Practice Guideline

SASQART: South African standards for quality assurance in radiotherapy

Hein Fourie, Thendo Alidzulwi, Willem P.E. Boonzaier, Didier Duprez, Jonathan Haynes, Sonwabile Ngcezu, Brendon Smith, Lourens J. Strauss, Demaré Wahl, Christoph J. Trauernicht

Received: 10 Mar. 2025; Accepted: 11 Mar. 2025; Published: 31 May 2025

Copyright: © 2025. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The SASQART practice guidelines were set forth by the South African Medical Physics Society & South African Association of Physicists in Medicine and Biology. The intended purpose of this document and the individual topic-specific sections is to provide guidelines as to a minimum set of tests, result tolerances and a minimum frequency of these tests to be performed by medical physicists and radiation therapy staff in a radiation oncology department to promote patient safety. The tests, tolerances and frequencies from the international references have been adapted to realistically reflect the South African working environment and resource availability, while maintaining the highest clinical and scientific quality of care achievable.

Contribution: Replaces the 2014 guidelines, establishing recommended quality assurance standards for radiation oncology in South Africa.

Keywords: SASQART; radiotherapy; quality assurance; Linac; dosimetry; radiation protection.

Introduction

In November 2021, a task group was appointed by the South African Medical Physics Society (SAMPS), a member society of the South African Association of Physicists in Medicine and Biology (SAAPMB). This task team was chosen to be representative of multiple provinces in the country, private, academic and public radiotherapy facilities, and to incorporate medical physicists with different areas of expertise. The task group was given a mandate to produce a document that was intended to update or replace the existing 2014 SASQART guidelines that are referred to in the South African Health Products Regulatory Authority (SAHPRA) license conditions for medical radiotherapy devices. The document was intended to cover all forms of quality assurance (QA) to be performed in a clinical Radiation Oncology Department at the time of the formation of the task group.

The intended purpose of this document and the individual topic-specific sections is to provide guidelines as to a minimum set of tests and tolerances, and a minimum frequency of these tests to be performed by medical physicists and radiation therapy staff in radiotherapy to promote patient safety. The tests and test frequencies were adapted based on both local experience and additional international guidelines, such as those from Canadian Association of Provincial Cancer Agencies (CAPCA), American Association of Physicists in Medicine (AAPM), International Atomic Energy Agency (IAEA), Institute of Physics and Engineering in Medicine (IPEM) and Netherlands Commission on Radiation Dosimetry (NCS). The CAPCA gave permission for us to use their Standards for Quality Control as a basis for the original 2014 SASQART documents. The assistance and information sharing of CAPCA is appreciated but they are not in any way responsible for the final SASQART documentation. The test frequencies from the international references have been adapted to realistically reflect the South African working environment, while ensuring patient safety. There was a long process of consultation between task team members, and the comments from the South African medical physics community were incorporated after the first round of edits in 2023. The final documents have been agreed upon by all task team members as recommendations to be proposed to SAMPS.

These tests and their frequency are unique to the environment of radiotherapy and should not be applied where the same equipment is used in other disciplines. For example, the tests for a computed tomography (CT) scanner are limited to the requirements for imaging for radiotherapy and do not cover the more rigorous demands of a CT scanner used in diagnostic radiology.

This document is only to be used as a guideline and not as a legally binding document for licensing conditions. If any clinic can show that their equipment shows historical stability beyond the frequency of testing suggested, then the professionalism of the medical physicist should allow for a reduction in the test frequency. In contrast, where equipment is known to have inherent instability below ‘normal’ standards, the medical physicist should perform tests at shorter intervals than suggested in this document.

The Radiation Protection document has been specifically designed for implementation by the Department of Health and SAHPRA to ensure radiation safety.

The techniques employed to establish the compliance of a particular test to the tolerances suggested in this document remain totally within the preference of the medical physicist, who should be able to explain the methodology adequately. It is beyond the scope of this document to prescribe experimental techniques and vendor-specific equipment. This should be left to the professional judgement of the physicist at each clinic. If tolerance cannot be reached because of economic, vendor, mechanical or electronic constraints, there should be documentation to show how the clinical procedures are adapted to accommodate these anomalies, without impacting upon patient safety. These tests should be conducted by a qualified medical physicist or radiotherapy personnel trained by a qualified medical physicist. Any test exceeding tolerance should be reported to a qualified medical physicist to determine the course of action.

The format of this document specifies tests which need to be performed within certain time periods. These time periods are depicted in Table 1.

The tests performed during commissioning may be repeated during the routine quality control intervals. For quantities that can be measured, the ‘performance’ of a test is compared to an action and tolerance level. If the difference between the measured and expected value is at or below the tolerance level, no action is required. If the difference is larger than the ‘action’ level, immediate action is required. If this is not immediately possible, the use of the system must be restricted to clinical situations in which the identified inadequate performance is of no, or acceptable and understood, clinical significance.

Hein Fourie

Chair: SASQART Task Group

Christoph Trauernicht

Chairperson: SAMPS

Cobalt-60 teletherapy units

Kilovoltage x-ray radiotherapy machines and Intra-Operative Radiotherapy

CT scanners and CT-simulators

Dosimetry equipment

Devices for absolute dosimetry

Devices for relative dosimetry

Quality assurance devices

Brachytherapy remote afterloaders

Megavoltage electronic portal imaging devices

Image guided radiotherapy

Intensity modulated radiotherapy and Volumetric modulated arc therapy

Medical linear accelerators

Multileaf collimators

Radiation protection

Therapeutic radioisotope administration

Record and verify systems

Conventional radiotherapy simulators

Stereotactic radiosurgery/radiotherapy – Gamma knife based

Stereotactic radiosurgery/radiotherapy – Linac based

Treatment planning systems

Treatment planning system auxiliary equipment

Bore based medical linear accelerators (such as halcyon, tomotherapy and MRI-linacs)

Acknowledgements

The SASQART task group would like to acknowledge and thank the following persons who authored the original 2014 SASQART guideline documents: Emma Viviers, Graeme Lazarus, Nanette Willemse Joubert, Freek du Plessis and Hannelie MacGregor.

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. The author, C.J.T., serves as an editorial board member of this journal. The peer review process for this submission was handled independently, and the author had no involvement in the editorial decision-making process for this manuscript. The authors have no other competing interests to declare.

All authors contributed equally to the writing, review and editing of the initial draft(s). H.F. and C.J.T. were lead contributors to the final review and editing, and project administration.

This article followed all ethical standards for research without direct contact with human or animal subjects.

The article processing fee was generously covered by the South African Association for Physicist in Medicine and Biology.

Data sharing is not applicable to this article as no new data were created or analysed in this study.

The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

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