Massoud Samiei, independent international expert collaborating with the IAEA, WHO, IARC, UICC, Oxford University and INCTR
Following the adoption of the UN resolution on Prevention and Control of Noncommunicable Diseases (NCDs) in 2011, and the targets set by the World Health Assembly in 2012, health authorities in low- and middle-income countries (LMIC) have embarked on strengthening and integrating NCD policies and programmes into national health-planning processes. In this context, providing equitable and affordable access to cancer care for all who need it, and making the essential medicine, health technologies and specialists available, is a high priority for cancer control, where radiotherapy remains a vital and cost-effective intervention. However, planners and investors in LMIC face major obstacles in the delivery of radiotherapy services, including a shortage of 5,000 megavoltage units; accessibility and affordability of treatment; lack of a workforce of clinicians, nurses and support staff needed to run radiotherapy clinics, and their education and training; the choice of technologies and suppliers; and maintenance of equipment, among others. These challenges are discussed in this paper along with brief references to the IAEA’s efforts to address the problem and its PACT initiative.
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In 2010, there were 7.5 million new cases of cancer in LMIC less than 30% of whom had access to any reasonable treatment services. With increased population age, due to improvements in primary health care and survival from communicable diseases2, as well as adoption of unhealthy life styles, populations in LMIC face an expected rise in annual cancer incidence of nearly 70% by 2030 over the 2010 rates3.
Cancer is however not a death sentence; there are proven ways to prevent and cure cancer. The good news is that medicine, health technologies, skills and experience already exist to treat and cure cancer. All people in LMIC deserve full access to cancer prevention and care. Over 40% of cancers can be prevented, and a third can be successfully cured.
Thus, the question of providing affordable means of treating this growing number of patients, particularly in terms of medicine and health technology such as diagnostic radiology and radiotherapy, has become increasingly prominent in the minds of policy-makers in LMIC, in addition to concerns about the most feasible strategies for cancer prevention and control. If they could do for all what we do for a few, millions of lives could be saved. This has also been a priority for many UN agencies and active international organizations such as the UICC4 and INCTR5, but has been given a new emphasis following the comprehensive resolution approved by all UN Member States in September 2011 on the prevention and control of NCDs, among which cancer is a leading cause of death6. The matter has been given even higher urgency following the 2012 World Health Assembly’s decision to set a global target of 25% reduction of premature mortality from NCDs by 2025 as a key target, among another 10 targets, for the implementation of the UN resolution7.
Within the UN system, the International Atomic Energy Agency (IAEA) has a unique role to work with its Member States and multiple partners worldwide to promote safe, secure and peaceful nuclear technologies for sustainable development in food and agriculture, environmental protection, energy, industry and health. In health, radiation medicine know-how and technologies9,10 are indispensable for cancer diagnosis, cure and care, where radiation and radioactivity play fundamental roles.
Worldwide, radiotherapy is a major part of investments in the fight against cancer. Depending on the type of cancer, on average some 50–60% of all cancer patients require radiotherapy during the course of their disease, either on its own or in combination with surgery, chemotherapy, hormonal therapy, or immunotherapy11,12. Over the past 40 years, the IAEA has developed strong technical expertise and acquired unrivalled experience in working with LMIC to build capacity in diagnostic radiology, nuclear medicine and radiotherapy services at national level. It has mechanisms in place to provide assistance in all relevant aspects, such as needs assessment, planning, training, econometric analysis, implementation, and development of radiation protection, safety and security infrastructure10.
Although, due the limited funding available to the IAEA, this assistance remains far from adequate to respond fully to the growing demand caused by the looming cancer epidemic, it has gradually enabled many countries to gain experience in providing higher quality cancer treatment and care to at least a portion of their patients, while also creating more awareness about the enormity of the problem13. Some of the key challenges which will be faced by LMIC governments and investors attempting to address the problem, especially in response to the UN resolution on NCDs, are discussed here.
