World Health Organization · 1st edition, 2021 · 142 pages
Technical procurement guidance for radiation oncology departments establishing or upgrading external beam and brachytherapy services in low- and middle-income countries.
- Issuer
- World Health Organization
- Edition
- 1st edition, 2021
- Audience
- Radiation oncologists, medical physicists, biomedical/clinical engineers, IT professionals, hospital administrators, policy-makers, programme managers, procurement officers, logisticians, national health products regulatory authorities, national radiation regulatory authorities, global procurement agencies, manufacturers.
- Evidence
- Expert consensus technical specifications based on IEC and ISO standards, IAEA dosimetry protocols, and international professional society recommendations (AAPM, ESTRO, IPEM, Canadian Partnership for Quality Radiotherapy).
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
This joint WHO/IAEA publication provides comprehensive technical specifications for radiotherapy equipment commonly used in cancer treatment, addressing both external beam radiotherapy (EBRT) and brachytherapy. The document defines three equipment packages linked to health system capacity, with Package 1 including cobalt-60 teletherapy or single-photon energy LINAC plus conventional simulators, Package 2 adding multi-energy LINACs with electrons and CT simulators, and Package 3 incorporating advanced capabilities such as IMRT, VMAT, and image-guided radiotherapy.
The guide covers major treatment equipment (LINACs, cobalt-60 units, HDR brachytherapy afterloaders, orthovoltage units), associated imaging equipment (CT simulators, conventional simulators, C-arm fluoroscopy, ultrasound), treatment planning systems, oncology information systems, and essential ancillary equipment including patient immobilization devices, mould room equipment, dosimetry and quality control instruments, and radiation safety equipment. Each specification includes relevant IEC and ISO standards, detailed technical requirements, radiation safety measures, and quality assurance recommendations.
The publication emphasizes that approximately 50% of cancer patients require radiotherapy during their disease course, with cervical cancer showing particular benefit (18% five-year survival improvement, 33% local control benefit). The technical specifications support the WHO Global Strategy for cervical cancer elimination and build upon the 2017 WHO Lists of Priority Medical Devices for Cancer Management, providing practical guidance for procurement committees involving radiation oncologists, medical physicists, biomedical engineers, IT professionals, and administrators.
Key points
For clinicians — doses and thresholds as stated in the guideline
- External beam treatment units: LINAC with 6 MV photon beam (single-energy) or 6 MV + 10 MV with electrons 6–15 MeV (multi-energy); cobalt-60 teletherapy with minimum 2.0 Gy/min initial dose rate at 100 cm SSD; both require 100 cm source-to-axis distance with ≤2 mm mechanical isocentre sphere
- CT simulator: large bore ≥80 cm diameter, minimum 16-slice capability, flat carbon fibre couch top indexed for immobilization equipment, DICOM 3.0 compliant with direct TPS connectivity, external laser system for patient alignment
- HDR brachytherapy: cobalt-60 afterloader with 74 GBq ±10% source activity, minimum 20 channels, automatic applicator verification, CT-MR compatible gynaecological applicator sets (Fletcher, ring, vaginal), source replacement after 3-year lifetime
- Treatment planning system: 3D capability with DICOM image import/export, photon beam algorithms using advanced methods (convolution, Boltzmann transport, Monte Carlo), electron pencil beam or Monte Carlo algorithms, IEC 61217 scale convention, dose calculation accuracy meeting IAEA TECDOC 1540 Table 4 criteria
- Multileaf collimator (Package 2): minimum 80 motorized leaves, 1 cm maximum leaf width at isocentre, interleaf leakage <4%, leaf position accuracy ≤1 mm at isocentre, suitable for 3D-CRT and capable of IMRT/VMAT delivery
- Reference dosimetry equipment: waterproof Farmer chamber (~0.6 cm³), plane parallel chamber (~0.4 cm³) for electrons, reference-class electrometer (IEC 60731), calibration at PSDL/SSDL every two years, dosimetry following IAEA TRS-398 absorbed dose to water protocol
- Radiation protection: concrete bunker shielding calculated per IAEA Safety Reports Series No. 47, neutron protection measures for photon energies >8 MV, comprehensive radiation survey at commissioning, controlled area designation per International Basic Safety Standards, facility access interlocks and emergency-retract buttons
- Quality assurance: daily constancy checks with automated multi-detector system, reference dosimetry monthly, comprehensive annual testing per AAPM TG-142 or equivalent, independent MU calculation before first treatment or before 10% prescribed dose delivered
