Implementing Image-Guided Radiotherapy for Pediatric Cancer in Bangladesh: A Medical Physicist’s Perspective on Practical Strategies, Policy Needs, and Quality Assurance

Pediatric cancer represents a growing global health concern, with the burden falling disproportionately on low- and middle-income countries (LMICs), where access to timely diagnosis and effective treatment remains limited. In Bangladesh, recent estimates suggest that between 4200 and 8000 children are newly diagnosed with cancer each year, with leukemia and central nervous system (CNS) tumors being the most prevalent. However, late-stage presentation, limited healthcare infrastructure, and high out-of-pocket treatment costs contribute to alarmingly low survival rates, far below those observed in high-income countries. Radiotherapy is a cornerstone in the multidisciplinary management of pediatric cancers. Among recent advancements, image-guided radiotherapy (IGRT) has emerged as a critical technology, enabling real-time imaging and precise radiation delivery, thereby minimizing damage to adjacent healthy tissues, which is an especially important consideration for the growing and sensitive anatomy of pediatric patients. Despite its proven efficacy, IGRT remains underutilized in Bangladesh due to systemic challenges, including a lack of modern radiotherapy equipment, shortages of trained medical physicists, and the absence of standardized pediatric-specific treatment protocols. This paper addresses the urgent need for IGRT integration within the pediatric oncology landscape of Bangladesh, drawing on the pivotal role of medical physicists. It presents a set of practical, context-specific strategies for implementing IGRT and motion management techniques in resource-constrained settings. Emphasis is placed on optimizing existing linear accelerator infrastructure, adopting hybrid imaging workflows, and building capacity through targeted training and collaboration. Additionally, the study offers policy-level recommendations aimed at fostering sustainable investment, developing national clinical guidelines, and ensuring equitable access to advanced radiotherapy services for pediatric patients. By combining technical insight with health systems thinking, this work seeks to support the advancement of evidence-based, precision-driven pediatric cancer care in Bangladesh and other similar LMIC contexts.