Lu177 and Y90 in Cancer Treatment Human Health

2150 Use of PET-CT with Gallium-68 Labelled Prostrate Specific Membrane Antigen in the Diagnosis and Follow-up of Patients with Prostate Cancer Human Health

2158 Comparison of Planar Multiple Gated Acquisition (MUGA) Scanning, Single Photon Emission Computed Tomography-MUGA and Echocardiography in the Evaluation of Chemotherapy Related Cardiotoxicity Human Health

E13044 PET/CT in the Evaluation of Locally Advanced Breast Cancer Human Health

2058 Altered Fractionation and Radio Sensitization in Head-and-Neck Cancer Radiotherapy Human Health

2125 Image-based treatment planning in cervical cancer Human Health 2137 Modern radiotherapy techniques in cervical cancer Human Health 2062 Doctoral CRP in Advanced Imaging Modalities Human Health

2117 Dosimetry in Molecular Radiotherapy for Personalized Patient Treatments Human Health

1774 Coordinate a CRP on radiolabelled generator based alpha emitters (2010-2014) (in conjunction with 2.5.1.3) Human Health

1775 Coordinate a CRP on the use of targeted radiolabelled peptides for the diagnosis and treatment of solid tumours (2010-2013) (jointly with 2.5.1.3) Human Health

2056 Strengthening Biological Dosimetry. Human Health

2109 Clinical applications of biodosimetry Human Health

1563 Quality Assurance of Imaging Equipment Used in Radiotherapy (Activity 10) Human Health

1988 Coordinate a CRP on Treatment-related Uncertainties in Image-Based Radiation Therapy (jointly with 2.2.3.3) (2013-2015) Human Health

E11004 To establish national programmes and investigate their impact on the performance of quality control procedures of nuclear medicine instruments in Asia 1984-04-09 1988-09-07 1989-12-01

E12014 The standardization of I-131 treatment for hyperthyroidism with an intent to optimize radiation dose and treatment response (RCA) 1995-01-15 2000-08-31 2000-12-13

E13012 The diagnosis and follow up of prostatic cancer by RIA 1996-06-15 1999-12-31 1999-12-31

E13013 Efficacy and toxicity of 153-Samarium radiopharmaceuticals in the treatment of painful skeletal metastases 1996-04-15 2000-10-19 2000-10-19

E13017 Evaluation of Tc-99m based radiopharmaceuticals in the diagnosis and management of breast cancer patients 1997-07-15 2000-07-14 2000-10-16

E13019 Doctoral CRP on Management of Liver Cancer Using Radinuclide Methods with Special Emphasis on Trans-Arterial Radioconjugate Therapy and Internal Dosimetry 2000-09-01 2005-12-31 2006-01-23

E13020 Intravascular Radionuclide Therapy (IVRNT) Using Liquid Beta-Emitting Radiopharmaceuticals to Prevent Restenosis Following Percutaneous Transluminal Coronary Angioplasty 2000-11-15 2004-1231 2005-11-15

E13023 Radiopharmaceutical imaging to predict and evaluate the response of breast cancer to neoadjuvant chemotherapy 2001-08-01 2005-11-30 2006-02-13

E13024 Improvement in the Treatment of Acute Lymphoblastic Leukemia (ALL) by the Detection of Minimal Residual Disease (MRD) 2002-10-24 2006-12-31 2007-12-14

E21001 Testing of the code of practice for absorbed dose determination in photon and electron beams

1988-10-01 1993-11-04 1993-11-04

E21002 Development of a quality assurance programme for Secondary Standard Dosimetry Laboratories (SSDLs) 1996-07-15 1999-12-31 1999-12-31

E21004 Development of Techniques at SSDLs for the Dissemination of Absorbed Dose to Water Standards 2001-04-01 2004-03-31 2004-12-30

E23001 Computer Application in Clinical Dosimetry

E23002 Biophysical Aspects of Radiation Quality

E23003 Development of a Transfer Instrument for Neutron Dosimetry Intercomparison E23004 Reactor In-Pile Dosimeter Intercomparison and Standardization

E24002 Electron high-dose intercomparison for radiation processing 1983-07-11 1987-09-30 1987-1013

E24003 Development of quality control dosimetry techniques for particle beam radiation processing