Experience with radiotherapy in developing countries
The reality in LMIC is harsh. Despite being home to 85% of the world’s population, there are only around 4,400 megavoltage machines in LMIC, less than 35% of the world’s radiotherapy facilities11,14, leaving most cancer patients in LMICs without any access to potentially life-saving radiotherapy treatment. The current incidence of cancer in LMIC (about 8 million new cases per year15) indicates a need for about 9,600 units (see below calculation methodology); a shortage of over 5,000 megavoltage machines. This inequity goes even further when comparing the availability of radiotherapy services across regions. For example, as can be seen in Figure 1, Europe has 17 times as many radiotherapy units as are available in Africa per million inhabitants, while Latin America and the Caribbean region has just one-third of the number of machines available per capita in North America16,12.
The lack of availability in radiotherapy treatment does not stem from a lesser need in LMIC. In fact, the needs are higher than high-income countries, because due to an absence of effective prevention and early detection and screening services, as well as lack of adequate diagnostic and treatment facilities, a higher proportion of cancers in LMIC are detected at an advanced stage, leaving palliative radiotherapy (or use of opioids) as one of the only options for treatment, even for cancers that, when detected in earlier stages, have curative treatment options12. In this regard, the role of radiotherapy in the palliative care of cancer patients is particularly relevant for LMIC (and probably will remain as important in the next decade or two according to many experts)17,18. The symptoms most commonly relieved with palliative radiotherapy are pain, bleeding and organ obstruction caused by tumours17. The cost of a single fraction of palliative treatment may be less than US$5 in developing countries where staff costs are also low18. This compares very favourably to some of the chemotherapy regimens, which can only be palliative for metastatic common solid tumours17,20. Palliative radiotherapy is a cost effective modality, but the extent provided depends on resources available19. Currently, over 80% of megavoltage cobalt machines available in many LMIC are providing nothing but palliative treatment21,22 (which, incidentally, requires less planning and radiation fractionations and thus increases the throughput of the machine17). Although palliative radiotherapy as a medical practice has well-established procedures and guidelines17,19, it is reported that due to the overwhelming number of patients seeking treatment, and the severe shortage of radiotherapy equipment and workforce in LMIC, the staff are sometimes forced to compromise on simulation, dosimetry and frequent machine calibration in order to treat more patients. This is not of course a desirable situation, since in the first place it is not in line with safety standards and IAEA and WHO guidelines and recommendations regarding the use of ionizing radiation in medicine23,24, and secondly, it does not allow radiotherapy to develop to its full potential in LMIC and acquire recognition as an effective curative intervention, as it is elsewhere. It might also discourage further investments in these countries by donors due to fears of accidents or malpractice.
To have a closer look at the reality in LMIC, it would be useful to refer to a detailed map on “Global access to radiotherapy” (Figure 2) provided by the IAEA PACT Programme Office25 using IAEA´s DIRAC database26 and other available information.
The following considerations may help clarify the significance of the numbers on the map:
‰ According to a study in Australia, supported by other work in Sweden and Canada, for every 1,000 new cancer patients, 523 would need radiotherapy as part of their treatment (52%), out of which 120 patients (23%) would require re-treatment12,27. The IAEA experience, however, suggests that in developing countries this figure is higher; at least 60%19. This rate will remain higher in the next decades until cancer prevention and early detection programmes, as well as other cancer services and public education programmes are operational and effective in LMIC.
‰ Based on acceptable international standards for a sustainable delivery of radiotherapy28, and several expert reviews by the IAEA11, it is recommended that each radiotherapy machine should treat on average up to 500 patients per year (can be higher when fully utilized in shifts). Since some patients will require re-treatment, the number of treatment courses per year per machine will be higher than the number of incident cases requiring radiotherapy.
‰ The crude cancer incidence rate is the vital input for determining the number of treatments (and thus the number of radiotherapy machines) needed for a specific country. (Age-standardised rates, on the other hand, are used for cancer risk assessment and epidemiological studies)29.