Equipment Packages for Radiotherapy Services
Table extracted from the guideline
| Component | Package 1 | Package 2 | Package 3 |
|---|---|---|---|
| EBRT Treatment Unit | Cobalt-60 (≥100 cm SAD) and/or single-photon LINAC; orthovoltage as needed | Package 1 + single or multiple energy LINAC with electrons | Multiple energy LINACs with IMRT, VMAT, IGRT, SRS, SBRT |
| Treatment Unit Accessories | Laser positioning; standard/customized blocks; OIS with RVS | Laser; blocks with/without MLC; OIS with RVS; EPID; portal imaging | MLC/mini-MLC; EPID; in-room MV/kV imaging; motion management; OIS with RVS |
| Treatment Planning | 3D TPS (DICOM-compatible) | 3D TPS (DICOM-compatible) | 3D TPS with IMRT, VMAT, IGRT, SRS, SBRT capabilities |
| Simulation Imaging | Conventional digital simulator with laser; access to CT | Package 1 + dedicated CT simulator with moveable laser | CT simulator with 4DCT; access to MRI/PET-CT; fiducial markers |
| Brachytherapy Unit | HDR remote afterloader | HDR remote afterloader | HDR remote afterloader |
| Brachy Source | Cobalt-60 | Cobalt-60 or Iridium-192 | Cobalt-60 or Iridium-192 |
| Brachy Applicators | Cervical (ring, ovoid, vaginal cylinders); endometrial; transfer tubes | Cervical (ring with interstitial needles, ovoid, vaginal); endometrial; transfer tubes | CT-MR compatible cervical intracavitary/interstitial; prostate needles; endometrial; transfer tubes |
| Brachy Planning | 2D TPS | 2D or 3D TPS | 3D TPS |
| Brachy Imaging | Conventional simulator or C-arm; ultrasound with convex probe | Conventional simulator or C-arm or CT simulator; ultrasound (convex + endorectal) | CT simulator; access to MRI; ultrasound (convex + endorectal) |
Source: World Health Organization, Technical Specifications of Radiotherapy Equipment for Cancer Treatment. Reproduced in summary form.
From the guideline
Verbatim
“Radiotherapy has the potential to benefit approximately 50% of cancer patients during the course of their disease.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Chair of Georgia's Public Health Institute and having supported health system strengthening in the South Caucasus through WHO collaboration, I recognize this technical specification addresses a critical gap in cancer care infrastructure across our region. The document's three-tiered package approach aligns perfectly with phased capacity development appropriate for middle-income countries like Georgia, Armenia and Azerbaijan. I would particularly stress to Georgian colleagues the importance of the quality assurance framework detailed in Sections 3.2.5, 3.10.5, and 4.2.5—establishing stable dosimetry calibration chains through SSDL access and implementing daily constancy checks with automated systems are non-negotiable prerequisites before treating the first patient. The realistic implementation caveat concerns human resources: procuring a LINAC or cobalt-60 unit without first securing permanently employed, internationally-trained medical physicists and establishing service contracts with qualified biomedical engineers will result in expensive idle equipment, as several former Soviet countries have unfortunately demonstrated. Georgia should leverage IAEA technical cooperation for initial commissioning and consider regional collaboration on expensive quality assurance phantoms and neutron survey meters.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia’s ongoing UHC programme and national cancer control efforts require strategic investment in radiotherapy capacity. The country currently has limited radiotherapy infrastructure relative to cancer burden, with cervical cancer incidence of approximately 14.8 per 100,000 women (GLOBOCAN 2020). This specification supports implementation of evidence-based radiotherapy for cervical cancer treatment as part of WHO elimination strategy (90% treatment target). Georgian radiotherapy departments should prioritize Package 1 or 2 implementation based on available infrastructure, qualified workforce (radiation oncologists, medical physicists, radiation therapists), and secure funding for equipment lifecycle including cobalt-60 source replacement every 5 years or LINAC maintenance contracts. Establishing quality assurance programmes requires access to secondary standards dosimetry laboratory calibration services, potentially through regional cooperation with neighbouring countries. Radiation regulatory framework and concrete bunker construction capabilities are prerequisites; collaboration with IAEA technical cooperation programme can support commissioning and staff training. Regional sharing of expensive anthropomorphic phantoms for end-to-end testing is advisable.
