Radiotherapy Coverage in Romania

V. Cernea1,2, A. Irimie1,2, N. Todor2

1UMF ”Iuliu Hațieganu” Cluj-Napoca 2Institutul Oncologic ”Prof. Dr. Ion Chiricuta” Cluj-Napoca

Conferinta SRROM Sibiu 15-17 octombrie 2015

Istoric al centrelor de RT din România

• Reţeaua actuală a centrelor de radioterapie a fost concepută şi realizată între anii 1970-1987: • criterii epidemiologice • criterii de ordin geografic. • 16 centre de RT echipate in general cu aparate cobalt

ROKUS M (URSS) • 1998-2000 reechiparea acestora cu aparate de cobalt

Theratron, 2 AL cu MLC si 4 AL fara, 4 aparate brahiterapie, sisteme de planning, echipamente dozimetrie

• 2009 IOCN 1 AL de mare performanta +CTsim+planning • 2010-2013, 2 AL IOB, 2 AL IRO Iasi, 1AL Sp. Militar

Bucuresti

• CENTRE PRIVATE • 3 Bucuresti • 1 Brasov • 1 Sibiu • 1 Cluj• 1 Timisoara

• in prezent mai avem 14 centre in sistemul public

Metodologia studiului

• Chestionar electronic adresat centrelor celor 27 centre de RT inregistrate la CNCAN dupa cum urmeaza

• centre din sistemul public

• 14 centre cu echipament de MV

• 7 centre cu echipament de kV

• centre in sistemul privat - 7 cu echipament MV

• Chestionarul a fost completat on-line fiind structurat astfel:

1. date privitoare la institutie

2. date privitoare la platforma de megavoltaj

3. date privitoare la platforma de kilovoltaj

4. date privitoare la platforma de brahiterapie

5. date privind incadrarea cu personal

6. date privind activitatea departamentului

01.Bucuresti-IOB02.Cluj-IOCN03.Iasi-IRO04.Bucuresti-Elias05.Bucuresti-Coltea06.Bucuresti-Sp.Militar07.Craiova08.Timisoara09.BaiaMare10.Bucuresti-CCSM

11.Constanta12.Galati13.Oradea14.Tg.Mures15.Arad-Sp.Judeteandeurgenta16.Cluj-Inst.Gastroenetrologie17.Cluj-Sp.Clinicdeurgenta18.Deva-Sp.Judeteandeurgenta19.Ploiesti-Sp.Municipal20.Tirgoviste-Sp.Judeteandeurgenta21. Brasov - Oncocard22. Bucuresti - Amethyst23. Bucuresti - Graal24. Bucuresti - Neolife25. Cluj - Amethyst26. Sibiu - Polisano27. Timisoara Oncohelp

Mediana=

12ani Media= 19ani

Mediana=7.5ani Media=6.3ani

Simulatoare radioterapie (n=15; 6 clasice, 13 CT sim)

