Is Cobalt-60 Therapy Still Needed

for Developing Countries?

Yimin Hu1 Hao Wu2

1. Professor, Radiation Oncology Dept.,

Cancer Institute (Hospital), CAMS, Beijing, China
President, Chinese Society of Medical Physics
E-mail: [email protected]

2. Medical Radiation Physics, Radiation Oncology Dept.

Peking University Cancer Hospital, Beijing, China
E-mail: [email protected]
Is Cobalt-60 Therapy Still Needed
for Developing Countries?

** The three major means for Cancer treatment

** Cobalt-60 unit vs 6MV linac

** Cobalt-60 based after-loader vs Ir-192 based after-loader

** Conclusions
Is Cobalt-60 Therapy Still Needed
for Developing Countries?

** The three major means for Cancer treatment

** Cobalt-60 unit vs 6MV linac

** Cobalt-60 based after-loader vs Ir-192 based after-loader

** Conclusions
The three major means for Cancer treatment
The relative contributions to the cancer survivals

5 years cancer survivals by treatment

1900s 1930s 1960s 1990s (2013)
5% 15% 30% 45% (67%)
American Cancer Society: Cancer facts & figures 1995

The relative contributions to the cancer survivals by

Surgery 22%
Radiotherapy 18%
Chemo 5%
Eur J Cancer 1992; 28A:2061-2069

The reasons for 55% treatment failure

Uncontrolled on site 18%
uncontrolled on mets 37%
Total 55%
Cancer 1983; 51; 2401-2409
The workhouse of the RT units
*Linear Accelerators:
X-rays: 4MV~25MV
Electron beams: 4MeV~25MeV

*Cobalt-60 tele-therapy unit Er=1.17MeV, 1.33MeV

(It is still the workhouse RT unit in developing countries)

*Cobalt-60 or Ir-192 high dose-rate afterloader

*X()-rays stereotactic treatment system

Is Cobalt-60 Therapy Still Needed
for Developing Countries?

** The three major means for Cancer treatment

** Cobalt-60 unit vs 6MV linac

** Cobalt-60 based after-loader vs Ir-192 based after-loader

** Conclusions
 Cobalt-60 unit vs 6MV linac

Cobalt-60 unit (SAD 80cm) 6MV LA unit (SAD 100cm)

GWXJ80 from NPIC 600CD from Varian
 Cobalt-60 vs 6MV-X on beam characristics

Items Energy Source Dmax Doserate PDD FSZ P80%-20% Source

DIA (cm) (cGy/min) At d= (cm) (mm) Replacement
(mm) At SAD 10cm (wave guide)
Unit

Cobalt-60 1.33MeV ~20 0.5 200 55% 5x5 10 ~Every 6-7

1.17MeV years

6MV Linac 6MV-X <2x3 1.5 ~600 67% 0.5x0.5 7 Depends on

patient load
~ 2~5 years
(1500 HT hrs)

Comment Though the concerned features such as Beam Energy, PDD, Field Size, Dose-rate , Beam
Penumbra are much clinically similar, and the cobalt-60 Source replacement & disposal, is a
little concerned, but the clinical down time for cobalt-60 unit is much less than the LAs.
 Cobalt-60 unit vs 6MV linac on cost-effect

Item Source replacement Reliability Power Supply Skilled Person

(up time) Required Required

Unit
Cobalt-60 ~120000 USD 98% Much Less Less need
/7years
(source disposal
included)

6MV linac ~150,000 USD /2~years 95% Much Higher Much need
(waveguide not
included)

Comment Cobalt-60 Unit offers, compared with 6MV-X ray linac,

more reliability,
less need good power supply,
less need skilled persons to take care of
Cobalt-60s Plan vs 6 MV-Xs Plan: Nasopharynx Cancer (9 Beams IMRT Plan)

Cobalt-60s Plan 6 MV-Xs Plan

Cobalt-60s Plan vs 6 MV-Xs Plan: Nasopharynx Cancer (2 Opposing Beam )

