In this episode the astronomy writer Keith Cooper is on hand to chat about the surprising discovery of phosphine in the atmosphere of Venus. He explains that here on Earth, microbial life is the only natural source of phosphine – which could mean that life exists in the clouds of Venus. Cooper also speculates about how future missions to the “habitable zone” of the Venusian atmosphere could search for life.
Today, there is a huge disparity in cancer care across the world with people living in low- and middle-income countries having limited access to the best radiotherapy treatments. This imbalance is the focus of the social enterprise company EmpowerRT, which was founded by the University of North Carolina medical physicist Sha Chang. In this episode, Chang and her colleague Cielle Collins talk to Physics World’s Tami Freeman about what can be done to provider greater access to the best treatments.
EmpowerRT, a social enterprise company spun out from the University of North Carolina (UNC), has an impressive goal: to help resource-limited cancer clinics in developing countries improve radiotherapy, at just 5–10% of the cost of purchasing modern technology.
Currently, there is a huge disparity in cancer care across the world. About 70% of deaths from cancer occur in low- and middle-income countries (LMICs) and, according to the World Health Organization, it is these LMICs that will face the highest increase in cancer death rates in decades to come.
One underlying reason for this disparity is that many cancer clinics in LMICs still rely on older generation radiotherapy equipment, with no funds available to update to modern digital-based systems and the associated infrastructure. And while advances in radiation therapy technologies, such as the introduction of intensity-modulated radiotherapy (IMRT, which has been standard-of-care for years in developed nations), can improve tumour targeting and clinical outcomes, such systems are simply too expensive for many cancer clinics in LMICs.
“This is the really sad truth,” says EmpowerRT’s founder and president Sha Chang. “Many patients in developing countries die and suffer, not because the world doesn’t know how to treat their cancers, but because they have no access to the treatments. Our mission is to help people in low-resource countries to improve the quality of radiotherapy using existing resources, without spending millions of dollars that they don’t have.”
EmpowerRT is tackling this problem by offering a technology that enables any radiation delivery system to provide IMRT, using a low-cost compensator placed in front of the treatment beam. The compensator comprises a styrofoam mould filled with tungsten granules. It can be fabricated using a milling machine, assembled on site and, after treatment, the tungsten can be recycled to treat other patients. “The core belief of EmpowerRT is that we can advance cancer care by doing more with less, doing more with what is already available, and doing it simply”, says Sha.
Similar to modern radiotherapy systems, the IMRT compensator shape is individually designed to attenuate the radiation beam to maximize dose to the tumour target while minimizing dose to nearby healthy tissue. “Using this approach, we can make existing radiation therapy machines in LMICs deliver a more advanced treatment. That’s the beauty of it,” says Sha. She explains that the recyclable compensator IMRT solution was developed at UNC before multileaf collimator (MLC)-based machines were widely available, and was used in treatments for 14 years and 1400 patients before UNC terminated its use after migrating to digital-based radiotherapy.
“We developed the recyclable compensator IMRT technology at a time when we were in a manual operating environment that’s still used in many low-resource settings. So we know this technology is feasible in that environment,” says Sha. “We want to give our proven technology a second life that can benefit more cancer patients.”
In addition to the recyclable compensator IMRT technology, EmpowerRT also offers treatment planning software and e-chart, a digital patient chart software designed for manually operated clinics. “Our goal is to bring the many benefits of a record and verify system to low-resourced clinics in LMICs,” says Sha. “We are also bringing in grid therapy, a novel therapy that benefits large and late-stage tumours, which are more prevalent in developing countries.”
The company also provides extensive training and support, to help sites introduce IMRT – everything from quality assurance and patient selection to setup – in order to establish an effective and safe treatment programme.
EmpowerRT has now installed this technology at its first site – the Cancer Diseases Hospital in Zambia. The country’s sole cancer hospital, it has three basic radiotherapy machines, none of which were previously able to deliver IMRT.
The EmpowerRT team offered remote training on the treatment planning software and also travelled to Zambia three times for extended onsite training and dry runs. Sha notes that the training focused on knowledge transfer: “we train the trainer, and then watch the trainer train others,” she explains.
