CANCER MANAGEMENT
74 CANCER CONTROL 2014
and huge gaps in access to radiotherapy. The "Closing the
Cancer Divide" report by the Global Task Force on Cancer
Care and Control highlighted that between one third and a
half of global cancer deaths are avoidable and 80% of these
are in low- and middle-income countries.2
One of the largest gaps in access to cancer treatment is in
radiotherapy. Radiation therapy is recognized as an essential
tool in the cure and palliation of cancer, and is indicated in
over half of new cancer patients.
3-12 The number of patients
who would benefit from radiotherapy during the course of
their disease has been reported to range between 40-62%.
The number depends on the extent of disease at
presentation and the profile of the cancers observed in the
population. The profile of cancers seen in childhood and
young adults with high numbers of haematologic
malignancies and fewer solid tumours is associated with a
lower demand in young patients, in those with haematologic
malignancies, and a larger demand in older patients with
solid tumours.
Access to radiotherapy
Radiotherapy plays an important and significant role in the
management of some of the most common cancers in the
world including breast, lung, prostate, cervix, rectal, and
head and neck. In low- and middle-income countries, the
need for radiation therapy may be higher because of the
advanced stage of disease at presentation.
Unfortunately, the access to radiation therapy is
inadequate in many countries. The access to radiotherapy is
seriously limited in many low- and middle-income countries
and non-existent in others. The lack of radiotherapy
resources has been highlighted by the IAEA for several
decades. Although the lack of radiotherapy resources is most
acute in low-income countries, underinvestment in
radiotherapy has been documented in all parts of the world.13
The delays in radiotherapy have been shown to be
associated with poorer outcomes yet waiting lists are
common and access to appropriate care is compromised.14
The IAEA is a United Nations agency that deals with the
nuclear industry. A small part of its efforts are devoted to
radiotherapy. IAEA maintains a voluntary database of global
radiotherapy resources, known as DIRAC.
15 Of the 190
countries that send reports for the IAEA directory, 40 have
no radiotherapy at all. The 2010 IAEA publication estimated
a need for an additional 7,000 radiotherapy machines in the
world. Although the number of radiotherapy machines and
centres is a good surrogate for access, the geographical
distribution of equipment also matters. It has been shown
that the utilization of radiotherapy drops sharply with
increasing distance to the radiotherapy treatment centre.
The recent publication from IAEA stated that 80% of
Africans do not have access to radiotherapy.
16 As a sobering
example, 29 of 52 African nations have no radiotherapy
facilities at all, and these 29 countries comprise an estimated
198 million people. The availability of radiotherapy
equipment varied from 8.6 machines per million people in
high-income countries (per World Bank definition), to 1.6
per million in high-middle income, 0.71 in low-middle income
and 0.21 per million in low-income countries.
A recent review on planning cancer control activities in
Latin America and the Caribbean identified huge disparities
in the availability of radiotherapy with 6 radiotherapy units
per 10 million people reported in Bolivia and 18 machines
for 3.3 million people in Uruguay.17 Although the IAEA
DIRAC database constitutes a useful resource, its validity
has been questioned and the information has not been
independently validated.
Several national and international efforts to improve
radiotherapy planning and to evaluate its cost-effectiveness
have been undertaken. The largest have been the QUARTS
and the HERO project by ESTRO.18,19
Barriers to the implementation of radiotherapy
There are numerous barriers to the effective
implementation of radiotherapy services. In addition to the
fundamental shortage of radiation equipment, the shortages
of qualified personnel including radiation oncologists,
medical physicists and radiation therapists also represents a
barrier. It is difficult to ascertain which comes first, the lack
of investment in equipment leading to shortages of trained
personnel, as there is little incentive to train if radiotherapy
facilities and therefore jobs are not available, or the lack of
trained personnel which limits the decision to invest in the
construction of and the equipment for a new radiotherapy
department. The concept of the "brain drain" is often given
as the cause of personnel shortages but a lack of investment
in jobs may indeed be a stronger driver of shortages.
Although human resources pose a problem, novel ideas on
how to enhance health professionals' education are
emerging.20
Geography presents another barrier to accessing
radiotherapy. A need for a sound geographic distribution of
equipment is highlighted as distance to the cancer facility is a
barrier. In most countries, even high-income countries,
radiotherapy is available in densely populated areas or urban
centres with limited access in rural or sparsely populated
areas.
A number of perceptions limit the investment in