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Cury FL, Viani GA, Gouveia AG, Moraes FY. In reply to Niu et al: Meta-analysis of 5-day preoperative radiotherapy for soft tissue sarcoma (5D-PREORTS). Radiother Oncol 2024; 195:110255. [PMID: 38522598 DOI: 10.1016/j.radonc.2024.110255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/21/2024] [Indexed: 03/26/2024]
Affiliation(s)
- Fabio L Cury
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, McGill University, Montreal, Canada.
| | - Gustavo A Viani
- Ribeirao Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Andre G Gouveia
- Department of Oncology - Division of Radiation Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Canada
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Silverwood S, Lichter K, Conway A, Drew T, McComas KN, Zhang S, Gopakumar GM, Abdulbaki H, Smolen KA, Mohamad O, Grover S. Distance Traveled by Patients Globally to Access Radiation Therapy: A Systematic Review. Int J Radiat Oncol Biol Phys 2024; 118:891-899. [PMID: 37949324 DOI: 10.1016/j.ijrobp.2023.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/30/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE This study aimed to systematically review the literature on the travel patterns of patients seeking radiation therapy globally. It examined the distance patients travel for radiation therapy as well as secondary outcomes, including travel time. METHODS AND MATERIALS A comprehensive search of 4 databases was conducted from June 2022 to August 2022. Studies were included in the review if they were observational, retrospective, randomized/nonrandomized, published between June 2000 and June 2022, and if they reported on the global distance traveled for radiation therapy in the treatment of malignant or benign disease. Studies were excluded if they did not report travel distance or were not written in English. RESULTS Of the 168 studies, most were conducted in North America (76.3%), with 90.7% based in the United States. Radiation therapy studies for treating patients with breast cancer were the most common (26.6%), while external beam radiation therapy was the most prevalent treatment modality (16.6%). Forty-six studies reported the mean distance traveled for radiation therapy, with the shortest being 4.8 miles in the United States and the longest being 276.5 miles in Iran. It was observed that patients outside of the United States traveled greater distances than those living within the United States. Geographic location, urban versus rural residence, and patient population characteristics affected the distance patients traveled for radiation therapy. CONCLUSIONS This systematic review provides the most extensive summary to date of the travel patterns of patients seeking radiation therapy globally. The results suggest that various factors may contribute to the variability in travel distance patterns, including treatment center location, patient residence, and treatment modality. Overall, the study highlights the need for more research to explore these factors and to develop effective strategies for improving radiation therapy access and reducing travel burden.
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Affiliation(s)
- Sierra Silverwood
- Michigan State University College of Human Medicine, Grand Rapids, Michigan.
| | - Katie Lichter
- Department of Radiation Oncology, University of California, San Francisco, California
| | | | - Taylor Drew
- Stritch School of Medicine, Maywood, Illinois
| | - Kyra N McComas
- Department of Radiation Oncology Vanderbilt University Medical Center, Nashville, Tennessee
| | - Siqi Zhang
- Biostatistics Analysis Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Hasan Abdulbaki
- University of California, San Francisco, School of Medicine, San Francisco, California
| | | | - Osama Mohamad
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Botswana-UPenn Partnership, Philadelphia, Pennsylvania
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Gouveia AG, Viani GA, Bratti VF, Marta GN, Hanna SA, Jacinto AA, Silva MS, Hamamura AC, Rosa AA, Castilho MS, Carson L, Hopman WM, Sullivan R, Booth CM, Aggarwal A, Hanna TP, Moraes FY. Challenges in building radiotherapy capacity: A longitudinal study evaluating eight years of the Brazilian radiotherapy expansion plan. J Cancer Policy 2024; 39:100459. [PMID: 38029960 DOI: 10.1016/j.jcpo.2023.100459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 11/12/2023] [Accepted: 11/23/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND In 2012, the Brazilian government launched a radiotherapy (RT) expansion plan (PER-SUS) to install 100 linear accelerators. This study assesses the development of this program after eight years. METHODS Official reports from the Ministry of Health (MoH) were reviewed. RT centres projects status, timeframes, and cost data (all converted to US dollars) were extracted. The time analysis was divided into seven phases, and for cost evaluation, there were five stages. The initial predicted project time (IPPT) and costs (estimated by the MoH) for each phase were compared between the 18 operational RT centres (able to treat patients) and 30 non-operational RT centres using t-tests, ANOVA, and the Mann-Whitney U. A p-value < 0.05 indicates statistical significance. RESULTS A significant delay was observed when comparing the IPPT with the overall time to conclude each 48 RT centres project (p < 0.001), with considerable delays in the first five phases (p < 0.001 for all). Moreover, the median time to conclude the first 18 operational RT centres (77.4 months) was shorter compared with the 30 non-operational RT centres (94.0 months), p < 0.001. The total cost of 48 RT services was USD 82,84 millions (mi) with a significant difference in the per project median total cost between 18 operational RT centres, USD1,34 mi and 30 non-operational RT centres USD2,11 mi, p < 0.001. All phases had a higher cost when comparing 30 non-operational RT centres to 18 operational RT centres, p < 0.001. The median total cost for expanding existing RT centres was USD1,30 mi versus USD2,18 mi for new RT services, p < 0.0001. CONCLUSION After eight years, the PER-SUS programs showed a substantial delay in most projects and their phases, with increased costs over time. POLICY SUMMARY Our findings indicate a need to act to increase the success of this plan. This study may provide a benchmark for other developing countries trying to expand RT capacity.
