,nr J Rad,ul,on Onnrk~~y Bd Phy\ Vol. Pnnted ,n the U.S A. All nghts resewed.
I?.
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121 I-1274
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0360-3016/90 $3.00 + .oO C? 1990 Pergamon Press plc
??Special Feature: Developing Countries
THE RADIOTHERAPY KAWEE
SITUATION
TUNGSUBUTRA,
IN THAILAND M.D.,
D.Sc.,
AND SOUTH
D.M.R.T.,
EAST ASIA
F.R.C.R.
Kaweevej Hospital, 1002/l Tarksin Road, Dhonburi, Bangkok, 10600, Thailand The situation of radiotherapy in Thailand from its beginning to the present is reported. The situation of radiotherapy in other countries of South East Asia is also analyzed from the data or information requested through the Radiological Society of each country. The situation of radiotherapy in each country will be discussed in terms of equipment, facilities, personnel, teaching and training, research, and clinical practices. In each country, efforts have been made to develop radiotherapy facilities so that services can be given at a modern standard. Some countries has attained that standard and full range of radiotherapy has been available. An effort has been made to help each other and exchange knowledge by organizing the Asian and Oceanian Society of Radiology (AOSR) and the Asian Association of Radiology (AAR) tnrough which Congress of Radiology has been organized every 2 alternate years. Radiotherapy in Thailand and South East Asia, Clinical practices, Teaching and training, AOSR and AAR Congress.
In 1928, x-ray diagnostic equipment was first installed in Siriraj Hospital with only one trained radiologist in Diagnostic Radiology from the United States. Radiotherapy at that time was a mysterious subject.( 10) In 1940, radiotherapy was started by a locally trained radiodiagnostician who studied abroad at Cambridge and graduated with a diploma in Medical Radiotherapy and Electrology afterward. The equipment available at that time was one superficial lo-50 KV, a deep X ray 220 KV, and a 400 KV.* With later development, a convergent beam therapy, 220 KV, was also installed.(4) Ten years later in 195 1, Radium Therapy was introduced by the radiodiagnostician mentioned above. The Radium Therapy available was surface radium using radium plaque, interstitial radium using needles, and intracavitary radium using radium tubes and needles in the so-called “butterfly”
applicators. The intracavitary radium applicator was a modification of the Stockholm techniques. The intracavitary radium applicator consisted of two parts: the intrauterine part and the vaginal part. The intra-uterine part consisted of a rubber tube which contained three radium tubes of 15 mg, 10 mg, and 10 mg from the fudus to the cervix, respectively. The length of the intra-uterine applicator was adjustable according to the length of the uterine cavities. The vaginal radium applicators consisted of two boxes of radium with a central holder. The distance between the two boxes was adjustable by a central screw at the holder. Inside the box, there were four radium needles of 5 mg each, so each box contained 20 mg of radium. We used the Manchester dosage system for all kinds of Radium Therapy (2). In 1953, Tele-radium was introduced into the Army Hospital (King Monkutkloa Hospital): at the same time Nuclear Medicine was also introduced into Siriraj Hospital. Radioiodine was introduced into Siriraj Hospital not only for diagnostic purposes but also for the treatment of thyrotoxicosis and thyroid cancer. Since then, other isotope therapies have been introduced to treat both benign and malignant diseases such as Au’“~ seeds using the Royal Marsden gold grain gun( 15) Ta’*’ wire with introducer (3) and Sr9” eye applicators (14). Colloidal Au19’ was also used for relieving ascites and pleural effusion for palliative treatment of cancer.
Presented at the 17th International Congress of Radiology, Paris, France, 1 July 1990. Acknowledgments-The author gratefully acknowledges the President of the Radiological Socety of the member countries
of the AAR who provided us with the information of the situation of radiotherapy in his own country. Accepted for publication 24 May 1990. * Maximar.
