Medical physics aspects of cancer care in the Asia Pacific region
1 Physical Sciences, Peter MacCallum Cancer
Centre, and RMIT University, Melbourne, Australia
2 Department of Clinical Oncology, Prince of
Wales Hospital, Hong Kong, China
3 Cancer Institute (Hospital), Chinese Academy of Medical Sciences, China
4 Department of Radiation Oncology, Christian Medical College, Vellore, India
5 Physics Department, University of Indonesia, Jakarta, Indonesia
6 Dept of Radiology & Medical Engineering, Kansai University of International Studies, Hyogo, Japan.
7 Department of Radiation Oncology, Chonnam National University Hospital, Republic of Korea
8 Radiotherapy Department, National Cancer Center, Ulaanbaatar, Mongolia
9 B.P.Koirala Memorial Cancer Hospital,
Bharatpur, Chitwan, Nepal
10Department of Radiation Oncology, Jose R. Reyes Memorial Medical Center, Manila, Philippines
11 Department of Therapeutic Radiology, National
Cancer Centre, Singapore.
12 Division of Medical Physics, National Cancer
Institute, Sri Lanka
13 Department of Medical Imaging and
Radiological Sciences, Chang Gung University, Taiwan
14 Department of Radiology, Faculty of Medicine,
Chulalongkorn University, Bangkok, Thailand
15 K Hospital, National Cancer Institute, Hanoi, Vietnam
16 Department of Biomedical Imaging, University
of Malaya, and Medical Physics Unit, University of Malaya Medical Centre, Kuala
Ad-hoc working group on Medical Physics in the Asia Pacific Region. Except for the organizers and the sponsor of the survey the members
are listed in alphabetical order of contributing countries.
Medical physics plays an essential role in modern
medicine. This is particularly evident in cancer care where medical physicists
are involved in radiotherapy treatment planning and quality assurance as well
as in imaging and radiation protection. Due to the large variety of tasks and
interests, medical physics is often subdivided into specialties such as
radiology, nuclear medicine and radiation oncology medical physics. However, even
within their specialty, the role of radiation oncology medical physicists
(ROMPs) is diverse and varies between different societies. Therefore, a
questionnaire was sent to leading medical physicists in most countries/areas in
the Asia/Pacific region to determine the education, role and status of medical
Answers were received from 17 countries/areas representing
nearly 2800 radiation oncology medical physicists. There was general agreement
that medical physicists should have both academic (typically at MSc level) and
clinical (typically at least 2 years) training. ROMPs spent most of their time
working in radiotherapy treatment planning (average 17 hours per week); however
radiation protection and engineering tasks were also common. Typically, only
physicists in large centres are involved in research and teaching. Most
respondents thought that the workload of physicists was high, with more than
500 patients per year per physicist, less than one ROMP per two oncologists being
the norm, and on average, one megavoltage treatment unit per medical physicist.
There was also a clear indication of increased complexity
of technology in the region with many countries/areas reporting to have
installed helical tomotherapy, IMRT (Intensity Modulated Radiation Therapy),
IGRT (Image Guided Radiation Therapy), Gamma-knife and Cyber-knife units. This
and the continued workload from brachytherapy will require growing expertise
and numbers in the medical physics workforce. Addressing these needs will be an
important challenge for the future. � 2008 Biomedical Imaging and
Intervention Journal. All rights reserved.
Keywords: Medical physics; education
Medical Physics is an applied branch of physics which is
concerned with the applications of physics concepts and methods to the
diagnosis and treatment of human disease (compare, for example: http://www.aapm.org/medical_physicist/default.asp).
As this is a vast field, it is common to divide medical physics into
subspecialty areas such as radiology, nuclear medicine and radiation oncology
medical physics. In radiation oncology, medical physicists are accepted as
important members of the team delivering radiation therapy. They work with
oncologists, radiation therapists (also referred to as RTTs, technologists or
therapy radiographers), nurses and engineers to provide quality care for cancer
patients. In addition to this, they provide services to other medical
professions such as radiologists and nuclear medicine specialists, whose input
into cancer care is essential.