1989-04-15 1995-05-20 1995-05-20

E24004 PERFORMANCE TESTING OF DOSIMETRY EQUIPMENT 1989-11-15 1993-11-04 1993-11-04

E24005 THERAPY LEVEL DOSIMETRY WITH ALANINE/ESR SYSTEM 1990-12-15 1993-06-21 1993-06-21

E24006 Characterization and evaluation of high-dose dosimetry techniques for quality assurance in radiation processing 1995-06-15 1999-10-15 1999-09-03

E24007 Development of a quality assurance programme for radiation therapy dosimetry in developing countries 1995-12-15 2001-12-31 2001-12-31

E24008 Dose determination with plane-parallel ionization chambers in therapeutic electron and photon beams 1996-07-15 2000-11-30 2000-11-30

E24009 Development of a Code of Practice for dose determination in photon, electron and proton beams based on measurement standards of absorbed dose to water 1997-09-01 2002-12-15 2002-1215

E24010 Alanine-ESR dosimetry for radiotherapy 1997-12-05 1997-12-05 1997-12-05

E24011 Electron Paramagnetic Resonance (EPR) biodosimetry 1998-04-01 2001-12-31 2001-12-31

E24012 Development of TLD-based quality audits for radiotherapy dosimetry in non-reference conditions 2001-12-15 2007-02-28 2007-12-14

E24013 Development of procedures for quality assurance for dosimetry calculations in radiotherapy 2004-04-01 2007-12-06 2007-12-06

E24014 Development of Procedures for in Vivo Dosimetry in Radiotherapy 2004-12-15 2008-10-13 2008-10-13

E33001 Radiation Hematology

E33002 Mechanism of Radiosensitivity and Repair

E33003 Improvement in Radiotherapy of Cancer Using Modifiers of Radiosensitivbity of Cells

E33004 Radiation Biology of Auger Emitters and their Therapeutic Applications

E33005 Exploration of the possibility of high LET radiation for non-conventional radiotherapy in cancer 1980-01-02 1985-01-01 1985-01-01

E33006 Improvement of cancer therapy in Asian countries by the combination of treatment by conventional radiation and physical or chemical means (RCA) 1982-04-02 1987-11-30 1987-12-11

E33007 Improvement of cancer therapy by the combination of treatment by conventional radiation and physical or chemical means 1982-04-02 1987-09-30 1988-04-01

E33008 Introduction of computerized dosimetry and database in radiotherapy of carcinoma of the cervix in Asian countries (RCA) 1990-06-01 1994-04-07 1994-04-08

E33009 COMPUTER-ASSISTED RADIOTHERAPY PLANNING FOR TUMOURS OF THE HEAD AND NECK (GLOBAL) 1990-12-15 1994-04-07 1994-04-07

E33010 Radiation responsiveness criteria for human tumours as determinant for therapeutic modality planning 1992-12-15 1999-05-27 1999-10-13

E33011 Modern techniques in brachytherapy of cancer with special reference to the developing countries 1993-12-01 1998-12-31 1998-12-31

E33012 Clinical application of radiosensitizers in cancer radiotherapy 1994-09-15 2002-12-31 200212-31

E33013 Randomised clinical trial of radiotherapy combined with Mitomycin C in the treatment of advanced head and neck tumours 1995-04-15 2003-04-30 2003-03-26

E33014 Application of heavy charged particles in cancer radiotherapy 1995-04-01 1999-12-31 199912-20

E33015 Quality assurance in radiotherapy for Latin America 1995-12-15 1999-06-30 1999-02-18

E33016 The use of radiotherapy in advanced cancer 1995-12-15 2000-08-31 2000-12-20

E33017 Regional hyperthermia combined with radiotherapy for locally advanced cancers 1997-12-15 2002-12-15 2002-12-15

E33018 Aspects of Radiobiology Applicable in Clinical Radiotherapy - Increase of the Number of Fractions per Week 1998-09-15 2006-05-31 2006-05-08

E33019 Comparative Evaluation of Two Head and Neck Immobilisation Systems CRP declined

E33020 Human Immunodeficiency Virus (HIV) markers in patients treated with radiotherapy for cervical cancer 2000-03-01 2001-12-22 2001-12-22

E33021 The role of teletherapy (TT) supplementary to intraluminal high dose rate (ILHDR) brachytherapy (BT) in the palliation of advanced oesophageal cancer 2002-09-01 2006-12-14 2006-1122

