Need for radiotherapy in low and middle income countries – the silent crisis continues

AI-assisted clinical decision making (CDM) for dose prescription in radiosurgery of brain metastases using three-path three-dimensional CNN

Purpose

AI modeling physicians' clinical decision-making (CDM) can improve the efficiency and accuracy of clinical practice or serve as a surrogate to provide initial consultations to patients seeking secondary opinions. In this study, we developed an AI network to model radiotherapy CDM and used dose prescription as an example to demonstrate its feasibility.

Materials/Methods

152 patients with brain metastases treated by radiosurgery from 2017 to 2021 were included. CT images and tumor and organ-at-risk (OAR) contours were exported. Eight relevant clinical parameters were extracted and digitized, including age, numbers of lesions, performance status (ECOG), presence of symptoms, arrangement with surgery (pre- or post-surgery radiation therapy), re-treatment, primary cancer type, and metastasis to other sites. A 3D convolutional neural network (CNN) architecture was built using three encoding paths with the same kernel and filters to capture the different image and contour features. Specifically, one path was built to capture the tumor feature, including the size and location of the tumor, another path was built to capture the relative spatial relationship between the tumor and OARs, and the third path was built to capture the clinical parameters. The model combines information from three paths to predict dose prescription. The actual prescription in the patient record was used as ground truth for model training. The model performance was assessed by 19-fold-cross-validation, with each fold consisting of randomly selected 128 training, 16 validation, and 8 testing subjects.

Result

The dose prescriptions of 152 patient cases included 48 cases with 1 × 24 Gy, 48 cases with 1 × 20-22 Gy, 32 cases with 3 × 9 Gy, and 24 cases with 5 × 6 Gy prescribed by 8 physicians. The AI model prescribed correctly for 124 (82 %) cases, including 44 (92 %) cases with 1 × 24 Gy, 36 (75 %) cases with 1 × 20-22 Gy, 25 (78 %) cases with 3 × 9 Gy, and 19 (79 %) cases with 5 × 6 Gy. Analysis of the failed cases showed the potential cause of practice variations across individual physicians, which were not accounted for in the model trained by the group data. Including clinical parameters improved the overall prediction accuracy by 20 %.

Conclusion

To our best knowledge, this is the first study to demonstrate the feasibility of AI in predicting dose prescription in CDM in radiation therapy. Such CDM models can serve as vital tools to address healthcare disparities by providing preliminary consultations to patients in underdeveloped areas or as a valuable quality assurance (QA) tool for physicians to cross-check intra- and inter-institution practices.

Bridging the Radiotherapy Education Gap in Africa: Lessons Learnt from the Cape Town Access to Care Training Programme Over the Past 5 Years (2015-2019)

The role of radiotherapy (RT) in cancer care is well described, with a clear correlation between access to radiotherapy and overall survival. Cancer mortality rates in Africa are substantially higher than those of the rest of the world, which may be partly attributed to lack of RT access and insufficient human resources. The Access to Care (A2C) Cape Town RT training programme was created in 2014 with the aim of supplementing practical RT training in the region, focusing on clinics moving from 2 to 3D conformal radiotherapy (3DCRT). The programme makes use of hybrid teaching methods, including pre-course e-learning followed by 17 on-site days of free-thinking design exercises, didactic learning, hands-on treatment planning computer sessions (39% of total teaching time), virtual simulation training and departmental demonstration sessions. Email support is offered to all teams for 3 months after each course to develop clinical protocols. Thirteen teams (radiation oncologist, medical physicist and radiation therapy technologist) from Africa attended the course between 2015 and 2019, with additional participants from seven South African and four international centres. E-learning done on the LäraNära training platform was only successful once formal progress tracking was introduced in 2019 (34% vs. 76% test completion rate). Delays between course attendance and initial clinical use of equipment proved to be detrimental to knowledge retention, with some centres having to send a second team for training. The course will be modified for remote teaching in 2021, to make provision for the global changes in travel due to Covid-19.

Real-World Evidence of Health Outcomes Related to Lung Stereotactic Body Radiation Therapy in Brazil

PURPOSE

Stereotactic body radiation therapy (SBRT) is an effective option for patients with both early-stage and oligometastatic non-small-cell lung cancer (NSCLC). However, data from Latin America are limited. Therefore, the aim of this study was to investigate the real-world outcomes of applying SBRT for lung lesions in a Brazilian institution.

METHODS

This study investigated a consecutive cohort of patients treated with SBRT for lung lesions (primary and metastasis). The study primary outcome was local control rates per lesion. Secondary outcomes included progression-free survival (PFS), overall survival (OS), and toxicity.

RESULTS

Between 2015 and 2019, a total of 216 patients received SBRT and were included in the study. The median follow-up was 24.5 months (5-70), primary NSCLC corresponded to 70% (n = 151) and nonprimary lung lesions to 30% (n = 65), respectively. Stage I NSCLC represented 56% (85 of 151) of the NSCLC cohort. The average number of fractions and total dose prescribed was 5 (3-10)/59 Gy (50-62 Gy). For stage I NSCLC (all lesions treated with a biologically effective dose [10] > 100 Gy), 2-year local control, OS, and PFS were 93.4%, 81.6%, and 80.7%, respectively. For stage IV lesions, if biologically effective dose (10) > 100 Gy or < 100 Gy, 2-year local control was 95.8/86.4% (P = .03), 2-year-OS was 81.6/60.5% (P = .006), and 2-year PFS was 38.9/17.9% (P = .10). Late toxicity was observed in 16.2% (n = 35) of the total cases.

CONCLUSION

Our results indicate that SBRT is effective (high local control and acceptable toxicity) for treating malignant lung lesions in a real-world scenario in Latin America.

Using Artificial Intelligence for Optimization of the Processes and Resource Utilization in Radiotherapy

The radiotherapy (RT) process from planning to treatment delivery is a multistep, complex operation involving numerous levels of human-machine interaction and requiring high precision. These steps are labor-intensive and time-consuming and require meticulous coordination between professionals with diverse expertise. We reviewed and summarized the current status and prospects of artificial intelligence and machine learning relevant to the various steps in RT treatment planning and delivery workflow specifically in low- and middle-income countries (LMICs). We also searched the PubMed database using the search terms (Artificial Intelligence OR Machine Learning OR Deep Learning OR Automation OR knowledge-based planning AND Radiotherapy) AND (list of Low- and Middle-Income Countries as defined by the World Bank at the time of writing this review). The search yielded a total of 90 results, of which results with first authors from the LMICs were chosen. The reference lists of retrieved articles were also reviewed to search for more studies. No language restrictions were imposed. A total of 20 research items with unique study objectives conducted with the aim of enhancing RT processes were examined in detail. Artificial intelligence and machine learning can improve the overall efficiency of RT processes by reducing human intervention, aiding decision making, and efficiently executing lengthy, repetitive tasks. This improvement could permit the radiation oncologist to redistribute resources and focus on responsibilities such as patient counseling, education, and research, especially in resource-constrained LMICs.

A new wave of leaders: Early evaluation of the interdisciplinary Foundations of Leadership in Radiation Oncology (FLiRO) program

PURPOSE

Effective leadership across all areas of radiation oncology (RO) is vital to fully realise the benefits of radiation therapy in cancer care. We report outcomes of a novel interdisciplinary leadership program designed for RO professionals under a global joint society initiative.

METHODS

The Foundations of Leadership in RO (FLiRO) program was designed for aspiring RO leaders. Initially delivered in a blended learning format, it was adapted to fully virtual in 2021. It comprised a webinar tutorial, on-line modules and homework followed by 'live' in-person/virtual workshops over an approximately 6-week period. Topics included personal awareness, effective teamwork, quality improvement skills, leading change and conflict management. An immediate post-program online survey was performed using Likert scales to measure self-reported educational value, interaction with others and the likely application of learning to practice. Open comments were invited.