The Asia-Oceania Federation of Organizations for Medical
Physics (AFOMP) was founded in 2000 to promote medical physics in the Asia and Oceania region and the advancement in status and standard of practice of the medical
physics profession (http://www.afomp.org/). It states that:
�A qualified Medical Physicist is a person who possesses a
university degree of at least a master level or equivalent in physical science
or engineering science and works in alliance with medical staff in hospitals,
universities or research institutes. He/she shall also have received clinical
training in the concepts and techniques of applying physics in medicine,
including training in the medical application of both ionizing and non-ionizing
radiation. This person shall have a thorough knowledge and be able to practice
independently in one or more sub-fields of medical physics, including imaging
physics, radiation therapy physics, nuclear medicine physics and radiation
This definition is similar to many others that have been
proposed by organisations all around the world such as the European Federation
of Organisations for Medical Physics (EFOMP � http://www.efomp.org/)  or the
American Association of Physicists in Medicine (AAPM � www.aapm.org). For
example, the International Atomic Energy Agency (IAEA) specified recently in
its TecDoc 1296 that:
�Medical physicists practicing in radiotherapy (or
radiation oncology) must be qualified as physicists with academic studies in
medical physics (typically at postgraduate level) and clinical training in
radiotherapy physics. Medical physicists specialized in radiotherapy physics
will be referred to as clinically qualified radiotherapy physicists.� 
The important points common to all these definitions are
that physicists working in a radiation oncology department have both an
academic education and clinical training. However, anecdotal evidence shows
that there is a wide variety of standards and requirements for medical
It is therefore timely to explore how medical physics is
practised in the different countries/areas of the Asia Oceania region. It is
the aim of the present article to
- Provide general information on the tasks undertaken by medical
physicists in the region
- Document what education and practical experience is required to become a
- Explore resources, status and job satisfaction of medical physicists
While this would apply similarly to nuclear medicine and
radiology, the present work focuses on radiotherapy and radiation oncology
medical physicists (ROMPs).
A simple questionnaire was designed to determine education
levels, work patterns and status of medical physics in radiation oncology. The
questionnaire was sent to 20 eminent physicists in the region who have been
active in the field for several years. Many of them have represented their
medical physics organizations at AFOMP, the International Organization of
Medical Physics (IOMP) and IAEA and, as such, were considered to be familiar
with the state of medical physics in their respective countries.
The questionnaire was distributed in English and covered
the following fields:
- What is the typical education level for physicists working in radiation
- Are these levels or similar education opportunities available in your
- What type of opportunities are there for medical physicists to
participate in continuing professional development (CPD)?
- What is the total number of radiotherapy physicists in your country?
- What is the number of megavoltage external beam radiotherapy units in
your country? (Please list Cobalt and linear accelerators separately)
- What is the ratio of ROMPs relative to the number of oncologists?
- What is the ratio of ROMPs relative to the number of patients treated
C. Typical time spent on specified tasks for ROMPs (hours per week)?
D. Professional organisations
- Name of your local professional organisation(s)
- How many members does this organisation have?
- Are ROMPs members of other professional organisations in your country?
(examples: radiation oncologists, radiology)
- Are ROMPs members of overseas professional medical physics
organisations? (examples: IPEM, AAPM)
E. What resources are typically available for ROMP work in your country?
- Dosimetry and QA equipment
- Are reference literature and books available?
- Do ROMPs have generally access to the Internet?
- Are discussions with senior colleagues possible?
F. Research and teaching
- Are ROMPs participating in research activities?
- Are ROMPs participating in clinical trials?
- Are ROMPs participating in teaching?
G. Overall satisfaction in the areas of professional recognition,
remuneration and workload.
In addition to this questionnaire, participants were
invited to provide as many free form comments as necessary. The original time
frame for answering the questions was 2 weeks; however, responses given after a
longer period were accepted. They reflect the status of March/April 2008. On
some occasions, additional details were elicited and provided in communication
Answers were received from 17 countries/areas representing
more than 2800 radiation oncology medical physicists. This constitutes a
response rate of 80%. Many of the answers were received within a few days of
sending out the questionnaire. Tables 1 to 5 show the results.
About half of the respondents provided additional
information in free form (up to several pages). This information was included
in the tables wherever possible. This has resulted in some columns that list
data not explicitly covered in the questionnaire (eg brachytherapy and other
treatment units). The information in these areas must be seen as preliminary
The fast and comprehensive reply of respondents in most
countries/areas illustrates the importance ROMPs place on documentation of
their practice and collaboration within the Asia Oceania region.
Education and training
All respondents agreed on the need for academic education
and clinical training. This is very much in line with the definitions of
medical physics listed in the introduction and the thinking in North America (http://www.aapm.org)
and Europe (http://www.estro.be and http://www.efomp.org/ ) . It is
interesting to see in table 1 that most respondents see the need for a higher
degree as an entry requirement for the profession. Without doubt, this reflects
the increasing complexity of the field. Most medical physics programs
throughout the world are postgraduate programs that provide specialist
knowledge on top of basic skills in physical sciences and mathematics (compare
eg http://www.campep.org/ or http://www-naweb.iaea.org/nahu/dmrp/syllabus.shtm).
