Scholarly article on topic 'Need for Radiotherapy in Low and Middle Income Countries – The Silent Crisis Continues'

Need for Radiotherapy in Low and Middle Income Countries – The Silent Crisis Continues Academic research paper on "Economics and business"

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{"Developing countries" / "low and middle income countries" / "radiotherapy availability" / "radiotherapy needs" / "radiotherapy utilisation" / resources}

Abstract of research paper on Economics and business, author of scientific article — E.H. Zubizarreta, E. Fidarova, B. Healy, E. Rosenblatt

Abstract About 57% of the total number of cancer cases occur in low and middle income countries. Radiotherapy is one of the main components of cancer treatment and requires substantial initial investment in infrastructure and training. Many departments continue to have basic facilities and to use simple techniques, while modern technologies have only been installed in big cities in upper-middle income countries. More than 50% of cancer patients requiring radiotherapy in low and middle income countries lack access to treatment. The situation is dramatic in low income countries, where the proportion is higher than 90%. The overall number of additional teletherapy units needed corresponds to about twice the installed capacity in Europe. The figures for different income level groups clearly show the correlation between gross national income per capita and the availability of services. The range of radiotherapy needs currently covered varies from 0% and 3–4% in low income countries in Latin America and Africa up to 59–79% in upper-middle income countries in Europe and Central Asia. The number of additional radiation oncologists, medical physicist, dosimetrists and radiation therapists (RTTs) required to operate additional radiotherapy departments needed is 43 200 professionals. Training and education programmes are not available in every developing country and in many cases the only option is sending trainees abroad, which is not a cost-effective solution. The implementation of adequate local training should be the following step after establishing the first radiotherapy facility in any country. Joint efforts should be made to establish at least one radiotherapy facility in countries where they do not exist, in order to create radiotherapy communities that could be the base for future expansion.

Academic research paper on topic "Need for Radiotherapy in Low and Middle Income Countries – The Silent Crisis Continues"

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Overview

Need for Radiotherapy in Low and Middle Income Countries - The Silent Crisis Continues

E.H. Zubizarreta, E. Fidarova, B. Healy, E. Rosenblatt

International Atomic Energy Agency, Vienna, Austria Received 8 August 2014; accepted 17 October 2014

Abstract

About 57% of the total number of cancer cases occur in low and middle income countries. Radiotherapy is one of the main components of cancer treatment and requires substantial initial investment in infrastructure and training. Many departments continue to have basic facilities and to use simple techniques, while modern technologies have only been installed in big cities in upper-middle income countries. More than 50% of cancer patients requiring radiotherapy in low and middle income countries lack access to treatment. The situation is dramatic in low income countries, where the proportion is higher than 90%. The overall number of additional teletherapy units needed corresponds to about twice the installed capacity in Europe. The figures for different income level groups clearly show the correlation between gross national income per capita and the availability of services. The range of radiotherapy needs currently covered varies from 0% and 3—4% in low income countries in Latin America and Africa up to 59—79% in upper-middle income countries in Europe and Central Asia. The number of additional radiation oncologists, medical physicist, dosimetrists and radiation therapists (RTTs) required to operate additional radiotherapy departments needed is 43 200 professionals. Training and education programmes are not available in every developing country and in many cases the only option is sending trainees abroad, which is not a cost-effective solution. The implementation of adequate local training should be the following step after establishing the first radiotherapy facility in any country. Joint efforts should be made to establish at least one radiotherapy facility in countries where they do not exist, in order to create radiotherapy communities that could be the base for future expansion.

© 2014 The Royal College of Radiologists. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/3.0/).

