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Radiotherapy in Low- and Middle-income Countries. What Can We Do Differently?
Clinical Oncology xxx (2016) 1e3 Contents lists available at ScienceDirect
Clinical Oncology journal homepage: www.clinicaloncologyonline.net
Editorial
Radiotherapy in Low- and Middle-income Countries. What Can We Do Differently? M.B. Barton *, E. Zubizarreta y, M. Gospodarowicz z * Collaboration
for Cancer Outcomes Research and Evaluation, Ingham Institute for Applied Medical Research, UNSW Australia, Liverpool, NSW, Australia y Applied Radiation Biology and Radiotherapy Section, Division of Human Health e Department of Nuclear Sciences and Applications, International Atomic Energy Agency, PO Box 100, 1400 Vienna, Austria z Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada Received 9 September 2016; accepted 15 September 2016
We know that cancer is already a major problem in lowand middle-income countries (LMIC). These are countries with an annual gross national income per person of US$12 476 or less [1]. It is estimated that in 2012 there were 8 million cancers cases in less-developed countries and by 2035 there will be 14.7 million cases of cancer in LMIC [2], an increase of over 80%. Radiotherapy is an essential part of effective cancer treatment and it is impossible to offer comprehensive cancer care without it. We estimate that about 6.5 million new cases of cancer in LMIC would benefit from radiotherapy at least once in the course of their illness [3]. The population benefit of radiotherapy is greatest in LMIC [4], where the access to radiotherapy is the lowest [3]. Although the number of megavoltage machines has increased over the last decade in high-income countries, the gap between demand and supply in LMIC has widened and there remains a deficit of more than 7000 machines worldwide [3]. Demand for radiotherapy will increase by nearly 80% over the next 20 years. Modelling of the benefits of investing in radiotherapy shows that 27 million lives in LMIC could be saved between 2015 and 2035 if access to radiotherapy was scaled up to meet demand. The net economic benefit would be US$278 billion from productivity gains [5]. In 36 countries there was no radiotherapy service at all. In these countries alone we estimated that 120 000 patients a year would benefit from radiotherapy but could not access it [3]. This is not new information and there has been a long
Author for correspondence: M.B. Barton, Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute for Applied Medical Research, UNSW Australia, Liverpool, NSW, Australia. E-mail address: [email protected] (M.B. Barton).
history of developing radiotherapy services in LMIC with a mixed track record of success. The International Atomic Energy Agency (IAEA) has been at the forefront of delivering aid in LMIC. They have built new departments and established education programmes and training networks. IAEA recognises that radiotherapy will only be appropriate when it is part of a comprehensive cancer control programme. Since 2005, the IAEA’s Program of Action for Cancer Treatment (PACT) has undertaken 81 imPACT reviews to provide recommendations to strengthen national cancer control capacity [6]. Programmes in Ghana started with a single department in Accra, which served as a nucleus for development and training. New departments have now been established elsewhere in the country with locally trained staff. Zambia is another success story. The Cancer Diseases Hospital opened in 2007 with a basic radiotherapy department including one linear accelerator, one cobalt machine, one high dose rate afterloader, an orthovoltage machine and conventional simulation. They added later a second cobalt machine, a second high dose rate afterloader, computed tomography simulator, magnetic resonance imaging, a training centre and a 160 bed inpatient facility. They began training programmes for radiation therapists and clinical oncologists and will establish satellite centres outside Lusaka. The establishment of the Cancer Diseases Hospital, including a training programme for radiation therapists and clinical oncologists, is a model of successful collaboration between the Government of Zambia, OPEC Fund for International Development and the IAEA. In countries such as Uganda and Papua New Guinea equipment costs and access to staff have resulted in prolonged interruptions to established services. The sole cobalt machine in Lae, Papua New Guinea was decommissioned in
http://dx.doi.org/10.1016/j.clon.2016.11.009 0936-6555/Ó 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Barton MB, et al., Radiotherapy in Low- and Middle-income Countries. What Can We Do Differently? Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.11.009
2
M.B. Barton et al. / Clinical Oncology xxx (2016) 1e3