Access to relevant courses and university training appears to be available in
most countries/areas in the region.
More complicated is the issue of clinical training. Again,
virtually all respondents agreed that clinical training should be required prior
to being able to practise radiation oncology medical physics. The typical time
period required for this varied between 1 and 3 years. However, while a
structured clinical training program is deemed to be essential, it is only
available in a few countries/areas. One can speculate about the reasons;
however, low staff number and high workload of experienced clinical physicists
appear to be contributing factors that make it difficult for practising ROMPs
to dedicate time for teaching and research. As the questionnaire shows,
teaching and research is often only part of the job description for physicists
in large academic centres. It also needs to be noted that a lot of the teaching
hours listed in table 3 are directed to other professions such as doctors in
In any case, the desired education for ROMPs will require
between six and eight years after finishing secondary school � a significant
time commitment that may not be reflected in salaries and status in all cases.
Given the rapid advances and changes in technology and the
need to work with potentially hazardous equipment, continuing professional
education appears to be essential. It is difficult to compare the answers in
table 1 � however, it is clear that there is no uniform access to relevant
education within the region. A more specific questionnaire would be required to
determine more precisely the perceived needs and available training and
educational offerings. As most medical physicists reported good access to the Internet
(table 4), there is an opportunity to provide online resources for continuing
professional development (CPD).
It is also important to note that CPD is an integral part
of certification of professionals . As professional responsibility increases
and societies expect high professional standards, certification of ROMPs will
become necessary in all countries/areas. Access to adequate education, clinical
training and CPD are essential for this to happen.
Resources and staffing
The percentage of cancer patients who have access to
radiotherapy services varies widely throughout the world as illustrated
recently for South America . The number of megavoltage treatment units also
varies significantly amongst countries/areas in the region, as can be seen in
table 2. Interestingly the number of ROMPs per machine and per oncologist is
fairly uniform in all countries/areas. This illustrates that employers and
health systems see physicists as a support person for other staff and equipment
rather than as a direct contributor to patient treatment. As such, it is not
surprising that the number of patients per physicist varies more significantly
(250 to 800) than the number of physicists per machine. Given the fact that
physics tasks are increasingly linked to the number of patients treated (eg
treatment planning, patient specific QA) this may further disadvantage
physicists in countries/areas with few megavoltage machines.
It is encouraging to see that most countries/areas have a
professional association that represents medical physicists. This provides an
important framework that can be used for promotion of medical physics issues
and patient safety, as well as education and sharing of resources.
Typical tasks and workload for ROMPs
Apart from Australia and New Zealand, physicists in other
countries/areas spent most of their time on radiotherapy treatment planning.
This is a significant responsibility that combines optimisation of treatment
approaches for individual patients with developing planning methods and
commissioning of treatment planning systems [6,7]. The emphasis on treatment
planning reflects a patient and service focus in the employment of most medical
physicists. Unfortunately, the workload and service focus result in only a few
medical physicists being actively involved in teaching and research. Both
activities have the potential to enhance job satisfaction and profile of staff
� more importantly, they would contribute to the much-needed clinical training
required to ensure adequate supply of qualified ROMPs in the future.
There is no doubt that, due to increasing awareness of
radiation safety and accident prevention [8-10], the responsibility of
physicists is increasing. ROMPs in all countries/areas spent at least part of
their time in radiation protection. However, it is the advances in technology
and the introduction of computing and imaging in radiotherapy, that makes the
role of physicists more and more important. All these advances make quality
assurance and accurate dosimetry increasingly important. However, it is
interesting to note that while dosimetric protocols have improved and
simplified [11,12], most protocols for quality assurance do not yet include
guidance for advanced technology [13,14]. This demonstrates the need for
independent critical thinking and a high level of professional competence for
medical physicists in order to develop procedures appropriate for their
Medical physicists typically have expertise in many
different areas such as radiation dosimetry, radiation protection and medical
imaging. Maybe not surprisingly, Weibo Yin reported recently that the largest
percentage growth of staff numbers in radiation oncology in mainland China from 1997 to 2006 was in medical physics . Given the fact that diagnostic procedures
are increasingly important in detecting and outlining cancer, the role of
medical physicists in imaging will increase.
Not listed in the tables is the involvement of medical
physicists in clinical trials. In several countries/areas this was noted with a
typical time allocation of a few hours. It appears that clinical trials will
continue to be essential in defining best clinical practice and there is a
trend to extend this to more countries/areas . It can be expected that
medical physics involvement in these trials for quality assurance and resource
allocation is also likely to continue to grow in the future.