RESULTS

170 participants from 36 countries and 6 continents took part from 2018 to 2021 (99 doctors, 36 physicists, 32 radiation therapists/RTTs and 3 others). 141 (83%) participants responded to the post-program survey. Average weightings for responders' views on whether pre-determined learning objectives were met ranged from 4.30 to 4.61 on a 5-point scale (1 = 'not met at all' and 5 = completely met). For the question addressing potential value of learning for application to their workplace, 124 of 130 (95%) of responders indicated that FLIRO would be 'very useful' or 'extremely useful'.

CONCLUSION

Initial evaluation of the FLiRO program supports its continuation and expansion with ongoing evolution based on emerging evidence around leadership education and participant feedback.

Recommendations for the treatment of vulvar cancer in settings with limited resources: Report from the International Gynecological Cancer Society consensus meeting

Introduction

Due to scant literature and the absence of high-level evidence, the treatment of vulvar cancer is even more challenging in countries facing limited resources, where direct application of international guidelines is difficult. Recommendations from a panel of experts convened to address some of these challenges were developed.

Methods

The panel met in Rio de Janeiro in September 2019 during the International Gynecological Cancer Society congress and was composed of specialists from countries in Africa, Asia, Eastern Europe, Latin America, and the Middle East. The panel addressed 62 questions and provided recommendations for the management of early, locally advanced, recurrent, and/or metastatic vulvar cancer. Consensus was defined as at least 75% of the voting members selecting a particular recommendation, whereas a majority vote was considered when one option garnered between 50.0% and 74.9% of votes. Resource limitation was defined as any issues limiting access to qualified surgeons, contemporary imaging or radiation-oncology techniques, antineoplastic drugs, or funding for the provision of contemporary medical care.

Results

Consensus was reached for nine of 62 (14.5%) questions presented to the panel, whereas a majority vote was reached for 29 (46.7%) additional questions. For the remaining questions, there was considerable heterogeneity in the recommendations.

Conclusion

The development of guidelines focusing on areas of the world facing more severe resource limitations may improve medical practice and patient care.

Cost containment analysis and access to treatment associated with adopting hypofractionated radiation therapy from the Brazilian perspective

Background

Estimates show that breast cancer, the leading cause of cancer death in females worldwide, will continue to increase in incidence, highlighting the need for increased treatment capacity. While postoperative radiation therapy (RT) is commonly used to reduce recurrence and mortality, research has shown that moderately hypofractionated radiation therapy (HFRT) and 5-fraction HFRT are equally safe and effective and can reduce treatment costs. This study aimed to compare the cost of conventional RT (50Gy/25), moderately HFRT (40.05Gy/15), and 5-fraction HFRT (26Gy/5) for breast cancer patients in Brazil.

Methods

The cost of each RT regimen was calculated using the International Atomic Energy Agency's Radiotherapy Cost Estimator Tool. The potential annual savings were then estimated by applying the cost of each regime to the 2020 Brazilian cancer incidence rates.

Findings

The average costs per patient for 25 fractions, 15 fractions, and 5 fractions are $2,699.20, $1,711.98, and $929.81, respectively. The annual cost savings associated with treating 70% of patients with 15 fraction HFRT and 30% of patients with 5 fraction HFRT as compared to treating all patients with 25 fraction RT is $72,929,315.40. The estimated annual productivity of 1 LINAC machine for 25 fractions, 15 fractions, and 5 fractions is 338, 647, and 1,310 patients, respectively.

Interpretation

The cost analysis revealed decreased patients' costs and potential for increased EBRT access associated with HFRT in the Brazilian perspective.

Funding

None.

Failure modes and downtime of radiotherapy LINACs and multileaf collimators in Indonesia

BACKGROUND AND PURPOSE

The lack of equitable access to radiotherapy (RA) linear accelerators (LINACs) is a substantial barrier to cancer care in low- and middle-income countries (LMICs). These nations are expected to bear up to 75% of cancer-related deaths globally by 2030. State-of-the-art LINACs in LMICs experience major issues in terms of robustness, with mechanical and electrical breakdowns resulting in downtimes ranging from days to months. While existing research has identified the higher failure frequency and downtimes between LMICs (Nigeria, Botswana) compared to high-income countries (HICs, the UK), there has been a need for additional data and study particularly relating to multileaf collimators (MLCs).

MATERIALS AND METHODS

This study presents for the first time the analysis of data gathered through a dedicated survey and workshop including participants from 14 Indonesian hospitals, representing a total of 19 LINACs. We show the pathways to failure of radiotherapy LINACs and frequency of breakdowns with a focus on the MLC subsystem.

RESULTS

This dataset shows that LINACs throughout Indonesia are out of operation for seven times longer than HICs, and the mean time between failures of a LINAC in Indonesia is 341.58 h or about 14 days. Furthermore, of the LINACs with an MLC fitted, 59 . 02 - 1.61 + 1.98 $59.02_{ - 1.61}^{ + 1.98}$ % of all mechanical faults are due to the MLC, and 57 . 14 - 1.27 + 0.78 $57.14_{ - 1.27}^{ + 0.78}$ % of cases requiring a replacement component are related to the MLC.

CONCLUSION

These results highlight the pressing need to improve robustness of RT technology for use in LMICs, highlighting the MLC as a particularly problematic component. This work motivates a reassessment of the current generation of RT LINACs and demonstrates the need for dedicated efforts toward a future where cancer treatment technology is robust for use in all environments where it is needed.

Modern Radiotherapy Technology: Obstacles and Opportunities to Access in Low- and Middle-Income Countries

Low- and middle-income countries (LMICs) have a large burden of cancer with differential population needs and outcomes compared to high-income countries. Access to radiotherapy, especially modern technology, is a major challenge. Modern radiotherapy has been demonstrated with better utility in overall cancer outcomes. We deliberate various challenges and opportunities unique to LMICs' set up for access to modern radiotherapy technology in the light of discussions and deliberations made during the recently concluded annual meeting of Tata Memorial Centre, India. We take examples available from various LMICs in this direction in our manuscript.

System-level capacity of high dose rate (HDR) brachytherapy for management of cervical cancer in an upper middle-income country: a case study from Brazil

BACKGROUND

Ensuring optimal access to radiotherapy (RT) facilities is challenging for many countries. External beam RT and brachytherapy (BCT) are required to treat advanced cervical cancer. In this analysis, we evaluate the system-level capacity of brachytherapy in Brazil and its relationship with access to complete cervix cancer radiation treatment with both external beam radiotherapy and BCT.

METHODOLOGY

We used official government reports to compile data on BCT and Linear accelerator (LINAC) numbers, geographic distribution and coverage, cervical cancer annual incidence, and prevalence in Brazil. We also evaluated changes in national BCT capacity between 2001 and 2021. The 2020 relationship between cervical cancer cases for RT per BCT unit, LINAC per BCT unit, and the LINAC supply for each Brazilian state and region were evaluated. For comparison, the LINAC per BCT unit ratio in Brazil was compared with Europe using International Atomic Energy Agency data.

RESULTS

85% (23/27) of Brazilian states have at least one brachytherapy unit; nationally, there are 117 cervical cancer cases for RT per BCT unit. Compared with the benchmark of 200 cervical cancer cases per BCT device per year, there are enough BCT units to fill capacity in Brazil nationally and regionally. The ratio of total cervix cancer cases per BCT unit decreased substantially over time from 142 in 2013 to 117 in 2021 (p<0.0001). Nationally, there are 252 LINAC units in the public system with a ratio of 1,985 new cancer cases/LINAC. Brazilian regions have a LINAC shortage ranging from 15 to 141 units. There were 2.55 LINACs per BCT unit in Brazil, compared with 3.25 in Europe (p=0.012).

CONCLUSION

Over 20 years, BCT capacity in Brazil has increased to meet the cervical cancer demand. However, the LINAC shortage has persisted over the decades, impacting the access to complete treatment and possibly the oncological outcomes. These data can help organize the patient treatment flow, avoid treatment delays, and improve survival.

Development of a Curriculum for the Implementation of Stereotactic Radiation Therapy Programs in Middle-Income Countries

PURPOSE

The aim of this work was to develop a curriculum to be used in the implementation of stereotactic radiation therapy programs in middle-income countries. The curriculum needed to be scalable and flexible to be easily adapted to local situations.