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Affiliation(s)
- Andre G Gouveia
- Department of Oncology, Division of Radiation Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, ON, Canada; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
| | - Gustavo A Viani
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Ribeirão Preto Medical School, Department of medical imagings, hematology and oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Vanessa F Bratti
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Gustavo N Marta
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Department of Oncology, Division of Radiation Oncology, Sírio Libanes Hospital, São Paulo, Brazil
| | - Samir A Hanna
- Department of Oncology, Division of Radiation Oncology, Sírio Libanes Hospital, São Paulo, Brazil
| | - Alexandre A Jacinto
- Radiation Oncology Department, Barretos Cancer Hospital, Barretos, SP, Brazil
| | - Mauricio S Silva
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Unit, Santa Maria Federal University, Santa Maria; and Clínica de Radioterapia de Santa Maria, Brazil
| | - Ana C Hamamura
- Ribeirão Preto Medical School, Department of medical imagings, hematology and oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Arthur A Rosa
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiotherapy Department Oncoclinicas Salvador and Hospital Santa Izabel, Salvador, BA, Brazil
| | - Marcus S Castilho
- Radiotherapy Department of the Felicio Rocho Hospital, Belo Horizonte, MG, Brazil; President, Brazilian Radiotherapy Society - SBRT, Brazil
| | - Laura Carson
- Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON, Canada; Department of Oncology, Queen's University, Kingston, ON, Canada
| | - Wilma M Hopman
- Kingston General Health Research Institute; Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Richard Sullivan
- Institute of Cancer Policy, Global Oncology Group, King's College London, London, UK
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON, Canada; Department of Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Ajay Aggarwal
- Department of Oncology, Queen's University, Kingston, ON, Canada; Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK; Department of Clinical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Timothy P Hanna
- Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON, Canada; Department of Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada; Department of Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Fabio Y Moraes
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON, Canada; Department of Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada.
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de Vocht DE, Schnog JJB, Merkies IS, Samson MJ. Untoward global effects of current guideline formulation of stereotactic radiotherapy for symptomatic brain metastases by international medical societies. LANCET REGIONAL HEALTH. AMERICAS 2023; 25:100584. [PMID: 37681018 PMCID: PMC10480773 DOI: 10.1016/j.lana.2023.100584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 09/09/2023]
Abstract
The quality of evidence leading to new oncological treatments suffers shortcomings, as has recently been addressed for drug approvals. In this 'Personal view', we evaluate the unintended effects of adopting stereotactic radiosurgery as the standard of care for patients with limited number of symptomatic brain metastases and favourable prognostic factors in international guidelines in view of the limitations in the evidence of efficacy and effectiveness, with special focus on countries with relatively limited resources.
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Affiliation(s)
| | - John-John B. Schnog
- Department of Haematology and Medical Oncology, Curaçao Medical Center, Willemstad, Curaçao
- Curaçao Biomedical & Health Research Institute, Willemstad, Curaçao
| | - Ingemar S. Merkies
- Department of Neurology, School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Neurology, Curaçao Medical Center, Willemstad, Curaçao
| | - Michael J. Samson
- Department of Radiation Oncology, Curaçao Medical Center, Willemstad, Curaçao
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Rosa AA, de Sousa CFPM, Pimentel LCF, Martins HL, Moraes FY, Marta GN, Castilho MS. Radiotherapy resources in Brazil (RT2030): a comprehensive analysis and projections for 2030. Lancet Oncol 2023; 24:903-912. [PMID: 37541272 DOI: 10.1016/s1470-2045(23)00284-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND The demand for radiotherapy in Brazil is unfulfilled, and the scarcity of data on the national network hampers the development of effective policies. We aimed to evaluate the current situation, estimate demands and requirements, and provide an action plan to ensure access to radiotherapy for those in need by 2030. METHODS The Brazilian Society for Radiation Oncology created a task force (RT2030) including physicians, medical physicists, policy makers, patient advocates, and suppliers, all of whom were major stakeholders involved in Brazilian radiotherapy care. The group was further divided into seven working groups to address themes