Clinical Oncology xxx (2016) 1e6

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Clinical Oncology
journal homepage: www.clinicaloncologyonline.net

Overview
Cobalt-60 Machines and Medical Linear Accelerators: Competing
Technologies for External Beam Radiotherapy
B.J. Healy *, D. van der Merwe y, K.E. Christaki *, A. Meghzifene *
* International Atomic Energy Agency, Vienna, Austria
y
University of the Witwatersrand, Johannesburg, South Africa

Received 7 October 2016; accepted 31 October 2016

Abstract
Medical linear accelerators (linacs) and cobalt-60 machines are both mature technologies for external beam radiotherapy. A comparison is made between
these two technologies in terms of infrastructure and maintenance, dosimetry, shielding requirements, staffing, costs, security, patient throughput and
clinical use. Infrastructure and maintenance are more demanding for linacs due to the complex electric componentry. In dosimetry, a higher beam energy,
modulated dose rate and smaller focal spot size mean that it is easier to create an optimised treatment with a linac for conformal dose coverage of the
tumour while sparing healthy organs at risk. In shielding, the requirements for a concrete bunker are similar for cobalt-60 machines and linacs but extra
shielding and protection from neutrons are required for linacs. Staffing levels can be higher for linacs and more staff training is required for linacs. Life cycle
costs are higher for linacs, especially multi-energy linacs. Security is more complex for cobalt-60 machines because of the high activity radioactive source.
Patient throughput can be affected by source decay for cobalt-60 machines but poor maintenance and breakdowns can severely affect patient throughput
for linacs. In clinical use, more complex treatment techniques are easier to achieve with linacs, and the availability of electron beams on high-energy linacs
can be useful for certain treatments. In summary, there is no simple answer to the question of the choice of either cobalt-60 machines or linacs for
radiotherapy in low- and middle-income countries. In fact a radiotherapy department with a combination of technologies, including orthovoltage X-
ray units, may be an option. Local needs, conditions and resources will have to be factored into any decision on technology taking into account the
characteristics of both forms of teletherapy, with the primary goal being the sustainability of the radiotherapy service over the useful lifetime of the
equipment.
Ó 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Key words: Cobalt-60 teletherapy; external beam radiotherapy; medical linear accelerator

Statement of Search Strategies Used and Introduction

Sources of Information
The International Atomic Energy Agency (IAEA) supports
The income classification of countries was taken from its member states in their efforts to provide access to safe
the World Bank, Country and Lending Groups, 2017 fiscal and effective radiotherapy. However, this does not extend to
year (http://data.worldbank.org/income-level/low-and- recommending one technology for radiotherapy over
middle-income). Data on availability of teletherapy another; in this case, in recommending cobalt-60 machines
machines were obtained from the International Atomic over medical linear accelerators (linacs) or vice versa. In the
Energy Agency Directory of Radiotherapy Centres (DIRAC) IAEA publication 1296 [1], the IAEA provides recommen-
publicly available online at http://www-naweb.iaea.org/ dations for a basic radiotherapy department and it describes
nahu/dirac/default.asp. the need for a ‘single-photon-energy teletherapy unit’
without specifying either a cobalt-60 machine or a linac.
The IAEA is often in a position to provide advice to its
Author for correspondence: B.J. Healy, International Atomic Energy
member states who are embarking on radiotherapy for the
Agency, PO Box 100, 1400 Vienna, Austria. Tel: þ43-1-2600-21659. first time or increasing their capability in radiotherapy. This
E-mail address: [email protected] (B.J. Healy). is usually as part of a technical cooperation programme

http://dx.doi.org/10.1016/j.clon.2016.11.002
0936-6555/Ó 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Healy BJ, et al., Cobalt-60 Machines and Medical Linear Accelerators: Competing Technologies for External
Beam Radiotherapy, Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.11.002
2 B.J. Healy et al. / Clinical Oncology xxx (2016) 1e6