The crude cancer incidence in LMIC is in the range of 500–2,500 per 1,000,000 people. However, depending on the region and their particular population pyramid, the average crude rate varies quite substantially3,30. Table 2 provides the crude cancer incidence for the LMIC regions and summarizes the need for radiotherapy (RT) machines in these regions based on the above assumptions.
It can thus be concluded that with current cancer incidence in the LMIC, and depending on the region, from 1–3 radiotherapy machines per one million population would be needed in normal circumstances (in high-income countries the ratio is 5–8 machines for one million population11 due to a much higher crude cancer incidence as can be seen in Table 2). More accurate figures can be estimated at country level for planning and investment purposes by factoring in re-treatment courses and cancer site-specific RT requirements. Incidentally, the IAEA recommended basic radiotherapy clinic11,19 starts treatment with one megavoltage machine (but has provisions for an additional unit) and one high-dose rate brachytherapy. Existing evidence shows clearly that large centres with more units (like centralized regional facilities in densely populated urban areas) are more cost-effective and efficient given adequate minimum staffing and resources29.
As can be seen on the PACT radiotherapy map, most LMIC have one machine for up to 5 million population or above (less than 0.2 machines per million!). Over 30 African and Asian countries have no services at all and in several others there is a single cobalt unit for over 30–40 million inhabitants. A few LMIC in Latin America and Asia have one machine per one million and below. Under these circumstances, recalling the acute need for palliative care, the radiotherapy clinics in most LMIC are overcrowded and unable to cope with the demand. As a result, in many countries the number of new patients treated per machine exceeds the recommended number of 500, often reaching 1,000 or more per machine per year with increased operating shifts.
To realize the severity of the situation portrayed by the map, and have comparable numbers, we must calculate the percentage of cancer patients needing radiotherapy a country can cover with its existing machines by dividing the number of machine they have to the number they need ideally based on country’s annual crude cancer incidence and the above assumptions. One can look more closely at Africa, where the majority of countries lack adequate services.
One among many examples of low availability of radiotherapy is Uganda, where there is only one radiotherapy service available to treat the country’s 27,100 yearly cancer cases. In order to treat the portion of these patients in need of radiotherapy, this single machine must annually treat about 16,000 people, a number that is 32 times the annual number of patients a radiotherapy unit can handle. Today, with the heroic efforts of staff and clinicians at the radiotherapy hospital in Kampala, about a 1,000 of these patients are treated, i.e. 5% coverage and leaving 95% without the opportunity to benefit from radiotherapy. Uganda needs at least about 20 operational radiotherapy units in order to respond adequately to its population demands. The lack of radiotherapy availability greatly reduces the number of patients who can actually receive treatment, and makes provision of treatment an unattainable option for many living in Uganda. The over-reliance on just one unit obviously causes prolonged waiting times for receiving treatment and affects the timing between the administration of radiation doses, which can seriously compromise clinical outcomes and treatment effectiveness16. The situation is not much better elsewhere in Africa. Only Egypt, with 85% coverage of cancer patients needing radiotherapy, Morocco with 89% coverage, and South Africa with about 100% coverage have an acceptable situation, although equitable access to these facilities and patients’ possibility of affording the treatment remains a question discussed further below. Libya also has an adequate number of machines, as can be seen on the radiotherapy map, however not all the machines available are utilized due to lack of cancer professionals31.
