The cancer burden in China is growing rapidly with cancer mortality becoming the leading cause of death since 2010. In 2015 it was estimated that there was 4,292,000 new cancer diagnosis and a staggering 2,814,000 cancer related deaths². By 2025 it is estimated that there will be 19.3 million new cancer cases worldwide, and China will account for one third of this number⁴. Investing in cancer care in China needs to happen rapidly as there is already a shortfall in treatment units especially in cities considered lower tier. The first Icon Cancer Centre in China opened at Jiangxian in the Shanxi province where there was a high incidence of lung, oesophagus and stomach cancers² and no local cancer services.

The Halcyon is the latest Varian linear accelerator and differs substantially from the conventional linac.  The most noticeable difference is the ring gantry design that enables the gantry to rotate four times faster whilst reducing the risk of collision. The Halcyons small footprint and self-shielding design means it will easily fit into existing bunkers. Another unique feature of the Halcyon is its MLC design which utilises a stacked and staggered layout. This negates the need for jaws, increases leaf speed, optimises modulation, and reduces interleaf transmission. The patient care workflow, in room controls and console work stations are drastically simplified compared to traditional linacs. These features combined with the increased speed of; the gantry, image capture, MLCs and beam delivery to decrease patient treatment times.

Icon’s decision to install Halcyon at its first Icon China site was made based upon its patient centred features as well as the highly favourable characteristics of the machine which enable efficient install, commissioning, training and treatment workflows.

The Halcyon machine arrived at the Jiangxian Red Cross Hospital as several major modules and was installed within four days. This is a substantially shorter time frame compared to the three weeks it takes to install most conventional linacs.  The commissioning process for Halcyon is made more efficient by the presence of only a single beam energy and prebuilt beam model, the entire process took between 8-10 days.  The Halcyon commissioning process presents unique challenges.  Differences in the design of the Halcyon such as the lack of light field and MLC design means the mechanical checks, water tank setup and MLC testing are different. Icon medical physicists from Australia with extensive experience commissioning and working on the Halcyon travelled to China to undertake both commissioning and deliver on site physicist training. This support proved invaluable.

An extremely important aspect of Icon’s goal in China is to introduce and uphold the Australian standard of care and expertise within Chinese departments. These ideals were especially important during the machine commissioning phase as it is the most vital step in the setup of a new department. The stringent and comprehensive commissioning program that was undertaken is standard practice for Icon departments regardless of geography.

A significant difference between the Australian and Chinese radiation therapy (RT) departments is the daily patient numbers. This was a significant factor that influenced Icon’s decision to utilise the Halcyon at the Jiangxian site. When compared to conventional linacs, the Halcyon system reduces patient setup, treatment delivery and imaging times. The use of the ring gantry, flattening filter free beam as well as the MLC design all allow for faster beam delivery whilst the simplified and semi-automated workflow helps to decrease patient set up times.

Implementing and maintaining Icons patient centred care approach was an important factor of the expansion. To ensure this standard was achieved the same level of technical and clinical expertise was required by Icon China staff. Daily image guided radiotherapy (IGRT) is not currently the standard of care at the majority of Chinese  departments. Daily IGRT for every patient was a non-negotiable for implementing Icon RT services in China. The Halcyon supported this as it requires image guidance prior to every treatment and this imaging dose is accounted for in the treatment planning. This feature of the Halcyon ensured that Icons standard of care was upheld by ensuring accurate daily treatment. The quality and efficacy of patient’s radiotherapy treatment depends on the quality of the treatment plan. Utilising Varian systems already familiar within Icon Australia, has enabled the sharing of our clinical expertise using eclipse with Icon China. This has allowed the sharing of Icons RapidPlan models to provide a high-quality treatment plan to patients in an efficient and consistent manner.

At Icon, the patient is always the priority. Varian has incorporated multiple patient focused features in the design of the Halcyon to improve the patient experience during treatment. The soft ambient lighting within the machine as well as the almost silent gantry and beam helps to relieve patient stress during treatment. The couch has an integrated camera and within the bore there is an intercom and speaker for easy communication with the treatment staff and the provision of in room music. The faster imaging, and treatment delivery times as well as the ability to remotely unload the patient from the machine all help to decrease the patients time on the treatment couch.

The overall simplification of the Halcyon system compared to conventional linacs has helped the Icon China RT training to be conducted in a more efficient time frame. There are multiple aspects of the Halcyon system which helped to improve training efficiency:

• The treatment workflow is conducted in 9 steps from beginning to end, this made training the technicians on the Halcyon simple and consistent and more accessible to staff new to the profession
• The bore design proved to be familiar to the technicians who mostly come from a medical imaging background.
• The Halcyon has no pendant and a simplified panel for couch control located on the machine, there are inbuilt touch screens that display patient information and machine parameters. This made the machine functionality easy to understand for the trainees.
• Because learning the general use of the machine was quick, the team could spend more time on important aspects of the technician job such as patient position and image matching.
• The technicians had varying degrees of understanding how to calculate isocentre shifts and most did not perform isocentre shifts regularly, therefore the auto shift function for positioning patients greatly reduced risk of error and training time.
• One of the most challenging aspects of training was image matching for staff that had never matched images. Training started with 2D imaging working through to CBCT matching which was facilitated by the automatic match the Halcyon system preforms straight after the verification image is taken.
• There was a significant language barrier however the machine controls and workflow were easily taught and understood. This was especially apparent when contrasted with teaching other more complex systems such as Aria and Eclipse which took significantly more time to train the staff to a competent level
• Another aspect of training is teaching technicians the safety features of a machine. When compared to the C arm linac the fully enclosed Halcyon reduces the risk of collision as the couch is the only moving part controlled by technicians and the bore has a touch guard that ensures patient safety. Due to the bore design the training did not have to stress the need for dry-runs or clearance checks.
• As part of the training course for Chinese technicians we also introduced a paperless workflow, this was one of the harder initiatives undertaken. The Varian system helped to automate some of the tasks that would normally be performed by the RT pre-treatment such as calculating couch values, isocentre shifts and scheduling treatments and appointments.
• We have extended our training to staff for other sites on the Halcyon and this has helped to facilitate the experienced technicians’ transition into new paperless processes. The touch screens were a really important tool for showing the positives to a paperless workflow such as having the patient setup information and patient details on the screen.