associated with radiotherapy care in Brazil. From March 1, 2019, to Aug 3, 2020, there were monthly meetings between the group's leaders and the Central Committee and six general meetings. First, a comprehensive search of all different national databases was done to identify all radiotherapy centres. Questionnaires evaluating radiotherapy infrastructure and human resources and assing the availability, distribution, capacity, and workload of resources were created and sent to the radioprotection supervisor of each centre. Results were analysed nationally and across the country's regions and health-care systems. A pre-planned review of available databases was done to gather data on active radiation oncology centres and the distribution of radiotherapy machines (linear accelerators [LINACs]) across Brazil. We used national population and cancer incidence projections, recommended radiotherapy usage from the medical literature, and national working patterns to project radiotherapy demands in 2030. An action plan was established with suggestions to address the gaps and meet the demands. FINDINGS The database search yielded 279 centres with an active radiotherapy registry. After applying predefined exclusion criteria, 263 centres were identified that provided external beam radiotherapy machines with or without brachytherapy. All 263 operational centres answered the questionnaires sent on Dec 9, 2019, which were then returned between Jan 1 and June 30, 2020. There were 409 therapy machines, 646 radiation oncologists, 533 physicists, and 230 989 patients undergoing radiotherapy (150 628 [65·2%] in the public health-care system and 80 937 [35·0%] in private). The mean annual occupation rate was 566 patients per treatment machine (SD 250). The number of residents per treatment machine ranged from 258 333 to 1 800 000. Technology availability varied considerably among regions and systems. In 2030, 639 994 new cancer cases are expected, which will require 332 797 radiotherapy courses. Therefore, 530 LINACs, 1079 radiation oncologists, and 1060 medical physicists will be needed. INTERPRETATION The expected increase in cancer incidence in the coming years will probably increase the disparities in cancer care and the burden for Brazilian patients. We provide a roadmap of the current situation and the particularities of the Brazilian radiotherapy network, which can serve as a starting point for cancer policy planning to improve this scenario. FUNDING Accuray, BRAINLAB, Elekta, IBA, ONE medical solution, SUN NUCLEAR corporation, VARIAN, and ZIGMA.
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Affiliation(s)
- Arthur Accioly Rosa
- Grupo Oncoclínicas, Salvador, Bahia, Brazil; Latin America Cooperative Oncology Group, Porto Alegre, Brazil
| | | | | | | | - Fabio Ynoe Moraes
- Latin America Cooperative Oncology Group, Porto Alegre, Brazil; Department of Oncology, Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada.
| | - Gustavo Nader Marta
- Latin America Cooperative Oncology Group, Porto Alegre, Brazil; Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil
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Andrade DAP, Veneziani AC, Paiva CE, dos Reis R, Filho CAF, Sanches AON, Barroso AWA, Paz ACMC, Kons GCDM, Preto DD, Budib MCB, Safro MA, Pinto GSF, Bilibio JP, Souza CDP. Discrepancies in breast cancer's oncological outcomes between public and private institutions in the southeast region of Brazil: a retrospective cohort study. Front Oncol 2023; 13:1169982. [PMID: 37441430 PMCID: PMC10333566 DOI: 10.3389/fonc.2023.1169982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/30/2023] [Indexed: 07/15/2023] Open
Abstract
Background Brazil is a middle-income country with inequalities in its healthcare system. The disparities between public and private services affect the diagnosis and treatment of patients with breast cancer. The aim of this study is to assess whether disease-free survival (DFS) and overall survival (OS) are different in public and private specialized centers. Patient and methods A retrospective cohort study with 1,545 breast cancer patients diagnosed from 2003 to 2011 at Barretos Cancer Hospital-BCH (public group, N = 1,408) and InORP Oncoclinicas (private group, N = 137) was conducted. A 1:1 propensity score matching (PSM) analysis was used to adjust the differences between the groups' characteristics (n = 137 in each group). Results The median age at diagnosis was 54.4 years. Estimated DFS rates at 1, 5, and 10 years were 96.0%, 71.8%, and 59.6%, respectively, at BCH and 97.8%, 86.9%, and 78%, respectively, at InORP (HR: 2.09; 95% confidence interval [CI], 1.41-3.10; p < 0.0001). Estimated OS rates at 1, 5, and 10 years were 98.1%, 78.5%, and 65.4%, respectively, at BCH and 99.3%, 94.5%, and 91.9%, respectively, at InORP (HR: 3.84; 95% CI, 2.16-6.82; p < 0.0001). After adjustment by PSM, DFS and OS results in 1, 3, and 5 years remained worse in the public service compared to the private service. Conclusion Patients treated in a public center have worse DFS and OS after a follow-up period of more than 5 years. These results were corroborated after carrying out the PSM.