the late 1990s because of mechanical safety concerns and not replaced for over 10 years [7]. Recruiting a radiation oncologist from overseas resulted in further delays. The service remains precarious because it relies on a single oncologist and there is no national training programme. In Uganda, the only radiotherapy machine broke ‘beyond repair’ in April 2016. Until it is replaced patients will have to travel to Kenya for radiotherapy if they can afford it [8]. However, the assistance offered has not been sufficient to reverse the trend of woefully inadequate access to radiotherapy globally. Although all the efforts are well intended, a major shift in approach is needed if we are to expect meaningful improvement. Having shown the need and the ability to implement and operate safe and effective radiotherapy programmes in most environments, serious investment is needed by the health care systems to reverse the trend. Investing in at least one comprehensive cancer centre with radiotherapy services and expecting this centre to train local experts is a starting point. We need to think and act differently if the global community is going to make any headway in meeting the huge demand for radiotherapy services in LMIC. New approaches need to be considered for radiotherapy. Attention to securing sufficient financing, optimisation of the scope of services, staff training, quality assurance, patients’ aid and assistance is required. In addition, needs such as roads, stable power supply and basic facility services are important. Furthermore, diagnostic services such as imaging and pathology, treatment modalities including surgery and chemotherapy are important to optimise the impact of radiotherapy. Basic understanding of the role of radiotherapy among referring physicians is also needed. Geographic distribution of services is important to secure access. The traditional stand-alone radiotherapy department with minimum two machines is not always feasible or economical. Single-machine departments with local or off-site planning have been trialled in high-income countries [9]. Populations with fewer than 500 new radiotherapy cases per year may be better served by contracting radiotherapy services in a nearby country. However, it is important to close the gaps in access to radiotherapy in populations with a high number of cancer patients first. Many countries rely on government support to purchase and maintain radiotherapy equipment and pay for staff. This works best where there are national health insurance schemes. Privateepublic partnerships or government financing supported by philanthropy are other possibilities. Financing new departments should include the maintenance and replacement costs. In Australia, the Health Program Grant scheme provides an activity-based payment that is quarantined for equipment replacement [10]. In many countries there are critical shortages of qualified cancer specialists. It would be expedient for radiation oncologists to be qualified to deliver chemotherapy as well as radiotherapy and to have a broader role in advocating for cancer control. Training should not only include opportunities in high-income countries but also southesouth collaborations such as VUCCnet that aim to provide training
that is appropriate to the local cancer case mix and available equipment [11]. To secure confidence in radiotherapy, safe treatment delivery is paramount. Physicists are crucial for quality assurance and equipment maintenance. However, in many countries medical physicists are not recognised as a health profession and therefore not supported. The global shortage of physicists is exacerbated by brain drain to high-income countries where the profession is supported. Current technologies offer prospects of remote monitoring and quality assurance offering access to expertise and may prove an effective alternative to employing staff on site. Other innovations in technology are needed. The fundamental design of the megavoltage machine has not changed in 50 years. A source mounted on a rotating gantry requires extensive primary shielding to cover the exit path. Quality assurance must be carried out on beam performance at multiple angles. Gantry integrity can fail as it did for the sole cobalt machine in Papua New Guinea. New designs such as the Nano-X [12] that use a fixed source and turn the patient could reduce equipment, building and maintenance costs. There is a plethora of agencies, non-government organisations, charities, professional organisations, expatriate groups and charitable organisations interested in cancer services in LMIC but there is no coordination of activity. Many organisations offer help and most act in isolation. Global coordination is needed for the wide range of volunteer and charity activities. An LMIC may engage with two or more organisations on the same subject without informing either of the other’s involvement. Countries with large expatriate populations are more likely to host activities as private initiatives that may not align with national priorities or be sustainable without government engagement. A global approach to coordinate strategy for engaging a volunteer workforce would maximise the gains and optimise the use of resources and share learnings.