METHODS

The curriculum was developed through a partnership between multidisciplinary teams from established clinics in both middle-income and high-income countries. The curriculum development followed a nonlinear progression, allowing greater flexibility throughout the process. A blended learning model was used, combining virtual and in-person interactions.

RESULTS

The initial training plan was based on a needs assessment provided by the learners and on the experience of the facilitators with stereotactic radiotherapy. The needs assessment was refined during in-person site visits at each institution which highlighted aspects of the training, such as image guidance workflows and technical specifications, that were not previously emphasized in the curriculum. Both teams found that the in-person visits were important for training purposes, but aspects of the curriculum delivery such as treatment planning and patient selection were well suited to virtual platforms. The training addressed all aspects of the stereotactic program, from patient selection to treatment, and included a review of both technical and clinical workflows.

CONCLUSION

The inclusion of contributions from both teams ensured that the curriculum covered the required elements of the stereotactic program implementation, met the needs of the learners, and was relevant to local practices. The nonlinear approach to the curriculum development allowed the flexibility to change the focus as the project progressed. The in-person visits were valuable in conducting a thorough needs assessment.

Inequality in Accessibility of Proton Therapy for Cancers and Its Economic Determinants: A Cross-Sectional Study

Background

Cancer is a leading cause of death in the world, and the estimated new cancer cases were 19 million and the estimated cancer deaths were around 10 million worldwide in 2020. Proton therapy (PT) is a promising treatment for cancers; however, only few patients with cancer received PT due to limited number of PT centers worldwide, especially in low- and middle-income countries.

Methods and Results

Cross-sectional country level data were collected from publicly available information. Lorenz curves and Gini coefficient were used to assess the inequality in accessing to PT, and zero-inflated Poisson models were used to investigate the determinants of number of PT facilities in each country. The Gini coefficients were 0.96 for PT centers and 0.96 for PT chambers, which indicated high level of inequality. Total GDP had a significant impact on whether a country had a practical PT center, whereas total GDP and GDP per capita had significant impacts on the number of PT centers.

Conclusion

Extremely high inequality exists in accessibility of PT centers among all countries in the world. Economic development was the most important factor determining the adoption of PT; thus, with the growth in global economics, more PT centers can be expected in near future.

Cancer Groundshot: Building a Robust Cancer Control Platform in Addition To Launching the Cancer Moonshot

Cancer Groundshot is a philosophy that calls for prioritization of strategies in global cancer control. The underlying principle of Cancer Groundshot is that one must ensure access to interventions that are already proven to work before focusing on the development of new interventions. In this article, we discuss the philosophy of Cancer Groundshot as it pertains to priorities in cancer care and research in low- and middle-income countries and the utility of technology in addressing global cancer disparities; we also address disparities seen in high-income countries. The oncology community needs to realign our priorities and focus on improving access to high-value cancer control strategies, rather than allocating resources primarily to the development of technologies that provide only marginal gains at a high cost. There are several "low-hanging fruit" actions that will improve access to quality cancer care in low- and middle-income countries and in high-income countries. Worldwide, cancer morbidity and mortality can be averted by implementing highly effective, low-cost interventions that are already known to work, rather than investing in the development of resource-intensive interventions to which most patients will not have access (i.e., we can use Cancer Groundshot to first save more lives before we focus on the "moonshots").

Utilization of radiation therapy and predictors of noncompliance among Syrian refugees in Turkey

Background

Access to cancer care is a problem that continues to plague refugees displaced from their home countries. The turbulent political crisis in Syria, which has led to millions of refugees seeking asylum in Turkey, merits further attention. We aimed to study the rate of utilization of radiation therapy among Syrian refugees with cancer living in Turkey in an attempt to identify the contributing factors predictive of non-compliance with prescribed RT.

Methods

In this retrospective review of 14 institutional databases, Syrian refugee patients in Turkey with a cancer diagnosis from January 2015 to December 2019 who were treated with RT were identified. The demographic data, treatment compliance rates, and toxicity outcomes in these patients were surveyed. Variable predictors of noncompliance such as age, sex, diagnosis, treatment length, and toxicity were studied. The association between these variables and patient noncompliance was determined.

Results

We identified 10,537 patients who were diagnosed with cancer during the study period, of whom 1010 (9.6%) patients were treated with RT. Breast cancer (30%) and lung cancer (14%) were the most common diagnoses with up to 68% of patients diagnosed at an advanced stage (Stage III, IV). 20% of the patients were deemed noncompliant. Treatment with concurrent chemoradiotherapy (OR 1.61, 95% CI 1.06–2.46, p = 0.023) and living in a refugee camp (OR 3.62, 95% CI 2.43–5.19, p < 0.001) were associated with noncompliance. Age, sex and treatment length were not significantly associated with noncompliance.

Conclusions

Noncompliance with radiotherapy among Syrian refugees in Turkey remains an area of concern with a multitude of factors contributing to these alarming numbers. Further studies to better ascertain the finer nuances of this intricately complex problem and a global combination of efforts can pave the way to providing a solution.

Toward Improved Outcomes for Patients With Lung Cancer Globally: The Essential Role of Radiology and Nuclear Medicine

PURPOSE

Key to achieving better population-based outcomes for patients with lung cancer is the improvement of medical imaging and nuclear medicine infrastructure globally. This paper aims to outline why and spark relevant health systems strengthening.

METHODS

The paper synthesizes the global lung cancer landscape, imaging referral guidelines (including resource-stratified ones), the reliance of TNM staging upon imaging, relevant multinational health technology assessments, and precisely how treatment selection and in turn patient outcomes hinge upon imaging findings. The final discussion presents data on current global gaps in both diagnostics (including imaging) and therapies and how, informed by such data, improved population-based outcomes are tangible through strategic planning.

RESULTS

Imaging findings are central to appropriate lung cancer patient management and can variably lead to life-prolonging interventions and/or to life-enhancing palliative measures. Early-stage lung cancer can be treated with curative intent but, unfortunately, most patients with lung cancer still present at advanced stages and many patients lack access to both diagnostics and therapies. Furthermore, half of lung cancer cases occur in low- and middle-income countries. The role of medical imaging and nuclear medicine in lung cancer management, as outlined herein, may help inform strategic planning.

CONCLUSION

Lung cancer is the number one cancer killer worldwide. The essential role that medical imaging and nuclear medicine play in early diagnosis and disease staging cannot be overstated, pivotal in selecting the many patients for whom measurably improved outcomes are attainable. Prevention synergized with patient-centered, compassionate, high-quality lung cancer management provision mandate that strategic population-based planning, including universal health coverage strategies, should extend well beyond the scope of disease prevention to include both curative and noncurative treatment options for the millions afflicted with lung cancer.

Longitudinal Remote SBRT/SRS Training in Latin America: A Prospective Cohort Study

Background

Continuing medical education in stereotactic technology are scarcely accessible in developing countries. We report the results of upscaling a longitudinal telehealth training course on stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS), after successfully developing a pilot course in Latin America.

Methods

Longitudinal training on SBRT and SRS was provided to radiation oncology practitioners in Peru and Colombia at no cost. The program included sixteen weekly 1-hour live conferencing sessions with interactive didactics and a cloud-based platform for case-based learning. Participant-reported confidence was measured in 16 SBRT/SRS practical domains, based on a 1-to-5 Likert scale. Pre- and post-curriculum exams were required for participation credit. Knowledge-baseline, pre- and post-curriculum surveys, overall and single professional-group confidence changes, and exam results were assessed.

Results

One hundred and seventy-three radiotherapy professionals participated. An average of 56 (SD ±18) attendees per session were registered. Fifty (29.7%) participants completed the pre- and post-curriculum surveys, of which 30% were radiation oncologists (RO), 26% radiation therapists (RTT), 20% residents, 18% medical physicists and 6% neurosurgeons. Significant improvements were found across all 16 domains with overall mean +0.55 (SD ±0.17, p&lt;0.001) Likert-scale points. Significant improvements in individual competences were most common among medical physicists, RTT and residents. Pre- and post-curriculum exams yielded a mean 16.15/30 (53.8 ± 20.3%) and 23.6/30 (78.7 ± 19.3%) correct answers (p&lt;0.001).