Cobalt-60s Plan 6 MV-Xs Plan

Cobalt-60s Plan vs 6 MV-Xs Plan: Lung Cancer (7 Beams IMRT Plan)

Cobalt-60s Plan 6 MV-Xs Plan

Cobalt-60s Plan vs 6 MV-Xs Plan: Lung Cancer ( 3 Beams 3DCRT Plan)

Cobalt-60s Plan 6 MV-Xs Plan

Cobalt-60s Plan vs 6 MV-Xs Plan: Cervix Cancer (7 Beams IMRT Plan)

Cobalt-60s Plan 6 MV-Xs Plan

Cobalt-60s Plan vs 6 MV-Xs Plan: Prostate Cancer (4 Beams 3DCRT Plan)

Cobalt-60s Plan 6 MV-Xs Plan

Does Cobalt 60 therapy unit be still needed for developing countries?

The beam characteristics of Cobalt 60 therapy unit

is clinically much similar to 6 MV-X ray linear accelerator, But

*Comparied with 6 MV-X Linac, Cobalt 60 therapy unit offers, :

more reliability,
less need good power supply system,
less need skilled persons to take care of

*The initial capital cost and after-installation maintanance cost in 5 years runing time
of a Cobalt 60 therapy unit are less than that of a 6MV-X ray Linac

*Though in 10 years runing time both costs are almost equal due to the Cobalt 60
source must be replaced every 5-7 years, the lifespan of a modern 6MV-X
ray Linac is getting shorter and shorter
as the morden advanced technology changes faster than ever before
Does Cobalt 60 therapy unit be still needed for developing countries?

The beam characteristics of Cobalt 60 therapy unit

is clinically much similar to 6 MV-X ray linear accelerator, But

*Comparied with 6 MV-X Linac, Cobalt 60 therapy unit offers, :

more reliability,
less need good power supply system,
less need skilled persons to take care of

*The initial capital cost and after-installation maintanance cost in 5 years runing time
of a Cobalt 60 therapy unit are less than that of a 6MV-X ray Linac

*Though in 10 years runing time both costs are almost equal due to the Cobalt 60
source must be replaced every 5-7 years, the lifespan of a modern 6MV-X
ray Linac is getting shorter and shorter
as the morden advanced technology changes faster than ever before
Does Cobalt 60 therapy unit be still needed for developing countries?

The beam characteristics of Cobalt 60 therapy unit

is clinically much similar to 6 MV-X ray linear accelerator, But

*Comparied with 6 MV-X Linac, Cobalt 60 therapy unit offers, :

more reliability,
less need good power supply system,
less need skilled persons to take care of

*The initial capital cost and after-installation maintanance cost in 5 years runing time
of a Cobalt 60 therapy unit are less than that of a 6MV-X ray Linac

*Though in 10 years runing time both costs are almost equal due to the Cobalt 60
source must be replaced every 5-7 years, the lifespan of a modern 6MV-X
ray Linac is getting shorter and shorter
as the morden advanced technology changes faster than ever before
Does Cobalt 60 therapy unit be still needed for developing countries?

The beam characteristics of Cobalt 60 therapy unit

is clinically much similar to 6 MV-X ray linear accelerator, But

*Comparied with 6 MV-X Linac, Cobalt 60 therapy unit offers, :

more reliability,
less need good power supply system,
less need skilled persons to take care of

*The initial capital cost and after-installation maintanance cost in 5 years runing time
of a Cobalt 60 therapy unit are less than that of a 6MV-X ray Linac

*Though in 10 years runing time both costs are almost equal due to the Cobalt 60
source must be replaced every 5-7 years, the lifespan of a modern 6MV-X
ray Linac is getting shorter and shorter
as the morden advanced technology changes faster than ever before
 Comparison on 5 yrs Survivals of NPC by Using 8MV-X and Co-60- Irradiation

8MV-X Co-60-

Total Case* 5yrs Total Case* 5yrs

Stage I/II 48/70 68.6% 59/73 80.8%

Stage III/IV 96/228 42.1% 92/220 41.8%

Average 144/298 48.6% 151/293 51.5%

Total Dose 60Gy~79.9Gy/225 (74.25%) 60Gy~79.9Gy/186 (64.19%)

Dose/Case 80Gy/76 (25.25%) 80Gy/105 (35.81%)

* All cases treated from 11/1978-10/1982 for 8MV_X from 1/1976-10/1982 for Co- 60

FromJiehua Yan, et al
Chinese Journal of Radiation Oncology,1988, Vol2(4)p2~4
Is Cobalt-60 Therapy Still Needed
for Developing Countries?

