Pediatric cancer constitutes a significant and growing public health challenge, with an estimated 300,000 new diagnoses each year in children under 19 years of age. While therapeutic advancements have markedly improved outcomes in high-income countries (HICs), low- and middle-income countries (LMICs) continue to face stark disparities in diagnosis, treatment access, and survival outcomes
In Bangladesh, the pediatric cancer burden is both substantial and underreported, with estimated annual incidence ranging from 4200 to 8000 new cases. Leukemia and central nervous system (CNS) tumors predominate among childhood malignancies. A large proportion of patients are present at advanced stages, often due to delays in diagnosis and limited access to specialized oncology services. Additionally, the overwhelming reliance on out-of-pocket payments poses a significant barrier to timely and effective treatment, contributing to survival rates that remain far below those observed in HICs. Radiotherapy services in Bangladesh are delivered through a network of public and private centers, employing a combination of Cobalt-60 machines and linear accelerators. While certain institutions have begun integrating advanced modalities such as stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT), the widespread availability of IGRT, particularly in pediatric settings, remains limited. The primary challenges include insufficient technological infrastructure, a shortage of trained medical physicists and radiation oncologists, and a lack of standardized pediatric-specific radiotherapy protocols.
Medical physicists occupy a central role in the delivery of high-quality radiotherapy, particularly in settings that require advanced imaging and treatment adaptation. Their responsibilities encompass equipment calibration, commissioning, quality assurance (QA), and treatment planning, each of which is critical to achieving the precision demanded by pediatric IGRT. Moreover, their expertise is indispensable in addressing the unique physiological and anatomical challenges posed by pediatric patients, including motion management and growth-related changes during treatment.
1) To delineate practical, resource-sensitive strategies for implementing IGRT and motion management techniques within the Bangladeshi pediatric oncology context, from the perspective of medical physicists.
2) To articulate evidence-informed policy recommendations and advocacy strategies aimed at integrating IGRT sustainably and equitably into the national pediatric cancer care framework.
Image Acquisition Modalities
A. Kilovoltage (kV) X-ray Imaging & Cone-Beam CT (CBCT): Daily image guidance using kV X-ray and CBCT is widely practiced in pediatric IGRT to verify patient positioning and anatomical alignment. These modalities provide high-resolution imaging critically for visualizing soft tissue and bony landmarks. However, their routine application must be judiciously balanced against increased cumulative imaging dose, particularly important in children due to their heightened radiosensitivity. In the context of Bangladesh, many modern linear accelerators are equipped with CBCT functionality, though their usage is often limited by throughput constraints, training gaps, and concerns regarding imaging dose. Time efficiency, image clarity, and dose management must therefore be prioritized when establishing imaging protocols.
B. Optical Tracking Systems: Surface imaging tools, including optical and laser-based systems, allow for real-time monitoring of patient movement without adding extra radiation exposure. These systems are particularly effective in spotting movement during treatment and maintaining consistent positioning. Although commercial options can be expensive, there is encouraging potential in creating affordable alternatives using locally available cameras or infrared-based technologies. For example, an inexpensive optical tracking setup using CCD cameras was successfully developed and tested in Indian healthcare facilities, showing great promise for cost-effective setup verification in radiotherapy (Paul et al., 2018). In light of budget limitations in Bangladesh, similar pilot projects could pave the way for scalable and affordable innovations (Paul et al., 2018).
C. Hybrid Imaging Workflows: Hybrid imaging workflows involve combining different imaging techniques—such as kilovoltage (kV) X-ray, cone-beam CT (CBCT), and surface or ultrasound imaging—based on the needs of the treatment and the available infrastructure. These blended approaches aim to enhance accuracy in patient positioning and movement control by using the strengths of each imaging method while keeping radiation exposure and costs as low as possible.
D. Medical Physicist’s Role: Medical physicists are responsible for calibrating image acquisition systems, assessing image quality, and optimizing imaging dose, ensuring safety while maintaining diagnostic clarity. Their understanding of modality-specific limitations is essential for protocol customization and patient-specific imaging plans.
Image Registration and Correction Techniques
Image registration is foundational in IGRT, facilitating alignment between planning and treatment datasets. Techniques include:
Both automated and manual registration methods are used, with manual input often necessary in pediatric patients due to variability in anatomy and positioning. Once discrepancies are identified, corrections are typically made via couch shifts or rotational adjustments.
E. Medical Physicist’s Role: Physicists develop and validate registration protocols, establish action thresholds for positional deviations, and quantify residual uncertainties. They play a critical role in minimizing error propagation and ensuring that corrective shifts maintain alignment precision across fractions.