Status and job satisfaction
Most respondents felt that medical physicists have
reasonable professional recognition. More significantly, several of those who
responded indicated an improvement in professional recognition and status over
time. This is no doubt related to the more visible need for scientific support
for complex treatment using sophisticated equipment. Remuneration was found to
vary largely between countries/areas and even within some countries such as India. However, at least in academic and private institutions, there appears to be an
acceptable level of salaries. It may be of concern that in times of staff
shortages these centres will attract most of the qualified staff while smaller
public centres with a focus on service provision may find it hard to attract
and maintain staff.
It is also interesting to note that many of the
respondents stated that ROMPs, in general, work long hours. From the data it is
impossible to tell if this is adequately remunerated � however, it is clear
that there are not enough trained medical physicists to perform the increasing
number of tasks. This is not confined to the region but appears to be a
worldwide phenomenon .
Limitations of the study
The present work has several limitations. They pertain to
the need to use a relatively brief questionnaire with many important omissions,
such as brachytherapy or the details on quality assurance and the way
physicists interact with colleagues. This is an aspect that will be addressed
in future surveys. Another significant problem is the impossibility of
characterising widely varying practices and employment conditions in many
countries/areas with a single answer. When salaries, eg in India, vary by more than a factor of 10 between different employers, it is difficult to
derive a single number, eg for job satisfaction.
The manuscript provides only a snapshot of conditions for
ROMPs in most countries/areas in the Asia/Pacific Region. The time frame for
participants to respond to the questionnaire did not allow them to perform
detailed research. Some countries/areas had data readily available due to other
recent activities [15,18]. However, in others, the results reflect a considered
judgement of the participant.
The manuscript is based on a simple questionnaire that is only
aimed at determining the broad picture. There may be bias in the selection of
the participants and others may have provided answers with different emphasis.
In addition to this, the questionnaire was only distributed in English which
could result in differences in interpretation as English is not the first (or
even the second) language in many participating countries/areas.
Given the variability of the situation of ROMPs throughout
the region it is surprising how similar many of the answers were. This
illustrates that medical physicists share a common work environment and face
similar challenges independent of the country they are working in. This forms
the foundation for effective communication in larger organisations such as
AFOMP. However, significant differences in resources remain and it will make
sense to pool information and resources wherever possible. Organisations such
as AFOMP have an important role to play by defining professional
responsibilities, and educational standards. An even more important role is to
bring physicists together by organising conferences and workshops. Given the
fact that many physicists work in small centres in isolation, this is essential
for safe and effective use of equipment for cancer treatment. Finally, journals
such as biij are essential in disseminating information � more so as it is an
�The present survey provides only a snapshot in time. It
will be essential to repeat this type of regional study to map trends in
medical physics employment and provide longitudinal data essential for long-term
planning of workforce and training development for medical physicists in the
The authors would like to thank Dr Ian Donald McLean from
the International Atomic Energy Agency for valuable comments and suggestions
and express their gratitude to all colleagues who have contributed to the
questionnaire. We would like to mention particularly Mr. An-Cheng Shiau, Mr.
Chien-yi Yeh, Dir. Agnette Peralta, PORI (Indonesian Radiation Oncologists
Society), Dr S D Sharma and Mr Vincent Ung (in alphabetical order). Finally, we
also acknowledge the support of all the medical physics association listed at
the end of the manuscript.
Table 1 Education, training and continued professional development (CPD) of medical physicists
Table 2 Equipment, staffing and resources � abbreviations: CK = cyberknife, GK = gammaknife, HT = helical tomotherapy, P = proton (and heavy ion) radiotherapy, SRS = stereotactic radiosurgery, MT = microtron
Table 3 Typical work patterns
Table 4 Professional organisations and professional resources available
Table 5 Satisfaction on a scale of 1 (worst) to 5 (best) - ) � please note that the satisfactory ratings are independently estimated by the individual authors without making reference to or comparison with other countries� norms. The ratings indicated by the authors are estimated based on different standards or norms and therefore have no correlations.
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|Received 16 June 2008; accepted 17 June 2008
Correspondence: Peter MacCallum Cancer Institute, Locked Bag 1, A�Beckett St., Melbourne, VIC8006, Australia. E-mail: firstname.lastname@example.org (Tomas Kron).
Please cite as: Kron T, Cheung KY, Dai J, Ravindran P, Soejoko D, Inamura K, Song JY, Bold L, Srivastava R, Rodriguez L, Wong TJ, Kumara A, Lee CC, Krisanachinda A, Nguyen XC, Ng KH,
Medical physics aspects of cancer care in the Asia Pacific region, Biomed Imaging Interv J 2008; 4(3):e33