Mediana= 7.5 ani Medie= 7 ani

Radioterapia Romania 2014-2015 Resurse umane

6766

4245

1314

64

125134

4153

1916151923

16

0 20 40 60 80 100 120 140 160

NrMedici20142015

NrFizicieni20142015

NrFizicieniExper9FizicaMedicala20142015

NrFizicieniExper9Radioprotec9e20142015

NrTehnicieni20142015

NrReziden920142015

Deficit5aniMedici20142015

Deficit5aniFizician20142015

Deficit5aniTehnicianRT20142015

Resurseumane2014-2015

Institutie AnRefrinta NrBolnaviTratati

NrBolnaviTratatirt

NrBolnaviTratatiBT

NrBolnaviTratatiCo

NrBolnaviTratatiAL

Bucuresti-CCSM

2014 147 147 0 0 147

BaiaMare 2013 230

Bucuresti-Sp.Militar

2015 880 650 230 0 650

Oradea 2014 1173 795 378 0 795

Constanta 2015 634 634 634 0

Galati 2014 1016 997 997

Tg.Mures 2014 1190 1190 1190

Iasi-IRO 2014 1454 1454 1454

Bucuresti-Coltea

2014 1687 1489 198 1489

Timisoara 2014 1913 1913 88 795 1118

Craiova

Cluj-IOCN 2014 2799 2550 249 889 1661

Bucuresti-IOB 2014 3900 3200 700 3200

TOTAL 17023 15249 1843 3545 11704

Pacienti RT megavoltaj servicii publice Romania 2014-2015

80230

350

750

957 973

1480 15001639

18011906

2553

2940

147230

650795

634

997

1190

1454 1489

1913

2550

3200

0

500

1000

1500

2000

2500

3000

3500

Bucures2-CCSM

BaiaMareBucures2-Sp.Militar

Oradea Constanta Gala2 Tg.Mures Iasi-IRO Bucures2-Coltea

Timisoara Craiova Cluj-IOCNBucures2-IOB

NrBolnaviTrata2Megavoltaj

2014* 2015*

80

350249

14801500 1639

992

1503

1682

2940

147

650795

0

1190

1454 1489

1118

1661

3200

0

500

1000

1500

2000

2500

3000

3500

Bucures2-CCSM

BaiaMareBucures2-Sp.Militar

Oradea Constanta Gala2 Tg.Mures Iasi-IRO Bucures2-Coltea

Timisoara Craiova Cluj-IOCNBucures2-IOB

NrBolnaviTrata2AL

2014* 2015*

230

501

957 973

809

403

871

0

230

0 0

634

997

795

889

0

200

400

600

800

1000

1200

Bucures2-CCSM

BaiaMareBucures2-Sp.Militar

Oradea Constanta Gala2 Tg.Mures Iasi-IRO Bucures2-Coltea

Timisoara Craiova Cluj-IOCNBucures2-IOB

NrBolnaviTrata2Co

2014* 2015*

Nr. pacienti cu BT 2014-2015

100 81

267

88

462

1500

0

230

378

198

88

249

700

0

200

400

600

800

1000

1200

1400

1600

Bucures2-CCSM

BaiaMareBucures2-Sp.Militar

Oradea Constanta Gala2 Tg.Mures Iasi-IRO Bucures2-Coltea

Timisoara Craiova Cluj-IOCNBucures2-IOB

NrBolnaviTrata2BT

2014* 2015*

RT în România vs standarde internaționale

• Standard international

• >60% dintre bolnavii cu cancer au nevoie de radioterapie pe parcursul evoluției bolii

• 1994: 42.287 bolnavi noi de cancer. RT megavoltaj 7.000= 16,5% vs

• 2011: 72.000 bolnavi noi de cancer, RT megavoltaj 19.490= 39,7%

• 2013: 73.000 bolnavi noi, RT megavoltaj 17.159= 23,5% !!

• 2014- 15.249 RT megavoltaj in sistemul public + cca 2000 in sintemul privat

Centre private RTechipamente si resurse umane

CENTRU AL BT Nr. medici

Nr. fizicieni

Experti fizica

medicalaTehnicieni

deficit medici 5

ani

deficit fizicieni 5

ani

deficit tehnicieni

RT

Amethyst Bucuresti 2 1 5 4 3 14

Amethyst CLUJ 1 1 3 4 1 12

Neolife 1 1 4 3 2 5 3 2 5

Sibiu 1 2 2 1 7

Total 5 3 14 13 6 38 3 2 5

Centre private RT-pacienti tratati

CENTRU RT externa BT 3D Tehnici speciale

Amethyst Bucuresti 805 76 5 IMRT

Amethyst CLUJ 375 33 2 IMRTIGRT

Neolife 220 30 20 Rapid Arc

Sibiu 596 Tomotherapy

TOTAL 1996 139 27

Acțiuni ale comunitații profesionale, SRRO, Comisiei de Oncologie a MS si a Comisiei de RT a CNAS

• 1994- N. Ghilezan: prima analiza a activitatii centrelor de RT cu propuneri pentru un plan național de RT

• 2008- Comisia de Oncologie- Raport privitor la starea RT și propuneri pentru un plan național de radioterapie (V. Cernea si colab.)