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Affiliation(s)
- Diocésio Alves Pinto Andrade
- Clinical Oncology Department, InORP Oncoclínicas Group, Oncology Institute of Ribeirão Preto, Ribeirão Preto, Brazil
| | | | - Carlos Eduardo Paiva
- Clinical Oncology Department, Division of Breast and Gynecologic, Barretos Cancer Hospital, Barretos, Brazil
| | - Ricardo dos Reis
- Gynecologic Oncology Department, Barretos Cancer Hospital, Barretos, Brazil
| | - Carlos Alberto Fruet Filho
- Clinical Oncology Department, InORP Oncoclínicas Group, Oncology Institute of Ribeirão Preto, Ribeirão Preto, Brazil
| | | | | | | | | | - Daniel D’Almeida Preto
- Clinical Oncology Department, Division of Urology, Barretos Cancer Hospital, Barretos, Brazil
| | | | | | | | | | - Cristiano de Pádua Souza
- Clinical Oncology Department, Division of Breast and Gynecologic, Barretos Cancer Hospital, Barretos, Brazil
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da Fonte ALF, Costa GJ, da Fonte Neto AS, Pinto RA, de Mello MJG. Epidemiology of laryngeal cancer in Brazil: Historical data from 2000 to 2019. Cancer Epidemiol 2023; 85:102397. [PMID: 37327505 DOI: 10.1016/j.canep.2023.102397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/30/2023] [Accepted: 06/03/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION To determine the incidence, morbidity, and mortality rate of laryngeal cancer in two decades and its epidemiological, clinical, and histological characteristics by sex in Brazil. METHODS This ecological study used three reliable sources of secondary data: population- and hospital-based cancer registries and the national mortality database. All data available from 2000 to 2019 were considered. RESULTS The incidence of male laryngeal cancer decreased from 9.20 to 4.95 per 100,000 from 2000 to 2018, while mortality slightly decreased from 3.37 to 3.30 per 100,000 from 2000 to 2019. In the same period, the female incidence decreased from 1.26 to 0.48 per 100,000; however, mortality slightly increased from 0.34 to 0.36 per 100,000. Of 221,566 individuals with head and neck cancer, 27 % presented laryngeal cancer. The median age was 61 years (54-69), and most individuals were male (86.6 %), smokers (66.2 %), diagnosed with locally advanced cancer (66.7 %), and squamous cell carcinoma as the main histological type (93.2 %). Male tended to be older (p < 0.001), white (p < 0.001), smokers (p < 0.001), and present late treatment initiation (p < 0.001) and early death (p < 0.001) compared with female. CONCLUSION The male laryngeal cancer affected mainly at productive age but with a decreased incidence, probably due to a reduction in smoking habit. However, mortality did not change, which may be explained by the late diagnosis and lack of access to radiotherapy.
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Affiliation(s)
- Ana Luiza Fassizoli da Fonte
- Department of Radiotherapy, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Pernambuco, Brazil; Department of Education and Research, Hospital de Câncer de Pernambuco, Recife, Pernambuco, Brazil
| | - Guilherme Jorge Costa
- Department of Education and Research, Hospital de Câncer de Pernambuco, Recife, Pernambuco, Brazil; Department of Pneumology, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Pernambuco, Brazil.
| | - Adilis Stepple da Fonte Neto
- Department of Education and Research, Hospital de Câncer de Pernambuco, Recife, Pernambuco, Brazil; Department of Head and Neck Surgery, Hospital de Câncer de Pernambuco, Recife, Pernambuco, Brazil
| | - Rodrigo Alves Pinto
- Department of Education and Research, Hospital de Câncer de Pernambuco, Recife, Pernambuco, Brazil; Department of Oncology, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Pernambuco, Brazil
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Nadella P, Iyer HS, Manirakiza A, Vanderpuye V, Triedman SA, Shulman LN, Fadelu T. Geographic Accessibility of Radiation Therapy Facilities in Sub-Saharan Africa. Int J Radiat Oncol Biol Phys 2023; 115:557-563. [PMID: 36725167 DOI: 10.1016/j.ijrobp.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 10/04/2022] [Accepted: 10/09/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE Access to radiation therapy in Sub-Saharan Africa (SSA) remains unacceptably low. Prior studies have focused on how many radiation therapy machines a country has but have not accounted for geographic accessibility, which is a known barrier to radiation therapy compliance. In this study, we describe accessibility measured as travel time by road to radiation therapy in SSA. METHODS AND MATERIALS This study used geographic information systems modeling techniques. A list of radiation therapy facilities was obtained from the Directory of Radiotherapy Centres. We obtained a 1 km2 surface of travel times using a least-cost-path algorithm implemented in Google Earth Engine (Google, Mountain View, CA). AccessMod 5 (World Health Organization, Geneva, Switzerland) was used to compute the percentage of each country's population with access to a radiation therapy facility within prespecified one-way travel time intervals. We then ranked countries using 3 measures of access: 2-hour geographic access, units per capita, and units per cancer case. RESULTS Only 24.4% of the population of SSA can access a radiation therapy facility within 2 hours of travel by road; access was 14.6% and 42.5% within 1 and 4 hours, respectively. More than 80% of Rwandans and South Africans were within 2 hours of radiation therapy, the highest in the region. Although countries with more radiation therapy units per capita tended to have higher 2-hour access, there was notable discordance between the 2 measures. Mauritania, Zambia, Sudan, and Namibia were among the top 10 countries ranked by machines per capita, but none ranked in the top 10 by 2-hour geographic access. There was similar discordance between 2-hour access and radiation therapy units per cancer case; Rwanda, Nigeria, Senegal, and Cote d'Ivoire ranked in the top 10 for the former but ranked worse using units per cancer case. CONCLUSIONS Prior measures of radiation therapy access provide an incomplete picture. Geographic location of radiation therapy centers is a crucial component of access that should be considered for future planning in SSA.