Immobilization Devices
Commercial vs. Custom-Made Solutions: Effective immobilization is critical to minimize motion during imaging and treatment. Commercial devices like thermoplastic masks, vacuum cushions, and bite blocks are widely used in pediatric radiotherapy. However, due to cost and availability limitations in Bangladesh, there is a growing interest in developing locally fabricated alternatives, e.g., using medical-grade foam, molded cushions, or 3D-printed molds tailored for pediatric anatomies. These cost-effective options, if properly tested, can offer comparable reproducibility and comfort.
Comfort and Compliance: In children, psychological comfort is paramount. Devices must be both effective and tolerable to reduce movement and encourage cooperation. Child-friendly designs and the involvement of play therapists can significantly enhance compliance.
Medical Physicist’s Role: Physicists oversee the design and testing of immobilization devices, evaluate reproducibility through setup imaging, and ensure device compatibility with both imaging and treatment systems.
Respiratory Motion Management
Free-Breathing Techniques: Free-breathing protocols remain the default in many Bangladeshi centers. Motion can be minimized through behavioral coaching, visual distraction tools, and optimized immobilization. These approaches are especially useful for younger children who may not tolerate active control strategies.
Breath-Hold Techniques: These include both coached deep-inspiration breath-hold (DIBH) methods and passive approaches like abdominal compression. While breath-hold techniques can significantly reduce organ motion (e.g., for mediastinal tumors), their feasibility in pediatric populations depends on age, cooperation, and training.
Respiratory Gating and Tracking: Advanced technologies such as respiratory gating or real-time tumor tracking, though valuable, are not widely available in Bangladesh. When present, their use is often limited by high maintenance costs, complex calibration needs, and training demands.
Medical Physicist’s Role: Medical physicists are essential in implementing and verifying respiratory motion protocols, quantifying residual motion, and selecting age-appropriate management strategies. They also contribute to commissioning gating systems and integrating them into the treatment planning process.
Clinical Use: Sedation or anesthesia is frequently required for very young or uncooperative children undergoing IGRT. This necessitates careful coordination to ensure safety, monitor vital signs, and maintain stable positioning throughout treatment.
Medical Physicist’s Role: Physicists collaborate closely with anesthesiology teams to synchronize imaging and treatment workflows, ensure prompt execution within sedation windows, and monitor for positional changes due to altered muscle tone or consciousness.
Successfully integrating pediatric IGRT in a resource-limited setting like Bangladesh requires a multi-tiered approach—blending clinical pragmatism with strategic investment, workforce development, and adaptive innovation. The following implementation strategies are organized into four key pillars: technology optimization, human resource development, infrastructure adaptation, and clinical protocol standardization.
Maximizing Existing Linear Accelerators: Many centers in Bangladesh already operate linear accelerators (LINACs) with some image-guided capabilities (e.g., kV imaging, basic CBCT). A prioritized strategy involves fully utilizing these existing technologies before procuring new equipment. This includes:
Low-Cost Innovations and Hybrid Models: In situations where commercial IGRT systems are too costly, combining affordable tools like portable ultrasound devices, inexpensive cameras for tracking movement, or modified immobilization materials (such as thermoplastics with reusable frames) can help bridge essential gaps. Morocco has already shown that it is possible to implement IGRT in low-resource environments by using existing linear accelerators along with cost-effective quality assurance protocols (Alami & El Majjaoui, 2016)
Preventive Maintenance and Sustainability: Ensuring long-term functionality of imaging and radiotherapy equipment through preventive maintenance contracts and training of biomedical engineers is essential. Resource wastage due to prolonged machine downtime is a recurring issue in LMIC settings and must be addressed proactively.
Specialized Training for Medical Physicists and Radiation Therapists: Targeted training programs are needed to enhance competencies in pediatric IGRT planning, imaging dose management, and motion mitigation strategies. Partnerships with international radiotherapy societies and online learning platforms (e.g., IAEA, ESTRO) can provide low-cost access to advanced education.
Multidisciplinary Team Training: A cohesive IGRT program requires synchrony between radiation oncologists, medical physicists, radiotherapy technicians, anesthesiologists, and pediatric support staff. Periodic workshops and simulations can promote shared understanding and coordinated care, especially in pediatric sedation, immobilization, and QA processes.
Task-Shifting and Role Sharing: In the face of human resource shortages, trained technicians and junior physicists can be empowered to carry out routine QA, registration checks, and patient setup under supervision, freeing senior staff for complex tasks.
Dedicated Pediatric Treatment Time Slots: Assigning specific time blocks for pediatric patients can optimize sedation scheduling, reduce anxiety, and improve throughput. Tailoring workflows to reduce waiting times and avoid treatment delays during sedation is crucial for young patients.
Space Modification for Child-Friendly Environments: Minor investments in child-centric design, such as murals, ambient lighting, music, or distraction tools, can improve patient cooperation and reduce the need for deep sedation, enhancing the feasibility of daily imaging and reproducible setups.