** The three major means for Cancer treatment

** Cobalt-60 unit vs 6MV linac

** Cobalt-60 based after-loader vs Ir-192 based after-loader

** Conclusions
 High dose-rate brachytherapy unit
ComparisonsCo-60 vs Ir-192
No.-- Items GZP3 Co-60 after-loader Ir-192 after-loader
1 Running costs Cobalt-60 Half-life 5.27Y Apart from the initial Ir-192 Half-life74.2d
(10 years based ) investment, the running costs after installation almost none. Replace the source at least 3 times /year, which costs ~12,000
USD/each~36,000 USD/year, and 10years ~370,000 USD for
source only, the extra laboring costs not included.

2 Clinical indications The clinical indications are almost the same for Co-60 and The clinical indications are almost the same for Ir-92 and Co-60,
Ir-92, Though the energy of Co-60 is little higher than that Though the energy of Ir-92 is little lower than that of Co-60.
of Ir-92.

3 Source specifications GZP3 Co-60 afterloader using 3 active co-60 sources of The most current Ir-192 after-loader has only 1 Ir-192 source with
each contains 5Ciequv Ir-192 ~13.75 Ci; out shell 10Ci activityout shell size 1.1mm6mmwith a length
size 1.5mm3.5mmwith a length of 1.5mwith of 2m. Though there are 18 channelsthey are delivered each
3 channels . As the three sources are independent, that by eachthat makes the delivery time 3 times longer.
makes the delivery time much shorter than that of one only
Ir-192 source after-loader unit. Average energy 0.4MeV, and half-life 74.2 days.
Average energy 1.25Mev, and half-life 5.27 years.

4 Clinical performance Co-60 based after-loader offers much reliable, repeatable As the Ir-192 source has a much lower energy and much shorter
and precise planning & delivery, that makes this kind of half-life, that makes calibrating the source activity and delivery-
after-loader clinically much more safety than that of Ir-192 time quite often.
based.
5 Safety As the source control and moving systems in GZP3 Co-60 As the source control and moving systems in most Ir-192 after-
after-loader are mechanically separated, that makes loader are mechanically integrated , that makes working staff on
working staff on duty much radiation safer while the source duty receives much more radiation while the source got stuck and
got stuck and fixed it. fixed it.

GZP3 After-loader Cobalt-60 based Ir-192 based after-loader

 High dose-rate brachytherapy unit
ComparisonsCo-60 vs Ir-192
No.-- Items GZP3 Co-60 after-loader Ir-192 after-loader
1 Running costs Cobalt-60 Half-life 5.27Y Apart from the initial Ir-192 Half-life74.2d
(10 years based ) investment, the running costs after installation almost none. Replace the source at least 3 times /year, which costs ~12,000
USD/each~36,000 USD/year, and 10years ~370,000 USD for
source only, the extra laboring costs not included.

2 Clinical indications The clinical indications are almost the same for Co-60 and The clinical indications are almost the same for Ir-92 and Co-60,
Ir-92, Though the energy of Co-60 is little higher than that Though the energy of Ir-92 is little lower than that of Co-60.
of Ir-92.

3 Source specifications GZP3 Co-60 afterloader using 3 active co-60 sources of The most current Ir-192 after-loader has only 1 Ir-192 source with
each contains 5Ciequv Ir-192 ~13.75 Ci; out shell 10Ci activityout shell size 1.1mm6mmwith a length
size 1.5mm3.5mmwith a length of 1.5mwith of 2m. Though there are 18 channelsthey are delivered each
3 channels . As the three sources are independent, that by eachthat makes the delivery time 3 times longer.
makes the delivery time much shorter than that of one only
Ir-192 source after-loader unit. Average energy 0.4MeV, and half-life 74.2 days.
Average energy 1.25Mev, and half-life 5.27 years.