E33023 Resource Sparing Treatment of Head and Neck Cancer 2003-09-15 2009-12-31 2009-01-16

E33024 Radiobiological and Clinical Study on Viral-Induced Cancers Response to Radiotherapy 200408-01 2006-07-31 2006-10-10

E35005 EXPLORATION OF THE MOLECULAR MECHANISM(S) OF THE STIMULATORY EFFECT (I.E. ADAPTIVE RESPONSE) OF LOW-DOSE AND LOW-DOSE-RATE RADIATION 1991-04-15 1994-12-31 199502-17

E35006 Methodologies for comparative estimation of carcinogenicity of chemical pollutants and radiation released from fossil-fuelled and nuclear energy cycles 1992-12-04 1996-07-31 1997-04-01

E35007 Comparative assessment of teletherapy modalities 2001-08-01 2003-07-31 2003-05-28

E42001 Improvement of methodology of the epidemiological studies of health impacts from low-level ionizing radiation 1981-12-04 1985-12-03 1985-12-03

E24018 Development of Quality Audits for Advanced Technology (IMRT) in Radiotherapy Dose Delivery Human Health 2013-06-04 2016-06-03

E24021 Testing of Code of Practice on Small Field Dosimetry Human Health 2015-09-03 2018-09-02

E12017 Standardizing Interpretation Criteria for Early Response Evaluation with 18f-FDG PET/CT in Paediatric Lymphoma Human Health 2013-07-04 2018-07-04

E13039 Enhancing Capacity for Early Detection and Diagnosis of Breast Cancer Through Imaging Human Health 2011-11-18 2016-11-18

E13042 Radiation Therapy Planning of Non-small cell lung cancer based on PET/CT. (Diagnostic component) Human Health 2014-05-29 2017-05-28

E13044 PET/CT in the Evaluation of Locally Advanced Breast Cancer Human Health

E33030 Altered Fractionation and Radio-Sensitisation in Head and Neck Cancer Radiotherapy Human Health 2008-10-30 2016-10-30 2015-12-17

E33033 Short Course Versus Standard Course Radiotherapy, in Elderly and/or Fragile Patients with Glioblastoma Multiform (GBM) Human Health 2009-02-04 2015-02-04 2015-03-27

E33034 Resource-Sparing Curative Treatment for Rectal Cancer Human Health 2009-09-04 2014-09-04 2015-11-26

E33035 Resource Sparing Curative Radiotherapy for Locally Advanced Squamous Cell Cancer of the Head and Neck Human Health 2010-11-15 2018-11-14

E33036 Randomized Phase III Clinical Trial of Stereotactic Body Radiation Therapy versus Transarterial Chemoembolization in Hepatocellular Carcinoma Human Health 2014-05-29 2018-05-28

E33037 Evidence-Based Assessment of Radiotherapy Demand and Quality of Radiotherapy Services Human Health 2014-02-13 2017-02-13

E33038 Radiation Therapy Planning of Non-Small Cell Lung Cancer based on PET/CT (Radiation Oncology component) Human Health 2014-05-29 2018-05-28

E33040 Quality Assurance of Volumes Definition for Three-Dimensional Treatment Planning Human Health 2015-05-12 2018-05-11

E24017 To Investigate the Relationship Between end to end Accuracy and Quality Assurance Extent and Depth in Radiotherapy Human Health 2013-06-04 2017-06-03

E33022 Doctoral CRP on Clinical and Experimental Studies to Improve Radiotherapy Outcome in AIDS Cancer Patients Human Health 2003-06-15 2010-06-14 2011-07-12

E33027 Improving Outcomes in Radiotherapy Using New Strategies of Treatment Delivery with Focus on Oesophageal Cancer Human Health 2006-12-15 2012-12-31 2013-01-28

E31006 Safety and Optimisation of Radiation Sterilization in Tissue Banking: Studies on Functional Properties of Irradiated Tissue Grafts Human Health 2010-03-18 2015-12-31

E31007 Instructive Surfaces and Scaffolds for Tissue Engineering Using Radiation Technology. (conducted jointly with F23030) Human Health 2014-04-04 2018-04-04

E33032 Improving Outcomes in Radiotherapy using Novel Biotechnologies: Modification of Tissue Reactions and the Use of Stem Cell Therapeutics Human Health 2008-10-30 2012-10-30 2012-11-15