Remote Planning and Consultation Models: To help address staffing shortages in rural healthcare centers, remote treatment planning and collaboration through telemedicine can be valuable solutions. Centralized hubs, where experienced physicists are based, can support satellite centers by reviewing treatment plans and overseeing IGRT quality assurance. However, for this approach to work effectively, there must be strong infrastructure in place—including reliable internet, secure systems for data sharing, and adherence to patient data privacy standards. These foundational elements are crucial to ensuring remote radiotherapy services are both effective and ethically sound.
Development of Resource-Adapted Clinical Protocols: Establishing simplified, yet effective, IGRT protocols tailored to common pediatric tumor types (e.g., medulloblastoma, rhabdomyosarcoma, Wilms tumor) is essential. Protocols should include:
National and Institutional Guidelines: Bangladesh currently lacks standardized national guidelines for pediatric IGRT. Development of such guidelines—endorsed by national oncology societies and public health bodies—would provide a roadmap for consistent, equitable care delivery across centers.
Data Collection and Quality Metrics: Establishing registries to track pediatric IGRT usage, treatment outcomes, imaging doses, and setup errors is key for continuous quality improvement. Even in low-resource settings, simple digital tools or spreadsheet-based audits can support data-driven refinement.
The successful integration of pediatric IGRT in Bangladesh hinges not only on technological and clinical advancements but also on overcoming a range of systemic and operational barriers. This section outlines key challenges and presents pragmatic solutions tailored to the national context—focusing on infrastructure, workforce capacity, workflow management, and data systems.
Revised Assessment of Current Capabilities: Although more linear accelerators (LINACs) in Bangladesh now come with onboard imaging, these capabilities are often not fully utilized. A practical strategy for improvement would be to focus on installing or activating key IGRT features like kilovoltage (kV) imaging for planar checks. These systems are not only more affordable than cone-beam CT (CBCT) but also applicable in many clinical situations. Planar kV imaging works well for tumors located in areas with clear and stable bone structures, such as the brain, head and neck, and pelvic regions. On the other hand, CBCT is still necessary for treating regions like the chest and abdomen, where internal anatomy moves more and soft tissue detail is essential.
Revised Implementation Recommendations:
Maintenance and Technical Support: Downtime due to equipment failure is a major bottleneck in consistent radiotherapy delivery. Delays in technical support and the lack of spare parts contribute to extended service interruptions.
Solutions:
Medical Physicist’s Role: Physicists serve as key liaisons between clinical teams and service engineers, playing a pivotal role in early fault detection, system diagnostics, and preventive maintenance scheduling.
Power Supply Stability: Unreliable electricity supply can compromise patient safety and treatment quality. Frequent outages also risk damaging sensitive equipment.
Recommendations:
Current Gaps: Bangladesh faces a critical shortage of specialized professionals in pediatric radiation oncology, including medical physicists, radiation oncologists, radiation therapy technologists (RTTs), and pediatric oncology nurses. The limited availability of hands-on pediatric training further compounds the issue.
Targeted Training Programs
For Medical Physicists:
For Radiation Therapy Technologists (RTTs):
Multidisciplinary Training:
Skill Retention Strategies: To curb the loss of skilled professionals, especially those leaving the public sector for higher-paying private roles, there needs to be a focus on offering meaningful incentives. This could include clear career growth opportunities, housing and transportation support, and performance-based bonuses for individuals who commit to long-term roles in government-run cancer centers. Creating more opportunities for local research, promoting international exchange programs, and acknowledging achievements through career advancement can also play a key role in keeping talent within the public healthcare system—a pressing concern in the context of Bangladesh.
Patient Flow Management: Pediatric radiotherapy requires highly coordinated workflows, particularly for sedated or anxious children. Reducing unnecessary delays is essential for minimizing distress and improving treatment reproducibility.
Recommendations:
Pre-Treatment Procedures: Standardizing pre-treatment protocols enhances efficiency and reduces errors. Key steps include:
Daily Treatment Protocols: Clear SOPs for daily IGRT workflows should address:
DICOM and PACS Integration: Many centers in Bangladesh lack fully integrated DICOM-compliant systems, creating silos between treatment planning, image acquisition, and patient record systems.
Recommendations:
Data Security and Patient Privacy: As digital systems expand, ensuring compliance with international data protection standards is essential, even in resource-limited settings.
Key Steps:
Medical Physicist’s Role: Medical physicists play a central role in:
Children undergoing radiotherapy present a unique set of challenges that necessitate stringent, comprehensive quality assurance (QA) protocols. Pediatric patients are significantly more sensitive to ionizing radiation due to their developing tissues and organs. Moreover, their longer post-treatment life expectancy increases the risk of late effects such as secondary malignancies, cognitive deficits, and growth abnormalities. The precision of radiation delivery, therefore, must be uncompromising. Image-guided radiotherapy (IGRT), while improving targeting accuracy, introduces its own QA complexities. These include ensuring spatial accuracy in imaging systems, validating image registration, controlling imaging dose, and verifying the effectiveness of motion management protocols. For medical physicists, pediatric IGRT QA is not just a procedural task—it is a clinical imperative.