“The training was excellent and the time spent was more than expected, with various hands-on and ‘real patient’ practice cases,” says Mulape Kanduza, chief medical physicist at the Cancer Diseases Hospital. “My first impression was ‘why is this renowned professor from UNC interested in working with our department?’. Effort was put both by the trainees and trainers and I believe the output is evident.”
Challenges such as machines breaking down and long delays in performing repairs, which are not uncommon in a LMIC environment, exacerbated by COVID-19-related travel restrictions, mean that the Cancer Diseases Hospital has not been able to complete an IMRT patient treatment yet. “But we have overcome many unexpected challenges, and the Zambia team of doctors, physicists and radiation therapy technologists all learned a great deal,” says Sha. “They are confident that they can do this new procedure independently, with us remotely doing the review and monitoring. That’s the success.”
“The future is very positive in that we have created a lasting relation to draw from,” Kanduza tells Physics World. “The positive outcome [will be] seeing an IMRT patient treatment being executed and knowing that the outcomes will be much better than treating with other conventional techniques.”
“Improved quality assurance in the workflow, using the Excel-based e-chart to review treatment records, has allowed us to think differently and to acknowledge change,” Kanduza adds. “One measurable outcome is that EmpowerRT’s e-chart system can work in a low-income setting such as ours.”
Looking ahead, EmpowerRT is now in talks with cancer clinics in Nigeria and Indonesia. The company is also partnering with organizations such as Clinton Health Access Initiative, which has worked for decades to reduce the burden of disease in LMICs, and Rayos Contra Cancer, which focuses on global radiotherapy training.
“We are also writing an NIH small business proposal targeted to feasible and effective cancer solutions in LMICs,” says Sha. “The next step is not only looking for where we can help, but how as a social enterprise company we can continue to grow, to partner with more like-minded global cancer care organizations and make a difference together.”
Followinghard–earned success in Zambia, Sha Chang’sEmpowerRTsocial enterprise venture eyes broader reach forits low-cost, high-quality cancer solution.
Shellie Edge, Innovate Carolina , Tuesday, July 28th, 2020
Cancer treatment providers in developing countries often lack equipment and training to provide the most advanced type of care. EmpowerRT is working to change that.
When Innovate Carolina last caught up with Sha Chang, founder of social enterprise EmpowerRT and professor at the UNC School of Medicine, she was thrilled that her venture had just secured its first test site in Africa. Now, just two years later, EmpowerRT has wrapped its initial work at the Zambia Cancer Disease Hospital and is looking to bring its solution to cancer patients in other areas of the world.
EmpowerRT improves cancer treatment in low-to-middle-income countries (LMICs) with a solution similar to modern treatment technology, but at less than 10% of the cost. At the Zambia test site, EmpowerRT demonstrated the feasibility of its solution in a clinical setting. The field work also allowed the team to test baseline methods for preparing and deploying its solution to other low-resourced areas.
“Changing the world doesn’t mean that everyone needs to find the next big thing. We should emphasize sharing knowledge and the inventions we already have, so we can create real benefit to people in need,” said Chang, director of medical physics research in the medical school’s radiation oncology department. “I hope to make a meaningful impact in cancer treatment with our solution that enables resource-limited cancer clinics to do more with less.”
“Our mission is to help people in developing countries improve cancer therapy without spending millions of dollars they don’t have.” — Sha Chang
EmpowerRT focuses on LMICs, where its solution is needed most. According to the World Health Organization, cancer is the second leading cause of death globally, accounting for an estimated 9.6 million deaths in 2018. Approximately 70% of those deaths occurred in LMICs, and by 2030, cancer mortality rates in LMICs are projected to increase by more than 70%. By contrast, they are projected to decrease by 30% in high income countries (HICs), according to the National Cancer Institute.
The reason for the disparity is multifold. Many developing countries lack resources dedicated to cancer research and treatments, and most radiotherapy clinics in those countries still rely on basic or outdated equipment. In addition, those clinics lack the funds, training and infrastructure to implement modern 3D and intensity-modulated radiation therapy (IMRT) technology, which is more effective in treating cancer with fewer side effects.
Chang sees EmpowerRT’s novel adaptation of technology that was previously developed and clinically used at UNC hospital as a potential equalizer.