Key words: Developing countries; low and middle income countries; radiotherapy availability; radiotherapy needs; radiotherapy utilisation; resources

Statement of Search Strategies Used and Sources of Information

The list and income classification of countries was taken from the World Bank, Country and Lending Groups, 2015 fiscal year (http://data.worldbank.org/about/country-and-lending-groups). Data on the population, number of cancer cases per country and per region, and the number of cancer cases for each cancer site were obtained from GLO-BOCAN 2012 (http://globocan.iarc.fr/Pages/fact_sheets_ population.aspx). Data on the availability of radiotherapy equipment were obtained from the International Atomic Energy Agency Directory of Radiotherapy Centres (DIRAC), publicly available online at http://nucleus.iaea.org/HHW/

Author for correspondence: E.H. Zubizarreta, International Atomic Energy Agency, Wagramer Strasse 5, A1400-Vienna, Austria. Tel: +43-1260021669; Fax: +43-1-2600721668.

E-mail address: zubi.iaea@gmail.com (E.H. Zubizarreta).

DBStatistics/DIRAC/ and at http://www-naweb.iaea.org/ nahu/dirac/default.asp. We used an internally produced Excel sheet with data from December 2013.

Introduction

About 57% of the cancer cases worldwide occur in low and middle income countries (LMIC) according to GLOBO-CAN 2012 [1]. Radiotherapy is one of the main components of modern cancer treatment and requires substantial capital investment, trained professionals in several disciplines, high precision equipment and a particular external and internal organisational structure. Most of the indications for radiotherapy are related to cancer treatment and it is not possible to set up a cancer control programme if radiotherapy is not available. Radiotherapy has experienced a fast technological advance in the last two decades, which has improved precision in treatment planning and delivery.

http://dx.doi.org/10.1016/j.clon.2014.10.006

0936-6555/© 2014 The Royal College of Radiologists. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/).

On the other hand, this technological advance and improved precision require increased quality assurance needed to provide treatments safely. All these developments have been quickly implemented in developed countries at a full scale. Traditional two-dimensional radiotherapy has been replaced by three-dimensional conformal radiotherapy, intensity-modulated radiotherapy and image-guided radiotherapy. The remaining cobalt tel-etherapy machines have been largely replaced by linear accelerators (LINAC) with multileaf collimators and image guidance, capable of delivering intensity-modulated radiotherapy and volumetric modulated arc therapy. Today, cobalt machines represent only 7% of the external beam radiotherapy (EBRT) equipment in high income countries (HIC). The estimated demand for radiotherapy in developed countries and regions is in general supplied.

Several analyses of radiotherapy resources in LMIC at the regional level have been published [2-11 ]. When published, these reports were essential to understand the situation in developing countries and to present reference sources for comparison when carrying out new analyses.

This article gives an overview of the demand for radiotherapy in LMIC, with additional detail for different world regions, but it does not aim to make future projections. It presents a summary of the most relevant indicators used to calculate the number of machines needed, with an alternative one based on the number of fractions per machine. The problem of staffing and training in LMIC is also discussed.

Estimating the Need for Radiotherapy

Data Sources

Economies were classified according to the definitions of the World Bank for the current 2015 fiscal year. The list from the World Bank includes 214 economies, of which 139 are in the category of LMIC [12].

LMIC were grouped into regions, defined as per the division used by the International Atomic Energy Agency (IAEA) Technical Cooperation Department. Europe and Central Asia include LMIC from Europe and the post-Soviet countries in Asia. Asia and the Pacific refers to LMIC from the rest of Asia and Oceania. The other two regions are Africa and Latin America.

The number of existing machines was primarily obtained from the IAEA Directory of Radiotherapy Centres (DIRAC) as of December 2013, with the addition of Kosovo, South Sudan and the West Bank and Gaza and a minor correction of data in some countries [13].

The population and the number of cancer cases per region and country were taken from GLOBOCAN 2012, which presents data from 184 countries [1].

From the 139 LMIC on the World Bank list of economies, 15 small countries not reported by DIRAC or GLOBCAN were excluded from the analysis. The final number of countries included was 124, divided in 35 low income countries (LIC), 44 lower-middle income countries (L-MIC) and 45 upper-middle income countries (U-MIC).