E33039 Improving Radiotherapy Treatment Planning for Patients with Nasopharyngeal Carcinoma in Low and Middle Income Countries Human Health 2015-09-03 2018-09-28

E35008 Strengthening of "Biological dosimetry" in IAEA Member States: Improvement of current techniques and intensification of collaboration and networking among the different institutes Human Health 2012-02-10 2016-03-31

E24016 Development of Quality Audits for Radiotherapy Dosimetry for Complex Treatment Techniques Human Health 2009-03-26 2012-09-30 2013-01-28

E21007 Development of Quantitative Nuclear Medicine Imaging for Patient Specific Dosimetry Human Health 2009-06-11 2014-06-11 2015-07-15

E21008 Development of Advanced Dosimetry Techniques for Diagnostic and Interventional Radiology Human Health 2010-06-11 2013-06-11 2014-11-19

E24015 Doctoral CRP on Quality Assurance of the Physical Aspects of Advanced Technology in Radiotherapy Human Health 2008-06-15 2013-12-31 2015-01-15

E13035 Longitudinal Monitoring of Complicated Osteomyelitis by SPECT/CT Human Health 2008-10-30

2011-10-31 2013-01-28

E13037 The Use of Sentinel Lymph Node in Breast, Melanoma, Head & Neck and Pelvic Cancers Human Health 2010-10-12 2013-12-31 2013-11-22

E15020 Application of FDG-PET and Molecular Gene Profiling for Risk Stratification of Diffuse Large B-Cell Non-Hodgkin's Lymphoma in Different Ethnic Populations Human Health 2006-09-15 2012-03-31

2012-12-31

E13033 Evaluation of the Biological Safety and Clinical Efficacy of 177 Lu-EDTMP for Bone Pain Palliation in Metastatic Prostate Cancer (PhaseI/II Clinical Trial) Human Health 2007-03-15 2012-03-31 2012-0404

E33025 Resource Sparing Curative Treatment in Breast Cancer Human Health 2005-10-01 2012-09-30 2013-01-30

E33026 Clinical/Radiobiological Study on Viral-Induced Cancers' Response to Radiotherapy, with Comprehensive Morbidity Assessment Human Health 2006-09-15 2014-09-14 2015-02-02

E33028 Investigation of Optimal Radiotherapy Regimen and Type of Irradiation in Treatment of Painful Bone Metastasis Human Health 2007-07-01 2013-07-01 2013-07-17

E33029 Radiotherapy and Chemotherapy in Advanced Non-Small Cell Lung Cancer Human Health 2007-12-01 2013-12-31 2013-10-10

E33031 Optimisation of Radiotherapy in Low Resource Settings: Paediatric Cancer Patients Human Health 2008-10-30 2013-10-31 2014-08-06

F22049 Production and Utilisation of Emerging Positron Emitters for Medical Applications with an Emphasis on Cu-64 and I-124 Radioisotope Production and Radiation Technology 2010-01-04 2014-1231 2013-09-17

F22053 Therapeutic Radiopharmaceuticals Labelled with New Emerging Radionuclides (67Cu, 186Re, 47Sc) Radioisotope Production and Radiation Technology 2016-03-18 2019-03-17

F22062 Accelerator-based Alternatives to Non-HEU production of Mo-99/Tc-99m Radioisotope Production and Radiation Technology 2011-12-14 2015-12-13 2016-03-23

F22045 Development of 99mTc Radiopharmaceuticals for Sentinel Node Detection and Cancer Diagnosis Radioisotope Production and Radiation Technology 2007-09-15 2010-12-07 2010-12-07

F22048 Development of 18F-labeled Radiopharmaceuticals (beyond [18F]FDG) for use in Oncology and Neurosciences Radioisotope Production and Radiation Technology 2009-01-12 2014-01-11 2013-12-16

F22050 Development of Ga-68 based PET-Radiopharmaceuticals for Management of Cancer and other Chronic Diseases Radioisotope Production and Radiation Technology 2010-11-15 2015-11-15

F22052 Development and Preclinical Evaluations of Therapeutic Radiopharmaceuticals Based on Lu-177 and Y-90 Labeled Monoclonal Antibodies and Peptides Radioisotope Production and Radiation Technology 2011-02-07 2016-02-06 2016-03-23