Bridging worlds to create societal value: A global perspective on implementation of MR-Linac technology
Authors:   , Hehakaya Charisma 
Published: May 2023

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.