Conclusion

Longitudinal telehealth training is an effective method for improving confidence and knowledge on SBRT/SRS amongst professionals. Remote continuing medical education should be widely adopted in lower-middle income countries.

Treatment of cervical cancer: overcoming challenges in access to brachytherapy

INTRODUCTION

Brachytherapy is an essential component of the cervical cancer treatment paradigm as it contributes to improved clinical outcomes and overall survival. Yet brachytherapy remains globally underutilized, with disparities in access at both national and international levels.

AREAS COVERED

The review explores current brachytherapy utilization practices and efforts being undertaken to address barriers to implementation in low-, middle-, and high-income countries, and how these efforts are projected to impact future brachytherapy access. The content presented is based on a review of published literature and the authors' collective clinical experiences.

EXPERT OPINION

There exists a tremendous opportunity to expand access to essential brachytherapy services for women with cervical cancer. Many national and international brachytherapy efforts exist; yet it remains imperative that such focused efforts continue to grow and provide further access to this critical treatment modality for women in need worldwide.

Impact of time to initiation of postoperative radiotherapy after neoadjuvant chemotherapy on the prognosis of breast cancer: a retrospective cohort study in China

The optimal time to the initiation of postoperative radiotherapy (TTR) in breast cancer patients after neoadjuvant chemotherapy (NAC) and surgery is unclear. We explored the association between TTR and outcomes among breast cancer females to determine the optimal timing for radiotherapy. We included 1022 women with breast cancer who underwent NAC and surgery between 1997 and 2019. Patients were categorized into three groups based on the TTR: <8 weeks, 8-16 weeks, and > 16 weeks. We used Cox proportional hazards models and analyzed the hazard ratios (HRs) for breast cancer-specific mortality (BCSM) and all-cause mortality (ACM). The median TTR for the cohort was 97 days. Compared to patients with TTRs of 8-16 weeks, those with TTRs <8 weeks or > 16 weeks had an increased risk of BCSM (HR, 2.59; 95% confidence interval [CI], 1.26-5.36 and HR, 2.01; 95% CI, 1.24-3.28, respectively) and ACM (HR, 2.32; 95% CI, 1.17-4.56 and HR, 1.92; 95% CI, 1.24-2.98, respectively) after adjusting for the confounders. Furthermore, at TTR of >16 weeks, each additional week of TTR was associated with a 3% increase in BCSM risk and 2% increase in ACM risk. Our findings suggest that patients who have undergone NAC and surgery show lower BCSM and ACM risks at TTR of 8-16 weeks compared with <8 weeks or > 16 weeks. This article is protected by copyright. All rights reserved.

Rhabdomyosarcoma in low- and middle-income countries: A report from the Asociacion de Hemato-oncología Pediatrica de Centro América (AHOPCA)

This report describes the results of an observational study dedicated to rhabdomyosarcoma developed by the Asociación de Hemato-oncología Pediatrica de Centro América (AHOPCA) between 2001 and 2018. Overall, 337 previously untreated patients < 18 years old were included in the analysis; 58% had unresected disease, and 19% were metastatic at diagnosis. With a median follow-up of 6.6 years, five-year event-free and overall survival rates were 30% and 33%, respectively. Local progression/relapse was the main cause of treatment failure.

Neoadjuvant chemotherapy followed by surgery in cervical cancer: past, present and future

Background

Cisplatin-based concurrent chemoradiation is the standard treatment for locally advanced cervical cancer. In view of the difficulties associated with implementation of standard radiation protocols in low- and middle-income countries and the associated toxicities of chemoradiation, neoadjuvant chemotherapy followed by surgery has been tried as an alternative treatment for locally advanced cervical cancer.

Methods

A comprehensive review was undertaken of the existing literature, caveats and potential avenues of neoadjuvant chemotherapy followed by surgery compared with chemoradiation in locally advanced cervical cancer.

Results

Randomized studies conducted in the pre-chemoradiation era comparing neoadjuvant chemotherapy followed by surgery with definitive radiotherapy alone showed favorable outcomes with the chemo-surgical approach. However, contemporary studies evaluating the role of neoadjuvant chemotherapy followed by surgery have failed to establish this approach as the standard. About 25–30% of patients who undergo neoadjuvant chemotherapy remain inoperable and require definitive chemoradiation. A similar proportion of patients would require adjuvant (chemo)radiation after neoadjuvant chemotherapy followed by surgery, resulting in excessive morbidity. Evaluation of time trends across the past few decades reveals that the advancements in delivery of radiation (external beam and brachytherapy) have translated into improvement in outcomes for locally advanced cervical cancer, while a similar trend was not observed for surgery or chemotherapy.

Conclusion

Neoadjuvant chemotherapy followed by surgery cannot be considered a standard of care in patients with locally advanced cervical cancer. This approach needs further clinical research to generate robust high-quality evidence especially for the sub-sets that might potentially benefit in terms of survival, toxicity and quality of life, against the gold standard treatment of concomitant chemoradiation.

The state of gynecologic radiation therapy in low- and middle-income countries

A disproportionate burden of gynecologic malignancies occurs in low- and middle-income countries. Radiation therapy is an integral component of treatment for gynecologic malignancies both from a curative (locally advanced cervical cancer) and palliative (bleeding cervical or pelvic mass) standpoint. Critical to understanding how better to serve patients in this regard is understanding both the extent of disease epidemiology and the radiotherapy infrastructure to treat these diseases. In this review, we explore various geographic regions and how they address a unique set of challenges specific to the peoples and culture of the region. We identify common threads across regions, including sparse distribution of radiation equipment, geographic access, and specialized training. We also highlight examples of success in the use of telemedicine and cross-cultural partnerships to help bolster access to training to ensure increased access to adequate and appropriate treatment of gynecologic malignancies.

Inter-Fractional Variations in Volume and Radiation Dose to the Organs at Risk, High-Risk Clinical Target Volume and Implication of Image-Guided Adaptive Planning During Intracavitary Brachytherapy of Carcinoma Cervix

Background

Geometrical and anatomical variations occur during the brachytherapy of carcinoma cervix and dose optimization is necessary for every fraction of high‑dose rate intracavitary brachytherapy (HDR-ICBT) for carcinoma of the cervix. A single planned treatment is usually delivered for multiple fractions without consideration of inter-fractional applicator positioning variations and organ motion, which may lead to substantial differences between the planned and delivered doses.

Aim and objectives

This study was aimed at evaluating the inter-fractional variation in volume and radiation dose to organs at risk during ICBT for cervical cancer. Furthermore, the doses to high-risk clinical target volume (HRCTV) and the role of adaptive planning in ICBT were assessed.

Materials and methods

Twenty-two patients with carcinoma of the cervix Stage IB2-IVA receiving ICBT were enrolled in the study. All the patients were treated with ICBT four fractions in two applications. For the first application, magnetic resonance imaging-based planning was done, and for the next three fractions, computed tomography (CT) scans were done before every treatment fraction. The CT images were contoured and replanned by keeping the First (I) fraction of each application as the reference. Dose-volume histograms (DVH) were generated, and details of D2cc (DVH on a volume of 2cc) of bladder, rectum, and sigmoid colon (organs at risk-OAR) and D90 HRCTV (dose covering 90%) were documented.

Results

In patients receiving ICBT, variations in OAR D2cc ranged from 1.5 to 2.5Gy for the bladder (p- 0.001), from 2.0 to 3.2Gy (p-0.005) for the rectum and from 1.5 to 3.5Gy for the sigmoid colon (p 0.103). The p-value was significant for D2cc when compared with the OAR volume for the bladder and rectum in both applications, whereas it was not significant for the sigmoid colon. The percentage change in HRCTV coverage was 7% in the first application and by 16% in the second application because of adaptive planning.