“Our mission is to help people in developing countries improve cancer therapy without spending millions of dollars they don’t have,” said Chang. “Our four-prong solution — hardware, software, service and training — can help cancer clinics in low-to-middle-income countries save up to $3 million when our solution is brought to their clinic.”
At Zambia Cancer Disease Hospital, Chang and her team focused on proving that the EmpowerRT solution can maximize the value of radiation therapy equipment that already exists in clinics to deliver affordable, high-quality treatment with low toxicity.
“With global cancer care, there are many challenges including availability, cost and barriers to adoption,” added Chang. “The EmpowerRT solution aims to do more with less: do more with what is already available in the low-resource clinics; do more with the knowledge and technology we have already; and do it simply.”
During the test phase in Zambia, Chang and her team faced many hurdles. Their learning curve involved adjusting to a different work culture, while dealing with broken equipment and inexperienced hospital staff. They also had to contend with the country’s strained financial situation and schedule delays caused by extended government holidays. Chang quickly realized that her team would have to work through unanticipated twists outside their control.
“I am not going to lie. I felt completely hopeless many times,” said Chang. “But somehow, there is a force pushing me to put one foot in front of the other, and that pays off. We exceeded my expectations.”
The team’s persistence paid off. They installed software and hardware, conducted training on compensator-IMRT treatment planning, recyclable device fabrication and quality assurance to doctors, therapists and physicists to use EmpowerRT’s solution safely in their clinic. The team also implemented a train-the-trainer program, proving how user-friendly the software is.
Several innovation and entrepreneurship programs at UNC-Chapel Hill — including CUBE, Startup UNC, and KickStart Venture Services — worked with Chang and EmpowerRT throughout the venture’s evolution. Support from these programs arrived in many forms: entrepreneurship mentoring, grants and networking, to name a few.
With lessons learned during its time in Africa and through ongoing support from programs at Carolina, the team is working on a small business proposal to develop and bring more feasible and low-cost radiation therapy solutions to more low- and middle-income countries.
“You have to have strong partnerships. You have to have shared determination,” said Chang. “There’s no question we’re making an impact that profit-driven large companies are not. We are pioneering an innovative social enterprise pathway to reduce global cancer care disparity by maximizing the resources and knowledge that already exist in the world.”
“Bringing modern radiotherapy treatments to low- and middle-income countries has been a challenge for a lot of major vendors, because the infrastructure and the resources are just not ready to take on all the high-tech products that are being produced,” Parth Amin, EmpowerRT’s director of partnerships, said.
EmpowerRT addresses this issue by modifying existing radiation therapy machines in developing countries at five to 10 percent of the cost of purchasing modern machines and technology.
The Davis Memorial Health System, Cancer Care Center in Elkins, West Virginia graciously donated a Mapcheck device to EmpowerRT in the summer of 2019. Mapcheck is a sophisticated and expensive electronic dosimetry device that is essential for patient safety and quality evaluation for clinical IMRT application.
The Davis Cancer Care Center was happy to make the donation of the MapCheck device. Being a rural hospital based program we understand the issues of not always having the funds needed to purchase much needed equipment. It was great working with Dr Sandwall everything went smooth and I’m glad the MapCheck will be put to good use.
Duane Boyce, B.S., CMD, RT (R)(T) Davis Memorial Health System, Cancer Care Center Director
Medical physicists use Mapcheck to measure the 2-dimensional IMRT radiation map before actual patient treatment. The device compares the map against the planned IMRT radiation map produced by the treatment planning software. It provides data for a physicist to analyze the difference that the clinical physicist can decide if it is safe for patient treatment.
Donations like the Mapcheck Device is one way EmpowerRT is able to provide Personalized Cancer Care, Everywhere.
EmpowerRT is a new, social enterprise startup with a mission to help people in developing countries by improving cancer radiation therapy without spending millions of dollars on modern treatment technology. We spoke with its founder, Sha Chang, Ph.D.,FAAPM, DABR, about the mission of EmpowerRT. In support of their mission, Sun Nuclear has provided a device to EmpowerRT for commissioning. As we celebrate International Day of Medical Physics, EmpowerRT is a prime example of this year’s theme – Medical Physics for Patient Benefit.