References [1] New country classifications by income level. Available at: http:// blogs.worldbank.org/opendata/new-country-classifications2016; 2016 (accessed 7 September 2016). [2] Ferlay J, Soerjomataram I, Ervik M, et al. GLOBOCAN 2012 v1. 0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. Lyon: International Agency for Research on Cancer. Available at: http://globocan.iarc.fr; 2013. [3] Yap ML, Zubizarreta E, Bray F, Ferlay J, Barton M. Global access to radiotherapy services: have we made progress during the past decade? J Global Oncol 2016;2(4):207e215. [4] Yap ML, Hanna TP, Shafiq J, et al. The benefits of providing external beam radiotherapy in low- and middle-income countries. Clin Oncol. [5] Atun R, Jaffray DA, Barton MB, et al. Expanding global access to radiotherapy. Lancet Oncol 2015;16(10):1153e1186. [6] imPACT Review. Available at: http://cancer.iaea.org/impact. asp; 2016 (accessed 7 September 2016). [7] Barton MB, Frommer M, Shafiq J. The role of radiotherapy in cancer control in low- and middle-income countries. Lancet Oncol 2006;7(7):584e595.
Please cite this article in press as: Barton MB, et al., Radiotherapy in Low- and Middle-income Countries. What Can We Do Differently? Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.11.009
M.B. Barton et al. / Clinical Oncology xxx (2016) 1e3 [8] Uganda’s radiotherapy machine for cancer treatment breaks. Available at: http://www.bbc.com/news/world-africa-35997075; 8 April 2016 (accessed 7 September 2016). [9] Shakespeare TP, Turner M, Chapman A. Is rural radiation oncology practice quality as good as the big smoke? Results of the Australian radiotherapy single machine unit trial. Australas Radiol 2007;51(4):381e385.
3
[10] The Radiation Oncology I. A vision for radiotherapy. Canberra: Commonwealth of Australia; 2002. [11] Programme for Action for Cancer Therapy. Available at: cancer. iaea.org/vuccnet.asp; 2016 (accessed 7 September 2016). [12] Eslick EM, Keall PJ. The Nano-X linear accelerator: a compact and economical cancer radiotherapy system incorporating patient rotation. Technol Cancer Res Treat 2014. tcrt.2012.500436.
Please cite this article in press as: Barton MB, et al., Radiotherapy in Low- and Middle-income Countries. What Can We Do Differently? Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.11.009
Clinical Oncology journal homepage: www.clinicaloncologyonline.net
Editorial
Radiotherapy in Low- and Middle-income Countries. What Can We Do Differently? M.B. Barton *, E. Zubizarreta y, M. Gospodarowicz z * Collaboration
for Cancer Outcomes Research and Evaluation, Ingham Institute for Applied Medical Research, UNSW Australia, Liverpool, NSW, Australia y Applied Radiation Biology and Radiotherapy Section, Division of Human Health e Department of Nuclear Sciences and Applications, International Atomic Energy Agency, PO Box 100, 1400 Vienna, Austria z Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada Received 9 September 2016; accepted 15 September 2016
We know that cancer is already a major problem in lowand middle-income countries (LMIC). These are countries with an annual gross national income per person of US$12 476 or less [1]. It is estimated that in 2012 there were 8 million cancers cases in less-developed countries and by 2035 there will be 14.7 million cases of cancer in LMIC [2], an increase of over 80%. Radiotherapy is an essential part of effective cancer treatment and it is impossible to offer comprehensive cancer care without it. We estimate that about 6.5 million new cases of cancer in LMIC would benefit from radiotherapy at least once in the course of their illness [3]. The population benefit of radiotherapy is greatest in LMIC [4], where the access to radiotherapy is the lowest [3]. Although the number of megavoltage machines has increased over the last decade in high-income countries, the gap between demand and supply in LMIC has widened and there remains a deficit of more than 7000 machines worldwide [3]. Demand for radiotherapy will increase by nearly 80% over the next 20 years. Modelling of the benefits of investing in radiotherapy shows that 27 million lives in LMIC could be saved between 2015 and 2035 if access to radiotherapy was scaled up to meet demand. The net economic benefit would be US$278 billion from productivity gains [5]. In 36 countries there was no radiotherapy service at all. In these countries alone we estimated that 120 000 patients a year would benefit from radiotherapy but could not access it [3]. This is not new information and there has been a long
Author for correspondence: M.B. Barton, Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute for Applied Medical Research, UNSW Australia, Liverpool, NSW, Australia. E-mail address: [email protected] (M.B. Barton).