Inequity of access to radiotherapy goes beyond just availability. Accessibility of radiotherapy is another challenge. In order for radiotherapy to be accessible, it must be provided in a way that takes into account the geographic distribution of the population and the direct and indirect costs of receiving treatment (considering distances to be travelled by patients and their caring close family members to treatment centres, as well as affordability and distribution of treatment services, among others). Accessibility can even be an issue in upper-middle income countries, which maintain large numbers of cancer centres, but have inconsistencies in treatment accessibility across the country. In Brazil, which has 250 radiotherapy units treating roughly 650 patients per machine, it is estimated that 86,000 patients, or over 25% of all Brazilian cancer patients, have no access to treatment each year, not because of lack of availability, but because of distribution discrepancies32. Over half of all radiotherapy units are located in southern region, and the best-developed centres are in the private sector leaving some entire areas with just a few machines to treat thousands of new patients. These numbers demonstrate that, even if extensive numbers of radiotherapy units are present in a country, it does not guarantee that these units provide equitable access to all of those seeking radiotherapy. Accessibility is even more of a problem where availability is limited. For instance, Zambia, a low-income country, established its first cancer centre in 2006 in Lusaka with IAEA support. Nevertheless, this centre, the only one in the country, is located over 1,000 kilometres from population concentrations near Zambia’s borders, making it much harder for many patients who cannot afford the travel to, and stay in, the capital to seek treatment. These examples demonstrate that radiotherapy must not only be available, it must also be equitably accessible to all populations. Thus, access and not only availability is a vital determinant for outcomes.
Beyond the issues of availability and distribution of radiotherapy facilities, another factor influencing outcomes for patients is affordability of treatment. The costs associated with treatment contribute to the global inaccessibility of cancer services in most countries. For example, when looking at the price of radiotherapy treatment compared to incomes in LMIC, the cost is staggering, and most patients, having no health insurance, would find it impossible to pay for treatment on their own. The inability to pay for treatment could create a different form of inaccessibility that prevents even those in close proximity to a cancer centre from receiving treatment. Even in LMIC that maintain government-owned radiotherapy facilities with the potential to provide therapy for free or at a negligible cost to the patient, these facilities are commonly charged through social security fees, which could make treatment unattainable for the low-income portions of society16. For those who can afford social security, the economic cost of treatment is then shared with the government. In Ethiopia, only a limited portion of the population receives state-provided health insurance, but, even for those lucky enough to have some assistance in paying health costs, when it comes to cancer, the insurance only covers a maximum of 25% of fees spent in public hospitals for diagnostic, surgery and radiotherapy, and provides no support for chemotherapy or palliative care costs. In Indonesia, a different situation can be found, with the poorest segments of society receiving treatment funded by public health insurance, but the “middle class”, being ineligible for public funding, generally do not have the means to pay for relatively expensive treatments offered by private hospitals. Compulsory health insurance is the norm in other countries, such as Moldova, where the state covers 55% of costs, leaving the patient to pay the remaining balance.
With so many diverse methods of costing radiotherapy services for patients in LMIC, it is difficult to say that there is one general cost for radiotherapy, but it can be seen that making treatment affordable to patients requires some form of cost sharing between the patient and the government. When governments bear a portion of cancer treatment cost, that burden is directly based on establishing radiotherapy clinics by procuring and maintaining all the essential equipment, operating the facilities and paying staff. With the average initial investment for a standard (or basic) radiotherapy clinic with two megavoltage units around US$5–6 million (including building, equipment and human resource development – the latter is an essential investment for developing countries as they need to train the workforce for each new cancer clinic), many countries are deterred by such capital costs associated with initiating a national radiotherapy service12. These investments can however be amortised over the life of the building and equipment, which is generally taken as 20 years. Depending on the discount rate used and the type of equipment, this may be in the range of US$250,000 to US$400,000 annually for LMIC. In addition to these costs, there are operational and auxiliary costs for staff salaries, overheads and materials, including source replacement, and quality assurance that are required over time. These costs can run to anything from US$150,000 to US$250,000 annually.
