Image-Guided Radiation Therapy Practices In Low- and Middle-Income Countries: A Multi-Institutional Survey and Initial Findings
Abstract
Purpose
To evaluate the use of image-guided radiation therapy (IGRT) tools and physics plan review practice in low- and middle-income countries (LMICs). By identifying barriers to IGRT implementation, this study aims to inform best practices that optimize treatment precision and patient safety. We describe the development of the survey and report initial results from early deployment.
Methods
A 28-question survey was developed using Qualtrics in resource-limited settings. The survey was structured into four domains: (1) institutional demographics and equipment inventory; (2) available IGRT modalities;(3) site-specific and treatment delivery–specific use of IGRT; and (4) Physics safety and plan review practices. The complete study protocol was submitted to the Institutional Review Board (IRB). Following IRB approval, the survey was pilot tested by three physicists, after which minor revisions were made. The survey was then distributed through professional societies and social media platforms. Responses collected within one week of deployment were analyzed as a preliminary dataset.
Results
Responses were received from eight cancer centers across Mexico, Turkey, Jordan, Nigeria, Libya, Philippines, Pakistan and Indonesia. EPID/MV imaging was the most reported IGRT modality (88%), followed by kV CBCT (75%) and on-board kV imaging (50%). While 88% reported performing end-to-end testing for new IGRT procedures and 75% reported routine IGRT QA programs, only 63% reported an established action plan for managing large setup deviations. 88% of institutions reported physicist verification of the treatment plan prior to transfer to the record-and-verify system, while 75% reported a physicist-performed plan check after record-and-verify but before treatment delivery. Key barriers to IGRT included limited technology availability, insufficient QA resources, and funding constraints.
Conclusion
Early results demonstrate adoption of core IGRT practices across LMIC, alongside variability in QA standardization. These findings highlight opportunities for targeted guidance and education to support safe, and scalable IGRT implementation.