Sites with lower patient volumes are more concerned about the cost of their operation since they have less revenue being collected. Sites that purchase pre-owned equipment tend to spend less not only on the equipment, but also maintenance contracts since they often choose to pay for time and material on an as-need basis, or they negotiate lower service contract pricing with secondary providers.

Apart from the MR-Linacs and PET-Linacs that have been developed in recent years, there have been few major enhancements to conventional linacs over the past decade, making it more difficult for treatment facilities to differentiate themselves based on technology alone. Some sites are choosing pre-owned equipment and using some of the funds saved to market their facility more generally and continually educate referring physicians at events such as wine and cheese evenins. In some markets, promoting IMRT and /or IGRT (e.g., with portal imaging) can be sufficient as a technology equalizer or differentiator. Once patients referrals have increased, and novel machines have established themselves in the market, a more advanced machine can be considered to replace the pre-owned equipment in future years.

In general, more economical solutions lower the financial risk of the business as it minimizes exposure to events such as reduced patient referrals, changes to reimbursement, competitive actions, etc.

In general, linear accelerator relocations are expensive and the process can incur additional costs to replace disrupted parts. It could be advantageous to purchase a pre-owned unit, increase patient referrals (e.g., general marketing and further education initiatives), and after a few years when it is time to relocate, make equipment decision based on:

• the patient volume at that time
• new equipment technology introduced to the market its demand
• any recent change to competitive activity

An empty vault can be an ideal revenue opportunity for pre-owned equipment and provide an advantage against a competitive site that has invested in new equipment and a bunker due to their corresponding high cost of capital and operation.

A backup machine can have several advantages. Firstly, the need for quick service response is reduced, allowing a more economical service solution to be implemented (i.e. like a “time and materials” option). In addition, as the patient referrals increase due to marketing initiatives, the backup machine can be put to work without requiring additional work shifts. Often, the return of investment of new equipment cannot be justified for a backup machine.

An immediate need for additional equipment may exist due to high treatment demand on existing equipment or patients that come to the facility for other services and also need radiation therapy treatment. There may also be a need for more advanced treatments such as IGRT and/or VMAT). The investment risk is far less with pre-owned equipment and the lower cost allows time to make adjustments (i.e., further grow the referrals) according to the full operational expense. As the business grows and next generation technology is adopted and demanded by the market, in the future the facility will be better prepared to decide on further investment in more advanced equipment.

Any purchase should be considered in terms of the immediate, mid and long-term objectives of the organization. Whether it be a first linac or an additional linac, it may have a low volume of patients initially, and could take time to build up the referrals. Since there has not been any major change in treatment capabilities of conventional linacs over the last 10 years, a pre-owned machine may make sense at this time to meet the immediate demand while saving funds for a future generation machine once it is defined and established in the market.

It is important to understand the dynamics of the local market and demographics, and how they may change over time. Different markets value and respond differently to technology. Sites with older equipment may purchase newer units with the hope they will not lose referrals to other sites with newer equipment. Often, a site with older equipment but good marketing and education/communication to the referring physicians can be far more profitable than a site with new equipment and the associated higher costs.