Planning and peer review in sub-Saharan Africa: a needs assessment and feasibility study of cloud-based technology to enable remotepeer review and training

Abstract

ABSTRACT Background: A major challenge for radiotherapy centers in low- and middle-income countries (LMICs) is ensuring that the treatment delivered is consistently of high quality. The WHO,1 the American Society for Radiation Oncology (ASTRO),2 and the Royal College of Radiologists (RCR)3 have all addressed the importance of peer review in radiotherapy in recent years, recommending it as a vital quality-assurance measure for any radiotherapy center to ensure safe, high-quality treatment. It is therefore imperative that multidisciplinary radiotherapy teams in LMICs receive adequate training in radiotherapy planning and have access to ongoing expert input and peer review to achieve this. Methods: We undertook five site visits between June 2018 and September 2019 at four collaborating centers, which were chosen to reflect a range of public and private facilities across western, eastern, and southern Africa: Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana Sweden Ghana Medical Centre (SGMC), Accra, Ghana Ocean Road Cancer Institute (ORCI), Dar Es Salaam, Tanzania Gaborone Private Hospital (GPH), Gaborone, Botswana. Two visits to ORCI were undertaken because of the installation of two new linear accelerators following the first study visit. For the initial needs assessment, we reviewed the existing radiotherapy treatment facilities, including treatment machines, treatment planning systems, simulators, and treatment capability (ie, 2D, 3D conformal, IMRT, and brachytherapy). Results: The results are discussed in two sections: Radiotherapy equipment and infrastructure, IT capability, and Gen X Viewer operability Themes emerging from staff interviews, with respect to radiotherapy planning, education and training, and existing peer-review practice. Discussions: Our four collaborating centers represent a spectrum of radiotherapy treatment facilities across western, eastern, and southern Africa, and exemplify practices in both the public and private sectors. They displayed differences in radiotherapy capacity and staffing levels, and varied treatment equipment and planning systems, reflective of the range of radiotherapy facilities in LMICs. The site visits highlighted a lack of formal peer-review practice among clinicians who are delivering 3D conformal radiotherapy. Installation of the Gen X cloud software was achieved in three of the four sites; however, it has only demonstrated full functionality in one center (SGMC). Poor or variable internet connection speed was the main barrier to achieving full functionality of the software in three of the four centers (KATH, ORCI, and GPH). This was particularly problematic at KATH and precluded installation of Gen X there. At ORCI and GPH, installation was successful, but subsequent difficulties with data set export from the local treatment planning systems prevented full functionality of the software. While the Gen X Viewer is compatible with multiple treatment planning systems, a lack of familiarity with the data set export function of local planning systems made this step difficult to navigate, particularly in the context of a busy clinical department where clinicians and physicists have high workloads. At SGMC, the IT capability was sufficient to allow download of the software and to achieve transfer of the data sets relatively quickly; however, further technical issues (requiring frequent software updates and changes to database settings) have prevented ongoing reliable functioning.