UDUTH radio-oncology ‘villagers’ and their distinguished indigene, the LINAC

In verbose Nigerian parlance, with singular honour and great privilege, permit me to introduce to you a rare breed I met recently in Sokoto - the Linear Accelerator machine popularly known as LINAC, used for treating cancer patients. On Thursday, 23rd of November 2017, I stood in awe before this great invention that has the capacity to save so many lives.

Doctors have been using radiation-filled glass tubes implants to destroy cancer cells since 1898. Although radioactive implants are still used to boost the amount of radiation at a tumor site, most radiation therapy now is delivered by linear accelerators. The machine produces millions of volts of energy that travels in a straight line, at almost the speed of light and with great precision to the tumour site, such that damage to nearby bones, organs, muscles and nerves is minimal.

This machine is greatly lacking in Nigeria. To serve our population of 170M, the W.H.O. recommends 300 machines. The state of New Jersey, USA with a population of just nine million people, has 29 functional LINACs in hospitals across the state. Although 9 LINACs were purchased in 2009 under the VAMED (what is this?) deal during President Olusegun Obasanjo’s regime, no lasting maintenance agreement was signed and it was later discovered that some were refurbished. Thus the machines, now tired and technologically outdated, are often down. The exception is the Linac in the Oncology unit of the Usman Dan Fodio University Teaching Hospital (UDUTH), Sokoto. I wanted to find out why.

The first point to stress is that the linear accelerator does not work in isolation. It needs a “village” with a governing structure and planning to function. I choose to call the UDUTH team a village because they are a cluster of humans settled together and bound by a similar language, culture and futuristic ideals. Last week I met the UDUTH village and their distinguished indigene, the LINAC.

We were welcomed by the ‘village head’, Dr. Yakubu Ahmed, CMD, and his rare breed of villagers - Dr. Mallami Aliyu, Head of RadioOncology; Dr. Ibrahim Shinkafi, Radiologist (and yes, my “brother”); Umar Mohammed, a Biomedical Engineer; and Faruk Ibrahim, a Mould Technician.. I will explain later why they are a rare breed, and why our failure to follow their path is one of the reasons we have a deficient cancer treatment system in Nigeria.

My team and I, accompanied by Dr. Abubakar Dakingari were taken through the steps of radiotherapy treatment. It is quite a complex, precise and fascinating process. Some of these steps, particularly in the treatment planning system (T.P.S.), are omitted in some of our centres, at great cost to the wellbeing of the patients.

One such step is the CT-simulation, which takes a detailed scan of the area affected by cancer and smaller sites to which it has spread. The picture obtained is processed at a Work Station with the help of a computer system and the tumour area, along with possible sites of spread is marked (contour). The normal tissue is also marked to spare it from radiation. UDUTH is currently the only unit in the entire country that does this.

Once satisfied with the planning, the clinical oncologist immediately passes the plan for treatment, otherwise it has to be replanned all over.

Planning then moves to the Mould Room, where the technician creates moulds made from lead blocks to shield normal tissue from radiation.

Finally the patient, positioned in a special plastic mesh strap, faces the LINAC for radiotherapy. Including the positioning of the patient, each session takes about 15 minutes, although the actual treatment lasts only three minutes. The unit in Sokoto takes about two weeks to plan each patient and sees an average of 10 patients daily.

The term ‘radiation’ is frightening enough as it is, and even with my medical training, the futuristic sight of the linear accelerator chamber was quite awe-inspiring. The chamber itself is dominated by the round, eight-foot-diameter ‘’face’’ of the device. It felt like being on a Dr. Who set. If the machine awed me, then surely, the average patient would find it nothing short of intimidating. A 3000kg lead door separates patients from the technicians who run the accelerator and watch the procedure on coloured television monitors. They can also exchange communication with the patient, which makes the experience more tolerable and reassuring, especially for the first session. We were also taken behind the chamber to the main engine room and brain of the machine where any issues with the LINAC often originate. This is where biomedical engineers like Umar Mohammed spend most of their time. This was where he met us with the friendly words, “welcome to my home!” .To be continued… Dr. Zainab Bagudu, a Paediatric Consultant, is the Wife of the Governor of Kebbi State.