history of developing radiotherapy services in LMIC with a mixed track record of success. The International Atomic Energy Agency (IAEA) has been at the forefront of delivering aid in LMIC. They have built new departments and established education programmes and training networks. IAEA recognises that radiotherapy will only be appropriate when it is part of a comprehensive cancer control programme. Since 2005, the IAEA’s Program of Action for Cancer Treatment (PACT) has undertaken 81 imPACT reviews to provide recommendations to strengthen national cancer control capacity [6]. Programmes in Ghana started with a single department in Accra, which served as a nucleus for development and training. New departments have now been established elsewhere in the country with locally trained staff. Zambia is another success story. The Cancer Diseases Hospital opened in 2007 with a basic radiotherapy department including one linear accelerator, one cobalt machine, one high dose rate afterloader, an orthovoltage machine and conventional simulation. They added later a second cobalt machine, a second high dose rate afterloader, computed tomography simulator, magnetic resonance imaging, a training centre and a 160 bed inpatient facility. They began training programmes for radiation therapists and clinical oncologists and will establish satellite centres outside Lusaka. The establishment of the Cancer Diseases Hospital, including a training programme for radiation therapists and clinical oncologists, is a model of successful collaboration between the Government of Zambia, OPEC Fund for International Development and the IAEA. In countries such as Uganda and Papua New Guinea equipment costs and access to staff have resulted in prolonged interruptions to established services. The sole cobalt machine in Lae, Papua New Guinea was decommissioned in
http://dx.doi.org/10.1016/j.clon.2016.11.009 0936-6555/Ó 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Barton MB, et al., Radiotherapy in Low- and Middle-income Countries. What Can We Do Differently? Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.11.009
2
M.B. Barton et al. / Clinical Oncology xxx (2016) 1e3
the late 1990s because of mechanical safety concerns and not replaced for over 10 years [7]. Recruiting a radiation oncologist from overseas resulted in further delays. The service remains precarious because it relies on a single oncologist and there is no national training programme. In Uganda, the only radiotherapy machine broke ‘beyond repair’ in April 2016. Until it is replaced patients will have to travel to Kenya for radiotherapy if they can afford it [8]. However, the assistance offered has not been sufficient to reverse the trend of woefully inadequate access to radiotherapy globally. Although all the efforts are well intended, a major shift in approach is needed if we are to expect meaningful improvement. Having shown the need and the ability to implement and operate safe and effective radiotherapy programmes in most environments, serious investment is needed by the health care systems to reverse the trend. Investing in at least one comprehensive cancer centre with radiotherapy services and expecting this centre to train local experts is a starting point. We need to think and act differently if the global community is going to make any headway in meeting the huge demand for radiotherapy services in LMIC. New approaches need to be considered for radiotherapy. Attention to securing sufficient financing, optimisation of the scope of services, staff training, quality assurance, patients’ aid and assistance is required. In addition, needs such as roads, stable power supply and basic facility services are important. Furthermore, diagnostic services such as imaging and pathology, treatment modalities including surgery and chemotherapy are important to optimise the impact of radiotherapy. Basic understanding of the role of radiotherapy among referring physicians is also needed. Geographic distribution of services is important to secure access. The traditional stand-alone radiotherapy department with minimum two machines is not always feasible or economical. Single-machine departments with local or off-site planning have been trialled in high-income countries [9]. Populations with fewer than 500 new radiotherapy cases per year may be better served by contracting radiotherapy services in a nearby country. However, it is important to close the gaps in access to radiotherapy in populations with a high number of cancer patients first. Many countries rely on government support to purchase and maintain radiotherapy equipment and pay for staff. This works best where there are national health insurance schemes. Privateepublic partnerships or government financing supported by philanthropy are other possibilities. Financing new departments should include the maintenance and replacement costs. In Australia, the Health Program Grant scheme provides an activity-based payment that is quarantined for equipment replacement [10]. In many countries there are critical shortages of qualified cancer specialists. It would be expedient for radiation oncologists to be qualified to deliver chemotherapy as well as radiotherapy and to have a broader role in advocating for cancer control. Training should not only include opportunities in high-income countries but also southesouth collaborations such as VUCCnet that aim to provide training
