Brachytherapy in India - a long road ahead

Current status and future readiness of Indian radiation oncologists to embrace prostate high-dose-rate brachytherapy: An Indian Brachytherapy Society survey

Purpose

This survey aimed to understand the practice pattern and attitude of Indian doctors towards prostate brachytherapy.

Material and methods

A 21-point questionnaire was designed in Google form and sent to radiation oncologists practicing in India, using texts, mails, and social media. Responses were collated, and descriptive statistical analysis was performed.

Results

A total of 212 radiation oncologists from 136 centers responded to the survey questionnaire, with majority (66%) being post-specialty training > 6 years. We found that about 44.3% (n = 94) of respondents do not practice interstitial brachytherapy for any site, and majority (83.3%, n = 175) do not practice high-dose-rate (HDR) prostate brachytherapy. Only 2.8% (n = 6) of doctors preferred boost by brachytherapy compared with 38.1% (n = 80) of respondents, who favored stereotactic body radiation therapy (SBRT) boost. When asked about the indication of HDR prostate brachytherapy in Indian setting, 32.5% (n = 67) of respondents favored monotherapy, 46.1% (n = 95) of oncologists thought boost as a good indication, and 21.4% (n = 44) preferred re-irradiation/salvage setting. The most cited reason for prostate brachytherapy not being popularly practiced in India was lack of training (84.8%, n = 179). It was also noted that out of 80 respondents who practiced SBRT for prostate boost, 37 would prefer HDR brachytherapy boost if given adequate training and facilities.

Conclusions

The present survey provided insight on practice of prostate brachytherapy in India. It is evident that majority of radiation oncologists do not practice HDR prostate brachytherapy due to lack of training and infrastructure. Indian physicians are willing to learn and start prostate brachytherapy procedures if dedicated training and workshops are organized.

Health Services Research in Brachytherapy: Current Understanding and Future Challenges

Brachytherapy is an integral component of cancer care. Widespread concerns have been expressed though about the need for greater brachytherapy availability across many jurisdictions. Yet, health services research in brachytherapy has lagged behind that in external beam radiotherapy. Optimal brachytherapy utilisation, to help inform expected demand, have not been defined beyond the New South Wales region in Australia, with few studies having reported observed brachytherapy utilisation. There is also a relative lack of robust cost and cost-effectiveness studies, making investment decisions in brachytherapy even more uncertain and challenging to justify, despite its key role in cancer control. As the range of indications for brachytherapy expands, providing organ/function preservation for a wider range of diagnoses, there is an urgent need to redress this balance. By outlining the work undertaken in this area to date, we highlight its importance and explore where further study is required.

Geographic and demographic distribution and access to brachytherapy in India with its implications on cancer care

PURPOSE

Geographic access to medical care varies for nearly every specialty in India. Given the special nature of its treatments, which sometimes necessitate numerous visits over a lengthy period, and the substantial-high fixed cost infrastructure requirements for radiation facilities, radiation oncology is particularly prone to regional inequities in access to care. Brachytherapy (BT) is emblematic of several of these access difficulties since it necessitates specialized equipment, the capacity to maintain a radioactive source, and particular skill sets. The study was conducted to report the availability of BT treatment units in relation to state-level population, overall cancer incidence, and gynecologic cancer incidence.

METHODS AND MATERIALS

The availability of BT resources at the state level in India was and the population of each state was estimated using data from the Government of India's Census. The number of cancer cases was approximated for each state and union territory. The total number of gynecological cancers that required BT was determined. The BT infrastructure was also compared to those of other nations in terms of the number of BT units available per million people and for various malignancies.

RESULTS

A heterogeneous geographic distribution of BT units was noted across India. India has one BT unit for every 42,93,031 population. The maximum deficit was seen in Uttar Pradesh, Bihar, Rajasthan, and Odisha. Among the states having BT units, the maximum units per 10,000 cancer patients was noted in Delhi (7), Maharashtra (5) and Tamil Nadu (4) and the least was noted in the Northeastern states (<1), Jharkhand, Odisha, and Uttar Pradesh. In BT of gynecological malignancies alone an infrastructural deficit ranging from 1 to 75 units were noted across the states. It was noted that only 104 out of the 613 medical colleges in India had BT facilities. On comparing the BT infrastructure status with other countries India had one BT machine for every 4,181 cancer patients when compared to United States (1 every 2,956 patients), Germany (2,754 patients), Japan (4,303 patients), Africa (10,564) and Brazil (4,555 patients).