Yet, despite these expenses, the administration of radiotherapy, when evaluated per fraction throughout the lifetime of a machine (normally 20 years), is actually a relatively cheap procedure19. Even after factoring in all levels of cost related to the procurement, maintenance and operation of a machine, estimates from 2004 place the cost per fraction for a cobalt machine at a median of US$4.87 and for linacs at a median of US$11.02 (these figures do not include the costs for physicians)20. Chemotherapy costs estimated in the same manner can reach over US$600 per treatment20. In view of the above and many similar studies, radiotherapy is considered to be a cost-effective intervention. With radiotherapy’s low fraction cost, it has been estimated that, when curative treatment has been received by an individual, upon their return to work, the costs accrued by the government for providing this radiotherapy treatment will be regained in the form of that individual’s economic contribution over the course of a few years. The exact number of years required depends on a country’s gross national income (GNI) per capita as defined by the World Bank33. In a recent study, it was estimated that the mean break-even point on a radiotherapy investment for low-income, low-middle and upper-middle income countries is 12.1, 4.5 and 1.9 years, respectively34. When analysing results from treatment in high-income countries, it is found that 60% of adult cancer patients are still alive five years after treatment, making the prospect of reaching these break-even points quite feasible35,36. In this respect, it could be argued that when investment in a radiotherapy service leads to improved quality of life and survival, radiotherapy could be considered part of a cost-effective solution to the growing cancer problem. However, it must also be noted that curative treatment is not very common in LMIC. Unfortunately, due to the absence of public awareness and adequate cancer services, the majority of cases currently present at stage III or IV, making palliative radiotherapy and end-of-life care the only possible form of treatment.
Outside of the realm of costs, other challenges that can arise in the establishment of a radiotherapy service are in the selection and procurement of radiotherapy equipment. The first issue these days is the choice between cobalt machines and the linear accelerators or linacs. Cobalt-60 units have traditionally been considered the more robust work horses to place in new cancer clinics in developing countries. Their cost is lower, and they are easier to operate for treatment delivery, planning, and maintenance21. However, cobalt machines have become much more sophisticated and their prices have increased. Also the cost of cobalt-60 sources is much higher and there are heightened security concerns after the 9/11 incident making the transport and return of spent sources more complicated. Some linac manufacturers have also provided incentives like participating in the investment at country level through joint ventures (some good examples are in Peru, Turkey and Vietnam). As a result, there are already many developing countries in Asia and Latin America (and a few in Africa) who are operating linacs, though with some maintenance issues. On the other hand, a few manufacturers have recently placed on the market small, single-energy linacs (4-6MeV) at lower overall costs. Others are following suit. Thus, for the LMIC governments or investors, the choices could be soon roughly comparable when combining initial capital and future recurring costs between cobalt and linac machines. It is clear that the current and emerging need for teletherapy units in developing countries cannot be met by cobalt machines alone37. The selection of equipment will depend on the country’s radiotherapy experience and its financial and technical capacity and the available workforce. For cobalt machines, which have a useful life of 20 years, in addition to their increased initial cost, the main issue today is the need to replace the cobalt-60 source every 5–6 years (about US$150,000), requiring often disposal of the old sources at very high costs (US$250,000 to US$350,000, save prior arrangements during procurement). For the cobalt-60 source, special authorization and licensing is required from other countries in transit, unless the supplier is able to use international routes and direct transport means20. For linacs, which can be operated for 10–12 years before replacement, the capital cost is still high and their commissioning, operation, training, QA programmes and maintenance requirements are more complex and costly18,21. For most LMIC, having operated and used cobalts for a number of years, a mix-choice is probably the right approach when resources are available.
The second issue is the choice of the manufacturer. For most LMIC, the radiotherapy manufacturer from which the government is purchasing a unit is generally located far from the purchasing country, most commonly in Europe or North America (though a few more producers have emerged on the market in recent years from Argentina, China, Czech Republic and India). Besides the additional transportation costs associated with this, there are also issues that arise in terms of unit maintenance, particularly the length and extent of a unit’s warranty. If a unit’s warranty or after-sale service is insufficient, countries that are already operating with limited resources could be confronted with the issues of finding a cobalt-60 source replacement or transporting the spent source, or needing to bring in maintenance workers and parts from Europe or North America to repair a broken cobalt or linac unit. All at high costs. Oftentimes, if the warranty has expired, or does not adequately cover the costs, a cancer centre may be forced to leave a machine non-operational, due to insufficient funds to support maintenance and upkeep or source replacement. In order to overcome problems of maintenance and support, it is important to ensure that all acquired equipment comes with a maintenance contract and that the contract is set up with a company with well established service centres close to where the radiotherapy unit will be housed. It would also be beneficial if, in areas that do not have immediate access to a radiotherapy producer, adequate local maintenance staff is trained by the supplier of the radiotherapy units and employed by the cancer centre, helping to drive down the costs associated with long-distance travel between a user and a producer.