agreed between the IAEA and the member state. In either carried out by teletherapy in LMICs and the remainder by
case, the IAEA presents the information on the available brachytherapy (excluding the area of radionuclide therapy
mature technologies to the country for them to make an with unsealed sources). The most widely used form of
informed decision as to the appropriate technology for their brachytherapy in LMICs is the treatment of cervical cancer,
country, taking into account their specific needs, existing which requires both teletherapy and brachytherapy as the
local conditions and resources. standard treatment.
Countries embarking on radiotherapy also need to be The basis of the cobalt-60 machine is a high activity
aware of equipment needed for patient treatment simulation, sealed source producing 1.17 MeV and 1.33 MeV gamma
treatment planning and dosimetry. The IAEA Human Health rays [6]. The source activity on delivery can be from 185 to
Reports No. 10 presents the complete solution for planning a 555 TBq [6]. The source is driven to an open position and
radiotherapy department [2], while Brown et al. [3] describe a collimation is used to limit the beam to the treatment
10 step process for implementing radiotherapy. target. By way of contrast, in the linac, the high-energy
The purpose of this overview is to present in an objective photons are generated electrically. In effect, the linac com-
manner the characteristics of cobalt-60 machines and linacs ponents of the klystron or magnetron, waveguide, electron
as applied to external beam radiotherapy (also termed tel- gun, target, monitor chamber, steering coils and ancillary
etherapy) and in consideration of their appropriateness in control electronics [7], replace the radioactive source of the
low- and middle-income countries (LMICs). cobalt-60 machine, and here-in lies the complexity of the
linac over the cobalt-60 machine.

Distribution of Cobalt-60 Machines and

Linacs in Low- and Middle-income Infrastructure, Maintenance and
Countries Downtime

Since their introduction in the 1950s, cobalt-60 machines Infrastructure requirements are extensive for a linac: three
were the dominant player in teletherapy, but they were phase mains power for the klystron or magnetron power
overtaken by linacs in the 1970s and 1980s as linac tech- supply, chilled water for system cooling, an air compressor to
nology matured. According to the DIRAC database [4], there drive the target and 24 h air-conditioning to maintain
are currently 2048 cobalt-60 machines and 5185 linacs in equipment at a constant temperature, ensure constant
LMICs. Furthermore, the IAEA/WHO TLD audit programme output, reduce humidity and remove ozone during operation.
in teletherapy has shown over many years decreasing re- A cobalt-60 machine on the other hand may only require
quests by hospitals for audits of cobalt-60 machines over single-phase power, an air compressor and a radiation area
linacs (Figure 1). In the latest data, more than 80% of requests monitor. Air-conditioning may be required depending on
are for audits of linacs, indicative of an increase in the humidity and ambient temperature.
number of linacs in radiotherapy departments. Given the complexity of the electrical systems outlined
previously, it follows that the maintenance required of a
linac will be more extensive than that for a cobalt-60 ma-
Physical Characteristics chine. A linac can require 8 full days of preventative main-
tenance per year, whereas in an ideal environment 3 days
Cobalt-60 machines and linacs both are capable of per year are required for a cobalt-60 machine. Catastrophic
providing teletherapy. Teletherapy is the dominant form of linac failures may also require that the system is re-
radiotherapy, with typically 86e96% [5] of radiotherapy commissioned.

Fig 1. The number of cobalt-60 and linear accelerator (linac) beams checked by IAEA/WHO TLD audit per year.

Please cite this article in press as: Healy BJ, et al., Cobalt-60 Machines and Medical Linear Accelerators: Competing Technologies for External
Beam Radiotherapy, Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.11.002
 B.J. Healy et al. / Clinical Oncology xxx (2016) 1e6 3

Downtime (percentage of time out of service during 10 Gy/min has meant stereotactic treatments and hypo-
clinical periods due to breakdown) is an important consid- fractionated treatments can be achieved with much
eration in equipment selection. Properly maintained linacs shorter treatment times. One advantage of this is that
can achieve a downtime of 2% or less, which is comparable treatments are less likely to be compromised by patient
with cobalt-60 machines. In LMICs, downtime is most often movement during treatment.
exacerbated by a lack of local accredited maintenance
expertise and delays in the importation of spare parts.
Shielding Design (Protection and Safety)