Questions this guideline answers
Quick answers
What is the minimum initial investment for a basic radiotherapy service?
Package 1 requires either a cobalt-60 teletherapy unit (100 cm SAD, minimum 2.0 Gy/min initial dose rate) or single 6 MV photon energy LINAC, conventional digital simulator with laser system, 3D treatment planning system, HDR brachytherapy afterloader with cobalt-60 source (74 GBq), associated applicators, plus essential dosimetry equipment (reference-class electrometer, Farmer chamber, plane parallel chamber for electrons, water phantom) and radiation safety equipment. The cobalt-60 option has lower purchase cost and maintenance costs than LINAC but requires source replacement every 5 years.
Why does the specification recommend 100 cm SAD for cobalt-60 units rather than 80 cm?
While 80 cm SAD provides higher dose rate for the same source activity due to closer patient positioning, 100 cm SAD allows sufficient clearance for isocentric treatment techniques at all gantry angles. Departments procuring two cobalt-60 units should consider one 100 cm and one 80 cm SAD unit to enable source cascading: when the 100 cm unit source decays and requires replacement, the used source can be transferred to the 80 cm unit where it may provide adequate dose rate for several additional years, representing major resource savings.
What are the neutron protection requirements for higher energy LINACs?
LINACs with photon beam energies above 8 MV generate neutrons and neutron capture gamma radiation requiring additional shielding measures. The concrete bunker walls designed for primary beam and scatter should be sufficient for neutron absorption, but control measures may be necessary at the entrance (borated polyethylene and lead thickness calculated per IAEA Safety Reports Series No. 47 or NCRP Report No. 151). Careful maze design (length, turns, cross-sectional area) can reduce entrance shielding requirements. A neutron survey meter is required for commissioning radiation surveys. Short-term activation products (aluminium-28, half-life 2.24 min) necessitate brief staff entry delay after high-energy irradiation. The 10 MV option minimizes neutron issues compared to 15 or 18 MV.
How often must reference dosimetry equipment be calibrated?
Reference-class and field-class electrometers, Farmer-type ionization chambers, and plane parallel chambers require calibration at a primary standards dosimetry laboratory (PSDL) or secondary standards dosimetry laboratory (SSDL) every two years. Calibration must be in terms of absorbed dose to water in conjunction with an electrometer for Farmer chambers, with cobalt-60 build-up cap included. Plane parallel chambers for electron beams can be calibrated at PSDL/SSDL or cross-calibrated against the reference Farmer chamber in the radiotherapy department. Survey meters require protection-level calibration with caesium-137 every two years. Daily constancy checks use strontium-90 check sources between calibrations.
- Issuer
- World Health Organization
- Type
- Technical document
- Edition
- 1st edition, 2021
- Status
- Current
- Published
- 2021-03-05
- Languages
- English
- Scope
- Technical specifications for external beam radiotherapy and brachytherapy equipment procurement for cancer treatment in low- and middle-income countries, including LINACs, cobalt-60 teletherapy units, HDR brachytherapy afterloaders, CT simulators, conventional simulators, treatment planning systems, oncology information systems, and all ancillary dosimetry, quality control, and radiation safety equipment.
- Audience
- Radiation oncologists, medical physicists, biomedical/clinical engineers, IT professionals, hospital administrators, policy-makers, programme managers, procurement officers, logisticians, national health products regulatory authorities, national radiation regulatory authorities, global procurement agencies, manufacturers.
- Pages
- 142
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978 92 4 001998 0
- Evidence
- Expert consensus technical specifications based on IEC and ISO standards, IAEA dosimetry protocols, and international professional society recommendations (AAPM, ESTRO, IPEM, Canadian Partnership for Quality Radiotherapy).
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
World Health Organization. Technical specifications of radiotherapy equipment for cancer treatment. Geneva: World Health Organization; 2021. 142 p. Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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