From 3D to 5D radiotherapy: A blitzkrieg of DTH!

Abstract

Surfing the waves of sustained economic growth and the growing confidence of the private health care sector in the last decade, the practice of Radiotherapy in India has made a rapid transition from 3D to 5D. At the beginning of the decade, 3 dimensional conformal Radiotherapy (3D CRT) was gaining foothold in major radiotherapy centres across India. Requiring only a modest infusion of technology, funds and training, the returns of sparing more normal tissues by shaping or conforming the radiation beams to the 3 dimensions of the tumour and target volume were impressive. But the real technology transition came to India in this decade with the installation of few dozen LINACs capable of delivering Intensity Modulated RT (IMRT). The last few years have witnessed the installation of at least a dozen machines with even greater precision achievable by incorporating the 4th dimension of real time organ or tumour motion (4D RT) and Image Guided RT (IGRT). For the first time, private health care sector surged ahead of publically funded academic centres in terms of acquiring high end technology and delivering some form of IMRT or IGRT to large number of patients. The newly acquired high end LINAC technology and specialized machines were more than a status symbol and became a critical element in the marketing strategy of new entrants as well as established corporate hospitals. The new world of radiation technology in India is witnessing tangential launch of knifes, arcs, tomos, gyros and robots in a crowded cyber space. Not to be left behind, less conspicuous variants of IMRT and IGRT technology are being promoted as 'the best machine' or 'first in India', 'first in western India', 'first in this city' or 'first in this part of the city'. One is reminded of how the crowning glory of Miss Universe and Miss World on Indian beauties had a trickle down effect of bestowing pride and some business opportunity on local talents like Miss Chandigarh and Miss Chembur. Not surprisingly, the market mantra of finding something different in ones machine or acquiring a machine with some difference and then going to the town with 'my machine is the best in….' seems to be a successful business model. Before the nuances of IMRT and IGRT could be understood and their indications for the clinical spectrum seen in Indian clinics could be firmed up, stories of their inappropriate use in various centres started gaining credence. In this state of technology flux and increasing use and misuse of overpriced IMRT and IGRT, the corporate health managers introduced the 5th dimension of radiotherapy - '5D RT'. I have used the term 5th D for 'Direct to Home - DTH' approach, akin to DTH Television with which we are getting familiar. In a country pregnant with talent hunts, reality shows and breaking news on hundreds of TV channels, DTH TV beamed the good, bad and ugly of TV directly into our homes in a tech savvy fashion which the local cablewallah could never do. But has DTH RT brought in the same quality, choice and value for money for the consumers of cancer care in the country? The DTH RT approach unleashed in the recent past has employed all forms of media including newspapers, popular weeklies, elite magazines, in flight magazines, bill boards, bus stops and even popular TV shows for unabashed advertisements which is sometimes in the garb of popular articles and interviews. The public and the professionals were struck with the loud and unambiguous message of how a new space age radiation technology would be the game changer in cancer management. Talking to my colleagues from different oncologic disciplines within and outside the Tata Hospital, I realized that many of us were concerned about the instant effect of this DTH blitzkrieg, with the public imagination going in an overdrive. The stories we shared ranged from parents wanting new age radiation technology to cure their child's leukaemia without chemotherapy, anxious women wishing away surgery and chemotherap