CONCLUSION

The study identified the deficits of BT facilities in terms of geographic and demographic aspects. This research provides a roadmap for the development of BT infrastructure in India.

Gynaecological Oncology in India: Past, Present and Future

Gynaecological cancers contribute to a substantial portion of the global cancer burden. Traditionally, these cancers have been treated by generalists, including gynaecologists and surgeons. However, owing to increasing sophistication and challenges in their management, a new sub-speciality of Gynaecologic Oncology, dedicated to these women's comprehensive care, has emerged in recent times. The emergence and evolution of this sub-speciality will facilitate a holistic approach to treating women suffering from gynaecological cancers, including tailored surgical techniques, fertility preservation, precision medicine, hormone modulators, targeted therapy and immunotherapy, which can be achieved within the framework of multidisciplinary management. Hence, we decided to write this synopsis to shed light on the evolution of this discipline in India and offer current and future perspectives.

Gynecologic Oncology: On the Shoulders of Giants

Gynecologic oncology is considered a new field, but its roots are buried deep in the past. As with other tumors, the earliest progress in modern times started with anesthesia and surgery. This was followed by landmark achievements in pathology, cytology, radiotherapy, chemotherapy, tumor virology, generation of high-quality evidence, and, more recently, genetics and genomics. Some of the most notable progresses in gynecologic cancers have been made by integrating the expertise of various specialties in multimodality management approaches. In this article we review the most important milestones in the history of gynecologic oncology and acknowledge the contributions of pioneers who made these possible.

Artificial intelligence in brachytherapy: a summary of recent developments

Artificial intelligence (AI) applications, in the form of machine learning and deep learning, are being incorporated into practice in various aspects of medicine, including radiation oncology. Ample evidence from recent publications explores its utility and future use in external beam radiotherapy. However, the discussion on its role in brachytherapy is sparse. This article summarizes available current literature and discusses potential uses of AI in brachytherapy, including future directions. AI has been applied for brachytherapy procedures during almost all steps, starting from decision-making till treatment completion. AI use has led to improvement in efficiency and accuracy by reducing the human errors and saving time in certain aspects. Apart from direct use in brachytherapy, AI also contributes to contemporary advancements in radiology and associated sciences that can affect brachytherapy decisions and treatment. There is a renewal of interest in brachytherapy as a technique in recent years, contributed largely by the understanding that contemporary advances such as intensity modulated radiotherapy and stereotactic external beam radiotherapy cannot match the geometric gains and conformality of brachytherapy, and the integrated efforts of international brachytherapy societies to promote brachytherapy training and awareness. Use of AI technologies may consolidate it further by reducing human effort and time. Prospective validation over larger studies and incorporation of AI technologies for a larger patient population would help improve the efficiency and acceptance of brachytherapy. The enthusiasm favoring AI needs to be balanced against the short duration and quantum of experience with AI in limited patient subsets, need for constant learning and re-learning to train the AI algorithms, and the inevitability of humans having to take responsibility for the correctness and safety of treatments.

Emerging infrastructures: the politics of radium and the validation of radiotherapy in India's first tertiary cancer hospital

This article traces the history of India’s first tertiary cancer hospital, Tata Memorial Hospital (TMH). TMH was originally conceived in 1932 as a philanthropic project by the Tatas, an elite Parsi business family in Bombay. The founding of TMH represented a form of philanthro-capitalism which both enabled the Tatas to foster a communal acceptance for big businesses in Bombay and provide the Tatas with the opportunity to place stakes in the emerging nuclear research economy seen as essential to the scientific nationalist sentiment of the post-colonial state. In doing this, the everyday activities of TMH placed a heavy emphasis on nuclear research. In a time when radium for the treatment of cancer was still seen as ‘quackery’ in much of the world, the philanthro-capitalist investment and the interest in nuclear research by the post-colonial state provided an environment where radium medicine was able to be validated. The validation of radiotherapy at TMH influenced how other cancer hospitals in India developed and also provided significant resources for cancer research in early-mid twentieth century India. Ultimately, this article identifies ways in which cancer comes to be seen as relevant in the global south and raises questions on the relationship between local and global actors in setting health priorities.