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Affiliation(s)
- Pranay Nadella
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Hari S Iyer
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Verna Vanderpuye
- National Center for Radiotherapy, Oncology and Nuclear Medicine, Korlebu Teaching Hospital, Accra, Ghana
| | - Scott A Triedman
- Center for Global Cancer Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts; Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Lawrence N Shulman
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Temidayo Fadelu
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts; Center for Global Cancer Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts.
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In Reply to Chang et al. Int J Radiat Oncol Biol Phys 2023; 115:248-249. [DOI: 10.1016/j.ijrobp.2022.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 08/09/2022] [Indexed: 12/15/2022]
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Sarria GR, Martinez DA, Li B, Castillo RD, Salgado A, Pinillos L, Felix A, Bobadilla I, Ferraris G, Castilho M, Carmona J, Leon B, Aviles L, Ricagni L, Isa N, Flores C, Giordano FA, Zubizarreta EH, Polo A, Sarria GJ. Leveling Up the Access to Radiation Therapy in Latin America: Economic Analysis of Investment, Equity, and Inclusion Opportunities Up to 2030. Int J Radiat Oncol Biol Phys 2022; 116:448-458. [PMID: 36549348 DOI: 10.1016/j.ijrobp.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/30/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Latin America faces a shortage in radiation therapy (RT) units and qualified personnel for timely and high-quality treatment of patients with cancer. Investing in equitable and inclusive access to RT over the next decade would prevent thousands of deaths. Measuring the investment gap and payoff is necessary for stakeholder discussions and capacity planning efforts. METHODS AND MATERIALS Data were collected from the International Atomic Energy Agency's Directory of Radiotherapy Centers, industry stakeholders, and individual surveys sent to national scientific societies. Nationwide data on available devices and personnel were compiled. The 10 most common cancers in 2020 with RT indication and their respective incidence rates were considered for gap calculations. The gross 2-year financial return on investment was calculated based on an average monthly salary across Latin America. A 10-year cost projection was calculated according to the estimated population dynamics for the period until 2030. RESULTS Eleven countries were included in the study, accounting for 557,213,447 people in 2020 and 561 RT facilities. Approximately 1,065,684 new cancer cases were diagnosed, and a mean density of 768,469 (standard deviation ±392,778) people per available unit was found. By projecting the currently available treatment fractions to determine those required in 2030, it was found that 62.3% and 130.8% increases in external beam RT and brachytherapy units are needed from the baseline, respectively. An overall regional investment of approximately United States (US) $349,650,480 in 2020 would have covered the existing demand. An investment of US $872,889,949 will be necessary by 2030, with the expectation of a 2-year posttreatment gross return on investment of more than US $2.1 billion from patients treated in 2030 only. CONCLUSIONS Investment in RT services is lagging in Latin America in terms of the population's needs. An accelerated outlay could save additional lives during the next decade, create a self-sustaining system, and reduce region-wide inequities in cancer care access. Cash flow analyses are warranted to tailor precise national-level intervention strategies.
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Affiliation(s)
- Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany; Rayos Contra Cancer, Inc, Nashville, Tennessee.
