Note: This report originally appeared in the October 2008 edition of DOTmed Business News. A list of registered users that provide sales & service can be found at the end.

Death rates from cancer in the United States have decreased by 18.4 percent among men and by 10.5 percent among women since the early 1990s. That is more than half a million cancer deaths averted in the United States. We all know the benefit of early detection, but that's only half the story. Effective treatments, including radiation therapy, are the reason that the U.S. is home to 12 million cancer survivors. As the population ages, the demand for cancer treatment technologies is expected to increase.

"Cancer incidence is growing and we think that the overall [radiation oncology] market is growing at a low double-digit rate, so the market is very healthy. There is certainly room for three or four strong competitors in the marketplace," observed Fred Robertson, CEO, TomoTherapy Incorporated, Madison, WI. The company pioneered CT image guided radiation therapy (IGRT).




The U.S. market for linear accelerators is approaching $2 billion, according to DOTmed estimates. In addition to TomoTherapy, other OEMs include market leader Varian, along with Elekta and Siemens. The manufacturers are driving major trends including IGRT and intensity modulated radiation therapy (IMRT). The result is more precise and effective treatment achieved through advancements in imaging, treatment planning/simulation and delivery.

It's no wonder that the linear accelerator is being used in specialties that might have opted for traditional surgery in the past.

Simulators and Accessories Make the Difference

A broad ballpark estimate for the cost of a new linear accelerator is from $1.5 million for a typical configuration to about $3 million for an advanced system. It's important to remember that the linear accelerator itself is just a radiation machine for fractionated radiation therapy and radiosurgery. It's the accessories that enable advanced treatment approaches. For instance, ancillary imaging devices and multi-leaf collimators enable IGRT and IMRT.

In this sense, the technology lends itself well to the aftermarket where the basic LINAC device can be resold and in many cases augmented with high-tech, bolt-on components.




"The basic accelerator has not changed over the last 20 years. Only the external software and hardware have advanced radiation therapy. Unlike diagnostic imaging equipment, most upgrades to linear accelerators are external to the LINAC itself so a lot of aftermarket products can be put on to achieve a similar effect as manufacturers achieve with [integrated] technology," explained Greg Bare, Sales Director, Radiation Oncology Systems, San Diego, CA."

CT is the imaging technology now widely used in conjunction with software as a treatment planning tool. "The trend in simulation is away from conventional static film simulation to CT and we do see people replacing their old simulators pretty often. They are very rarely replacing an old simulator with a conventional simulator. They will always tend to go for a CT these days," said Tony Richardson, Marketing Director, Oncology Services International (OSI), Ramsey, NJ.




"Conventional X-ray units had been used for simulation but now CT scanners enhance the ability to locate and pinpoint accurately the target area. CT provides digital images and multiple slices. That can turn into three-dimensional plans for things like respiratory gating," said Greg Kramer, President, C&G Technologies, Inc., Jeffersonville, IN, specializing in pre-owned GE and Toshiba CT systems. In addition to their use prior to the procedure as a planning tool, some advanced systems have the CT onboard the LINAC or in the treatment room itself as a continual reference guide to revise treatment as the tumor moves or shrinks. Varian offers its On-Board Imager device, for example, which is mounted on the linear accelerator for generating radiographic, fluoroscopic, and cone-beam CT images just prior to treatment. However, Varian Medical Systems told DOTmed Business News that not all models of LINACs are upgradeable to IGRT. If a healthcare provider acquires a LINAC from a third party, Varian may be able to upgrade the system but first they would need to conduct an audit of technology and software to determine if the system meets specifications and is in fact upgradeable. There is a cost associated with the audit.TomoTherapy is another OEM noted for its integrated systems. Their Hi-Art system includes treatment planning, CT imaging, quality assurance, treatment delivery, and adaptive therapy.

"To understand the architecture of our system: We have a linear accelerator, the radiation source, that's mounted on a CT gantry. So it's a CT scanner that's used to both generate diagnostic images as well as during the treatment process," explained Robertson.

For treatment planning or simulation, typically 4- and 8-slice CT scanners are utilized, but 16-slice systems are not unheard of. Hospitals and cancer centers in the market for pre-owned equipment are looking for newer, late-model technology, like any other aftermarket.