Radiotherapy in India: History, current scenario and proposed solutions

The history and current status of a biomedical discipline in a country or region provide important health system indicators. During the last one hundred years, radiotherapy has established its position as a vital specialty in cancer management. It has proved to be one of the most cost effective ways of treating cancer providing both radical and palliative treatments depending on patient stage and performance status. However, access to radiotherapy for cancer patients in India is limited by several factors including physical proximity of centre, cost and availability of required technology. This article gives an outline of the history, existing radiotherapy facilities and future trends related to radiotherapy practice in India.

Indian Brachytherapy Society Guidelines for radiotherapeutic management of cervical cancer with special emphasis on high-dose-rate brachytherapy

Brachytherapy (BT) for locally advanced cervical cancer is vital for optimal outcomes. There is heterogeneity in brachytherapy treatment practice for cervical cancer across India. In an attempt to standardize various processes involved in cervical cancer brachytherapy, the expert members of the Indian Brachytherapy Society (IBS) developed a document related to radiation therapy treatment of cervical cancer with special emphasis on brachytherapy. The guidelines are based on high quality clinical evidence, expert opinion and consensus wherever evidence was lacking. The document provides a guide for external beam radiation and details of all the processes involved in high-dose-rate (HDR) brachytherapy including patient selection, preparation, principles and technique of BT applications, target and normal tissue definition, dose prescriptions, BT planning, reporting parameters, common complications of BT and their management, scope for research, etc. In summary, we present here practical tips and tricks, recording and reporting of cervical cancer brachytherapy, which can be implemented in various clinical environments and forms the basis of this report.

Treatment of locally advanced carcinoma cervix with special emphasis on brachytherapy: A practice pattern survey among young radiation oncologist of India

BACKGROUND

Carcinoma cervix is one of the two most common cancers of Indian women with very high morbidity and mortality burden. Although India probably is the leading country in numbers patients of cervix treated radically with combination of teletherapy and brachytherapy (BT), there is presumed diversity of practice across the country due to the inequality of available infrastructure, absence of uniform the training of the radiation oncologists, and absence of any national guidelines. The present survey was conducted to determine current practice patterns in management of locally advanced carcinoma cervix with regard to gynecologic high-dose-rate among the radiation oncologist across the country.

METHODOLOGY

A 25-item survey was undertaken to study the standard management pattern of Stage IIB-IIIB cervical cancer with special emphasis on the BT practice patterns among various young radiation oncologist working across the country. The survey was undertaken in person in the form of interview questionnaire among the younger members of association of radiation oncologist of India during two national conferences, along with telephonic interview of other members as obtained from the national directory.

RESULTS

About 57 young radiation oncologists from 57 centers across the country were surveyed. 25 of them represented private nonacademic centers, 24 represented government academic centers, the rest were from private academic, nongovernmental organization (NGO) run and other centers. The most common teletherapy dose prescribed was 46 Gy/23# for Stage II, and50 Gy/25 # for Stage III disease. HDR after loader with 192Ir is the most common machine (82.6%) in use and computed tomography scan is the most commonly (30/57) used imaging for planning. The most common intracavitary dose pattern for all stages was 7 Gy × 3 fractions (30/57s) and 9 Gy × 2 (12/57) fractions. Although in most centers, computed tomography-based delineation of organs at risk is done routinely; however, target volume delineation and dose prescription/optimization for the same is routinely done in handful of centers (5/57). The mean planned dose to Point A for combined external-beam radiation and BT (EQD210) was about 77.5 Gy for Stage IIIB and 72.6 Gy for Stage II disease.

CONCLUSION

Although fractionation patterns may vary, the overall mean dose administered for cervical cancer is similar across the country, which is slightly lower than the recommended doses as per stage by various international guidelines.