| | - David A Martinez
- Rayos Contra Cancer, Inc, Nashville, Tennessee; Department of Radiation Oncology, Oncosalud-Auna, Lima, Peru
| | - Benjamin Li
- Rayos Contra Cancer, Inc, Nashville, Tennessee; Department of Radiation Oncology, University of California, San Francisco, California
| | | | - Apolo Salgado
- Department of Radiation Oncology, Instituto Nacional del Cancer, Santiago de Chile, Chile
| | - Luis Pinillos
- Department of Radiation Oncology, Oncosalud-Auna, Lima, Peru
| | - Armando Felix
- Department of Radiation Oncology, Hospital de Oncologia Centro Medico Nacional Siglo XXI - IMSS, Mexico City, Mexico
| | - Ivan Bobadilla
- Radiotherapy Unit, Luis Carlos Sarmiento Angulo Cancer Treatment and Research Center - CTIC, Bogota, Colombia
| | - Gustavo Ferraris
- Radiotherapy Unit, Centro de Radioterapia Dean Funes, Cordoba, Argentina
| | - Marcus Castilho
- Radiotherapy Center, Hospital Felicio Rocho, Belo Horizonte, Brazil
| | - Jorge Carmona
- Radiotherapy Unit, Oncoserv, Santiago de los Caballeros, Dominican Republic
| | - Barbara Leon
- Radiotherapy Technical Unit, Hospital Carlos Andrade Marín, Quito, Ecuador
| | | | - Leandro Ricagni
- Department of Radiation Oncology, Hospital de Clinicas, Montevideo, Uruguay
| | - Nicolas Isa
- Department of Radiation Oncology, Clinica IRAM, Santiago de Chile, Chile
| | - Claudio Flores
- Department of Epidemiology and Applied Research, Auna Ideas, Lima, Peru
| | - Frank A Giordano
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | | | - Alfredo Polo
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Gustavo J Sarria
- Department of Radiation Oncology, Oncosalud-Auna, Lima, Peru; Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
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11
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Faroni L, Ferreira CG, Moraes F, Baldotto C, Zukin M, Aran V, Araujo LH. Real-World Evidence of Health Outcomes Related to Lung Stereotactic Body Radiation Therapy in Brazil. JCO Glob Oncol 2022; 8:e2200061. [PMID: 36351211 PMCID: PMC10166467 DOI: 10.1200/go.22.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Lilian Faroni
- Instituto COI de Pesquisa e Ensino, Rio de Janeiro, Brazil.,Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil
| | | | - Fabio Moraes
- Department of Oncology, Kingston General Hospital Queens University, Ontario, Canada
| | - Clarissa Baldotto
- Instituto COI de Pesquisa e Ensino, Rio de Janeiro, Brazil.,Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil
| | - Mauro Zukin
- Instituto COI de Pesquisa e Ensino, Rio de Janeiro, Brazil
| | - Veronica Aran
- Instituto Estadual do Cérebro Paulo Niemeyer (IECPN), Rio de Janeiro, Brazil
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12
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Corrêa FM, Migowski A, de Almeida LM, Soares MA. Cervical cancer screening, treatment and prophylaxis in Brazil: Current and future perspectives for cervical cancer elimination. Front Med (Lausanne) 2022; 9:945621. [PMID: 36091685 PMCID: PMC9449345 DOI: 10.3389/fmed.2022.945621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/03/2022] [Indexed: 11/13/2022] Open
Abstract
As a middle-income country, Brazil has one of the largest public health systems worldwide, which deals with free and universal access to health care. Regarding cervical cancer, the country possesses a large infrastructure for the screening of premalignant and malignant lesions, but yet based on old technology, having Papanicolaou as the major screening method, followed by colposcopy and treatment. Also, large disparities in access are present, which makes effectiveness of screening and treatment in different regions of the country highly unequal. In this review, we describe and evaluate the current screening, treatment and prophylactic (HPV vaccination) strategies to combat cervical cancer in Brazil, and discuss potential incorporation of more recent technologies in these areas in the country to pave its way toward cervical cancer elimination.
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Affiliation(s)
- Flávia M. Corrêa
- Cancer Early Detection Division, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Brazil
| | - Arn Migowski
- Cancer Early Detection Division, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Brazil
| | - Liz M. de Almeida
- Coordination of Prevention and Surveillance, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Brazil
| | - Marcelo A. Soares
- Oncovirology Program, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Brazil
- Department of Genetics, Universidade Federal Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
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13
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de Moraes FY, Marta GN, Mitera G, Forte DN, Pinheiro RN, Vieira NF, Gadia R, Caleffi M, Kauer PC, de Camargo Barros LH, Mathias C, da Conceicao Vasconcelos KGM, Booth C, Dos Santos Fernandes G. Choosing Wisely for oncology in Brazil: 10 recommendations to deliver evidence-based cancer care. Nat Med 2022; 28:1738-1739. [PMID: 35941378 DOI: 10.1038/s41591-022-01924-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Fabio Ynoe de Moraes
- Department of Oncology, Queen's University, Kingston, ON, Canada. .,Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Brazil.