Albania’s radiotherapy programme is an example of the difficulties that can arise from the selection and procurement of equipment. Here the issue is insufficient maintenance support despite the country’s serious efforts to provide cancer care services to its citizens. Having purchased one of their radiotherapy units in 2006, the cancer hospital could not at the time afford the annual maintenance proposal of the producer, which was US$110,000 annually or US$2.2 million over the course of the cobalt machine’s expected 20 year lifespan.
Moreover, one of the country’s three machines now requires a source replacement, which, priced at US$150,000, may take some time to acquire, leaving Albania’s nearly 8,000 cancer patients to receive treatment on only two machines38. Yet, there remain more issues that can arise in relation to the technical support needed to run a radiotherapy unit, and that is to do with the available workforce of clinicians, nurses and support staff and their education and training. The number of staff actually involved in the operation of a radiotherapy service can vary between centres, often depending on the number of available qualified professionals. For a basic radiotherapy centre treating up to 1,000 patients a year with two megavoltage teletherapy machines, a high-dose rate brachytherapy unit and other standard equipment such as an imaging device (a conventional or computed tomography simulator), immobilisation devices, shielding devices, a treatment planning computer system and physical dosimetry tools; the IAEA recommends a staffing of around 20 (4–5 radiation oncologists, 3–4 medical physicists, 7 radiation therapy technologists, 3 radiotherapy nurses, and a maintenance engineer)11,19. In more detail, this team consists of a radiation oncologist-in-chief, one staff radiation oncologist per 200–250 patients, one radiation physicist for every 400 patients, one dosimetrist or physics assistant per 300 patients, one mould room technician per 600 patients, four RTTs (radiation therapy technologists) per megavoltage unit treating up to 50 patients per day, 2 RTT-simulation for every 500 patients simulated annually, and RTT-brachytherapy as needed, as well as a nurse for every 300 patients, a social worker, a dietician, a physiotherapist and a maintenance engineer or electronics technician19. The staff requirements will increase if special or advanced techniques such as three dimensional treatment planning or conformal radiotherapy are employed. To ensure sustainability, it is also essential that centres gradually develop their capacity for local training of some of their own staff like technologists and provide continuous education programmes.
Unfortunately, meeting the staff requirements for a radiotherapy clinic is difficult as the world faces a shortfall of 4.3 million trained health workers and 57 countries are currently experiencing a health care workforce crisis, leaving health systems everywhere with insufficient staff available to meet the needs of their patients39. As stated earlier, many cancer clinics across the world are short of specialists, particularly medical physicists and oncology nurses. This is the case for most of Africa, and a significant number of countries in Asia, Latin America, and even Eastern Europe considering the number of new patients and the required staffing. Lack of well trained staff results in inappropriate or underutilization of the scarce radiotherapy facilities in most LMIC. Although some international programmes, such as those supported by the IAEA or ESTRO, offer fellowships for education and training, as well as continuous professional development, for cancer professionals, the number they can train is far below demand.
When looking solely at cancer professionals, it is estimated that in Africa alone there will be a deficit of 3,000 cancer health professionals over the next 10 years40. Education and training of oncology professionals is an urgent issue requiring new and innovative approaches, especially utilization of e-learning and online learning41.
Considering that some of the positions required to establish a radiotherapy service require a university degree, postgraduate studies and at least two years of clinical training, staffing radiotherapy centres will continue to be a challenge in LMIC19. In this context, there is an on-going discussion on the possibility of adjusting the number of professionals managing a megavoltage machine if a less complex linac requiring less dosimetry and less frequent calibration were to be developed. This issue merits a careful expert review. The IAEA guidelines clearly specify that the clinical use of ionizing radiation is a complex process and must involve highly trained personnel in a variety of interrelated activities as described above.