Conclusion

Significant variations in doses received by D2cc of the bladder and rectum as well as significant improvement in HRCTV coverage between the fractions were observed because of replanning. Hence, image-guided HDR-ICBT should be incorporated with adaptive planning when delivering in multiple fractions.

Radiation Oncology Residency Training in Latin America, a Call to Attention

Purpose

Despite the call to increase the number of radiation oncologists in Latin America, the quality, similarity, and number of residency training programs are unknown. We seek to describe the current state of residency programs in radiation oncology in Latin America.

Methods and Materials

Latin American Residents in Radiation Oncology performed a cross-sectional analysis of universities and training centers for radiation oncologists in Latin America. Latin American Residents in Radiation Oncology members identified and contacted current residents and specialists at each center to obtain information and documents that described their training curricula.

Results

As of 2020, 13 of 23 (56.5%) Latin American countries have radiation oncology training. Seventy-three training centers were identified (59 active and 14 inactive), associated with 28 universities. On average, each active center trains 2.6 new residents per year, and in total, 156 residents are trained annually. The average length of training programs is 3.6 years. Brazil and Mexico comprise 31 (52.5%) and 7 (11.9%) of active programs, respectively, and 64 (41.8%) and 50 (32.7%) residents, respectively. Training is available in 38 cities in 13 countries, and outside Brazil and Mexico, only 13 cities in 11 countries (9 capitals and 4 noncapital cities). Individualized curriculum documents were provided by 20 (83.3%) of 24 non-Brazilian programs, while 1 standardized guideline was provided for Brazilian training programs. These demonstrated variation between subjects taught, their devoted time, outside specialty rotations, and experiences in modern techniques. Seventy-five percent include volumetric modulated arc therapy, 70% stereotactic radiosurgery, and 55% stereotactic body radiation therapy training. One-hundred percent include gynecologic brachytherapy education and <50% brachytherapy education in other disease sites.

Conclusions

Training is highly centralized in capital cities. The number of trainees is insufficient to close the current human resource divide but is limited by available job openings. Over 50% of training programs now include technological training in stereotactic radiosurgery, stereotactic body radiation therapy, or volumetric modulated arc therapy; however, substantial variation still exists. The development of radiation oncology specialists must be improved and modernized to address the escalating demand for cancer care.

Characteristics Assessment of Online YouTube Videos on Radiotherapy for Lung Cancer

Introduction

The internet has become a mainstay source of health information for cancer patients. Online patient education videos are common; however, there have been no studies examining the quality of publicly available videos on radiotherapy for lung cancer (one of the most common forms of cancer). To fill this knowledge gap, we aim to systematically map and objectively assess videos discussing radiotherapy for lung cancer on YouTube.

Methods

The terms “radiotherapy for lung cancer,” “radiation for lung cancer,” “radiation therapy for lung cancer,” and “radiation treatment for lung cancer” were searched on YouTube using a clear-cache browser. Results were sorted by relevance and the top 50 English-language results for each search were recorded. After removing duplicates, each video was assessed for length, Video Power Index (VPI, which is the product of a video’s average daily views and like and dislike ratio), source, content, comment moderation, and misinformation. Two raters were used to ensure consistency. Results were evaluated using descriptive and inferential statistics.

Results

A total of 88 unique videos resulted from the search. The median video length was 4 minutes and 5 seconds. The average VPI was 10.9 (95% CI: 1.5-20.4) and the median number of views was 954.5. All videos were published between July 8, 2009 and November 18, 2020. Of the videos, 44% were published within the past two years. A total of 61% of the videos were from the USA, 14% were from the UK, 6% from Australia, 5% each from Canada and India, and other countries make up the remaining 10%. Most of the videos were published by healthcare facilities (39%) and non-profit organizations (31%). Content-wise, 95% of videos contain information specific to lung cancer. A total of 46 videos (52%) were targeted toward patient education. Of which, 37 covered radiotherapy for lung cancer, 12 covered side effects for radiotherapy, and 11 covered both. The other 42 videos (48%) were designed for a professional audience. Stereotactic body radiation therapy (SBRT)/stereotactic ablative radiotherapy (SABR) was the most commonly described radiotherapy modality (42%), and the physician interview was the most common format, being used in 59% of videos. Out of the 38 videos with at least one comment, only two (5%) were moderated by the host channel. None of the videos featured misleading information.

Conclusions

This study comprehensively surveyed YouTube videos pertaining to radiotherapy for lung cancer to provide a high-level overview of the information that patients may find online. Although nearly half of the videos describe lung cancer radiotherapy for patients, only a small proportion comprehensively cover both radiotherapy and its side effects. The results of our study can help guide the development of patient education tools and encourage healthcare providers to recognize the limitations of online health information and proactively address patient questions regarding radiotherapy. Future research could examine videos on other lung cancer treatment options or radiotherapy for other cancers.

Assessment of Breast Cancer Management in Sub-Saharan Africa

PURPOSE

To document progress and bottlenecks in breast cancer management in sub-Saharan Africa, subsequent to a 2013 pilot survey conducted through the African Organization for Research and Treatment in Cancer (AORTIC) network.

METHODS

An anonymous survey of breast cancer management was conducted in 2018 among AORTIC members. Results concerning respondent specialty, access to tumor boards, treatment accessibility, diagnostic services, and factors influencing treatment outcomes were compared with the 2013 findings.

RESULTS

Thirty-seven respondents from 30 facilities in 21 sub-Saharan Africa countries responded. The majority (92%) were clinical oncologists. Radiotherapy facilities were available in 70% of facilities. Seventy-eight percent of these had linear accelerators, and 42% had cobalt⁶⁰ machines. Eighty percent of facilities had multidisciplinary tumor boards. Immunohistochemistry was routinely performed in 74% of facilities, computed tomography scan in 90%, bone scan in 16%, and positron emission tomography scans in 5%. Anthracyclines, taxanes, tamoxifen, letrozole, anastrozole, and zoledronic acid were available in the majority; trastuzumab, fertility, and genetic counseling were available in 66%, 58%, and 16%, respectively. There were a 50% increase in oncologist respondents over 2013 and a > 50% increase in radiotherapy facilities, particularly linear accelerators. Availability of trastuzumab, aromatase inhibitors, and taxanes increased. Immunohistochemistry capacity remained the same, whereas facilities harvesting at least 10 axillary lymph nodes increased. Bone scan facilities decreased. Responses suggested improved diagnostic services, systemic therapies, and radiotherapy. Sociocultural and economic barriers, system delays, and advanced stage at presentation remain.

CONCLUSION

Clinicians in sub-Saharan Africa have basic tools to improve breast cancer outcomes, recording positive strides in domains such as radiotherapy and systemic therapy. Socioeconomic and cultural barriers and system delays persist. Workforce expansion must be prioritized to improve quality of care to improve outcomes.

This study highlights the current state of breast cancer management in Sub Saharan Africa, documenting key advancements , challenges and bottlenecks encountered in the sub region. Aside the major aspects of management, pertinent areas such as multidisciplinary tumour board engagements, fertility , genetic counselling and factors affecting outcome were explored. Majority of institutions manage breast cancer patients within a multidisciplinary setting using standard treatment guidelines. The high out of pocket cost of cancer treatment and advanced stage at presentation transcends in many sub Saharan countries negatively impacting outcomes. These results should serve as a benchmark to stakeholders , to guide urgent interventions required to further improve outcomes.

Willingness to pay for high-quality remote radiation oncology training in Latin America

Access to high-quality continuing medical education, particularly in Radiation Oncology, can be challenging in some developing countries due to economic barriers. Despite the current offer of free-access self-educational material, end user training faces a backlog still difficult to overcome. The purpose of this investigation is to report the willingness-to-pay profile of practitioners in Latin America, as a surrogate of quality perception of remote educational resources. Related factors include professional experience and baseline practice confidence levels. Most of practitioners would cover their own expenses, while an increased tendency in less-experienced professionals was observed. However, baseline knowledge confidence levels were not influential in decision making. This report contributes to better know the profile of Latin American professionals, in order to design future educational interventions in the region and bridging the current accessibility gap.