• 2010- IOCN Laboratorul de RT- audit IAEA Viena (QUATRO)

• 2011- Comisia de Oncologie- Evaluarea Retelei de RT propuneri de ameliorare a situatiei existente- trmisă tuturor ministilor sanatatii de atunci si pana in prezent (V. Cernea si colab)

• 2011- modificarea tarifelor de decontare ale serviciilor de RT bazată pe indicele de complexitate (Comisia de Radioterapie a CNAS (V. Cernea, M. Savu, S. Vlad)

• 2012- Misiunea imPACT a IAEA propuneri pentru un plan național de control ac cancerului Raport inaintat Ministerului Sanatatii pe canale diplomatice (OMS si IAEA)

• 2014- Studiu IAEA “Radiotherapy Utilisation Rate”: IOCN participant

1.Implementareaunuiregistrudecancercaresăacopereîntreagapopulaţiea

României(procesaflatinderularesubcoordonareaMS)

2.Estimareacâtmaicorectăanumăruluidebolnavioncologicicareaunevoie

deradioterapie;

3.Investiţii în infrastructura de radioterapie (clădiri şi echipamente) astfel

încâttoţibolnaviicucancer, indiferentderegiunegeograficăsăaibăacces

facil şi echitabil la servicii de radioterapie adecvate din punct de vedere

tehnicstandardeloracceptatepeplanEuropean;

4.Planificarea forţei de muncă în funcţie de numărul bolnavilor trataţi,

complexitateadotărilor tehnicedin fiecarecentruprecumşimisiunilorde

formare şi învăţământ din centrele majore de oncologie (institute

oncologice,centreuniversitare);

5.Asigurarea unui cadru legislativ adecvat susţinerii calităţii serviciilor de

radioterapie.Elaborareaşi/saumodificareaunoractenormativeprivitoare

la activitatea laboratoarelor de radioterapie, creşterea performanţelor

manageriale ale şefilor de servicii încât acestea să aibă o activitate în

parametriidecost-eficienţăcomparabilecunormativeleeuropene.

6.ÎnfiinţarealaInstitutulOncologic”Prof.Dr.IonChiricuţă”ClujauneiUnităţideManagementPilotNaţionalpentruLaboratoarelederadioterapie

Institutii vizitate IOCN IOB Oncocard Brasov Casa Sperantei Brasov CNCAN Agentia Nucleara Biroul Bucuresti al OMS

Raportul misiunii PACT 2012- concluzii generale

Diagnosticulşitratamentul • Îmbunătăţireainfrastructuriideradioterapieînceeacepriveştefacilităţileşiechipamentul.Numărulaparatelorde radioterapie trebui să crească pentru a răspunde cererii iar unităţile vechi trebuie înlocuite cu aparaturămodernă.

•Educaţia(şiinstruirea)şireţinereapersonaluluimedicalestecrucialîngeneral,iarîncazparticular: (i) trebuie depuse eforturi pentru a dezvolta un programde educaţiemedicală continuă pentru chirurgii careopereazăpacienţioncologici,şi, (ii)personalulmedicalradiologicesteoprioritateesenţialăcarenecesităatenţiedeosebită.Spitaleleşicentrelederadioterapietrebuiesăangajezepersonalsuplimentarşisăoferebeneficiipentruareţinepersonalul.Trebuiestabilite strategii urgente pentru iniţierea unor programede educaţie şi instruire pentru a încuraja personalulmedicalsărămânăînţară.

•Combaterea activă a „scurgerii de personal” prin oferirea de beneficii cadrelormedicale pentru amunci şi încercetareşiînfiinţareaunuiprogrammenitaîntoarceemigranţiiînţară.

•Stabilireaunorprogrameeducaţionalepentrufizicieniimedicalişitehnicieniideradioterapie. •Planificareapetermenlungaforţeidemuncănecesară,înfuncţiededezvoltareafacilităţilor,numărulanticipatdepacienţişicomplexitateaechipamentelorşiatehnicilor.

•Reconsiderarea medicamentelor oncologice esenţiale, conform disponibilităţii resurselor. Conform resurselordisponibilecitostaticilede‘patrustele’decifoartescumpe,potsăseconstituieîntr-unriscfinanciarmajor.

•Radioterapia tridimensională conformaţională (3D CRT) trebuie să devină tehnica standard în majoritateacentrelorderadioterapie iar tehnicilemaiavansate (IMRT, IGRT) trebuie implementate încentreleuniversitaredezvoltate.

•România poate obţine beneficii din analiza punctelor de referinţă şi a standardelor stabilite deUE în privinţadezvoltăriiasistenţeimedicaleoncologice.

