Bridging worlds to create societal value: A global perspective on implementation of MR-Linac technology

Abstract

The 1.5 Tesla magnetic resonance (MR) imaging with a linear accelerator (Linac), MR-Linac, is being implemented worldwide. It enables online and real-time, soft-tissue imaging and targeted MRI-guided radiotherapy (MRgRT). This approach allows a higher delivered radiation dose to the target in fewer sessions, also called (ultra)hypofractionation, permitting a shorter overall treatment time. MRgRT has the potential to provide improved targeting of the tumor, increased effectiveness and better patient convenience. Despite theoretical promises, implementing MR-Linac into oncology care is accompanied by uncertainty and risks given the lack of solid evidence on (cost-)effectiveness and expensive technology investments. This thesis combined qualitative and quantitative methods to explore the implementation and early cost-effectiveness scenarios of the MR-Linac for the treatment of prostate cancer.

We explored opportunities and challenges in implementation of MRLinac in the Netherlands and the United States (US). In both countries, opportunities were: the acquirement of (1) advanced MRI-guided radiotherapy technology with (2) the possibility for improved patient outcomes and (3) economic benefits, as well as (4) professional development and (5) a higher hospital quality profile. Barriers in both countries were: (1) technical complexities, (2) large staffing and structural investments, (3) the current missing evidence regarding the clinical benefits, and the presence of (4) professional silos. There are also differences in MR-Linac implementation between the Netherlands and the US.

We also compared the two-country cases and explored how MR-Linac implementation affects the organization of healthcare. Implementation affects the organization of healthcare at the individual (e.g., increased collaboration between individual physicians such as the radiation oncologist and radiologist), organizational (e.g., increased collaboration between different expertise departments such as radiation oncology, radiology and ICT) and institutional levels (e.g., regulatory and policy environment). Findings show that institutionalisation of convergent innovation affects the organisation of health care by: changing the traditional organisation of solving a medical problem, thereby transforming and reorganizing work in the health care environment, providing opportunities for individual user development, collective action and crosssectoral developments, and requiring the additional work of evaluating convergent innovation, including administrative tasks, innovation and research activities.

Health economic evaluation is important to identify circumstances under which technology implementation could be cost-effective, thereby informing decision-making regarding the use of the new technology. Five- and two-fraction MRgRT are gaining interest for the treatment of prostate cancer. Therefore, we also explored different early costeffectiveness scenarios of MR-Linac for the treatment of low- and intermediate-risk prostate cancer in the Netherlands and the United Kingdom (UK). We identified the necessary decrease in number of complications in order for the MR-Linac to become costeffective compared to standard care and what the maximum costs may be.

Clinical research on effectiveness and cost-effectiveness in implementation is still important, but not enough to realize the potential of complex medical technologies. These technologies combine scientific disciplines, functions or tools in a single solution-oriented method with clinical, technical, economic, organizational and social synergies for disease management.