Radiotherapy Utilisation (RTU) Calculation

A different RTU rate and the average number of fractions per radiotherapy course were obtained for each region using data from GLOBOCAN 2012 and the methodology and RTU factors for different cancer sites published by the Collaboration for Cancer Outcomes Research and Evaluation (CCORE) in their reports [14-16]. A retreatment rate of 25% was used with 3.3 fractions per course [16-18]. The optimal RTU tree for cervix cancer was the only one modified, and a detailed explanation is given in the brachytherapy section. The calculated RTU rates and the average number of fractions per course were 0.543 and 16.44 for Africa, 0.533 and 16.53 for Latin America, 0.501 and 15.95 for Europe-Central Asia and 0.495 and 16.29 for Asia-Pacific. Each set of factors was used to calculate the radiotherapy cases and the fractions for each country in each region.

Calculating and Reporting Radiotherapy Equipment Availability

A commonly used indicator for radiotherapy equipment availability is the number of teletherapy or megavoltage units per million population. It only needs a simple calculation based on easily available data, but it does not account for differences in cancer incidence and machine throughput. It will only be used in this overview for comparisons with old reports.

A benchmark of between 400 and 500 patients per treatment unit per year has been used to calculate machine throughput in several reports [11,19,20]. This benchmark does not make a distinction between long and short treatments and the assigned proportion of retreatments makes a big difference in the final results. The use of the average number of fractions for each cancer type, which in the end gives an average number of fractions for all cancer cases or treatment courses, is a step forward in terms of accuracy in the results. As the number of fractions in cases needing a second radiotherapy course is small, the relative weight of retreatments is smaller and more realistic [16]. This method makes the comparison between different operating hours on the machines easier. The benchmark of 450 patients per machine correlated well with the calculation based on average fractions, 25% of retreatment and 8 operating hours.

Some developed countries, like Canada and the UK, use extended working days or extended weeks to decrease waiting times. Cancer Care Ontario, in its report on Radiation Treatment Capital Investment Strategy from April 2012, recommends extending the treatment day to 12 h in larger centres and on 50% of the machines in smaller centres and to 10 h on the remaining 50% of machines [21].

The benchmark of 450 patients per machine, which corresponds to about 8 operating hours per day, seems adequate for HIC. For scenarios where radiotherapy demand is not satisfied, a treatment day of 10 h optimises the utilisation of equipment and decreases the number of machines needed. The working day could even be extended, but difficulties with transportation and auxiliary services at

the hospital could limit the operation of the department beyond 12 h [21].

There are many very well-structured reports on planning radiotherapy services at national or provincial levels in several countries, particularly Australia, Canada and the UK. These reports, publicly available, are an excellent source of information and should be used as a model for planning by LMIC [19-24].

Optimal Versus Actual Radiotherapy Utilisation

When the demand for radiotherapy is supplied, the proportion of different cancers treated and the total number of patients receiving radiotherapy (actual RTU) should coincide with calculations of optimal RTU. Currently, there are no data on actual RTU in LMIC, where the demand for radiotherapy is not satisfied. The IAEA is conducting a study in nine selected MIC representing the four regions to estimate their optimal and actual RTU. The logical assumption should be that in LIC and L-MIC cancer cases will be diagnosed at more advanced stages, when they become symptomatic, that surgery will play a smaller role and a higher proportion of cases will need radiotherapy. The proportion of short palliative radiotherapy courses should also be higher than in HIC or U-MIC. The calculation of the number of machines needed based on how many fractions can be delivered per machine per year divided by the number of fractions per patient is preferable to using 450 patients per machine for this scenario.

A benchmarking exercise carried out in Zambia is a good example of actual RTU being different from optimal RTU. The calculated proportion for the top five cancers requiring radiotherapy (using the modified tree for cervical cancer) were 32.8% for cervix, 11.9% for breast, 7.1% for Kaposi sarcoma, 6.9% for oesophagus and 5.7% for prostate. The radiotherapy centre treats 1152 patients (24 534 fractions) per year with one telecobalt machine (540 patients; 11 070 fractions/year) and one LINAC (612 patients; 13 464 fractions/year). The average number of fractions per patient is 21.3. The explanation for the relatively high figure of 21.3 is that cervix patients represent 48% (556/year) of all cases, breast 11%, head and neck 9% and prostate 7%. As they are not using hypofractionated protocols for breast and most prostate patients having localised disease, 75% of the patients have treatments of 5 weeks or more.