Radiotherapy in developing countries

Optimal radiotherapy utilisation rate in developing countries: An IAEAstudy

Eduardo Rosenblatt a, Michael Barton b,⇑, William Mackillop c, Elena Fidarova a, Lisbeth Cordero d,Joel Yarney e, Gerard Lim f, Anthony Abad g, Valentin Cernea h, Suzana Stojanovic-Rundic i,Primoz Strojan j, Lotfi Kobachi k, Aldo Quarneti l

a International Atomic Energy Agency, Nuclear Applications, Vienna, Austria; b Ingham Institute for Applied Medical Research, Radiation Oncology, Sydney, Australia; c Queen’sCancer Research Institute, Queen’s University, Kingston, Canada; d Hospital Mexico, Radiotherapy, San Jose, Costa Rica; e National Centre for Radiotherapy and Nuclear Medicine,Radiotherapy, Accra, Ghana; f National Cancer Institute, Putrajaya, Malaysia; g Lung Center of the Philippines Hospital, Radiation Oncology, Quezon City, Philippines; h RadiationOncology, Oncology Institute Cluj-Napoca, University of Medicine And Pharmacy, Cluj-Napoca, Romania; i Institute of Oncology and Radiology of Serbia, Radiation Oncology,Belgrade, Serbia; j Institute of Oncology, Radiation Oncology, Ljubljana, Slovenia; k Institut National de Cancer Salah Azaiz, Radiotherapy, Tunis, Tunisia; and l Hospital Pereira Rossell,Radiotherapy, Montevideo, Uruguay

a r t i c l e i n f o

Article history:Received 25 May 2015Received in revised form 9 June 2015Accepted 9 June 2015Available online 8 July 2015

Keywords:Radiotherapy utilisationRadiotherapy servicesMiddle income countries

a b s t r a c t

Optimal radiotherapy utilisation rate (RTU) is the proportion of all cancer cases that should receive radio-therapy. Optimal RTU was estimated for 9 Middle Income Countries as part of a larger IAEA project tobetter understand RTU and stage distribution.

! 2015 Elsevier Ireland Ltd. All rights reserved. Radiotherapy and Oncology 116 (2015) 35–37

Planning of efficient and equitable treatment services for a pop-ulation requires a rational and defensible estimate of demand. Thishas particular relevance for planning services that require signifi-cant capital expenditure such as radiotherapy. Radiotherapy is anessential mode of cancer treatment and contributes to the cureor palliation of many cancer patients. Radiotherapy facilities havea relatively high initial capital costs and their operation is staffintensive [1].

The proportion of cancer patients who receive radiotherapy isconsidered a useful benchmark of access to cancer services. It canbe compared to the proportion of all cancer patients who wouldbenefit from radiotherapy at least once has been termed the opti-mal radiotherapy utilisation rate (RTU). It has been estimated fordeveloped countries following an evidence-based method [2,3],criterion-based method [4] or based on assessment of current prac-tice. In Australia, optimal RTU was estimated at 52.3% in 2003 [2]and later revised to 48.3% in 2012 [3]. The RTU varies betweencountries with differing case-mix of cancer types [5–7] because dif-ferent tumour types have different indications for radiotherapy.

Countries with a higher proportion of cancers such as head andneck or uterine cervix with a large proportion of cases with indica-tions for radiotherapy, will have a higher RTU than those countrieswith higher proportions of cancers such as colon cancer and mela-noma with few indications for radiotherapy [5].

For developing countries, the proportion of cancer patients whorequire radiotherapy can be estimated from the distribution of can-cer types and stages. The purpose of this project was to assess theoptimal RTU rates in middle-income countries using an evidencebased method. The aim of this study was to estimate optimalRTU for each participating country.

Materials and methods

Optimal RTU

The optimal RTU was defined as the proportion of all cancerswith an indication for radiotherapy. An indication was defined asa clinical scenario where radiotherapy was the treatment of choicebecause it produced a superior outcome in terms of survival, localcontrol, palliation or had lower toxicity and the patient is fit fortreatment. Detailed methods and assumptions have previouslybeen published by the Collaboration for Cancer OutcomesResearch and Evaluation (CCORE) [2,3]. The CCORE model wasbased on Australian data.

http://dx.doi.org/10.1016/j.radonc.2015.06.0120167-8140/! 2015 Elsevier Ireland Ltd. All rights reserved.

⇑ Corresponding author at: Ingham Institute for Applied Medical Research, 1Campbell St Liverpool NSW 2170, PO Box 3151 Westfields Liverpool, Liverpool NSW2170, Australia.