Real-World Treatment Patterns of Lung Cancer in a Resource-Restricted Country: the Experience of Georgia

Lung cancer (LC) is the most common malignancy responsible for 1.8 million of deaths worldwide. Lung and bronchus cancer represents 13% (n = 1217) of all new cancer cases in Georgia. In 2018, in Georgian males lung cancer age-standardized incidence rate was 35.7/per 100 000, less compared to regional countries as Turkey (70.6), Russia (48.2), Ukraine (41.7), and Armenia (58.5), but higher than in neighbor Azerbaijan (25.5). Incidence is higher compared to central and eastern Europe (27.3) and near similar to North America (34.5). Georgia is an Eastern European, middleincome country with 3.7 million residents and one of the highest numbers of active smokers in the European Region. The Georgian health care system is divided into a public and a private sector, with coverage of nearly 100% of the population. There is a national healthcare system as well as private insurance and all patients, irrespective of insurance (private or governmental) can choose the hospital for treatment by themselves all over the country. The Basic Package of the Universal Health Care Program includes the treatment of oncologic patients, specifically surgery, chemotherapy, hormone therapy and radiotherapy and investigations and medications related to these procedures. The program covers all types of laboratory and instrumental investigations related to planned treatment. Georgia lacks an LC screening program for smokers and partially because of this, the majority of patients with lung cancer present at an advanced stage. The National Centre for the Disease Control (NCDC) showed that almost 90% of LC patients in the country present with advanced stages (III-IV) with 60% of patients having stage IV disease at diagnosis . Lung cancer is generally diagnosed at an advanced stage. For non-small cell lung cancer (NSCLC), the proportion with metastatic disease (TNM stage IV) ranged from 46.8% to 61.2% in developed countries. In recent years, there have been several publications addressing specifics of LC worldwide, but none concerning Georgia. In light of the rapidly changing landscape in the diagnosis, staging, and treatment of LC, we thought to define the state of practice in Georgia by convening specialists who treat LC across 13 institutions in our country with the goal to describe differences in access and approaches to LC.

Pediatric cancer care in Africa: SIOP Global Mapping Program report on economic and population indicators

INTRODUCTION

Inalignment with the World Health Organization (WHO) Global Initiative for Childhood Cancer (GICC), the International Society of Pediatric Oncology initiated a program to map global pediatric oncology services. As survival rates in Africa are low and data are scant, this continent was mapped first to identify areas with greatest need.

METHODS

Beginning November 2018, an electronic survey was sent to all known stakeholders, followed by email communications and internet searches to verify data. Availability of pediatric oncologists, chemotherapy, surgical expertise, and radiotherapy was correlated with geographic region, World Bank income status, Universal Health Coverage, population < 15 and < 24 years, percentage of gross domestic product spent on healthcare, and Human Development Index (HDI).

RESULTS

Responses were received from 48/54 African countries. All three treatment modalities were reportedly available in 9/48 countries, whereas seven countries reported no pediatric oncology services. Negative correlations were detected between provision of all three services and geographic region (P = 0.01), younger median population age (P = 0.002), low-income country status (P = 0.045), and lower HDI (P < 0.001).

CONCLUSION

This study provides a comprehensive overview of pediatric oncology care in Africa, emphasizing marked disparities between countries: some have highly specialized services, whereas others have no services. A long-term strategy to eliminate disparities in African pediatric cancer care should be aligned with the WHO GICC aims and facilitated by SIOP Africa.

MEETING ABSTRACTS

SIOP maps pediatric oncology services in Africa to address inequalities in childhood cancer services. Geel J, Ranasinghe N, Davidson A, Challinor J, Howard S, Wollaert S, Myezo K, Renner L, Hessissen L, Bouffet E. 51st Annual Congress of the International Society of Paediatric Oncology (SIOP), Lyon, France, October 2019. Pediatric Blood and Cancer Vol 66 S219-S219. Pediatric cancer care in Africa: SIOP Global Mapping Program report on economic and population indicators.

Estimation of the Need for Radiation Therapy Services According to the Incidence of Cancer in Colombia to 2035

Purpose

To estimate the supply and demand of current and future radiation therapy services by 2035 for Colombia.

Methods and Materials

The present study was performed by surveying different radiation therapy services identified in Colombia through the Colombian Association of Radiation Oncology. The demand was estimated based on incident cases and published information on the use of radiation therapy by type of cancer. Future demand was estimated under the assumption that incidence rates do not change and therefore the change in the number of cases is due to the change in the age structure of the Colombian population. Sensitivity analyses were conducted on the percentage of radiation therapy use by type of cancer. A Monte Carlo simulation was carried out to estimate the distribution of cases requiring radiation therapy, the amount of equipment, and the number of staff needed for care with the use of this technology.

Results

In total, Colombia has 69 linear accelerators, 2 radiosurgery equipment, 30 high-dose-rate brachytherapy pieces of equipment, 124 radiation therapy oncologists (113 working, 9 not working, and 2 not informed), and 275 radiation therapy technologists as of June 2020. It was estimated that to meet the current cancer burden the country would need a total of 162 radiation therapy oncologists, 121 medical physicists, and 323 radiation therapy technologists and to increase the number of radiation therapy technologists, radiation therapy oncologists, and medical physicists to 491, 246, and 184, respectively, to meet the disease burden by 2035 (73,684-88,743 cases per year).

Conclusions

In Colombia it is estimated that there is a deficit of human resources and technology for radiation therapy; therefore, there is need to investment resources from the public and private sectors to provide timely and quality care to cancer patients requiring this treatment.

50 years of radiotherapy research: Evolution, trends and lessons for the future

Rapid and relentless technological advances in an ever-more globalized world have shaped the field of radiation oncology in which we practise today. These developments have drastically modified the habitus¹ of health professionals and researchers at an individual and organisational level. In this article we present an analysis of trends in radiation oncology research over the last half a century. To do so, the data from >350,000 scientific publications pertaining to a yearly search of the PubMed database with the keywords cancer radiotherapy was analysed. This analysis revealed that, over the years, radiotherapy research output has declined relative to alternative cancer therapies, representing 64% in 1970 it decreased to 31% in 2019. Also, the pace of research has significantly accelerated with, in the last 15 years, a doubling in the number of articles published by the 10% most productive researchers. Researchers are also facing stronger competition today with a proportion of first authors that will never get to publish as a last author increasing steadily from 58% in 1970 to 84% in 2000. Additionally, radiotherapy research output is extremely unequally distributed in the world, with Africa and South America contributing to ∼3% of radiotherapy articles in 2019 while representing 23% of the world's population. This disparity, reflecting economic situations and radiotherapy capabilities, has a knock-on effect for the provision of routine clinical treatment. Since research activity is inherent to delivery of high quality clinical care, this contributes to the global inequity of radiotherapy services. Learning from these trends is crucial for the future not only of radiation oncology research but also for effective and equitable cancer care.

Radiation oncology practice during COVID-19 pandemic in developing countries

Radiation therapy (RT) is considered one of the cornerstone modalities of treatment for different cancer types. The preparation and delivery of RT requires a number of staff members from different disciplines within the radiation oncology department. Since the emergence of the corona virus disease 2019 (COVID-19) pandemic, RT, similar to other cancer care modalities, has been adapted to minimize patient and staff exposure without compromising the oncological outcomes. This was reflected in the dramatic practice changes that occurred in the past year to address the lockdown restrictions and fulfill the infection control requirements. RT practices differ across regions based on financial and training levels, and developing countries with limited resources have struggled to maintain radiation treatment services at a level equivalent to that in developed countries while following pandemic control guidelines. The response during the COVID-19 pandemic varied between developing countries according to the infection rate and RT technological capabilities. In this editorial, we review recently published articles addressing radiotherapy practice reports during the COVID-19 pandemic in developing countries.