"It seems that almost everyone wants linear accelerators on the refurbished market that have IMRT capabilities with multi-leaf collimators and image guidance as well," stressed Kenneth Wolff, President and CEO, RS&A Inc., Rural Hall, NC.

Nevertheless, older systems can play an important role in cancer treatment. Many are resold to small therapy centers in rural areas in the U.S., or exported.

RISMED Oncology Systems, through its sister company OncoAmerica, is bringing used Varian technologies to cancer centers in Venezuela and Mexico. "We like Varian because it is a reliable machine and most of the parts that Varian uses are from manufacturers in the industry. We can buy 90% of the components in the open market. Siemens and Elekta--many of their parts are proprietary--so every time you need a part you have to go back to those companies," explained Jose A. Rodriquez, President of the Huntsville, Alabama-based companies.

Independent service organizations like RISMED have a competitive yet symbiotic relationship to the OEMs. "We don't take business from [the OEMs] because whoever buys a machine from us for $100,000 cannot afford to buy a new, $800,000+ machine," Rodriguez said.

Needs Vary by Practice Setting

In addition to hospitals, more than 2,000 cancer treatment clinics in various networks throughout the U.S. use this equipment.

"More than half of our customers are in the free-standing community and of that about 60% are not individual centers but networks," said OSI's Richardson. "Working with those organizations the trend is for them to partner and form alliances with organizations like ours that can control their operating costs over the long haul--not just the initial purchase but for the lifetime of the equipment. That is often more money than the purchase of the equipment in the first place."

By many accounts, the for-profit clinics can be more high-tech than hospitals.

"Hospitals are slow to upgrade their equipment to the latest technology. I find that the free-standing clinics are usually more on the cutting edge than hospitals in radiation therapy," said Richard Kimball, President, Acceltek, Rio Rancho, NM. "In hospitals, budgeting is stricter because they know that radiation therapy is their cash cow. So they take all their excess revenue from radiation [oncology services] and apply it to all their negatives. In a free-standing clinic, they upgrade because they don't have to spend their profits somewhere else."

Service and Support Side of the Story

Top independent service organizations (ISOs) for used equipment provide sales, service, and parts at about 30 to 50% of OEM cost, several organizations have reported to DOTmed Business News. Some ISOs report significantly greater savings--up to 70% off the cost of new equipment.

Typical service and refurbishment requirements might include testing and replacing radiation damaged wiring and water lines and worn mechanical parts such as bearings and slides, as well as sprucing up cosmetics. Power supplies often need replacement. OEM software updates may be required.

The wave guide is the essential component of the LINAC and its failure may require an OEM replacement unit, although, depending on the manufacturer and ISO, the wave guide may be serviceable. Note that industry insiders told DOTmed that several companies in China are producing wave guides and may sell them for around $25,000 in the near future, compared to about $65,000 from the OEM in today's market.

ISOs that specialize in LINACs often partner with other companies to do the related CT scanner support. Technicians related that service of the CT simulator technology used in conjunction with linear accelerators requires more precise alignment in this radiation oncology application than for other uses.

Apart from discrete fixes, there's a larger issue related to LINAC service. "One of the things we are seeing is that people integrate technologies. It is becoming more important to train the centers in the workflow and how to use those technologies," said Tony Richardson, Marketing Director, Oncology Services International, Ramsey, NJ. "Although that's the traditional strength of the OEM, most centers don't have one single OEM's equipment. So having an organization that understands how all these black boxes fit together and can train the workflow is important."

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DOTmed Registered Linear Accelerators and Simulators Equipment Sales and Service Companies
Names in boldface are Premium Listings.

Domestic
Jose Rodriguez, RISMED, AL
DOTmed Certified
John Marquez, Therapy Remarketing Group, CA
Greg Bare, Radiation Oncology Systems, CA
Stewart Farber, Farber Medical Solutions, LLC, CT
DOTmed Certified/100
Greg Kramer, C & G Technologies, IN
DOTmed Certified/100
Chaz Beadling, TransAmerican, MD
Jeff Rogers, Medical Imaging Resources, Inc., MI
DOTmed 100
Karl Malashanko, Karl Malashanko, MI
Bruce Hull, Network Imaging Systems, NC
DOTmed Certified
Kenneth Wolff, RS&A, NC
Tony Richardson, Oncology Services International, NJ
Richard Kimball, Acceltek, NM

International
Abdelrahim Khalil, Besisc, Egypt

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