When radiotherapy demand is not satisfied then referral patterns, decisions to treat policies or preferences and other factors, such as the geographical distribution of services, play an important role in determining the actual RTU, which should be based on a case by case assessment and not on assumptions.

Current Status of Radiotherapy in Low and Middle Income Countries

There are 4221 installed teletherapy machines in LMIC. These represent between 38 and 49% of the machines needed, depending on the benchmark used. Between 4320 and 6958 additional units are required, which corresponds to about

twice the installed capacity in Europe [9]. The range of needs currently covered varies from 0% and 3-4% in LIC in Latin America and Africa up to 59-79% in U-MIC in Europe-Central Asia. The detailed analysis of the status of radiotherapy in LMIC is shown in Table 1. The subdivision of LMIC in LIC, L-MIC and U-MIC used for the analysis allowed a subset of indicators for each income group. The population in LMIC represents 82% of the world's population and from 187 countries included in DIRAC, 124 are LMIC. Around 5000 million people live equally distributed between L-MIC and U-MIC and 840 million in LIC. However, the number of cancer cases is double in U-MIC than in L-MIC. There are 39 countries without radiotherapy services and the correlation between gross national income per capita and the number of teletherapy machines proposed by Levin and Tatsuzaki [25] is reflected in the proportion of LIC, L-MIC and U-MIC without radiotherapy. Thirty-one per cent of teletherapy units are cobalt machines, compared with 7% in HIC. Each machine serves 1.4 million people, compared with 0.4 million per machine in HIC. This information is also presented in the table using two different benchmarks, the annual number of patients per machine for an 8 h treatment day and the number of fractions per machine per year for 10 operating hours. The number of machines needed was also calculated using these two benchmarks. The needs currently covered varied between 38 and 49% depending on the benchmark used. The subsets of indicators for different income groups show a similar trend.

A direct comparison between this analysis and the work published by Barton et al. [2] in 2006 is not possible. Many variables have changed since then. As an example, eight previous LMI European countries became HIC, and the Central Asian countries in our data were not added to Europe in that analysis. Equipment numbers were taken from DIRAC in both, but DIRAC included fewer countries at that time and the numbers are more accurate now.

IAEA invested V 263 million in cancer projects between 1980 and 2012, and this amount only represents about 2.5% of what would be necessary only to set up the additional radiotherapy facilities required, excluding training costs. The IAEA Advisory Group on increasing access to Radiotherapy Technology in LMIC and the Union for International Cancer Control (UICC) Global Task Force on Radiotherapy for Cancer Control are initiatives studying the problem of access to radiotherapy in order to develop strategies to improve the current situation.

Africa

Africa includes 51 LMIC and is the region with the largest proportion of LIC and the lowest access to radiotherapy. About 72% of the people in Sub-Saharan Africa live with less than $2 per day. The region is overwhelmed by many basic problems like infant mortality, infectious diseases and infrastructure needs, which are more urgent priorities than cancer care. Between 1991 and 2010 the number of cases with indication of radiotherapy increased 239% and the number of machines increased 286% [2-5,8]. The proportion of teletherapy machines per million people has improved from 0.184 to 0.260 since 1998 [2,5].

LIC, low income countries; L-MIC, lower-middle income countries; U-MIC, upper-middle income countries.

* This radiotherapy utilisation rate was obtained retrospectively by dividing the addition of radiotherapy courses for each country by the number of cancer cases.