| | - Gustavo Nader Marta
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Brazil.,Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo/Brasília, Brazil
| | | | - Daniel Neves Forte
- Palliative Care Program, Hospital Sírio-Libanês, Sao Paulo, Brazil.,Medical Emergencies ICU, Hospital das Clínicas, Sao Paulo University, São Paulo, Brazil
| | - Rodrigo Nascimento Pinheiro
- Vice President (2021-2023), Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil.,Surgical Oncology Residency at Hospital de Base, Distrito Federal, Brazil
| | | | - Rafael Gadia
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo/Brasília, Brazil
| | - Maira Caleffi
- Hospital Moinhos de Vento Porto Alegre, Porto Alegre, Brazil
| | | | | | | | | | - Christopher Booth
- Department of Oncology, Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen's University, Kingston, ON, Canada
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14
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Scott AA, Polo A, Zubizarreta E, Akoto-Aidoo C, Edusa C, Osei-Bonsu E, Yarney J, Dwobeng B, Milosevic M, Rodin D. Geographic Accessibility and Availability of Radiotherapy in Ghana. JAMA Netw Open 2022; 5:e2226319. [PMID: 35951324 PMCID: PMC9372791 DOI: 10.1001/jamanetworkopen.2022.26319] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Radiotherapy is critical for comprehensive cancer care, but there are large gaps in access. Within Ghana, data on radiotherapy availability and on the relationship between distance and access are unknown. OBJECTIVES To estimate the gaps in radiotherapy machine availability in Ghana and to describe the association between distance and access to care. DESIGN, SETTING, AND PARTICIPANTS This is a cross-sectional, population-based study of radiotherapy delivery in Ghana in 2020 and model-based analysis of radiotherapy demand and the radiotherapy utilization rate (RUR) using the Global Task Force on Radiotherapy for Cancer Control investment framework. EXPOSURES Receipt of radiotherapy and the number of radiotherapy courses delivered. MAIN OUTCOMES AND MEASURES Geocoded location of patients receiving external beam radiotherapy (EBRT); median Euclidean distance from the district centroids to the nearest radiotherapy centers; proportion of population living within geographic buffer zones of 100, 150, and 200 km; additional capacity required for optimal utilization; and geographic accessibility after strategic location of a radiotherapy facility in an underserviced region. RESULTS A total of 2883 patients underwent EBRT courses in 2020, with an actual RUR of 11%. Based on an optimal RUR of 48%, 11 524 patients had an indication for radiotherapy, indicating that only 23% of patients received treatment. An investment of 23 additional EBRT machines would be required to meet demand. The median Euclidean distance from the district centroids to the nearest radiotherapy facility was 110.6 km (range, 0.62-513.2 km). The proportion of the total population living within a radius of 100, 150 and 200 km of a radiotherapy facility was 47%, 61% and 70%, respectively. A new radiotherapy facility in the northern regional capital would reduce the median of Euclidean distance by 10% to 99.4 km (range, 0.62-267.7 km) and increase proportion of the total population living within a radius of 100, 150 and 200 km to 53%, 69% and 84%, respectively. The greatest benefit was seen in regions in the northern half of Ghana. CONCLUSIONS AND RELEVANCE In this cross-sectional study of geographic accessibility and availability of radiotherapy, Ghana had major national deficits of radiotherapy capacity, with significant geographic disparities among regions. Well-planned infrastructure scale-up that accounts for the population distribution could improve radiotherapy accessibility.
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Affiliation(s)
- Aba Anoa Scott
- National Centre for Radiotherapy and Nuclear Medicine, Korle Bu Teaching Hospital, Accra, Ghana
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Global Cancer Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Alfredo Polo
- International Atomic Energy Agency, Vienna, Austria
| | | | - Charles Akoto-Aidoo
- National Centre for Radiotherapy and Nuclear Medicine, Korle Bu Teaching Hospital, Accra, Ghana
| | - Clement Edusa
- Oncology Department, Sweden Ghana Medical Centre, Accra, Ghana
| | - Ernest Osei-Bonsu
- National Radiotherapy and Nuclear Medicine Centre, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Joel Yarney
- National Centre for Radiotherapy and Nuclear Medicine, Korle Bu Teaching Hospital, Accra, Ghana
| | - Bismark Dwobeng
- National Radiotherapy and Nuclear Medicine Centre, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Michael Milosevic
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Global Cancer Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Global Cancer Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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15
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de Siqueira GS, Hanna SA, de Moura LF, Miranda FA, Carvalho HDA, Marta GN. Moderately hypofractionated radiation therapy for breast cancer: A Brazilian cohort study. LANCET REGIONAL HEALTH. AMERICAS 2022; 14:100323. [PMID: 36777384 PMCID: PMC9903971 DOI: 10.1016/j.lana.2022.100323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Background Results from numerous clinical trials have led to a consensus that moderately hypofractionated radiation therapy is the ideal postoperative irradiation treatment plan in patients with breast cancer (BC). However, there are specific situations such as chest wall (with or without breast reconstruction) and regional node irradiation that still face obstacles in its widespread use. There is a lack of evidence supporting the use of moderately hypofractionated irradiation from the Latin American context. This study aims to describe the profile and clinical outcomes of patients treated with moderate hypofractionation for both early-stage (Stage I and II) and locally advanced BC (Stage III) regardless of the type of surgery in a Brazilian Oncology Center. Methods All patients with non-metastatic BC who were treated with moderately hypofractionated schedules of 40Gy in 15 fractions or 42.4Gy in 16 fractions between 2010 to 2019 at Hospital Sírio-Libanês, Brazil were retrospectively analyzed. The rates of local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS), distance recurrence-free survival (DRFS) and overall survival (OS) were estimated. Acute and late toxicity profiles were accessed for the entire cohort. Findings A total of 670 patients were included. The median age was 57 years and the median follow-up time was 31 months. Most of the patients had stage I and II breast cancer, and 81.6% underwent breast-conserving surgery. Of the 123 women who underwent mastectomy treatment, 29% (n = 37) had immediate reconstruction with implants and 28% (n = 35) with autologous tissue. Seventy-one per cent of the patients presented luminal subtype tumour and 84.3% received adjuvant hormonal therapy. Chemotherapy was administered to almost half of the patients and all 80 patients with Her-2 positive disease received trastuzumab-based systemic therapy. One-third of patients received regional node irradiation; boost was performed in 41.1% of treatments. The 5-year LRFS, RRFS, DRFS and OS was 95.6%, 97.6%,92.2% and 95.9%, respectively. Acute and late side effects profile were mild and only 2.9% of patients developed grade 3 dermatitis. Among patients with breast implants, 11.4% had capsular contracture. Interpretation In this Brazilian institution experience, moderately hypofractionated irradiation to the breast, chest wall (with or without breast reconstruction), and regional lymph nodes was safe and with an acceptable toxicity profile. Funding None.