E-mail address: michael.barton@sswahs.nsw.gov.au (M. Barton).

Radiotherapy and Oncology 116 (2015) 35–37

Contents lists available at ScienceDirect

Radiotherapy and Oncology

journal homepage: www.thegreenjournal .com

Radiotherapy and Oncology 116 (2015) 35–37

Optimal RTU does not include non-melanomatous skin cancersor benign neoplasms because these are not notified routinely tocentral cancer registries. It does not include retreatment by radio-therapy. In high income countries about 25% of cases will undergotwo or more courses of radiotherapy [8].

Cancer incidence data

In order to adapt the CCORE RTU model to other countries, dataon the proportion of incident cancer cases and the variation intypes of tumours in each country were taken from Globocan2012 [9]. Globocan provides data by tumour type for 27 cancertypes and total cancer incidence. The quality of data sources is alsoreported. The database does not report a separate ‘unknown’ cate-gory. The difference between the total cancer cases and the sum ofthe 27 identified cancer types is a combination of ‘other’ and ‘un-known’ cancers. ‘Other’ and ‘unknown’ are split roughly 50:50 inAustralia where ’other’ has an optimal RTU rate of 19% and ’un-known’ of 61%. The average is thus 40%. We have assumed this isthe same in participating middle income countries. It is probablyan underestimate as there are likely to be higher proportions ofunknown tumour type in middle income countries because ofpoorer access to diagnostic services.

Radiotherapy indications and epidemiological data weremerged to estimate optimal RTU in each participating country.

Results

Nine middle-income countries were selected to participate inthis assessment. There were two countries from Asia, Africa,South America and three from Europe. Data on the participatingcountries are shown in Table 1. During the study two countries(Slovenia and Uruguay) were reclassified as High IncomeCountries.

Optimal RTU

The optimal overall RTU rates for the participating countries areshown in Table 1. Optimal RTU ranged from 47% in Costa Rica to56% in Tunisia.

There was a difference of 9% between the lowest optimal RTU inCosta Rica (47%) and the highest in Tunisia (56%) that may be dueto variations in incidence of types of cancers treatable with radio-therapy (Fig. 1) that have a lower proportion of total incidence inCosta Rica than in Tunisia: bladder (1.8% vs. 6.5%), lung (6.6% vs.

Table 1Income and data quality in participating countries.

Country World bank2012 GNI/person ($USdollars)

Incomeclassification

Quality of data* OptimalRTU (%)

Ghana $1550 Low middle F. Frequency data 51Philippines $2500 Low middle B. High quality

regional(coverage 10% to50%)

53

Tunisia $4150 Uppermiddle

C. High qualityregional(coverage <10%)

56

Serbia $5280 Uppermiddle

B. High qualityregional(coverage 10% to50%)

52

Costa Rica $8820 Uppermiddle

A. High qualitynational orregional(coverage >50%)

47

Romania $8820 Uppermiddle

E. Regional data 52

Malaysia $9820 Uppermiddle

C. High qualityregional(coverage <10%)

53

Uruguay $13,580 High A. High qualitynational orregional(coverage >50%)

52

Slovenia $22,800 High A. High qualitynational orregional(coverage >50%)

48

* Source: Globocan 2102 [9].

Fig. 1. Distribution of tumour types by country.

36 Radiotherapy utilisation in developing countries

20.0%) and nasopharynx (0.8% vs. 3.8%). 27.4% of all cancers inGhana were cervix cancer and colorectal cancer was only 1.7% oftotal incidence. However, the category ’other and unknown’ inGhana was 11.5% probably reflecting issues with cancerregistration.

Discussion

It has been assumed that the optimal RTU rate should be signif-icantly higher in developing countries than in developed countries.This is based on the assumption that in LMI countries there arelimited or no prevention and early detection programmes, and ade-quate surgical services are limited, the majority of cancer patientspresent with advanced disease and most will not be amenable tosurgery or will require palliative radiotherapy. Optimal RTU forMiddle Income Countries in this study ranged from 47% to 56% ofall new cancer cases. These rates are similar to optimal RTU esti-mates for high income countries [7,10,11].

IAEA has initiated a project to collect actual utilisation and stagedata so that the optimal utilisation estimates can be refined byadding local staging data and actual utilisation can be more accu-rately estimated. This information will be invaluable for planningnational or regional radiotherapy services, national cancer controlprogrammes, budgeting for upgrade of services and technical coop-eration projects by the IAEA Technical Cooperation Programme andother stakeholders.

