Commissioning of Medical Linear Accelerators in India: A Survey of Regulatory Compliance, Clinical Implementation, and Professional Challenges.

PURPOSE: This study evaluated current clinical practices, regulatory compliance, and professional challenges encountered during the commissioning of advanced Linear Accelerators (LINACs) in India.

MATERIALS AND

METHODS

A nationwide survey using a structured 20-item questionnaire was conducted from August 2025 to March 2026. The questionnaire covered commissioning practices, staffing and vendor support, quality assurance (QA) procedures, clinical implementation, and participant opinions and suggestions. Responses were analyzed to assess trends in technology adoption and variations in commissioning workflows.

RESULTS

Data were obtained for 75 LINACs commissioned between 2020 and 2025 across 67 institutions. Frequently commissioned systems included Varian TrueBeam (37.3%), Varian Halcyon (18.7%), and Elekta Versa HD (16%). Advanced treatment techniques such as Volumetric Modulated Arc Therapy (VMAT), Stereotactic Radio Surgery (SRS), and Stereotactic Body Radiotherapy (SBRT) were commonly implemented; however, Total Skin Electron Therapy (TSET) and Total Body Irradiation (TBI) commissioning remained limited. More than one-fourth of the participants (26.7%) had no prior experience in LINAC commissioning. 87.8% participants considered the existing Atomic Energy Regulatory Board's QA requirements adequate, 89.3% supported mandatory inclusion of Treatment Planning System QA within the licensing process. Small-field dosimetry following International Atomic Energy Agency (IAEA) TRS-483 guidelines was performed by 60.8% of centers, while 77.3% had not participated in external dosimetric audits. Major challenges included workforce shortages and balancing commissioning with routine clinical responsibilities. Independent peer review before clinical implementation was recommended by 81.3% of respondents.

CONCLUSION

Advanced LINAC technologies are being successfully adopted in India; however, greater standardization, structured training, external audit participation, and independent verification frameworks are required to strengthen commissioning quality and patient safety across radiotherapy centers nationwide.