INTRODUCTION Thailand is a country in South East Asia surrounded by Burma to the West and Loa and Cambodia to the East. To the north of Thailand lies China; to the South is Malaysia. The population is now about 54 million people. The radiotherapy situation in Thailand will be briefly described in terms of equipment, facilities, personnel, teaching and training, research, and clinical practices. METHODS
AND
MATERIALS
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I. J. Radiation Oncology 0 Biology ??Physics
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November
In 1958, Tele-Co6’ machines were donated: one to Chulalongkorn Red Cross Hospital by the U.S.S.R. and another one to Siriraj Hospital by the U.S.A. From that time, supervoltage external irradiation was started. The cancer cases cured were cancer of the cervix and cancer at other accessible sites such as the lip, tongue, buccal mucosa, etc. In other words, the treatments preferred by surgeons and patients were intracavitary radium and interstitial radium only. External radiation was dreadful to patients and their relatives, and surgeons were reluctant to refer patients for postoperative radiotherapy. Inaccurate dosimetry combined with inexperienced nursing care and conventional deep x-ray machines without skin sparing effect, caused radiation sickness and severe skin reactions which created a stigma around radiotherapy at that time. Clinicians were not well aware of radiation hazards and one radiotherapist died of leukemia after having treated a number of people with interstitial and intracavitary radium. However, the Fletcher afterloading applicator was introduced for use in intracavitary radium and the Cs”’ tube was used to replace the radium tube to reduce radiation hazards to staff radiotherapists, physicists, and nurses. With the tripartite agreement in 1965, the Governments of Thailand and New Zealand, along with the World Health Organization, established a radiation protection unit to provide radiation safety services, radiation control, and protection. A secondary standard laboratory was developed and a team of six physicists was trained at the National Radiation Laboratory, Christchurch, New Zealand. This team returned to work in the Radiation Protection Laboratory, Thailand under the supervision of an expert from New Zealand ( 1,8). Film badge services were started and measuring the output of deep x-ray and Cobalt machines was done regularly. Beam direction techniques were emphasized in the treatment of cancer patients with accurate dosimetry. A machine for moulding thermoplastic was designed and locally made for use by Dr. Kawee Tungsubutra at Siriraj Hospital (7). Chemotherapy by radiomimetic drugs was introduced and practices by radiotherapists (6, 9, 11, 12). The application of radiobiology for the treatment of cancer by different techniques
Table 1. Time table for teaching
1990, Volume
19. Number
5
of radiotherapy was also introduced. In 1969, a simulator was installed in RAmathibodi Hospital, a new medical school where Radiotherapy and Nuclear Medicine Departments were started from scratch. In Ramathibodi Hospital, with the cooperation of the WHO and the New Zealand Government, a school of Radiographers was developed in 1970 and a school of Hospital Physicists in 1972 ( 1). In 1969, a linear accelerator was installed at the National Cancer Institute with the cooperation and assistance of the Japanese Government. After 1973. a full range of radiotherapy and nuclear medicine was practiced in all medical schools in Thailand. In 1973, a new medical school was started at Khon Kaen, the Northeastern part of Thailand which is the poorest part of the country (5). Again, with the cooperation of the New Zealand Government, a faculty of medicine at Khon Kaen University was established with a full range of equipment and teaching staff. After having been trained in the old medical schools, staff members have a chance to go abroad for a short period of time under the Staff Development Project. After 1973. each medical school was well-equiped with qualified staffs for surgery. pathology, radiotherapy. medical physics, and radiographer or radiological technicians. In 1979. computerized radiotherapy planning systems with isodose plotters were installed in the radiotherapy sections of the departments of radiology. Radium needles and tubes were replaced with Cs’“’ needles and tubes. In 1985, remote control afterloading intracavitary with a low dose rate technique was installed, and in the following year, remote control afterloading intracavitary with a high dose rate technique was also installed. In 1987. linear accelerators of 4 Mv and 10 Mv with electron beams were installed and used in clinical practice. However. very littel has been achieved on the research side: some epidermiological study has been done (15). Full ranges of radiotherapy were practiced for clinical purposes. Three post-graduate training courses were started in 1972 for General Radiology, Radiotherapy and Nuclear Medicine. and diagnostic Radiology.( 10) The courses include basic physics for radiology, radiobiology, and chemotherapy. (Table 1) In 1989, the course for radiotherapy and nuclear
and training
for each curriculum,
1972
Branch
General
Year Year I Year II Year III
(12 mos) (12 mos) (12 mos)
Total D = Diagnostic
radiology;
radiology
Diagnostic
radiology
Radiotherapy and nuclear medicine
D6 D6 D9
TN6 TN3 P3 TN3
D6 D9 D12
TN6 P3
D6 TN9 TN12
TN6 P3
D21
TN12 P3
D27
TN6 P3
TN27
D6 P3
T = Radiation
therapy;
N = Nuclear
medicine;
P = Pathology:
Suffix figure = number
of months,
Radiotherapy in Thailand and South East Asia 0 K. TUNGSUBUTRA
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Table 2. Number of diploma in radiology awarded by the Thai General Medical Council Radiotherapy and nuclear medicine
Total
51 1
19 4
195 30
50
23
14
87
200
75
37
312
Year
General radiology
Thailand
1972-1987 1988
125 25
Abroad
1972-1988
Total
up to 1988
Place of training
Radio-diagnosis
N.B.: Total members of the Radiological Society of Thailand: 424. Member who held post-graduate diploma in Radiology of both Thailand and abroad: 3 12. Other 112 members are those who held diploma or certificate of abroad qualification alone or non-medical members, honorary members, members of other specialities, e.g. surgery, obstetric and gynaecology, etc.
medicine was split into two separate courses, diotherapy and straight nuclear medicine.
straight
ra-
RESULTS
The number of doctors who have been trained locally and have graduated is shown in Table 2. For the whole country, we now have 16 Cobalt teletherapy machines and 5 linear accelerators with only two electron beams available for treatment. There are deep and superficial xray machines; all together there are 23 machines. The xray machines have mostly been used for benign diseases. For malignancies, either the Cobalt machines or the linear accelerators are used for external radiation. Interstitial and intracavitary radiotherapy are now practices in seven medical schools, but in the eighth medical school radiotherapy is not yet available. The National Cancer Institute is also well-equipped with a full range of radiation therapy including radioisotope therapy.
