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New cancer machine to be ready in one year

Dr Jackson Orem

The Uganda Cancer Institute (UCI) and its Radiotherapy department have been in the news after the country's only Cobalt-60 radiation machine, used in managing cancer, broke down.

Some reports have said the machine cannot be repaired, and that it will take two years to replace it.  On Monday, Richard M Kavuma asked the UCI director, DR JACKSON OREM, to explain the A-Z of this crisis.

Among other things, Dr Orem says the new modern equipment should be ready in one year, experts have alternatives to radiotherapy, and that efforts are being made to repair the erratic old machine.

We first wrote about this machine frequently breaking down in 2013, and we have been told it has been in use since 1995. When exactly did UCI decide that the machine had to be replaced?  

As you know, this department, Radiotherapy, was formerly part of Mulago hospital; and of course even the cancer institute was part of Mulago hospital until 2009. 

It was until around 2012/13 that it was decided that radiotherapy should be combined under Uganda Cancer Institute. That means the history of that equipment cannot be fully told without linking it to Mulago hospital. So, yes, it was in 1995 that Mulago hospital got that equipment. But somewhere midway, the source was replaced.

Your equipment is the big thing, but what matters is “the source”, which is the [part] which emits the radiation used for treatment. And that being radiation, it decays; and when it is too low, then there is need to replace it. So, what we are now talking about is the second source; it is not that the source has been working with the same source from the beginning up to now.

So, when was it decided that the equipment should be replaced?

Around 2013 is when we started planning to have new radiotherapy equipment. But now, we thought that new equipment alone would not be enough; we thought there was need to build a completely-new centre and within that centre we should have several modern radiotherapy equipment.

And we thought that once we had the new equipment, we would then retire the current equipment, because you cannot retire it when you don’t have an alternative.

The machine has been breaking down from time to time over the last few years. But we are now told that if it was in and out of coma, it is now completely dead! Has it retired itself? 

It’s not true. We are doing all it takes to make sure that we can repair it, of course with the aim that it can still provide some service, as we expedite the process for getting the new one in the country. And that means we should expedite the process of building the bunker.

But, are you confident that, technically, the machine can be repaired to provide a decent level of service?

That is what we are hoping for, because, you know, something must be done.

You are hoping, but is your confidence borne of technical viability? Word has already gone out that the machine is completely finished…

The right message is that now the source is weak and if you are to use the machine, you take a longer time to provide the required treatment. It is not that it is completely dead. If we can rectify it and it can provide some level of service, well and good.

We have been told that it has taken two years to get approval for the design of the new bunker by the International Atomic Energy Agency;  is it normal for IAEA approvals to take that long, or was it our problem in Uganda?

There was no substance in that information, because any approval depends on what you are presenting – and approval for what? Is it the equipment? Is it the structure?

We are told it took two years to get approval for the design.
What took long is the design process itself – not the approval. And the design process took long because, first of all, getting the people who can design that type of structure locally is not possible.

So, we had to get external support.  So, there was a consortium of an Indian company and a Ugandan company. So, getting that in place took one year, and then getting them to complete the designs is another year. That’s why they took long.

But is it true that the equipment was already bought and should be sent here any time?

We have paid for the equipment; what is left is for us to say that the bunker is already paid for us to say that now the bunker is ready, why don’t you start the process of manufacturing it so that it is delivered?

That is important because if it is manufactured today when we don’t have the bunker in place,  and then getting the bunker ready takes some time, since this is a radioactive source, it starts to decay. That means you are not going to use it for a long time and that means you are not going to get the worth of your investment.

What is the actual cost of getting the bunker ready?

The costed estimate of this new structure – it is not only one bunker, it is seven bunkers in one complex – the cost is Shs 31 billion. It will be seven bunkers that can house the most modern machines, and actually the way we designed it, it is supposed to go to the next generation of the best machines. The cost is Shs 31bn.

Health minister Elioda Tumwesigye talked about the brachtherapy radiation machine…How different is that from the cobalt-60?  

That one, we started using it in February; it has the same substance, as the one which is spoilt. The source is the same, only that the application is for internal use.

