CURRICULUM VITAE. Soehartati Gondhowiardjo, MD. PhD

Transcription

1 CURRICULUM VITAE Soehartati Gondhowiardjo, MD. PhD Born : Jakarta, September 1955 Education 1. GP : FKUI, Radiologist : FKUI, Radiation Oncologist : FKUI / Muenster (Germany) PhD : FKUI, 1998 (EBV LMP1 and Proliferation in NPC) Current Positions : Chairperson of Indonesian National Cancer Control Committee (KPKN) President of Indonesian Radiation Oncology Society (PORI) President of Federation of Asian Organizations of Radiation Oncology (FARO) Past President of South East Asia Radiation Oncology Group (SEAROG)

2 Implementation of New Technologies in LMIC: 3D HDR Brachytherapy Soehartati Gondhowiardjo ICARO2, Vienna, June 20 th -23 rd, 2017

3 Introduction In 2011 Potter et al. reported the clinical outcome of the patients treated after the introduction of IGBT ( ) vs historical controls, showed : Significant improvement in local control at 3 years; % in stage IB/IIB, and 85 90% in stage IIB IV relative reduction of pelvic recurrence of 65 70% compared to their conventional results. Overall survival rates at 3 years were 74 79% for stage IB/IIB, and 45% for stage IIIB, significantly increased compared to their historical series, and rates of severe morbidity were reduced Other institutions which have published their first results also showed promising outcomes Potter et al., Radiotherapy and Oncol.,2011

4 Conventional BT vs IGBT Rijkmans et al., Gynecologic Oncol., 2014

5 Kim, Hayeon et al. Cost-effectiveness analysis of 3D image-guided brachytherapy compared with 2D brachytherapy in the treatment of locally advanced cervical cancer Brachytherapy 2015, 14 (1):, 29-36

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7 Sensitivity Analysis... Note: The x-axis represents the difference in costs between 3D and 2D treatments. The y- axis is the difference in survival between 3D and 2D treatments. The X on the graph represents the baseline values. Area above the line slope represents that 3D image-guided brachytherapy is a favored strategy. (using a $50,000 per QALY gained threshold ) Kim, Hayeon et al. Cost-effectiveness analysis of 3D image-guided brachytherapy compared with 2D brachytherapy in the treatment of locally advanced cervical cancer. Brachytherapy 2015, 14 (1):, 29-36

8 IAEA/RCA RAS/6/062 Supporting 3D IGBT Services 4 RTCs were held from 2012 to 2015, NTC in each country ( ) 121 RO and MP were trained at RTCs. Training materials were available at the IAEA website. Guideline Transition from 2DBrachytherapy to 3D High Dose Rate Brachytherapy was published. Number of hospitals which implement 3D IGBT have Courtessy increased of Prof in RCA Shingo MS Kato, (11% in PLCC 2012, for 19% IAEA in RCA 2015) RAS. 6/062

9 Objective To Improve regional and national capacities for brachytherapy services by implementing 3D-IGBT by To strengthen the ability of RCA Member States to use the modern technology and evidence-based guidelines. Participating countries AUL, BAN, CHA, IND, INS, JPN, KOR, MAL, MON, MYN, PAK, PHI, SIN, THA, VIE (15 countries) Expected outcomes 1. Ros & MPs in RCA MSs are trained in the knowledge and techniques 2. Treatment guidelines for 3D IGBT are developed among RCA MSs. 9

10 Activities Training of ROs and MPs Regional Training Courses 4 RTCs (mumbai, chiang mai, saitama, singapore) NTCs in each country National Training Courses National Training Courses National Training Courses

11 Activities Transition from 2-D Brachytherapy to 3-D High Dose Rate Brachytherapy IAEA INTERNATINAL ATOMIC ENERGY DRAFT Guidelines IAEA TECDOC Transition from 2-D brachytherapy to 3-D high dose rate brachytherapy was published. Utilization of guideline Utilization of Guideline Utilization of guideline 11

12 Activities Surveys on 3D IGBT among RCA MSs 1 st survey: 2012 and to assess current status on resources and capabilities of 3D IGBT and 2 nd survey : 2015 to assess the progress

13 Survey Data Dissemination of 3D IGBT to RCA Countries No. of hospitals implementing 3D IGBT Country AUL CHA JPN MAL MON PHL SIN /23 10/300 22/135 0/7 0/1 2/25 3/ /23 20/300 39/135 5/8 0/1 3/32 3/3 THA 5/26 11/29 INS 0/27 5/29 All 62/520 62/547(11%) (12%) 103/ /560 (19%) (19%) 13

14 Survey Data Difficulties in introducing 3D IGBT in the hospital Difficulty in accessing MRI/CT at BT, in use CT/MRI for planning Shortage of equipment; CT/MRI, 3D TPS, MRI applicator Manpower shortage Limited time for 3D planning Heavy workload Poor cost/remuneration Small number of patient (MAL)???