Table 1

Data and calculations relevant to external beam radiotherapy in low and middle income countries (LMIC)

LMIC Total LIC L-MIC U-MIC

Number of countries 124 35 44 45

Population (million) A 5761.0 837.8 2525.2 2398.1

% 100% 14% 44% 42%

New cancer cases/year B 7 964 367 675 500 2 358 267 4930 600

Number of radiotherapy courses/year C = B x 0.5053 x 1.25* 5 030 353 439 981 1 482 826 3107 546

Number of radiotherapy fractions/year D = C x 16.31 81 991 583 7 202 258 24 153 656 50 707 313

% of countries without radiotherapy 31% 66% 27% 9%

Number of existing machines E 4221 62 1014 3145

Number of LINAC F 2919 25 523 2371

Number of Co60 machines G 1302 37 491 774

% of Co60 machines G/E 31% 60% 48% 25%

Machines/million population E/A 0.733 0.074 0.402 1.311

Radiotherapy courses/machine (450/year — 8 h/day) C/E 1192 7096 1462 988

Fractions/machine (9600/year — 10 h/day) D/E 19 425 116 165 23 820 16 123

Total machines needed H = C/450 11 179 978 3295 6906

(1 x 450 courses/year -8 operating hours/day)

Additional machines needed I = H—E 6958 916 2281 3761

% of needs currently covered E/H 38% 6% 31% 46%

Total machines needed J = D/9600 8541 750 2516 5282

(1 x 9600 fractions/year -10 operating hours/day)

Additional machines needed K = J—E 4320 688 1502 2137

% of needs currently covered E/J 49% 8% 40% 60%

A detailed analysis of the status of radiotherapy in Africa is shown in Table 2. Twenty-eight countries do not have radiotherapy services, 14 have three or fewer machines and only seven have more than 10 machines. Cobalt machines represent 30% of the equipment. There is an average of 3.8 million people per machine, which varies a lot between different income categories. Between 22 and 28% of the needs are covered depending on the benchmark used.

Countries without radiotherapy are slowly setting up their first departments. Sustainability is a problem and expansion is mainly happening in countries with a larger number of machines.

Latin America

Latin America includes 22 LMIC, of which 14, representing 89% of the population, are U-MIC. Table 3 summarises the radiotherapy situation. Only two countries lack radiotherapy facilities. Cobalt machines represent 31% of the equipment. There is an average of 0.7 million people per machine. The number of EBRT machines per million population has increased from 1.376 to 1.523 in the last 10 years [2,7]. The needs are satisfied between 58 and 75%, depending on the benchmark used. Recently Brazil purchased 80 LINACS, which represent 23% of their installed machines and 9% of the installed capacity in Latin America.

Asia and the Pacific

Asia and the Pacific has 30 LMIC. With nearly 4000 million people, it is the most populated region. Only 8% of

the population lives in LIC. The status of radiotherapy is presented in Table 4. There are seven countries without radiotherapy services. The proportion of cobalt machines is 27%. The average population per machine is 1.5 million. The number of machines per million people in 1999 in 12 Asian countries was 0.3839 and the actual proportion is 0.661 for 30 countries [2,6]. The needs are covered in 34-45%, depending on the benchmark used.

Europe and Central Asia

Europe and Central Asia include 21 LMIC, of which only two are LIC. RTU indicators are presented in Table 5. Two countries do not have radiotherapy services. Cobalt machines represent 48% of the equipment, the highest proportion of all regions. Also, 0.5 million people are served per machine. The proportion of teletherapy machines per million people in European LMIC reported by Barton et al. [2] was 1.832 in 1998. The present analysis shows a proportion of 1.951 on a different subset of countries and Rosenblatt et al. [9] found an average of 5.288 machines per million people in 33 European countries. RTU supply is between 55 and 74%, depending on the benchmark used. The IAEA is conducting a patterns of care study in the region, with emphasis on radiotherapy quality indicators.