Why did you create EmpowerRT?
Cancer is the second leading cause of death globally, with an estimated 9.6 million related deaths in 2018. What is even more surprising is that approximately 70% of deaths from cancer will occur in Low to Middle-Income Countries (LMICs).1 This huge disparity between High-Income Countries (HICs) and Low-Middle Income Countries (LMICs) is simply unacceptable.
While there have been significant advancements in radiation therapy technology, these modern digital solutions are simply too expensive for cancer clinics in LMICs and require clean power and water, technology infrastructure, and highly trained professionals. These solutions are currently not affordable nor easily adoptable.
EmpowerRT was formed to bring clinically-proven, low cost solutions that have been successfully used to control cancers in HICs for the same cancers that are contributing to an extremely high mortality rate in LMICs. Our vision is to see a world where people in every country can have access to standard of care radiation therapy, regardless of income.
How does EmpowerRT support cancer clinics in less developed countries?
Intensity Modulated Radiation Therapy (IMRT) is the standard of care for many cancers in the U.S. and other HICs today but is still unavailable for the majority of cancer radiotherapy clinics in LMICs. EmpowerRT enables these clinics an IMRT solution on their existing treatment machines using largely their current workflow. Before commercial IMRT solutions first became available, the University of North Carolina at Chapel Hill (UNC) developed a recyclable compensator-based IMRT solution and used it clinically for 14 years before it was replaced by the modern automated solution widely used in HICs today.
EmpowerRT offers user-friendly IMRT treatment planning software, simple-to-use compensator fabrication technology, and service and training, including patient safety training, to LMICs clinics. EmpowerRT is giving the clinically proven, simple IMRT solution a second life in low resource clinics in LMICs. We can enable these clinics to deliver better cancer treatments now and, at the same time, prepare them for a smooth transition to the modern digital solutions in the future.
A simple device fabrication, the compensator is placed on the exit window of the linac to create an intensity modulated field. It can be recycled for multiple uses.
UNC pioneered the use of compensator with an in-house developed software in the clinic for 14 years and published many papers on its success. Over time, of course, radiation oncology technology became more sophisticated, and UNC ceased using the compensator in favor of modern radiotherapy solutions that include IMRT technology.
EmpowerRT is currently commercializing the same compensator-based IMRT solution that UNC has used for decades and aims to bring it to cancer clinics in LMICs.
For clinics in less developed countries whose existing linacs have not been equipped with modern technology like IMRT, the compensator device is an ideal solution to support personalized radiation therapy cancer care. It’s simple, low-cost and clinically proven. With user-friendly software and expert guidance and training, it’s a viable and affordable solution to enable resource-limited cancer clinics to reduce treatment toxicity for their cancer patients.
You just returned from your first clinic where you are implementing the compensator technology. How did you work with them to get this program started?
Yes, we traveled to Zambia to meet with our early adopter: Cancer Diseases Hospital in Lusaka, Zambia. Prior to going on-site, we conducted remote training on commissioning the treatment machines as well as the compensator IMRT beams. In addition to our technology, we used a MapCHECK™ array donated by Sun Nuclear, in support of collecting commissioning data. We also trained clinic staff on the software for treatment optimization. During our site visit, we met with the team there to understand their clinical workflows and identify the right people to receive training, so they can be the in-house experts for their clinic. In Spring of 2019, we plan to go back to Zambia to prepare for treating the first patient.
EmpowerRT is looking to grow. What other sites are you targeting?
We are looking to bring the EmpowerRT solution to cancer centers in Peru, India, Honduras, Vietnam and Brazil. Over 50% of clinics in these countries have outdated radiotherapy equipment that could be improved with EmpowerRT. We hope to get additional funding and donations so that we can continue to bring the EmpowerRT solution to cancer clinics worldwide. We estimate 4-5 million people are living with cancer in less developed countries where oncology equipment is outdated.
Fresh off our visit to Zambia, we are excited for the potential of this enterprise. It’s exciting to see the impact we can make. From our staff to donors like Sun Nuclear and partners like the Clinton Health Access Initiatives, we are looking forward to empowering more sites worldwide in the coming years.