Radiotherapy resources in Africa: an International Atomic Energy Agency update and analysis of projected needs

The number of patients with cancer in Africa has been predicted to increase from 844 279 in 2012 to more than 1·5 million in 2030. However, many countries in Africa still lack access to radiotherapy as a part of comprehensive cancer care. The objective of this analysis is to present an updated overview of radiotherapy resources in Africa and to analyse the gaps and needs of the continent for 2030 in the context of the UN Sustainable Development Goals. Data from 54 African countries on teletherapy megavoltage units and brachytherapy afterloaders were extracted from the Directory for Radiotherapy Centres, an electronic, centralised, and continuously updated database of radiotherapy centres. Cancer incidence and future predictions were taken from the GLOBOCAN 2018 database of the International Agency for Research on Cancer. Radiotherapy need was estimated using a 64% radiotherapy utilisation rate, while assuming a machine throughput of 500 patients per year. As of March, 2020, 28 (52%) of 54 countries had access to external beam radiotherapy, 21 (39%) had brachytherapy capacity, and no country had a capacity that matched the estimated treatment need. Median income was an important predictor of the availability of megavoltage machines: US$1883 (IQR 914-3269) in countries without any machines versus $4485 (3079-12480) in countries with at least one megavoltage machine (p=0·0003). If radiotherapy expansion continues at the rate observed over the past 7 years, it is unlikely that the continent will meet its radiotherapy needs. This access gap might impact the ability to achieve the Sustainable Development Goals, particularly the target to reduce preventable, premature mortality by a third, and meet the target of the cervical cancer elimination strategy of 90% with access to treatment. Urgent, novel initiatives in financing and human capacity building are needed to change the trajectory and provide comprehensive cancer care to patients in Africa in the next decade.

Hypofractionation: less is more?

One third of patients with bladder cancer present with muscle invasive bladder cancer (MIBC) which has a poor prognosis. International guidelines for the management of MIBC recommend radical cystectomy or bladder-preserving treatment based on radical radiotherapy with a form of radiosensitisation. In the UK, both conventional fractionation with 64 Gy in 32 fractions and hypofractionation with 55 Gy in 20 fractions are standard of care options with the choice varying between centres. A meta-analysis of individual patients with locally advanced bladder cancer from two UK multicentre phase 3 trials was published recently. This study evaluated the non-inferiority of a hypofractionated schedule compared to a conventional regime. This analysis confirmed the non-inferiority of the hypofractionated regimen, and noted superior locoregional control. We discuss the relevance of these findings to current practice while considering the radiobiology of hypofractionation, the role of systemic therapies and radiosensitisation, as well as the socioeconomic benefits.

Patterns of Palliative Radiotherapy Utilization for Patients With Metastatic Breast Cancer in Harare, Zimbabwe

PURPOSE

In sub-Saharan Africa, radiotherapy (RT) utilization and delivery patterns have not been extensively studied in patients with metastatic breast cancer.

METHODS

A retrospective cohort study of female patients with metastatic breast cancer seen at Parirenyatwa Radiotherapy Centre in Zimbabwe from 2014 to 2018 was conducted. Demographics, pathology, staging, and treatment data were abstracted through chart review. Fisher's exact test and chi-squared test of independence were used to compare proportions, and independent two-sample t-tests were used to compare means.

RESULTS

Of 351 patients with breast cancer, 152 (43%) had metastatic disease, median age 51 years (interquartile range: 43-61 years). Of those with metastatic disease, 30 patients (20%) received radiation to various metastatic sites: 16 spine; three nonspine bone metastases; six whole brain; and five chest wall or supraclavicular. Patients who received radiation were younger (46 v 52 years; P = .019), but did not differ significantly by performance status than those who did not. The most common dose prescription was 30 Gy in 10 fractions (33%). Five (17%) patients had treatment interruption and two (7%) had treatment noncompletion. Province of origin and clinical tumor stage were significant predictors of RT receipt (P = .002; and P = .018, respectively).

CONCLUSION

A minority of patients with metastatic breast cancer received RT (20%), and these were likely to be younger, with advanced tumor stage, and resided in provinces where RT is available. Conventional courses were generally prescribed. There is a need to strongly consider palliative RT as an option for patients with metastatic breast cancer and use of hypofractionated courses (e.g. 8 Gy in one fraction) may support this goal.

Global Radiotherapy: Current Status and Future Directions-White Paper

Recognizing the increase in cancer incidence globally and the need for effective cancer control interventions, several organizations, professional bodies, and international institutions have proposed strategies to improve treatment options and reduce mortality along with minimizing overall incidence. Despite these efforts, an estimated 9.6 million deaths in 2018 was attributed to this noncommunicable disease, making it the second leading cause of death worldwide. Left unchecked, this will further increase in scale, with an estimated 29.5 million new cases and 16.3 million deaths occurring worldwide in 2040. Although it is known and generally accepted that cancer services must include radiotherapy, such access is still very limited in many parts of the world, especially in low- and middle-income countries. After thorough review of the current status of radiotherapy including programs worldwide, as well as achievements and challenges at the global level, the International Atomic Energy Agency convened an international group of experts representing various radiation oncology societies to take a closer look into the current status of radiotherapy and provide a road map for future directions in this field. It was concluded that the plethora of global and regional initiatives would benefit further from the existence of a central framework, including an easily accessible repository through which better coordination can be done. Supporting this framework, a practical inventory of competencies needs to be made available on a global level emphasizing the knowledge, skills, and behavior required for a safe, sustainable, and professional practice for various settings. This white paper presents the current status of global radiotherapy and future directions for the community. It forms the basis for an action plan to be developed with professional societies worldwide.

Radiotherapy Practice for Treatment of Bone Metastasis in Ethiopia

PUROSE

Ethiopia has one cobalt radiotherapy (RT) machine to serve a population of more than 100 million. The purpose of this study was to report on patterns of palliative RT of bone metastasis in a severely low-capacity setting.

PATIENTS AND METHODS

Patient and treatment characteristics of patients irradiated for palliation of symptomatic bone metastasis were extracted from a retrospective database of patients treated between May 2015 and January 2018. This database included a random sample of 1,823 of the estimated 4,000 patients who were treated with RT within in the study period. Associations between the applied RT schedule and patient and tumor characteristics were evaluated with the χ² test. Hypothetical savings of RT sessions and time were compared in the case of a single-fraction policy.

RESULTS

From the database, 234 patients (13%) were treated for bone metastasis. Most patients were ≤ 65 years of age (n = 189; 80%) and female (n = 125; 53%). The most common primary sites were breast (n = 82; 35%) and prostate (n = 36; 15%). Fractionated regimens were preferred over single fraction: 20 Gy in 5 fractions (n = 192; 82.1%), 30 Gy in 10 fractions (n = 7; 3%), and 8 Gy in 1 fraction (n = 28; 12%). Factors associated with single-fraction RT included nonaxial sites of bone metastasis (P < .01) and an address outside Addis Ababa (P ≤ .01). If single-fraction RT would have been given uniformly for bone metastasis, this would have resulted in a 78% reduction in the number of RT sessions and 76% reduction in total RT time.

CONCLUSION

The pattern of palliative RT for bone metastasis in Ethiopia favors fractionated regimens over single fraction. Efforts should be made to adopt evidence-based and cost-effective guidelines.

Radiation Oncology in the Land of the Pyramids: How Sudan Continues to Push the Frontiers of Cancer Care in Eastern Africa

When faced with illness, Sudanese patients have traditionally relied primarily on folklore healers. In the recent past, Sudan increased its health care spending and placed ever-greater importance on medical education. Although traditional remedies still play an important role, Sudanese patients increasingly consult conventional medicine. Not only infectious diseases but also a rising burden of noncommunicable conditions, including cancer, represent major health care challenges. Therefore, Sudan will need to make the best out of the limited resources available and further increase investment in health care to confront these trends successfully. Sudan was one of the first African countries to recognize the importance of radiation oncology in multidisciplinary cancer care and began investing in it in the 1960s. Today, there are 4 comprehensive cancer centers in the country, which offer radiation therapy and employ 10 radiation therapy machines for a population of about 45 million people. This proportion is an indication that Sudan still has an underfunded health care system with a lack of infrastructure and human resources. The present manuscript intends to provide a well-rounded overview of radiation oncology in Sudan today.