Meeting report, “First Indian national conference on cervical cancer management - expert recommendations and identification of barriers to implementation”

Objective

In India, cervical cancer accounts for almost 14% of all female cancer cases. Although poverty continues to cast a wide net over the Indian subcontinent, the preceding three decades have borne witness to improvements in nutrition and sanitation for many citizens. However, due to an absence of a national immunization program to cover human papillomavirus (HPV) vaccination and lack of accessible cervical cancer screening, the disease is characterized by late detection, lack of access to affordable and quality health care, and high mortality rates. Treatment of cervical cancer is stage-specific and depends on the patient’s age, desire to preserve fertility, overall health, the clinician’s expertise, and accessibility to resources. There is a paucity of uniform treatment protocols for various stages of cervical cancer in India. Considering all these parameters, a need to optimize treatment paradigms for the Indian population emerged.

Methods/materials

Three expert panel meetings were held in different regions of India from 2016 to 2017. They were comprised of 15 experts from across the country, and included surgical oncologists, radiation oncologists, and medical oncologists. The panel members reviewed the literature from both national and global sources, discussed their clinical experience and local practices and evaluated current therapeutic options and management gaps for women diagnosed with cervical cancer.

Results

This article summarizes the expert opinion from these meetings. It discusses the available resources and highlights the current therapeutic options available for different cervical cancer stages: early stage disease, locally advanced tumors, recurrent/persistent/metastatic cancer. An Indian consensus governing treatment options emerged, including guidelines for use of the only approved targeted therapy in this disease, the anti-angiogenesis drug, bevacizumab.

Conclusions

The panel concluded that given the availability of state-of-the-art imaging modalities, surgical devices, radiotherapeutics, and novel agents in several population-dense urban centers, a uniform, multi-disciplinary treatment approach across patient care centers is ideal but not realistic due to cost and a paucity of third party payors for most Indian citizens. Preventative strategies including visual inspection with acetic acid to screen for precursor lesions (i.e., cervical intraepithelial neoplasia) with immediate referral for cervical cryotherapy and possible large-scale roll-out of the HPV vaccine in the near future can be expected to reduce mortality rates significantly in this country.

Challenges and Prospects for Providing Radiation Oncology Services in Africa

There are considerable challenges to meeting the demands of the impending cancer crisis in Africa. These include a rising incidence of cancer and cancer-related deaths, equipment and maintenance costs, and deficits in human resources and training. Addressing these issues would be crucial to tackling the increasing burden of cancer on the continent. Innovations in technology and collaborative efforts within the global oncology community have created promising solutions for establishing quality cancer care in Africa and eradicating the massive disparities that currently exist. A multifaceted approach that establishes access to quality radiation oncology services is needed to curtail this alarming trend. In this article, we describe the current status of radiotherapy services in Africa, barriers and opportunities to improve this integral component of comprehensive cancer care.

Radiation Oncology in India: Challenges and Opportunities

Rising cancer incidence and mortality in India emphasize the need to address the increasing burden of this disease and the stark inequities in access to radiotherapy and other essential medical treatments. State-of-the-art technology is available within the private sector and a few hospitals in the public sector, but 75% of patients in the public sector in India do not have access to timely radiotherapy. This inequity in access to radiotherapy in the public sector is amplified in rural areas, where most of India׳s population lives. A long-term government commitment to machine purchase and human resource development in the public sector is needed to improve access. A number of innovative initiatives to improve cancer treatment and access have emerged that could support such an investment. These include local production of equipment, twinning programs between institutions in high- and low-income countries to exchange knowledge and expertise, and nongovernmental and state-sponsored schemes to sponsor and support patients in their cancer journey. Strengthening of cancer registries and regulatory bodies with authority to enforce minimum standards is also required to improve care. The more uniform and frequent availability of high-quality radiotherapy can improve cancer outcomes and may be regarded as a marker of a comprehensive and equitable system of health care delivery.

The Unique Issues With Brachytherapy in Low- and Middle-Income Countries

Gynecologic carcinomas, including cervical cancer, present a significant burden on low- and middle-income countries (LMICs). Brachytherapy plays an integral role in the treatment of gynecologic carcinomas, as it is essential for both curative and palliative treatment. However, there are numerous geographic and economic barriers to providing brachytherapy to cancer patients in LMICs. This article examines the role and delivery of brachytherapy in gynecological cancer treatment; brachytherapy capacity in LMICs, including infrastructure, equipment, and human resources considerations; commissioning, training, and clinical implementation of brachytherapy in LMICs; other challenges, and strategies for improvement in brachytherapy delivery in LMICs, including innovation and current and upcoming international initiatives.