Brachytherapy

DIRAC presents the data on brachytherapy equipment divided between low dose rate manual afterloading, low dose rate remote afterloading, high dose rate (HDR) 192Ir

Table 2

Data and calculations relevant to external beam radiotherapy in Africa

Africa Total LIC L-MIC U-MIC

Number of countries 51 26 16 9

Population (million) A 1069.5 510.4 427.3 131.9

% 100% 48% 40% 12%

New cancer cases/year B 843 900 360 600 332 900 150 400

Number of radiotherapy courses/year C = B x 0.543 x 1.25 572 755 244 739 225 939 102 076

Number of radiotherapy fractions/year D = C x 16.44 9 415182 4023 125 3 714 083 1677 975

% of countries without radiotherapy 55% 81% 44% 0%

Number of existing machines E 278 15 136 127

Number of LINAC F 194 7 97 90

Number of Co60 machines G 84 8 39 37

% of Co60 machines G/E 30% 53% 29% 29%

Machines/million population E/A 0.260 0.029 0.318 0.963

Radiotherapy courses/machine (450/year - 8 h/day) C/E 2060 16,316 1661 804

Fractions/machine (9600/year - 10 h/day) D/E 33 868 268 208 27 309 13 212

Total machines needed H = C/450 1273 544 502 227

(1 x 450 courses/year -8 operating hours/day)

Additional machines needed I = H - E 995 529 366 100

% of needs currently covered E/H 22% 3% 27% 56%

Total machines needed J = D/9600 981 419 387 175

(1 x 9600 fractions/year -10 operating hours/day)

Additional machines needed K = J - E 703 404 251 48

% of needs currently covered E/J 28% 4% 35% 73%

LIC, low income countries; L-MIC, lower-middle income countries; U-MIC, upper-middle income countries.

and HDR 60Co [13]. It is difficult to know if centres are still using manual afterloading sets and low dose rate after-loaders are no longer supported by their manufacturers. For the purpose of this analysis, only 192Ir- or 60Co-based HDR machines and only indications for cervical cancer treatment were considered. Brachytherapy availability is important in

LMIC because cervical cancer accounts for 7.01% of the patients with indication of radiotherapy and radical treatment of this disease, even in its advanced stages, requires the combination of EBRT and brachytherapy. RTU for EBRT and brachytherapy in cervix cancer was calculated using the CCORE optimal RTU tree for cervix, modified to include 45%

Table 3

Data and calculations relevant to external beam radiotherapy in Latin America

Latin America Total LIC L-MIC U-MIC

Number of countries 22 1 7 14

Population (million) A 574.3 10.3 53.0 511.1

% 100% 2% 9% 89%

New cancer cases/year B 1 018 700 7900 55 200 955 600

Number of radiotherapy courses/year C = B x 0.5327 x 1.25 678 366 5261 36 758 636 347

Number of radiotherapy fractions/year D = C x 16.56 11 235 760 87 133 608 829 10 539 798

% of countries without radiotherapy 9% 100% 0% 7%

Number of existing machines E 875 0 38 837

Number of LINAC F 606 0 18 588

Number of Co60 machines G 269 0 20 249

% of Co60 machines G/E 31% - 53% 30%

Machines/million population E/A 1.523 0 0.718 1.638

Radiotherapy courses/machine (450/year - 8 h/day) C/E 775 - 967 760

Fractions/machine (9600/year - 10 h/day) D/E 12,841 - 16 022 12 592

Total machines needed H = C/450 1507 12 82 1414

(1 x 450 courses/year -8 operating hours/day)

Additional machines needed I = H - E 632 12 44 577

% of needs currently covered E/H 58% 0% 47% 59%

Total machines needed J = D/9600 1170 9 63 1098

(1 x 9600 fractions/year -10 operating hours/day)

Additional machines needed K = J - E 295 9 25 261

% of needs currently covered E/J 75% 0% 60% 76%

LIC, low income countries; L-MIC, lower-middle income countries; U-MIC, upper-middle income countries.