15 Current Radiotherapy Condition in FARO member countries World Population : 7 B people Asia Population : FARO Population : ASIA 60 % of World Population FARO 84% OF ASIA Population FARO 53 % of World Population

16 Radiotherapy In OUR REGION India P:1338 M M : 589 Ratio: 1:2.27 Pakistan P: 200 M M : 29 Ratio: 1: 6.89 Srilanka P: 20 M M : 14 Ratio: 1:1.43 No Bangladesh P:164 M M : 25 Ratio: 1:6.56 Singapore P: 6 M M : 20 Ratio: 1:0.3 Negara Thailand P:68 M M : 76 Ratio: 1:0.39 Population in Million China P:1386 M M : 2140 Ratio: 1:0.65 Total Machines Malaysia P: 31 M M : 47 Ratio: 1:0.15 Ratio TT : Pop 2017 Indonesia P: 261 M M : 80 Ratio: 1:3.26 / equipment Japan P:126 M M : 841 Ratio: 1: Japan : South Korea : The diversities in FARO Countries : a huge gap! 3 Singapore : Thailand : China : South Korea P: 50 M M : 1.36 Ratio: 1:0.3 6 Malaysia : Srilanka : Philippines : India : Philippines P:103 M M : 36 Ratio: 1: Indonesia : How about Brachytherapy?? 11 Bangladesh : Pakistan :

17 FARO Survey (2017): Availability of 3D Brachytherapy Availability of RT Centers, Brachytherapy service, and Brachytherapy 3D in FARO member countries Proportion of centers with EBRT only, 2D and 3D Brachytherapy % % % 70% 60% 50% 40% 21 % in average % % % 0 0% Japan Korea Singapore China Thailand Malaysia Phillipines Indonesia India Pakistan Sri Lanka Bangladesh Total RT centres RT Centers with BT 3D Brachytherapy EBRT Only 2D BT 3D BT (Except India and Malaysia)

18 FARO Survey (2017): Imaging modality for 3D Brachytherapy FARO Survey (2017): Most common diagnosis for BT: Cervical Cancer CT Scan is the most commonly used imaging

19 FARO Survey (2017): Challenges in implementing Brachytherapy 3D Lack of government investment Difficulty in accessing CT/MRI at BT Longer time to perform IGBT compared to 2D (2D: 5 pts, 3D: 2-3 pts) Lack of man power and training Higher workload for dosimetry/physics staff and physicians Additional cost for CT Scan for 3D brachytherapy (per session) Additional cost of an MRI prior to doing a 3D brachytherapy In some countries, health insurance doesn t cover the additional cost for 3D brachytherapy.

20 Survey Implementing 3D BT in Indonesia

21 Availability of 3D brachytherapy 3D Brachytherapy Source Development for 3D Brachytherapy in Indonesia 42 % (13/31) BT in Indonesia Iridium source 88% using Ir-192 source Cobalt source 2D vs 3D Brachytherapy centers in Indonesia Centers with 2D only BT equipment Centers with 3D BT equipment 81.25% centers with BT (13/16) in Indonesia are equipped with 3D applicator + 3D TPS

22 11 centers Challenges with 3D in performing BT equipment 3D available techniques 6 5 MRCCC Hospital 11 Soetomo Hospital 10 Santosa Bandung Hospital 9 4 Univ Hasanuddin Makasar Hospital 8 Dr Cipto Mangunkusumo Hospital 7 3 Murni Teguh Hospital Sardjito Hospital 5 Margono Soekarjo Hospital 4 Kariadi Hospital Semarang 3 Saiful Anwar Hospital 2 Access to CT/MR Dharmais Cancer Center 1 Time consumingreimbursement Lack of trained man power 0% 20% 40% 60% 80% 100% 120% Limited applicator % of 3D Pts % of 2D Pts Despite the availability of 3D applicator and 3D TPS, more than 64% of those centers are still performing 2D technique