4 Clinical performance Co-60 based after-loader offers much reliable, repeatable As the Ir-192 source has a much lower energy and much shorter
and precise planning & delivery, that makes this kind of half-life, that makes calibrating the source activity and delivery-
after-loader clinically much more safety than that of Ir-192 time quite often.
based.
5 Safety As the source control and moving systems in GZP3 Co-60 As the source control and moving systems in most Ir-192 after-
after-loader are mechanically separated, that makes loader are mechanically integrated , that makes working staff on
working staff on duty much radiation safer while the source duty receives much more radiation while the source got stuck and
got stuck and fixed it. fixed it.

GZP3 After-loader Cobalt-60 based Ir-192 based after-loader

 High dose-rate brachytherapy unit
ComparisonsCo-60 vs Ir-192
No.-- Items GZP3 Co-60 after-loader Ir-192 after-loader
1 Running costs Cobalt-60 Half-life 5.27Y Apart from the initial Ir-192 Half-life74.2d
(10 years based ) investment, the running costs after installation almost none. Replace the source at least 3 times /year, which costs ~12,000
USD/each~36,000 USD/year, and 10years ~370,000 USD for
source only, the extra laboring costs not included.

2 Clinical indications The clinical indications are almost the same for Co-60 and The clinical indications are almost the same for Ir-92 and Co-60,
Ir-92, Though the energy of Co-60 is little higher than that Though the energy of Ir-92 is little lower than that of Co-60.
of Ir-92.

3 Source specifications GZP3 Co-60 afterloader using 3 active co-60 sources of The most current Ir-192 after-loader has only 1 Ir-192 source with
each contains 5Ciequv Ir-192 ~13.75 Ci; out shell 10Ci activityout shell size 1.1mm6mmwith a length
size 1.5mm3.5mmwith a length of 1.5mwith of 2m. Though there are 18 channelsthey are delivered each
3 channels . As the three sources are independent, that by eachthat makes the delivery time 3 times longer.
makes the delivery time much shorter than that of one only
Ir-192 source after-loader unit. Average energy 0.4MeV, and half-life 74.2 days.
Average energy 1.25Mev, and half-life 5.27 years.

4 Clinical performance Co-60 based after-loader offers much reliable, repeatable As the Ir-192 source has a much lower energy and much shorter
and precise planning & delivery, that makes this kind of half-life, that makes calibrating the source activity and delivery-
after-loader clinically much more safety than that of Ir-192 time quite often.
based.
5 Safety As the source control and moving systems in GZP3 Co-60 As the source control and moving systems in most Ir-192 after-
after-loader are mechanically separated, that makes loader are mechanically integrated , that makes working staff on
working staff on duty much radiation safer while the source duty receives much more radiation while the source got stuck and
got stuck and fixed it. fixed it.

GZP3 After-loader Cobalt-60 based Ir-192 based after-loader

 High dose-rate brachytherapy unit
ComparisonsCo-60 vs Ir-192
No.-- Items GZP3 Co-60 after-loader Ir-192 after-loader
1 Running costs Cobalt-60 Half-life 5.27Y Apart from the initial Ir-192 Half-life74.2d
(10 years based ) investment, the running costs after installation almost none. Replace the source at least 3 times /year, which costs ~12,000
USD/each~36,000 USD/year, and 10years ~370,000 USD for
source only, the extra laboring costs not included.

2 Clinical indications The clinical indications are almost the same for Co-60 and The clinical indications are almost the same for Ir-92 and Co-60,
Ir-92, Though the energy of Co-60 is little higher than that Though the energy of Ir-92 is little lower than that of Co-60.
of Ir-92.