Imaging System QA: Regular and structured QA of IGRT imaging systems is essential to ensure accurate localization, reliable image quality, and minimal additional dose.
1) Daily/Weekly/Monthly QA Checks:
2) Imaging Dose Monitoring:
3) Medical Physicist’s Role:
4) Geometric Accuracy: Geometric consistency is the backbone of safe IGRT. Small positional errors in pediatric patients can lead to significant deviations in dose delivery. Key QA Parameters:
5) Medical Physicist’s Role:
Motion Management QA: Effective motion management in pediatric IGRT involves not only immobilization but also verifying that systems designed to detect or mitigate motion are functioning correctly.
QA for Immobilization Devices:
Gating/Tracking Systems (if available):
Medical Physicist’s Role:
Adaptive radiotherapy (ART), facilitated by frequent IGRT imaging, allows for real-time plan modification in response to anatomical changes—such as tumor shrinkage, weight loss, or growth in pediatric patients.
QA Considerations:
Medical Physicist’s Role:
Meticulous documentation is fundamental to maintaining clinical accountability, facilitating audits, and supporting quality improvement initiatives.
Core Requirements:
Medical Physicist’s Role:
Bangladesh has made progress in cancer control planning through the development of its National Cancer Control Strategy and Plan of Action (2009-2015) and subsequent sectoral health strategies. However, explicit mention of Image-guided radiotherapy (IGRT)—particularly in the pediatric context—is absent in most regulatory and policy frameworks. Radiotherapy is recognized as a core component of cancer treatment, but investment prioritization has historically focused on equipment quantity rather than quality or advanced imaging capabilities. Additionally, there is limited integration of pediatric oncology needs into national guidelines, resulting in a significant policy gap concerning pediatric-specific radiotherapy protocols, motion management strategies, and QA requirements. Key Gaps Identified:
Cost-Benefit Justification: Investing in pediatric IGRT presents a compelling long-term economic and public health case. While the initial cost of equipment and training may be substantial, the downstream benefits are manifold:
These benefits translate into both individual economic resilience and societal productivity gains over the lifetime of a pediatric cancer survivor.
Funding Models: Sustainable financing mechanisms must blend domestic resources with strategic external support. Potential models include:
Affordability for Patients: Given that over 60% of healthcare expenditure in Bangladesh is out-of-pocket, access to IGRT is highly inequitable. Policy reform should ensure that IGRT services are included in essential pediatric cancer care with full or partial subsidy mechanisms for impoverished families.
1) Revise the National Cancer Control Plan
2) Investment in Infrastructure
3) Human Resource Planning
4) Standardization and Clinical Guidelines
5) Data Collection and Research
6) International Collaboration
For IGRT to be successfully implemented, it’s essential to involve a broad range of stakeholders, including:
Raising both public and professional awareness is vital to building support for IGRT. Recommended activities include:
Medical physicists have a unique role to play by:
The integration of image-guided radiotherapy (IGRT) into pediatric cancer care represents not just a technological upgrade, but a moral and clinical imperative for Bangladesh. As childhood cancer survival continues to improve globally, the disparity in outcomes between high-income countries and low- and middle-income countries (LMICs) like Bangladesh underscores the urgent need for equitable access to precision radiotherapy. This paper has highlighted both the critical value and the practical feasibility of implementing pediatric IGRT in resource-limited settings. Despite financial constraints and infrastructural limitations, Bangladesh has a strong foundation to build upon: a growing network of radiotherapy centers, a committed healthcare workforce, and a rising tide of national and international engagement in pediatric oncology. By prioritizing essential imaging upgrades, developing cost-effective motion management solutions, and strengthening the technical capacity of medical physicists and treatment teams, the country can take meaningful steps toward delivering safe, precise, and child-friendly radiation therapy. Strategic investments in infrastructure, national guideline development, and workforce retention supported by clear policy commitments will be instrumental in ensuring long-term sustainability. Moreover, medical physicists must continue to play a leading role not only in maintaining technical excellence, but also in shaping health policy, educating stakeholders, and championing innovation tailored to the pediatric population. Looking ahead, the successful implementation of pediatric IGRT in Bangladesh will depend on the convergence of clinical evidence, policy leadership, and community advocacy. Through sustained collaboration between national stakeholders and global partners, it is possible to envision a future where every child with cancer in Bangladesh, regardless of socioeconomic status or geographic location, receives radiation therapy that is not only accessible, but also optimized, personalized, and life-affirming.