The evidence-based method of estimating optimal RTU hasbeen criticised for potentially overestimating the demand forradiotherapy [12]. It is the only method that can be readily adaptedto different distribution of cancer types and is not greatly affectedby different distributions of stage at diagnosis [6]. It is likely thatthe overall demand for radiotherapy is underestimated becausethe optimal RTU does not include cancers and conditions that arenot notified to a cancer registry such as non-melanomatous skincancer and benign neoplasms which are often treated with radio-therapy as well.

Conclusion

The optimal RTU rate in this group of middle-income countriesdid not differ significantly from that found in higher incomecountries.

Conflict of interest statement

The authors do not have any conflicts of interest to declare.

Acknowledgment

The International Atomic Energy Agency, Vienna, Austriafunded the meeting of national representatives and the data collec-tion and data processing for this project.

References

[1] Van Der Giessen PH, Alert J, Badri C, Bistrovic M, Deshpande D, Kardamakis D,et al. Multinational assessment of some operational costs of teletherapy.Radiother Oncol 2004;71:347–55.

[2] Delaney G, Jacob S, Featherstone C, Barton M. The role of radiotherapy incancer treatment. Cancer 2005;104:1129–37.

[3] Barton MB, Jacob S, Shafiq J, Wong K, Thompson SR, Hanna TP. Estimating thedemand for radiotherapy from the evidence. A review of changes from 2003 to2012. Radiother Oncol 2014;112:140–4.

[4] Kerba M, Miao Q, Zhang-Salomons J, Mackillop W. Defining the Need forProstate Cancer Radiotherapy in the general population: a Criterion-basedBenchmarking Approach. Clin Oncol 2010;22:801–9.

[5] Barton MB, Frommer M, Shafiq J. The role of radiotherapy in cancer control inlow- and middle-income countries. Lancet Oncol 2006;7:584–95.

[6] Borras JM, Barton M, Grau C, Corral J, Verhoeven R, Lemmens V. The impact ofcancer incidence and stage on optimal utilization of radiotherapy:methodology of a population based analysis by the ESTRO-HERO project.Radiother Oncol 2015;116:45–50.

[7] Borras JM, Lievens Y, Dunscombe P, Coffey M, Malicki J, Corral J. The optimalutilization proportion of external beam radiotherapy in European countries: anESTRO-HERO analysis. Radiother Oncol 2015;116:38–44.

[8] Barton M, Allen S, Delaney G, Hudson H, Hao Z, Allison R, et al. Patterns ofretreatment by radiotherapy. Clin Oncol 2014;26:611–8.

[9] Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C. GLOBOCAN2012 v1. 0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No.11. Lyon, France: International Agency for Research on Cancer; 2013(http://globocaniarcfr. 2014).

[10] Williams MV, Drinkwater KJ. Radiotherapy in England in 2007: modelleddemand and audited activity. Clin Oncol 2009;21:575–90.

[11] The Swedish Council on Technology Assessment in Health C. Aprospective survey of radiotherapy practice in Sweden. Acta Oncol1996;35:47–56.

[12] Mackillop WJ, Kong W, Brundage M, Hanna TP, Zhang-Salomons J, McLaughlinP-Y, et al. A comparison of evidence-based estimates and empiricalbenchmarks of the appropriate rate of use of radiation therapy in Ontario.Int J Radiat Oncol Biol Phys 2015;91:1099–107.

E. Rosenblatt et al. / Radiotherapy and Oncology 116 (2015) 35–37 37

Cauzele situatiei actuale• Dezinteresul si lipsa de viziune a decidentilor politici in

pofida actiunilor comunitatii profesionale

• Sistemul de rambursare al CNAS cel putin pana in 2012 (48,50 RON/sedinta)

• in prezent bazat pe indicele de complezitate-rezonabil

• lipseste decontarea separata a procedurilor de simulare si control de calitate

• absenta legislatiei specifice pentru laboratoarele de radioterapie

Solutii?• Proiect Banca Mondiala…

• rezolva doar o parte a problemei

• investitii serioase in echipamente si formarea de personal

• sistem corect de rambursare care sa permita dezvoltarea serviciilor de rt

• planul national de radioterapie, actualmente nerealist

• legislatie specifica