Dosimetry Characteristics The IAEA Safety Report Series No. 47 [9] sets out a
methodology for the design of radiotherapy bunkers to
There are distinct dosimetry differences between cobalt- meet radiation protection requirements for staff and
60 beams and linac-generated photon beams. A full dis- members of the public. In practice, this means the tele-
cussion of these differences is beyond the scope of this therapy unit is housed in a vault with concrete walls and the
overview and the reader is referred to the IAEA publication vault is connected to a maze, with the control area beyond
1296 [1]. To summarise the discussion in that publication: the maze entrance. The higher modal energy of a 6 MV linac
compared with a cobalt-60 machine means that the pri-
 Build-up: for cobalt-60 beams, the depth of the dose mary and secondary concrete barrier thicknesses will need
maximum is 5 mm, whereas for a 6 MV linac it is 16 mm. to be greater for the linac. For example, in worked examples
A greater depth of dose maximum is important for skin in IAEA Safety Report Series No. 47, the primary barrier
sparing and deep-seated tumours. thickness is 1.03 m for a cobalt-60 machine and 1.75 m for a
 Penumbra: in general, the penumbra for linac high- 6 MV linac, whereas the secondary barrier thickness is
energy photon beams is smaller than that for the 0.87 m for a cobalt-60 machine and 1.06 m for a 6 MV linac.
cobalt-60 gamma ray beam used without trimmers. A The barrier thicknesses will increase with the use of IMRT or
small penumbra is needed to spare critical structures. a higher maximum energy of the linac (for example 18 MV)
However, more accuracy is needed in patient posi- and consideration will also have to be given to protection
tioning and in matching of adjacent fields. from neutrons, with barriers at the maze entrance if the
 Penetration: the higher energy of a linac gives greater maximum energy of the linac is above 10 MV.
penetration, which reduces the integral dose to the The linac requires a larger footprint in the vault than an
patient when treating a deep-seated tumour. 80 cm source-axis-distance (SAD) cobalt-60 machine. For
 Dose rate: the reference dose rate from a linac is typi- example, one cobalt-60 machine manufacturer recom-
cally between 4 and 6 Gy/min, whereas the dose rate for mends a vault floor area of 35 m2, whereas a typical linac
a cobalt-60 machine is about 2.5 Gy/min for a new vault floor area is 53 m2. In planning teletherapy services,
source. Source decay means that the dose rate decreases the IAEA recommends construction of a bunker with a floor
and treatment times are longer by about 1% per month. area of at least 49 m2 to accommodate either a cobalt-60
 Beam profile: because of the use of a beam flattening machine or a linac [2].
filter, the beam uniformity of linacs is comparable with The implication of the previous data in this section is that
that of the cobalt-60 machine for both large and small it may not be straightforward to replace an 80 cm SAD
fields, provided that the linac is properly maintained. cobalt-60 machine with a linac in an existing cobalt-60
bunker. Additional shielding may be required (often in the
Since IAEA publication 1296 was released in 2008, there form of steel plates) and in the first instance it will need to
have been technology additions to linacs and cobalt-60 be checked if the floor area is sufficient for the linac and if
machines that are pertinent. First, kV and MV image the maze dimension (width and height) is sufficient to
guidance systems have been incorporated into linacs allow ingress of a linac as it is shipped. Additional physical
to allow daily online verification of patient treatment infrastructure will also need to be considered (see the sec-
position immediately before treatment. In principle, tion on infrastructure).
image guidance systems could also be incorporated
onto cobalt-60 machines. In fact, a cobalt-60 machine
incorporating image guidance with magnetic resonance Staff (Training and Numbers)
imaging is currently commercially available [8]. The up-
take of intensity-modulated radiotherapy (IMRT) and There are various models for staffing numbers for
volumetric-modulated arc therapy (VMAT) with multileaf radiotherapy based on patient numbers [1] or staff activity
collimators (MLCs) has been considerable since 2008 for and equipment levels [10]. Based on the technological
curative treatments. MLCs can be added to cobalt-60 ma- complexity of the linac over the cobalt-60 machine, it fol-
chines allowing IMRT and VMAT, but there does remain the lows that more staff hours are required for the linac in the
advantage of the linac being able to modulate the dose area of engineering, information technology support and in
rate, which allows an extra degree of freedom in optimis- medical physics for quality management.
ing the IMRT treatment. Finally, the advent of flattening- The complexity of the treatment technique is also a
filter-free beams on linacs with dose rates exceeding driver of staff numbers. For example, more staff numbers