3 Source specifications GZP3 Co-60 afterloader using 3 active co-60 sources of The most current Ir-192 after-loader has only 1 Ir-192 source with
each contains 5Ciequv Ir-192 ~13.75 Ci; out shell 10Ci activityout shell size 1.1mm6mmwith a length
size 1.5mm3.5mmwith a length of 1.5mwith of 2m. Though there are 18 channelsthey are delivered each
3 channels . As the three sources are independent, that by eachthat makes the delivery time 3 times longer.
makes the delivery time much shorter than that of one only
Ir-192 source after-loader unit. Average energy 0.4MeV, and half-life 74.2 days.
Average energy 1.25Mev, and half-life 5.27 years.

4 Clinical performance Co-60 based after-loader offers much reliable, repeatable As the Ir-192 source has a much lower energy and much shorter
and precise planning & delivery, that makes this kind of half-life, that makes calibrating the source activity and delivery-
after-loader clinically much more safety than that of Ir-192 time quite often.
based.
5 Safety As the source control and moving systems in GZP3 Co-60 As the source control and moving systems in most Ir-192 after-
after-loader are mechanically separated, that makes loader are mechanically integrated , that makes working staff on
working staff on duty much radiation safer while the source duty receives much more radiation while the source got stuck and
got stuck and fixed it. fixed it.

GZP3 After-loader Cobalt-60 based Ir-192 based after-loader

 High dose-rate brachytherapy unit
ComparisonsCo-60 vs Ir-192
No.-- Items GZP3 Co-60 after-loader Ir-192 after-loader
1 Running costs Cobalt-60 Half-life 5.27Y Apart from the initial Ir-192 Half-life74.2d
(10 years based ) investment, the running costs after installation almost none. Replace the source at least 3 times /year, which costs ~12,000
USD/each~36,000 USD/year, and 10years ~370,000 USD for
source only, the extra laboring costs not included.

2 Clinical indications The clinical indications are almost the same for Co-60 and The clinical indications are almost the same for Ir-92 and Co-60,
Ir-92, Though the energy of Co-60 is little higher than that Though the energy of Ir-92 is little lower than that of Co-60.
of Ir-92.

3 Source specifications GZP3 Co-60 afterloader using 3 active co-60 sources of The most current Ir-192 after-loader has only 1 Ir-192 source with
each contains 5Ciequv Ir-192 ~13.75 Ci; out shell 10Ci activityout shell size 1.1mm6mmwith a length
size 1.5mm3.5mmwith a length of 1.5mwith of 2m. Though there are 18 channelsthey are delivered each
3 channels . As the three sources are independent, that by eachthat makes the delivery time 3 times longer.
makes the delivery time much shorter than that of one only
Ir-192 source after-loader unit. Average energy 0.4MeV, and half-life 74.2 days.
Average energy 1.25Mev, and half-life 5.27 years.

4 Clinical performance Co-60 based after-loader offers much reliable, repeatable As the Ir-192 source has a much lower energy and much shorter
and precise planning & delivery, that makes this kind of half-life, that makes calibrating the source activity and delivery-
after-loader clinically much more safety than that of Ir-192 time quite often.
based.
5 Safety As the source control and moving systems in GZP3 Co-60 As the source control and moving systems in most Ir-192 after-
after-loader are mechanically separated, that makes loader are mechanically integrated , that makes working staff on
working staff on duty much radiation safer while the source duty receives much more radiation while the source got stuck and
got stuck and fixed it. fixed it.

GZP3 After-loader Cobalt-60 based Ir-192 based after-loader

 High dose-rate brachytherapy unit
ComparisonsCo-60 vs Ir-192
No.-- Items GZP3 Co-60 after-loader Ir-192 after-loader
1 Running costs Cobalt-60 Half-life 5.27Y Apart from the initial Ir-192 Half-life74.2d
(10 years based ) investment, the running costs after installation almost none. Replace the source at least 3 times /year, which costs ~12,000
USD/each~36,000 USD/year, and 10years ~370,000 USD for
source only, the extra laboring costs not included.

2 Clinical indications The clinical indications are almost the same for Co-60 and The clinical indications are almost the same for Ir-92 and Co-60,
Ir-92, Though the energy of Co-60 is little higher than that Though the energy of Ir-92 is little lower than that of Co-60.
of Ir-92.