Table 4

Data and calculations relevant to external beam radiotherapy in Asia and the Pacific

Asia and the Pacific Total LIC L-MIC U-MIC

Number of countries 30 6 15 9

Population (million) A 3847.0 304.6 1960.6 1581.8

% 100% 8% 51% 41%

New cancer cases/year B 5 416 398 295 700 1 766 798 3353 900

Number of radiotherapy courses/year C = B x 0.4949 x 1.25 3 350 411 182 911 1 092 885 2074 616

Number of radiotherapy fractions/year D = Cx 16.29 54 570 598 2 979 199 17 800 617 33 790 783

% of countries without radiotherapy 23% 17% 27% 22%

Number of existing machines E 2541 44 702 1795

Number of LINAC F 1845 18 379 1448

Number of Co60 machines G 696 26 323 347

% of Co60 machines G/E 27% 59% 46% 19%

Machines/million population E/A 0.661 0.144 0.358 1.135

Radiotherapy courses/machine (450/year — 8 h/day) C/E 1319 4157 1557 1156

Fractions/machine (9600/year — 10 h/day) D/E 21 476 67 709 25 357 18 825

Total machines needed H = C/450 7445 406 2429 4610

(1 x 450 courses/year -8 operating hours/day)

Additional machines needed I = H -E 4904 362 1727 2815

% of needs currently covered E/H 34% 11% 29% 39%

Total machines needed J = D/9600 5684 310 1854 3520

(1 x 9600 fractions/year -10 operating hours/day)

Additional machines needed K = J - E 3143 266 1152 1725

% of needs currently covered E/J 45% 14% 38% 51%

of the IB—IIA stages and 50% of stages IIB-IVA [14,15]. The average number of fractions was also calculated [16]. The EBRT utilisation rate was 85.4%, with an average of 25 fractions per EBRT course, and 71.4% of brachytherapy utilisation, with an average of 2.9 fractions per brachytherapy course. From the total number of 413 020 cervix cancer

cases in LMIC, 294 707 require brachytherapy, with 880 133 fractions. 440 HDR machines are needed, assuming that the procedure takes 1 h and that between eight and nine procedures are carried out per day. There are 402 available HDR machines in LMIC. The distribution per region is shown in Table 6.

Table 5

Data and calculations relevant to external beam radiotherapy in Europe and Central Asia

Europe—Central Asia Total LIC L-MIC U-MIC

Number of countries 21 2 6 13

Population (million) A 270.1 12.5 84.4 173.3

% 100% 5% 31% 64%

New cancer cases/year B 685 369 11 300 203 369 470 700

Number of radiotherapy courses/year C = B x 0.5005 x 1.25 428 821 7070 127 244 294 507

Number of radiotherapy fractions/year D = C x 15.95 6 841 686 112 802 2 030 128 4698 756

% of countries without radiotherapy 10% 0% 17% 8%

Number of existing machines E 527 3 138 386

Number of LINAC F 274 0 29 245

Number of Co60 machines G 253 3 109 141

% of Co60 machines G/E 48% 100% 79% 37%

Machines/million population E/A 1.951 0.240 1.636 2.228

Radiotherapy courses/machine (450/year — 8 h/day) C/E 814 2357 922 763

Fractions/machine (9600/year — 10 h/day) D/E 12 982 37 601 14 711 12 173

Total machines needed H = C/450 953 16 283 654

(1 x 450 courses/year -8 operating hours/day)

Additional machines needed I = H - E 426 13 145 268

% of needs currently covered E/H 55% 19% 49% 59%

Total machines needed J = D/9600 713 12 211 489

(1 x 9600 fractions/year -10 operating hours/day)

Additional machines needed K = J -E 186 9 73 103

% of needs currently covered E/J 74% 26% 65% 79%

Table 6

Availability of high dose rate (HDR) afterloaders in low and middle income countries

HDR HDR Needs

available needed covered

Africa 40 105 38%

Latin America 156 68 228%

Asia-Pacific 108 242 45%

Europe-Central Asia 98 24 407%

Total 402 440 91%

Although it seems that Latin America and Europe-Central Asia do not need additional brachytherapy afterloaders, equipment is not uniformly distributed between countries. Brazil, South Africa and Ukraine have 60, 38 and 37% of all HDR machines in their regions, although they have 43, 9 and 21% of the radiotherapy patients, respectively. Brachy-therapy needs and the distribution of brachytherapy resources in LMIC require further detailed analysis.