23 INVESTMENT HUMAN RESOURCE Survey Data (Summary) Difficulties in introducing 3D IGBT in the hospital Items Shortage of 3D BT Equipment (CT/MR applicator, TPS, CT/MR) IAEA RCA RAS6/062 FARO Survey 2017 Difficulties in accessing CT/MR at BT Lack of man power Higher workload TIME Longer time to perform IGBT COST Higher workload for dosimetry Additional cost of an MRI prior to doing a 3D brachytherapy In some countries, health insurance doesn t cover additional cost for 3D BT No OF PTS Small number of patients IROS Survey 2017 High demand BOT Training program Increase the number of HR Improve the system CT dedicated for BT Increase the number of HR Convinced the government to improve the tariff include the CT Cost sharing from the patients

24 Cost comparison of HDR Iridium vs Cobalt No Items HDR Iridium HDR Cobalt 1 Initial investment cost $781, $629, Maintenance cost $22,000-48,200 $22,000-37,000 3 Source (estimated for 10 years) $ 550,000 $ 110,000 4 Applicator set price $52,685 $7,185 5 Tariff for 5 year BEP $ $ Overall, HDR brachytherapy with Cobalt source showed a more costefficient, due to the less price for the cost of source replacement

25 Cost comparison of 2D vs 3D HDR Brachytherapy No Items Iridium Cobalt 1 Initial investment cost $781, $629, Maintenance cost $22,000-48,200 $22,000-37,000 3 Source (estimated for 10 years) $ 550,000 $ 110,000 4 Applicator set price $52,685 $7,185 5 Tariff for 5 year BEP 2D $555 $481 3D $925 $740 Cost difference 3D- 2D = ~ USD! Not included the additional cost for CT scan with/without MR imaging prior to BT 3D procedure! 3D HDR brachytherapy is more costly, but cost effectiveness could be better depends on clinical outcome and utility (use our own QALY gained threshold )

26 Special Acknowledgement for Data Contribution All FARO council members Prof Shingo Kato, PLCC for IAEA RCA RAS 6/062 Members of the Indonesian Radiation Oncology Society (IROS)

27 DRAFT Operational Agreement Project - RSCM Radiotherapy Medical Equipment UniT LINEAR ACCELERATOR Including Tax NO URAIAN Year 0 Investment Ye A INVESMENT VALUE 1.Unit Linac Total Invesment Operational Agreement Project 28,660,000, ,563 28,660,000, ,563 1 Interest Bank 2 Insurance rate 3 Collection Risk Rate 4 Trading Rate Preparation Radiothherapy Building (Thn 1) Total 7.00% 0.35% 0.25% 10.00% 3.00% 20.60% B NUMBER OF PATIENT INCOME PER YEAR Charge GOVERNMANT COVERAGE (MEDICARE) 1,606, % PRIVATE/OUT OF POCKET 43,300, % Radiotheraphy Income 239,326,560,000 20,815 3,117 23,932 C D E F HOSPITAL OPERATIONAL COST 40% 95,730,624,000 INVESTOR REVENUE= INCOME- HOSPITAL OPERASIONAL COST 60% 143,595,936,000 ACCUMULATION FROM INVESTOR REVENUE BEP CALCULATION 9,573 Rp 14,359 14,359 (20,204

28 DRAFT BISNIS PLAN Radiotherapy Medical Equipment UniT Brakiterapi (Dalam RUPIAH) - EXCL PPN NO URAIAN Tahun 0 Investasi A NILAI INVESTASI 1 Unit Brachytherapy 12,500,000,000 Total Investasi (24,6%) 12,500,000,000 B JUMLAH TINDAKAN PER TAHUN PENDAPATAN PER TAHUN Tarif Tarif rawat jalan 1,144, % Tarif rawat inap 80% Ringan 60% Sedang 40% 4,090, ,056, Pendapatan Radioterapi 38,923,591, C D E F OPERASIONAL RS (40%) ALOKASI INVESTASI (60%) 23,354,155, NILAI AKUMULASI ALOKASI INVESTASI PERHITUNGAN BEP

29 2 nd FARO MEETING: BENGALURU, INDia 9-10 November 2017 On ICC website: 3 rd FARO Meeting, BALI 2018 ion THANK YOU!

30 Website: Facebook: Contact Detail FARO Secretariat Office: Address c/o Radiation Oncology, Graduate School of Medicine, Gunma University Show Machi Maebashi-Shi, Gunma-Ken, Japan Tel For FARO Database: project.computesta.com/faro-db/web