3 Source specifications GZP3 Co-60 afterloader using 3 active co-60 sources of The most current Ir-192 after-loader has only 1 Ir-192 source with
each contains 5Ciequv Ir-192 ~13.75 Ci; out shell 10Ci activityout shell size 1.1mm6mmwith a length
size 1.5mm3.5mmwith a length of 1.5mwith of 2m. Though there are 18 channelsthey are delivered each
3 channels . As the three sources are independent, that by eachthat makes the delivery time 3 times longer.
makes the delivery time much shorter than that of one only
Ir-192 source after-loader unit. Average energy 0.4MeV, and half-life 74.2 days.
Average energy 1.25Mev, and half-life 5.27 years.

4 Clinical performance Co-60 based after-loader offers much reliable, repeatable As the Ir-192 source has a much lower energy and much shorter
and precise planning & delivery, that makes this kind of half-life, that makes calibrating the source activity and delivery-
after-loader clinically much more safety than that of Ir-192 time quite often.
based.
5 Safety As the source control and moving systems in GZP3 Co-60 As the source control and moving systems in most Ir-192 after-
after-loader are mechanically separated, that makes loader are mechanically integrated , that makes working staff on
working staff on duty much radiation safer while the source duty receives much more radiation while the source got stuck and
got stuck and fixed it. fixed it.

GZP3 After-loader Cobalt-60 based Ir-192 based after-loader

Is Cobalt-60 Therapy Still Needed
for Developing Countries?
** The three major means for Cancer treatment

** Cobalt-60 unit vs 6MV linac

** Cobalt-60 based after-loader vs Ir-192 based after-loader

** Conclusions

1. Cobalt 60 therapy unit provides relatively high energy gamma rays for
radiotherapy which are ideally suited for treatment of H & N tumors,
2. And even for other deeped tumors like Lung and Cervical cancers
if using MLC-based or compensator-based 3DCRT.
3. As the Running costs, Source specifications, Clinical performance, and Safety
concerned, Cobalt-based after-loader is better means than Ir-192 based one
for developing and even for developed countries.
Is Cobalt-60 Therapy Still Needed
for Developing Countries?
** The three major means for Cancer treatment

** Cobalt-60 unit vs 6MV linac

** Cobalt-60 based after-loader vs Ir-192 based after-loader

** Conclusions

1. Cobalt 60 therapy unit provides relatively high energy gamma rays for
radiotherapy which are ideally suited for treatment of H & N tumors,
2. And even for other deeped tumors like Lung and Cervical cancers
if using MLC-based or compensator-based 3DCRT.
3. As the Running costs, Source specifications, Clinical performance, and Safety
concerned, Cobalt-based after-loader is better means than Ir-192 based one
for developing and even for developed countries.
Is Cobalt-60 Therapy Still Needed
for Developing Countries?
** The three major means for Cancer treatment

** Cobalt-60 unit vs 6MV linac

** Cobalt-60 based after-loader vs Ir-192 based after-loader

** Conclusions

1. Cobalt 60 therapy unit provides relatively high energy gamma rays for
radiotherapy which are ideally suited for treatment of H & N tumors,
2. And even for other deeped tumors like Lung and Cervical cancers
if using MLC-based or compensator-based 3DCRT.
3. As the Running costs, Source specifications, Clinical performance, and Safety
concerned, Cobalt-based after-loader is better means than Ir-192 based one
for developing and even for developed countries.
Is Cobalt-60 Therapy Still Needed
for Developing Countries?
** The three major means for Cancer treatment

** Cobalt-60 unit vs 6MV linac

** Cobalt-60 based after-loader vs Ir-192 based after-loader

** Conclusions

1. Cobalt 60 therapy unit provides relatively high energy gamma rays for
radiotherapy which are ideally suited for treatment of H & N tumors,
2. And even for other deep tumors like Lung and Cervical cancers
if using MLC-based or compensator-based 3DCRT.
3. As the Running costs, Source specifications, Clinical performance, and Safety
concerned, Cobalt-based after-loader is better means than Ir-192 based one
for developing and even for developed countries.