Please cite this article in press as: Healy BJ, et al., Cobalt-60 Machines and Medical Linear Accelerators: Competing Technologies for External
Beam Radiotherapy, Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.11.002
4 B.J. Healy et al. / Clinical Oncology xxx (2016) 1e6

are required to operate an IMRT program than a 3D Security

conformal radiotherapy (3D-CRT) program. But it does not
necessarily follow that treatment complexity is necessarily Global concerns about the possible use of radioactive
higher for a linac service. material for malicious purposes have heightened in the last
Linacs require a higher level of staff training, particularly decade or so. In this regard, regulatory agencies have paid
for those using the technology for patient treatments attention to the security of radioactive sources used medi-
(radiation therapy technologists) and those supporting safe cally and in this case in teletherapy as well as brachyther-
and effective use (medical physics, engineering, IT support). apy. In this respect, the advantage of the linac is clear; there
For example, the medical physics staff must understand is no radioactive source to raise security concerns with re-
in detail the proper function of the linac’s monitor chamber, gard to hospital security, and likewise in the security
which is not needed on a cobalt-60 machine. Mis- required for shipment, decommissioning and long-term
conceptions or misunderstandings of the role of the storage of sources. For the linac, control measures need to
monitor chamber by the medical physicists can lead to be in place to prevent malicious or unwarranted use of the
dosimetry errors, which affect all patients. For high-energy linac, but this can be as simple as locking away the control
linacs, electron dosimetry needs to be covered by medical console key out of hours.
physicists and there are differences between photon beam
and electron beam dosimetry, which require education and
training. Cobalt-60 Source Exchange

The cobalt-60 source with a half-life of 5.27 years needs

Costs to be replaced about every 5 years or so. There is a disad-
vantage in continuing to use a source past 5 years in longer
The IAEA in its procurement process for technical coop- treatment times and thus reduced patient throughput. The
eration considers not just the up-front cost of equipment IAEA recommends that the dose rate should not fall below
such as teletherapy machines, but also the life-time cost 0.4 Gy/min under reference conditions at the depth of dose
considering maintenance and repair of the equipment dur- maximum [1]. There are security and safety concerns
ing the complete life-cycle. Using 15 years as the maximum with source exchanges and a plan needs to be in place for
life of a cobalt-60 machine or linac, after a standard 1 management of the old source through either recycling or
year of warranty in which repairs and maintenance are long-term storage. When procuring cobalt-60 teletherapy
included, 14 years of the cost of maintenance and repairs machines for countries under technical cooperation, the
need to be considered. This can be provided either through IAEA insists that the supplier commits to the return and
a service contract with a supplier or distributor, or through disposal of the old source.
resourcing an in-house maintenance engineering service
with trained staff, equipment and spare parts. Table 1 gives
indicative costs for cobalt-60 machines and linacs, but Multi-energy Linac versus Single-energy
excludes additional hardware and software costs required Linac
for maintaining extended record and verify systems or
specialised treatment planning for advanced techniques. When characterising cobalt-60 machines against linacs it
One possibility for defraying the cost of cobalt-60 source can be overlooked that there are large differences among
exchange is the availability of a both a 100 cm SAD cobalt-60 linacs themselves. The single photon energy linac (usually
machine and an 80 cm SAD cobalt-60 machine from the with 6 MV) is very different from a multi-energy linac,
same supplier in the one radiotherapy department. In this which has a number of photon energies and electron en-
case, the sources can be cascaded from the 100 cm SAD ergies. The single-energy linac can have a vertical wave-
machine to the 80 cm SAD machine to prolong the useful guide, which removes the need for a bending magnet and
life of a single source. its associated complexity, and beam steering is likely to be

Table 1
Indicative costs of cobalt-60 machines and linear accelerators (linacs) in Euro

Cobalt-60 machine 6 MV linac with Multi-energy linac

excluding MLC, EPID and RVS MLC, EPID and RVS (including electrons)
with MLC, EPID and RVS
Up-front cost including 1 year 600 000 900 000 1 500 000
of warranty
14 year service contract 500 000 1 260 000 2 100 000
Source exchanges (2 of) 280 000 NA NA
Total cost over 15 years 1 380 000 2 160 000 3 600 000
MLC, multileaf collimator; RVS, record and verify system.
EPID, electronic portal imaging device.