However, the IAEA minimum personnel requirements are adopted from the experience in more developed countries and the recommendations of ESTRO and EFOMP. In 2008, a panel of IAEA experts agreed that the personnel requirements may have to be adjusted for LMIC, where the increased ratio of palliative to radical cases and simpler and shorter treatment protocols reduce the duration of professional involvement with each patient11.
The problem is exacerbated further in LMIC, where a lack of resources and the prospect of better pay drive trained professionals to work in high-income countries. The loss of trained medical professionals in specialized areas such as radiotherapy is an increasing problem, particularly in Africa and parts of Asia. This bears directly on the quality of radiotherapy delivered in LMIC. In many cases, the cancer care professionals who remain in the country have limited access for practice on radiotherapy and other radiation medicine equipment due to a lack of adequate facilities (and time, as most often they work in more than one normal shift), and may require additional training to apply new techniques or to operate newly acquired technologies. Additionally, workforce strength may require that a small group of professionals take on a larger-than-recommended role in the operation of machinery, requiring further specialized training to operate a radiotherapy unit efficiently and effectively.
Finally, as procuring a machine is fruitless without the proper understanding of its utilization and a sufficient workforce to operate it, while procuring a radiotherapy unit it is important that manufacturers be obliged to provide specialized training for local engineers on the use and maintenance of their product in order to ensure that those operating the machine would use it effectively and safely.
The role of the IAEA
Understanding the radiotherapy needs of its developing Member States, the IAEA has, for over forty years, worked in over 100 LMIC to deploy robust radiotherapy and nuclear medicine programmes, expending over US$250 million on cancer-related assistance under its Technical Cooperation Programme42, with technical support provided by its Division of Human Health43. This has enabled many IAEA Member States to establish safe and effective diagnostic radiology, radiotherapy and nuclear medicine capacity to provide treatment and higher quality diagnosis and care to a portion of their cancer patients. The IAEA also assists Member States with appropriate advice and support for human resources capacity building. Where resources are available, this helps Member States to achieve and maintain higher standards of professional practice43.
With the incidence of cancer on the rise in LMIC, there is an increased demand for IAEA assistance to introduce or expand radiotherapy capacity. The resources available to the IAEA are, however, inadequate to address this huge need. But the existing cancer infrastructure in these countries, although far from being able to respond fully to all needs, is potentially the best available launching platform to extend the IAEA’s assistance by encouraging investments in other cancer control components, especially advocacy and public education, cancer registry and surveillance system, prevention, early detection and screening, and palliative care. Recognizing that strategic planning and capacity building for cancer therapy cannot occur without extensive collaboration with other international key players, in 2004 the IAEA established the Programme of Action for Cancer Therapy (PACT)13,44 in support of the World Health Assembly’s call to action against cancer. PACT stands as the IAEA’s umbrella programme for combating cancer and builds upon IAEA’s extensive experience in radiation medicine knowhow and technology10,43. PACT works closely with WHO, its regional offices and other key cancer control stakeholders through the WHO-IAEA Joint Programme on Cancer Control.
The Joint Programme was established in 2009 to enable LMI Member States to improve their cancer control and care capabilities by integrating radiation therapy and nuclear medicine investments into a comprehensive national cancer control programme45.
With LMIC facing an upsurge of cancer incidence rates in the coming years and recognizing that the radiotherapy resources available to fight cancer in LMIC are negligible in some areas and non-existent in others, PACT amongst its several strategic plans has launched an initiative to engage the manufacturers, users and experts in an open forum called the Advisory Group on increasing access to Radiotherapy Technology in low- and middle-income countries (AGaRT)46 to find the way forward to expand radiotherapy facilities. AGaRT, deemed “frugal innovation” by Harvard47, was first conceptualized in 2009 to bring together radiotherapy manufacturers, regional experts and international organizations from around the world to find affordable, suitable and sustainable solutions to address the shortfall of radiotherapy machines in LMIC.