that is appropriate to the local cancer case mix and available equipment [11]. To secure confidence in radiotherapy, safe treatment delivery is paramount. Physicists are crucial for quality assurance and equipment maintenance. However, in many countries medical physicists are not recognised as a health profession and therefore not supported. The global shortage of physicists is exacerbated by brain drain to high-income countries where the profession is supported. Current technologies offer prospects of remote monitoring and quality assurance offering access to expertise and may prove an effective alternative to employing staff on site. Other innovations in technology are needed. The fundamental design of the megavoltage machine has not changed in 50 years. A source mounted on a rotating gantry requires extensive primary shielding to cover the exit path. Quality assurance must be carried out on beam performance at multiple angles. Gantry integrity can fail as it did for the sole cobalt machine in Papua New Guinea. New designs such as the Nano-X [12] that use a fixed source and turn the patient could reduce equipment, building and maintenance costs. There is a plethora of agencies, non-government organisations, charities, professional organisations, expatriate groups and charitable organisations interested in cancer services in LMIC but there is no coordination of activity. Many organisations offer help and most act in isolation. Global coordination is needed for the wide range of volunteer and charity activities. An LMIC may engage with two or more organisations on the same subject without informing either of the other’s involvement. Countries with large expatriate populations are more likely to host activities as private initiatives that may not align with national priorities or be sustainable without government engagement. A global approach to coordinate strategy for engaging a volunteer workforce would maximise the gains and optimise the use of resources and share learnings.
References [1] New country classifications by income level. Available at: http:// blogs.worldbank.org/opendata/new-country-classifications2016; 2016 (accessed 7 September 2016). [2] Ferlay J, Soerjomataram I, Ervik M, et al. GLOBOCAN 2012 v1. 0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. Lyon: International Agency for Research on Cancer. Available at: http://globocan.iarc.fr; 2013. [3] Yap ML, Zubizarreta E, Bray F, Ferlay J, Barton M. Global access to radiotherapy services: have we made progress during the past decade? J Global Oncol 2016;2(4):207e215. [4] Yap ML, Hanna TP, Shafiq J, et al. The benefits of providing external beam radiotherapy in low- and middle-income countries. Clin Oncol. [5] Atun R, Jaffray DA, Barton MB, et al. Expanding global access to radiotherapy. Lancet Oncol 2015;16(10):1153e1186. [6] imPACT Review. Available at: http://cancer.iaea.org/impact. asp; 2016 (accessed 7 September 2016). [7] Barton MB, Frommer M, Shafiq J. The role of radiotherapy in cancer control in low- and middle-income countries. Lancet Oncol 2006;7(7):584e595.
Please cite this article in press as: Barton MB, et al., Radiotherapy in Low- and Middle-income Countries. What Can We Do Differently? Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.11.009
M.B. Barton et al. / Clinical Oncology xxx (2016) 1e3 [8] Uganda’s radiotherapy machine for cancer treatment breaks. Available at: http://www.bbc.com/news/world-africa-35997075; 8 April 2016 (accessed 7 September 2016). [9] Shakespeare TP, Turner M, Chapman A. Is rural radiation oncology practice quality as good as the big smoke? Results of the Australian radiotherapy single machine unit trial. Australas Radiol 2007;51(4):381e385.
3
[10] The Radiation Oncology I. A vision for radiotherapy. Canberra: Commonwealth of Australia; 2002. [11] Programme for Action for Cancer Therapy. Available at: cancer. iaea.org/vuccnet.asp; 2016 (accessed 7 September 2016). [12] Eslick EM, Keall PJ. The Nano-X linear accelerator: a compact and economical cancer radiotherapy system incorporating patient rotation. Technol Cancer Res Treat 2014. tcrt.2012.500436.
Please cite this article in press as: Barton MB, et al., Radiotherapy in Low- and Middle-income Countries. What Can We Do Differently? Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.11.009