Staffing, Education and Training Needs

Often the analysis of radiotherapy demand is overly focused on equipment. New radiotherapy departments require significant investment in infrastructure and equipment, but the availability of qualified professionals to run these departments can be a difficult problem to solve in LMIC. Training a radiotherapy team takes years and is expensive. A detailed calculation on staffing needs in LMIC is difficult because available data on the number of professionals are inaccurate. Where training programmes are established, new professionals graduate every year and figures can change quickly and not be reflected if data are not constantly updated. In some regions multi-employment is common. DIRAC requests information about full-time equivalence, but usually only the total numbers are reported, and the number of professionals in those regions could be overestimated. In countries where clinical oncologists are also responsible for the administration of chemotherapy the assessment is more difficult.

The estimation of additional staff needed to operate new required facilities is possible. Existing guidelines on staffing levels usually assume 8 working hours per day [11,19,20,26]. National regulations in many countries reduce the number of working hours per day for different professionals. The following calculation was based on hypothetical facilities with four EBRT machines, one fluoroscopic or computed tomography simulator, one treatment planning system (TPS) and one HDR afterloader, operating 10 h daily, 5 days per week [27]. A maximum of 2356 patients (38 400 fractions) can be treated annually with EBRT and 643 cervical cancer cases (1920 fractions) can be treated with HDR brachytherapy. Each of these departments will require 12 radiation oncologists, six medical physicists, three dosi-metrists or treatment planners and 19 radiation therapists (RTTs), all working 8 h per day. If all 4320 additional meg-avoltage machines required in LMIC are accommodated in

this way, the total number of additional professionals needed will be 12 960 radiation oncologists, 6480 medical physicists, 3240 dosimetrists and 20 520 RTTs. Training costs are less visible in countries where radiotherapy is well established and training programmes are available. Trainees demand time from academic staff, but they are part of the working force and contribute to the activities of the department. In countries where there are no radiotherapy facilities or training possibilities, the only solution is to train professionals abroad. IAEA supports full training overseas of candidates from LIC and shares the cost in the case of MIC, trying to use academic institutions within the same region. The grant includes travel, living expenses and training fees during the total duration of the training programme. The cost varies between V 50 000 and V 68 000 per professional per year, depending on the region. Education of a radiation oncologist costs between V 200 000 and V 272 000 and a medical physicist or an RTT between V 100 000 and V 136 000. Training an entire basic team consisting of four radiation oncologists, three medical physicists and seven RTTs will cost between V 1 850 000 and V 2 516 000. When establishing the first radiotherapy facility in a country, training abroad cannot be avoided and the budget allocated for training, construction of the facility and the acquisition of equipment should be available simultaneously. This is one of the reasons why radiotherapy is perceived as an expensive discipline when managers do not realise that a well-designed building will be functional for 30-40 years, machines can run for 15 years and trained staff should treat patients without needing the same high initial investment in training again. After the initial phase of making the department fully operational it is essential to begin local training programmes in order to limit expenditure and ensure sustainability and future expansion of the services. This was the strategy used by Zambia, which implemented a curriculum for RTTs shortly after beginning operation, and more recently a training programme for radiation oncologists. In Africa there are only 10 countries where it is possible to train radiotherapy professionals, and new programmes are needed.

Professionals working in basic departments will need additional training when advanced technologies are installed.

Conclusions

More than 50% of patients requiring radiotherapy in LMIC do not have access to treatment. The situation is dramatic in LIC, where the proportion is higher than 90%. Although 4221 teletherapy machines are available in LMIC, between 4300 and 7000 additional units are needed. This situation can improve, but still a large proportion of patients with indication for radiotherapy will not have access to treatment in the near future. Meanwhile, a possible strategy is to join efforts to establish at least one radiotherapy facility in countries where they do not exist, in order to create radiotherapy communities that could be the base for future expansion.

Acknowledgements

The authors wish to thank Yaroslav Pynda for his help in

handling the data from DIRAC.

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