The rationale behind the AGaRT initiative is to make radiotherapy technology accessible to cancer patients all over the world, regardless of their location or financial situation, through the development of radiotherapy packages that address all of the aforementioned issues with provision of radiotherapy services46. By addressing issues of accessibility, affordability, suitability and sustainability, the IAEA through AGaRT works to increase the cost-effectiveness and feasibility of providing radiotherapy treatment and to assist LMIC to tackle their cancer burden in a practical way through partnerships with key organizations and the industry. AGaRT’s aim is to encourage the development of a US$1 million radiotherapy package that integrates all essential radiotherapy technology with high quality and safety, as well as delivery, commissioning, training of maintenance staff and longer term support for maintenance. In addition to the reduced costs associated with such a machine, these radiotherapy packages will also utilize uncomplicated, easy to handle technologies that are simple to control and maintain, allowing countries without experience in operating radiotherapy units to effortlessly transition into radiotherapy use.
Also, to support the long-term sustainability of radiotherapy units, AGaRT encourages the provisions for “whole of life” support packages from radiotherapy suppliers that will ensure affordable functionality for the entire life cycle of a unit46. This will include evolution in the contracting of radiotherapy units, the repatriation and re-supply of radioactive sources, the development of a regional expertise for radiotherapy unit repairs in low-resource settings and financial planning that might make the initial procurement of equipment more expensive, but that has the potential to reduce aggregate costs over time.
Recalling the extreme shortage of resources and staff in LMIC facing ever increasing demand for treatment by a growing number of new cancer patients, it would be desirable to utilize initiatives such as AGaRT to press for megavoltage machines which do not require frequent calibration and dosimetry measurements or perhaps the on-site presence of a medical physicist (thus optimising the time of any physicist available). This could also have a significant impact on the mix of staff required for running a radiotherapy clinic effectively and safely.
There has already been a response to the AGaRT initiative with some radiotherapy manufacturers developing new systems that consist of megavoltage units (4–6 MeV linacs) and include several basic capabilities and software to provide for an integrated treatment system. These systems also include a warranty and training to educate operators on system use. It is hoped that more initiatives like these will continue to develop and be tailored to provide for the individual needs of regions and health systems.
Conclusions
The current situation in most LMIC with an average of less than 30% of all cancer patients having access to any services is totally unacceptable. There is a lot that the international community can do by supporting global partnerships and joint programmes among the various active key players. To meet the needs of the growing number of cancer patients a complete solution will need to be developed that can address all facets of radiotherapy acquisition and use, assisting the ever-growing number of patients in LMIC to access the radiotherapy treatment that they require. More affordable solutions to the cancer epidemic are urgently required as with each passing day the number of those afflicted with the disease climbs and the global impact of cancer continues to grow. Radiation therapy is an essential component of cancer treatment and must be made available to all who need it.
The encouraging news is the high level resolution adopted in September 2011 by the United Nations’ General Assembly on Prevention and Control of Noncommunicable Diseases (NCDs) following the leadership and extensive efforts of WHO, supported by other UN agencies and a significant number of NGOs. This is the first time that the global community has recognized at the highest international forum, with strong support of all countries, the burden of NCDs, including cancer, and their serious social and economic impact in LMIC. The implementation of this resolution, as requested by the General Assembly, will open the way for the donor community to look at successful programmes and interventions that can offer suitable and sustainable solutions for developing countries. In this context, to ensure the development of effective and sustainable treatment capacity in LMIC, radiotherapy and palliative care services should be planned at the national level as an integrated component of a national cancer control programme with careful long-term infrastructure and workforce planning within the scope of targets defined to implement the resolution on NCDs.
The relative success of recent international efforts such as IAEA’s PACT partnership, its AGaRT and VUCCnet initiatives, and the Joint Programme with WHO are encouraging. No doubt such collective efforts, if maintained and strengthened with support from the industry, can play a major role in making radiotherapy technology accessible and affordable to cancer patients all over the world, regardless of their location or financial means. l