For instance, if the cancer is in a body cavity, where body cavity means mouth, or for the women, the cervix, anus, etc, you can push what we call the applicator inside there and deliver. That one is there, working.

A shelter for patients at Uganda Cancer Institute

This issue is quite distressing especially for patients and their families; but what exactly are the clinical implications of a patient not getting the radiotherapy as and when prescribed?  

To explain that, we have to go back to the type of patients that we get.  Eighty percent of our patients come when the disease is advanced. That means that it has spread beyond the place where it started. And anyone who has that type of cancer, the best treatment is chemotherapy or what we call systemic treatment. That means treatment which [move]around the body. 

You give a patient a drug and then it circulates all over the body. Treatment like radiotherapy, we call those local treatment, because they treat a specific geographical region of the body.

Now if majority of our patients come with cancers which are advanced, what is the role of radiotherapy for those types of patients? The role is for palliation: for instance, someone has a painful spread to the bone, or someone has something on the skin, we use radiotherapy to control that. That does not mean after the radiotherapy, the rest of the disease all over the body has also been taken care of. T

hat requires that we work as a team. After one person has done his part, another person will do his part. That means that we have one component of the team that will not be working as we required. But that doesn’t mean that no treatment or no benefit is to be received by the patient from the other aspects of the treatment that the patient is receiving.

In any case, if the patients are getting their radiotherapy for pain control, we have other means of pain control: we can use morphine for controlling pain, and we can use other agents. What that means is that for our patients, in the absence of radiation, we should now maximize those other ways of controlling symptoms. 
I think that is really the thing which people are not understanding.
 
Let me also ask you about some of the figures that we are working with in the newsrooms: Uganda Cancer Institute, we understand receives 44,000 different patients a year?

We are talking about patient days, not patient numbers! The difference is that one patient may come several times [in a year]. When you multiply that, you get the patient days.

What estimates do we have on patient numbers?

That one, the best we can do is to talk about how many new cases. And these are about 5,000 new cases a year, coming to the Uganda Cancer Institute.

And 27,648 different patients a year for the radiotherapy machine? 

Those ones, because they are using equipment, you can still talk about patient days, but you can also talk about sessions.  For instance, if you went in the morning and you got something, and you went back in the afternoon and you got something, those are two sessions, but one patient.

Finally, give us some realistic timelines: when can we expect actual progress at the radiotherapy department?

I think the key process now, is to expedite the process of getting this new bunker in place. As I speak, today, we are doing the bid evaluation for the contractor. We have very good contractors – three of them – who have expressed interest.

If we can get them on board and give them the funds that they need, and ask them to expedite the process, I am almost certain that within six months we should be able to have the construction completed. That leaves us with maybe the next six months to install the equipment, and then pretest. So within a year, if everything worked like a clock, we should be able to have the service restored or even taken beyond what we are now having.

You said the equipment has to be manufactured on order: how long would that take?

That one can take even three months, and then shipment can take from weeks to a month.

Shall we have to wait for the bunker to get completed before the manufacturing starts?

No! Not all. The moment the work starts, we should just place the order. So we are looking at maximum a year...

In the meantime, you said you will be trying to resuscitate the old radiotherapy machine: when do you envisage to get  it back into some use?

Well, we are getting some people to start work now. Maybe within a week or so we should be able to know whether we can restore some service.

But that said, if a patient’s problem is pain control, we can still control pain. If the issue is fluid, we can still drain the fluid using surgery. And if it is metastasis to the bone that is causing pain, we adjust the dose of morphine. Of course radiotherapy is good in the sense that it is quick; you just put it there and the pain is gone. But we can still adjust or increase the dose of morphine to achieve the same outcome.

Any last message to Ugandans on this issue?

I think one thing I can say is that radiotherapy is not a magic bullet that once you are given, cancer is cured. Far from it. It’s a local treatment. That means it only targets a certain part of where the cancer is.

And if the situation is like what we have in this country, where most people are coming when their disease has spread all over the body, they need systemic treatment like chemotherapy, which we have, in order to control the cancer. Not radiotherapy.

rimkav@observer.ug

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