LINAC in cancer treatment: The UDUTH model

At the Usman Danfodio University Teaching Hospital there are machines, and there is also the Linear Accelerator, commonly known as the LINAC. A true scientific marvel, it is used to treat cancer patients.

Historically, doctors used radiation-filled glass tubes implants to destroy cancer cells since 1898. But this was imprecise and collateral damage was much. The modern LINAC, is a laser guided missile producing millions of volts of energy travelling in a straight line at nearly the speed of light to strike directly at the tumour site. It is so precise, damage to nearby bones, organs, muscles and nerves is often negligible.

TheWorld Health Organisation recommends that for Nigerias’s population of 170 million, we have 300 of these machines. Only in 2009 did Nigeria acquire just 4, only to find that they were mostly refurbished and most have since fallen into disrepair.

My medical colleagues will agree with me that somehow, of all the 9 Oncology service centers we have the country, the one that functions most of the time, is that of the Usman Dan Fodio University Teaching Hospital Sokoto. As the Medicaid Cancer Foundation engaged partners with a view to set up a treatment center, we decided to visit the Sokoto unit to to find out how they got the right formula.

Thus in November 2017, I finally got to meet UDUTH’s LINAC. I met it in safe hands and fully catered for by a team of very professional fellows led by Dr. Yakubu Ahmed, the CMD who leads the management. Also present were Dr. Mallami Aliyu, Head of Radio-Oncology; Dr. Ibrahim Shinkafi, Radiologist (and yes, my “brother”); Umar Mohammed, a Biomedical Engineer; and Faruk Ibrahim, a Mould Technician.

The close knit group of professionals took us round the unit.

Radiotherapy is quite a complex and precise process requiring certain steps, any of which if neglected could result in death. One such step is the CT-simulation, which takes a detailed scan of the area affected by cancer and the smaller sites to which it has spread. Shockingly, as basic as this process seems, UDUTH is currently the only unit in the entire country that does it.

A session lasts about 15 minutes, with the actual treatment lasting only three. It can take about two weeks to plan each patient and the UDUTH unit sees an average of 10 patients daily.

The term ‘radiation’ is frightening enough, and even with my medical training, the futuristic sight of the linear accelerator chamber was mind blowing. The chamber itself is dominated by the round, eightfoot-diameter ‘’face’’ of the device. I stood in awe staring and imagining how intimidating it must appear to patient who comes into contact with this revolutionary technology for the first time.

Behind the chamber lies the main engine room and brain of the LINAC. This is where biomedical engineers like Umar spend most of their time, and this was where he met us with the friendly words, “welcome to my home!”

Therapy is given in about 25 identical doses spread over five weeks to further limit radiation damage to healthy tissue and reduce the side effects.

The process I have described here is far from exhaustive; it is a simplified summary. Still, one can begin to grasp the complexity of cancer treatment. A deeper probe will throw up other vital aspects of the process like power supply, which must not only be stable, but delivered at a steady voltage to the power boards of the machines. Maintenance agreements with the equipment manufacturers are also very crucial and are a great part of why the other LINACS, bought less than a decade ago, are now moribund.

The whole process requires great foresight and one must factor in the years required to train staff ahead of equipment acquisition. All this obviously has huge financial implications. As a nation, we have a low credit rating, which means that we do not often qualify for financial agreements. In most cases, by the time a machine is turned on in Nigeria, it has to have been paid for in full. These are controllable, yet often neglected, steps in planning. Some of our problems stem from being a wealthy nation. Decisions are taken at top levels often without input from relevant parties, particularly those who will use the equipment. Thus while we can afford the equipment even without financial concessions, we rarely have the foresight to plan ahead. UDUTH, is an exception.

The tertiary institutions housing the LINACS did not train the biomedical engineers and the other professionals required to run the LINAC prior to acquisition. The machine came with only its operation softwares and so it was a matter of time before problems arose. Soon weary of the trial and error approach, the UDUTH radio-oncology folks got wise and took matters into their own hands, largely bypassing tedious red tape. At this point, I must salute the incredible effort of one person, the pioneer head of department, Professor B.B Shehu, a Kebbi State indigene and first neurosurgeon from Northern Nigeria. I applaud the foundation he and his pioneering team laid, which bequeathed to the unit the efficiency with which it operates today. Not only were they able to plan an efficient unit, they also put in place a sustainable succession plan which is evident in the unit.

To study as a biomedical engineer is a straightforward three year degree program. The snag is that the advancement of technology is fast and complicated. Various parts, software systems, devices are constantly being created and upgraded. The undergraduate curriculum of a biomedical engineering student does not guarantee being an all round service engineer. He or she has to be retrained once a new system is devised.

UDUTH invests years ahead in human resources for health and hand picks the best students early. Overall, as a nation, we do not invest enough in the human resources required to run our health system.

Yet another issue affecting cancer care in Nigeria is what I call corporate slavery by industrialized nations. Equipment manufacturers have a tight syndicated control over the end users particularly in Africa and the developing world. I have first-hand experience of this. When we started the Medicaid Radio-diagnostic Center in 2005, we acquired solely GE equipment, including the first privately owned CT scan in Abuja. At the time, GE had only two engineers to service and maintains all their equipment in the country.

The UDUTH team is brilliantly ahead of the game in all the ways I have enumerated, and in many more I don’t have the liberty to divulge. With such ingenuity the unit remains open and functional 90% of the time. Thus, it is very common to find patients from all over Nigeria in Sokoto for treatment.

The rare breeds I have mentioned above with their ingenuous methods make up the team that is required to manage cancer patients with radiotherapy. To have one without the other is almost useless. Having started and run a diagnostic centre for nine years, I have the advantage of living firsthand through many of these problems. I am no doubt guilty of many of the lapses but I am learning step by step, and by collaborating with minds at the UDUTH Radio-Oncology unit, my learning curve is shortening.

As we mark world Cancer day on February 4th, I celebrate the entire clinical and management team of the Usman Dan Fodio University Teaching Hospital Sokoto and encourage other units to engage them without arrogance and learn, so that together, we can give Nigerian cancer patients a fighting chance.

Dr. Shinkafi-Bagudu is the wife of Kebbi State Governor and founder Medicaid Cancer Foundation. still