DISCUSSION
Other countries in South East Asia Six Asian countries have organized to form an Asian Association of Radiology (AAR): Thai, Singapore, Malaysia, Indonesia, Phillippines, and Brunei. A scientific meeting is arranged every 4 years. Thailand was recently the host for the AAR ongress in November 1988. There is also another international association of Radiology, that
is, the Asian and Oceanian Society of Radiology (AOSR) ofwhich there are 24 member countries. This organization also holds a scientific congress every 4 years. Every 2 years there will be an AAR Congress and AOSR congress alternately. Following are two examples demonstrating the situation of radiotherapy in each country. Singapore. A full range of radiotherapy is being practiced. The training for radiotherapist includes being locally trained first and then receiving further study in the United Kingdom. This was started in 1953 and has been fully modernized up until the present (personal communication, Dr. Chia Kim Boon, 12 April 1989.) Brunei. This country has only 230,000 people and only 20-30 patients need raduitgeraot treatnebt each year. These patients are sent on government expenses to either Kuala Lumpur or Singapore for treatment (personal communication, Dr. H.J. Mohamad Bin Abdul Kadir, 29 March 1989). Other countries in South East Asia such as Malaysia and Indonesia also have facilities and trained personnel to provide up-to-date services to patients. The question that remains is whether the facilities and services are adequate or not for the size of the population. The question of distribution and quantity of available services is still unsatisfactory, not only for radiotherapy but also for other hi-tech specialities existing in the non-industrialized countries. If its is necessary to import equipment for the hi-tech services, the question of adequate budgeting still exists. However, if each country organizes its facilities to have staff locally trained, we hope to increase services to treat people adequate and to keep the quality of care up to modern standards.
REFERENCES
Krisanachinda, A.; Pirabul, R.; Vinisorn, S.; Leksakulchai, S.; Boonkittichareon, V. The role of medical physicists in Thailand. T.J.R. 24:2, 93-95; 1987. Meredith, W. J. Radium dosage, the Manchester system. Edinburgh and London: E. & S. Livingstone Ltd.; 1985. Suwanik, R.; Tungsubutra, K.lE2 Tantalum in the treatment of cancer. Siriraj Med Gazette 13:9:499-504; 196 1.
Suwansuthi, R.; Tungsubutra, K. The results of conventional and convergent beam radiation. Thai J. Radiol. 3: 1:9-12; 1965. Tungsubutra, K. “Binbakaya Bidyabed Memorial Lecture, 1986.” A comer of the establishment of the Faculty of Medicine, Khon Kaen University T. J. R. 23: 1:7-12; 1986. Tungsubutra. K. The clinical uses of cytosine arabinoside
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November 1990, Volume 19, Number 5
and lymphoma.
11. Tungsubutra, K. Toyomycin in the treatment of some malignant diseases. T.J.R. 4:2:67-77; 1966. 12. Tungsubutra, K. The treatment of lymphoma with cytosine arabinoside. Asian J. Med. 9:383-386; Nov. 1973. 14. Tungsubutra, K.; Lopanthusri, T.; Kanchararan, D.90Sr in the treatment of some eye diseases. Acta of the International Meeting of Opthalmologists, Tokyo, 1965. 15. Tungsubutra, K.; Pesi, M.; Tungvorapongchai, V. Cancer epidemiology in Thailand. In: Mould, R.F., unsubutra, K., eds. Carcinoma of the cervix in developing areas. London: Adam Hilger Ltd; 1986: 187- 190. 15. Tungsubutra, K.: Unhanant, S. Primary report of the treatment of some malignant diseases by radioactive gold grain implantation. Siriraj Med. Gazette 19:43 l-440: 1967.
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7. Tungsubutra, K. A machine for moulding thermoplastic. Thai Natl. Res. Council 12:306-3 14; June 1966.
J.
8. Tungsubutra, K. A part of the history of radiological protection service in Thailand. T.J.R. 23:1:83-86; 1986. 9. Tungsubutra, K. Primary report on the clinical effect of COPP on some malignant diseases. Acta of the gth International Cancer Congress, October 1966, Tokyo. 10. Thungsubutra, K. Radiology in Asean countries training and practice: case of Thailand. 5’h Congress Asean Association of Radiology, Bangkok, Thailand, November 16- 18, 1988:334-341.