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 B.J. Healy et al. / Clinical Oncology xxx (2016) 1e6 5

more stable on the single-energy linac without the bending large patients. A solution is to treat using a constant source-
magnet. Also, a mechanised carousel to supply different surface-distance technique instead of an isocentric tech-
filters for different energies is not required on the single- nique, which takes longer. 100 cm SAD cobalt-60 machines
energy linac, nor is a mechanism to change the target for will obviously have equivalent manoeuvrability to linacs.
different photon energies. For these reasons, the most The use of multiple shifts to treat patients on teletherapy
appropriate comparison to be made against a cobalt-60 is widespread in LMICs. For example, three 6 h shifts from
machine is against a single-energy 6 MV linac. 6 am to 12 midnight is possible. Another factor driving
In the same sense, the option of a single-energy 4 MV multiple shifts is the relative cost of staff versus equipment
linac needs to be discussed here. In the early days of linacs, in LMICs (see [13; figure 8]). Where staff costs are relatively
4 MV linacs were quite common. The beam penetration low compared with equipment costs it makes economic
closely matched that of cobalt-60 gamma rays and clini- sense to hire more staff and run more shifts than invest in
cians were familiar with clinical outcomes of cobalt-60- additional equipment. From a safety and quality perspec-
based treatments. Nowadays the 4 MV beam is very rare tive, multiple shifts often do not allow sufficient time for
on a linac, as it has been recognised that in the trade-off quality control activities, which then have to be carried out
between entrance dose and exit dose 6 MV provides an on weekends or during short breaks in treatment.
optimal solution for most patients [11]. Also IMRT and Downtime also plays a role in patient throughput; if the
VMAT are commonly carried out with 6 MV, as concerns are machine is non-operational due to malfunction then patient
raised with neutron dose to the patient for higher energies throughput is affected while repair and subsequent checks
with the higher number of MU for modulated treatments. are carried out. The advantage of departments with multi-
ple machines cannot be overstated here; as the ability to
transfer patients from one machine to another means that
Patient Throughput disruption to patient treatments due to machine break-
down can be minimised.
An important consideration for radiotherapy departments
is patient throughput, i.e. how many patients can be treated
per hour. This is an important consideration in LMICs where Clinical Use
lack of access to radiotherapy [12] means that waiting times
for radiotherapy can be long and existing resources are fully Radiotherapy can generally be divided into treatments of
utilised. Cobalt-60 treatment times are affected by source curative intent and palliative intent, and it can be said that
decay, but it can be argued that in terms of the overall palliative treatments often require less complexity of
appointment time for the patient in the treatment room, the technique than those that are curative. It follows that a
beam-on time is only a fraction of the overall time, irre- cobalt-60 machine can provide the same service as linacs
spective of cobalt-60 or linac technology. 80 cm SAD cobalt for palliative treatments, and Page et al. [14] argue that
units also have decreased manoeuvrability, especially for cobalt-60 machines are vital for meeting future challenges

Table 2
Characteristics of cobalt-60 machines and linear accelerators (linacs)

Item Cobalt-60 machine Single-energy linac Multiple-energy linac

Physical Relatively simple Complex electrical equipment More complex electrical
characteristics equipment
Dosimetry Limited by source size, Smaller source size, versatile dose Smaller source size, versatile
1 MeV gamma ray beam energy rate, 6 MV X-ray beam energy dose rate including FFF, multiple
X-ray beam energies up to 20 MV
Shielding Concrete bunker and maze Concrete bunker and maze with Concrete bunker and maze with
requirements thicker walls thicker walls and possibly neutron door
Staff Baseline Higher than baseline particularly in Higher than single energy linac,
medical physics, engineering and IT particularly in medical physics.
support. More training required. More training required.
Costs Baseline Slightly higher than baseline Significantly higher than baseline
Security Security measures Easily compliant Easily compliant
required for source in place and
for source exchange
Source Every 5 years NA NA
exchange
Clinical use Can easily provide simple Can more easily provide complex Can more easily provide complex
treatment techniques treatment techniques treatment techniques, allows
superficial treatments with electrons
Patient Affected by source decay Can be compromised by poor Can be compromised by poor maintenance
throughput maintenance
FFF, flattening-filter-free.

Please cite this article in press as: Healy BJ, et al., Cobalt-60 Machines and Medical Linear Accelerators: Competing Technologies for External
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6 B.J. Healy et al. / Clinical Oncology xxx (2016) 1e6

for access to radiotherapy, including palliative treatments. over the 10e15 year useful life of the equipment. It is not
The ubiquitous availability of an MLC, in-room electronic an efficient use of resources to purchase equipment that
imaging and a record and verify system on a linac makes it cannot be maintained in providing continuity in radio-
easier to provide a more complex treatment for curative therapy services.
intent.
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Please cite this article in press as: Healy BJ, et al., Cobalt-60 Machines and Medical Linear Accelerators: Competing Technologies for External
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