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Affiliation(s)
| | - Samir A. Hanna
- Department of Radiation Oncology, Hospital Sírio-Libanês, Brazil
| | | | | | - Heloísa de Andrade Carvalho
- Department of Radiation Oncology, Hospital Sírio-Libanês, Brazil,Latin American Cooperative Oncology Group, Porto Alegre, Brazil
| | - Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, Brazil,Latin American Cooperative Oncology Group, Porto Alegre, Brazil,Corresponding author at: Department of Radiation Oncology, Hospital Sírio, Libanês, Rua Dona Adma Jafet 91. Sao Paulo, SP. Brazil. 01308-050.
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16
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Hanna SA, Gouveia AG, Moraes FY, Rosa AA, Viani GA, Massuda A. Lessons from the Brazilian radiotherapy expansion plan: A project database study. LANCET REGIONAL HEALTH. AMERICAS 2022; 14:100333. [PMID: 36777394 PMCID: PMC9903577 DOI: 10.1016/j.lana.2022.100333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background The Radiotherapy Expansion Plan for Brazil's Unified Health System (PER-SUS) was an innovative program designed by the Ministry of Health in 2012 to provide improvements to the challenging problem of access to radiotherapy in the country. This study sought to analyze the execution and implementation of installations proposed by PER-SUS, and their capacity to address the problems of radiotherapy access in Brazil. Methods From the first release (February 2015) until October 2021, all PER-SUS monthly progress reports were retrospectively analyzed. The beneficiary institutions, project location, project status, project type, dates of the progress on the stages, and reasons for cancellations or possible justifications for changing the status were collected. Brazilian geographic data, health care demands, and cancer incidences were correlated. Finally, we performed an Ishikawa diagram and 5W3H methodology, aiming to better understand the findings and to yield possible ways to improve the access to radiotherapy. Findings After ten years, the PER-SUS project delivered nearly 50% of the planned implementation of radiotherapy equipment. There was a 17% growth in the national number of linear accelerators (LINACS) with PER-SUS, against a 32% increase in cancer incidence in Brazil in the same period. The following points were identified: a high rate of beneficiary exclusions reflecting inappropriate selection or inadequate planning; delays in execution related to bureaucratic obstacles and underestimation of the requirements (logistics/people); early closing of the equipment factory as a result of lack of project prioritization by the Government. Interpretation Only about 50% of PER-SUS are being carried out. However, delays and exclusions of beneficiaries were observed. The dimension of the need for radiotherapy care in Brazil is greater than considered, and might not be fully attended by PER-SUS. Geographic, epidemiological, logistical, and economic variables could be reevaluated to allow better strategic planning and improvement proposals. PER-SUS could be optimized for the next decade, by involving all stakeholders' participation, alignment, and engagement. In the future, the States and regions with a higher LINAC shortage should be prioritized to improve RT access across the country. Considering the data and the initial project deadline, PER-SUS did not achieve the pre-established goals specified by the Brazilian Government. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Affiliation(s)
- Samir Abdallah Hanna
- Radiation Oncology Department, Hospital Sírio-Libanês, São Paulo, SP, Brazil,Corresponding author.
| | - Andre Guimaraes Gouveia
- Radiation Oncology Department, Américas Centro de Oncologia Integrado, Rio de Janeiro, RJ, Brazil
| | - Fabio Ynoe Moraes
- Department of Oncology, Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Arthur Accioly Rosa
- Radiation Oncology Department, Oncoclinicas Salvador, Hospital Santa Izabel, Salvador, Brazil
| | - Gustavo Arruda Viani
- Ribeirão Preto Medical School, Department of Medical Imaging, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Adriano Massuda
- School of Business Administration, Fundação Getulio Vargas (FGV EAESP), São Paulo, SP, Brazil
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