Can the Adoption of Hypofractionation Guidelines Expand Global Radiotherapy Access? An Analysis for Breast and Prostate Radiotherapy

PURPOSE

The limited radiotherapy resources for global cancer control have resulted in increased interest in developing time- and cost-saving innovations to expand access to those resources. Hypofractionated regimens could minimize cost and increase access for limited-resource countries. In this investigation, we estimated the percentage cost-savings per radiotherapy course and increased radiotherapy access in African countries after adopting hypofractionation for breast and prostate radiotherapy. For perspective, results were compared with high-income countries.

METHODS

The cost and course of breast and prostate radiotherapy for conventional and hypofractionated regimens in low-resource facilities were calculated using the Radiotherapy Cost Estimator tool developed by the International Atomic Energy Agency (IAEA) and then compared with another activity-based costing model. The potential maximum cost savings in each country over 7 years for breast and prostate radiotherapy were then estimated using cancer incidence data from the Global Cancer Observatory database with use rates applied. The increase in radiotherapy access was estimated by current national capacities from the IAEA directory.

RESULTS

The estimated cost per course of conventional and hypofractionated regimens were US$2,232 and $1,339 for breast treatment, and $3,389 and $1,699 for prostate treatment, respectively. The projected potential maximum cost savings with full hypofractionation implementation were $1.1 billion and $606 million for breast and prostate treatment, respectively. The projected increase of radiotherapy access due to implementing hypofractionation varied between +0.3% to 25% and +0.4% to 36.0% for breast and prostate treatments, respectively.

CONCLUSION

This investigation demonstrates that adopting hypofractionated regimens as standard treatment of breast and prostate cancers can result in substantial savings and increase radiotherapy access in developing countries. Given reduced delivery cost and treatment times, we anticipate a substantial increase in radiotherapy access with additional innovations that will allow progressive hypofractionation without compromising quality.

External Beam Radiotherapy in Western Africa: 1969-2019

AIMS

We describe the absolute and per capita numbers of megavoltage radiotherapy machines (MVMs) in Western Africa from 1969 to 2019.

MATERIALS AND METHODS

Western Africa was defined in accordance with the United Nations' delineation and inclusive of 16 countries. A literature search for publications detailing the number of cobalt-60 machines (COs) and linear accelerators (LINACs) in radiotherapy centres was carried out. Population data from the World Bank Group and crude cancer rates from the International Agency for Research on Cancer were used to calculate ratios of million persons per MVM and MVMs per 1000 cancer cases.

RESULTS

The numbers of MVMs in Western Africa in 1969, 1979, 1989, 1999 and 2009 were zero, two, three, six and nine, respectively. In 2019 there were 22 MVMs distributed across Ghana (five), Côte d'Ivoire (two), Mali (one), Mauritania (two), Nigeria (nine) and Senegal (three). Nine countries (56.3%) had no history of external beam radiotherapy (EBRT). The largest increase in absolute EBRT capacity occurred from 2017 to 2019, during which 13 MVMs were commissioned. The largest decrease in EBRT capacity occurred from 2015 to 2017, during which four LINACs and three COs were rendered non-operational. The ratio of million persons per MVM improved from 67.0 in 1979 to 17.8 in 2019. As of 2019, there was 0.09 MVM per 1000 cancer cases.

CONCLUSIONS

Western African nations have experienced an increase in the absolute number of MVMs and per capita radiotherapy capacity during the last 50 years, especially in the last decade. As non-functional LINACs contributed to a temporary decline in the EBRT infrastructure, dual use of CO/LINAC technologies may act to promote the availability of EBRT treatment in centres with capacity for multiple MVMs.

Surveying the Challenges to Improve Linear Accelerator-based Radiation Therapy in Africa: a Unique Collaborative Platform of All 28 African Countries Offering Such Treatment

Radiation therapy is a critical component for curative and palliative treatment of cancer and is used in more than half of all patients with cancer. Yet there is a global shortage of access to this treatment, especially in Sub-Saharan Africa, where there is a shortage of technical staff as well as equipment. Linear accelerators (LINACs) offer state-of-the-art treatment, but this technology is expensive to acquire, operate and service, especially for low- and middle-income countries (LMICs), and often their harsh environment negatively affects the performance of LINACs, causing downtime. A global initiative was launched in 2016 to address the technology and system barriers to providing radiation therapy in LMICs through the development of a novel LINAC-based radiation therapy system designed for their challenging environments. As the LINAC prototype design phase progressed, it was recognised that additional information was needed from LMICs on the performance of LINAC components, on variables that may influence machine performance and their association, if any, with equipment downtime. Thus, a survey was developed to collect these data from all countries in Africa that have LINAC-based radiation therapy facilities. In order to understand the extent to which these performance factors are the same or different in high-income countries, facilities in Canada, Switzerland, the UK and the USA were invited to participate in the survey, as was Jordan, a middle-income country. Throughout this process, LMIC representatives have provided input on technology challenges in their respective countries. This report presents the method used to conduct this multilevel study of the macro- and microenvironments, the organisation of departments, the technology, the training and the service models that will provide input into the design of a LINAC prototype for a LINAC-based radiation therapy system that will improve access to radiation therapy and thus improve cancer treatment outcomes. It is important to note that new technology should be introduced in a contextual manner so as not to disrupt existing health systems inadvertently, especially with regards to existing staffing, infrastructure and socioeconomic issues. A detailed analysis of data is underway and will be presented in a follow-up report. Selected preliminary results of the study are the observation that LINAC-based facilities in LMICs experience downtime associated with failures in multileaf collimators and vacuum pumps, as well as power instability. Also, that there is a strong association of gross national product per capita with the number of LINACs per population.

MRE11 as a molecular signature and therapeutic target for cancer treatment with radiotherapy

MRE11, the core of the MRE11/RAD50/NBS1 complex, is one of key DNA damage response proteins. Increasing evidence suggests that its expression in cancer cells is critical to developing radioresistance; as such, MRE11 is an emerging marker for targeted radiosensitization strategies. Elevated MRE11 in tumor tissues has been associated with poor survival in patients undergoing radiotherapy, although in some cancer types, the opposite has been noted. The recent discovery of ionizing radiation-induced truncation of MRE11, which decreases its efficacy, may explain some of these paradoxical findings. The progress of research on the biological modulation of MRE11 expression is also discussed, with the potential application of small molecule or large molecule inhibitors of MRE11 for enhancing radiosensitivity. Current research has further highlighted both nuclease and non-nuclease activities of MRE11 in cancer cells treated with ionizing radiation, and differentiation between these is essential to verify the targeting effects of radiosensitizing agents. These updates clarify our understanding of how MRE11 expression may be utilized in future stratification of cancer patients for radiotherapy, and how it may be leveraged in shaping novel radiosensitization strategies.

Mobilising stakeholders to improve access to state-of-the-art radiotherapy in low- and middle-income countries

In an ongoing effort to improve access to state-of-the-art radiotherapy in low- and middle-income countries (LMICs), a joint symposium was organised by the non-governmental, non-profit organisation Medical physicists in diaspora for Africa e.V. (MephidA e.V.) in collaboration with the Germany-based Cameroon-German medical doctor’s association (Camfomedics e.V.) and the Harvard-based Global Health Catalyst summit. The goal of the symposium was to discuss the technical and structural challenges faced in African LMIC settings, re-evaluate strategies to overcome the shortfall of radiotherapy services and ameliorate the situation. The meeting brought together industry partners, including radiotherapy machine vendors and dosimetry solution providers, alongside public health, oncology and medical physics experts. This paper summarises the deliberations and recommendations based on the ongoing efforts including the use of information and communication technologies towards the provision of expert knowledge and telemedicine, the use of solar energy to avoid power outages and the use of high-end technology for enhanced quality assurance. We also present the experiences on the first linac installation at the Rwanda Military Hospital, the challenges faced in this LMIC as well as the patient’s demography, reflecting the reality in most sub-Saharan LMICs.