Attitude and practice of brachytherapy in India: a study based on the survey amongst attendees of Annual Meeting of Indian Brachytherapy Society

PURPOSE

We performed a survey amongst attendees of the 4(th) Annual Meeting of Indian Brachytherapy Society to study the patterns of brachytherapy practice and attitude towards brachytherapy use.

MATERIAL AND METHODS

A 19-point questionnaire was designed and e-mailed to the attendees immediately after the conference. Descriptive analysis of the responses were done and satisfaction index was used as a tool for evaluation of the program effectiveness. Binomial test was used to assess the difference between distributions of responses and Mann-Whitney U test was used to assess the correlation between responses. P value (2-tailed) of < 0.05 was taken significant for all statistical analysis.

RESULTS

Of a total of 202 attendees, 90 responded to the survey (response rate: 44.5%). Seventy-two percent belonged to an academic institute while 28% belonged to non-academic institutes. Eighty-six percent were radiation oncologists and 10% were medical physicists. Eighty-nine percent respondents used high-dose-rate, 14% - pulse-dose-rate, and 13% used low-dose-rate brachytherapy facility. Orthogonal X-rays, computed tomography, and magnetic resonance imaging was used for brachytherapy planning by 56%, 69%, and 14%, respectively. Ninety-three percent of them thought that lack of training is a hurdle in practicing brachytherapy and 92% opined that brachytherapy dedicated meetings can change their perception about brachytherapy. Seventy percent respondents admitted to make some changes in their practice patterns after attending this meeting. Ninety-seven percent of them would like to attend future meetings and 98% felt the need to include live workshops, hands on demonstrations, and video presentations in the scientific programme.

CONCLUSIONS

The survey highlights a positive attitude towards increasing brachytherapy use, and may serve as an important guiding tool in designing teaching and training programmes; thus overcoming the hurdles in successful and widespread use of a quality brachytherapy programme at radiotherapy centers.

Expanding global access to radiotherapy

Radiotherapy is a critical and inseparable component of comprehensive cancer treatment and care. For many of the most common cancers in low-income and middle-income countries, radiotherapy is essential for effective treatment. In high-income countries, radiotherapy is used in more than half of all cases of cancer to cure localised disease, palliate symptoms, and control disease in incurable cancers. Yet, in planning and building treatment capacity for cancer, radiotherapy is frequently the last resource to be considered. Consequently, worldwide access to radiotherapy is unacceptably low. We present a new body of evidence that quantifies the worldwide coverage of radiotherapy services by country. We show the shortfall in access to radiotherapy by country and globally for 2015-35 based on current and projected need, and show substantial health and economic benefits to investing in radiotherapy. The cost of scaling up radiotherapy in the nominal model in 2015-35 is US$26·6 billion in low-income countries, $62·6 billion in lower-middle-income countries, and $94·8 billion in upper-middle-income countries, which amounts to $184·0 billion across all low-income and middle-income countries. In the efficiency model the costs were lower: $14·1 billion in low-income, $33·3 billion in lower-middle-income, and $49·4 billion in upper-middle-income countries-a total of $96·8 billion. Scale-up of radiotherapy capacity in 2015-35 from current levels could lead to saving of 26·9 million life-years in low-income and middle-income countries over the lifetime of the patients who received treatment. The economic benefits of investment in radiotherapy are very substantial. Using the nominal cost model could produce a net benefit of $278·1 billion in 2015-35 ($265·2 million in low-income countries, $38·5 billion in lower-middle-income countries, and $239·3 billion in upper-middle-income countries). Investment in the efficiency model would produce in the same period an even greater total benefit of $365·4 billion ($12·8 billion in low-income countries, $67·7 billion in lower-middle-income countries, and $284·7 billion in upper-middle-income countries). The returns, by the human-capital approach, are projected to be less with the nominal cost model, amounting to $16·9 billion in 2015-35 (-$14·9 billion in low-income countries; -$18·7 billion in lower-middle-income countries, and $50·5 billion in upper-middle-income countries). The returns with the efficiency model were projected to be greater, however, amounting to $104·2 billion (-$2·4 billion in low-income countries, $10·7 billion in lower-middle-income countries, and $95·9 billion in upper-middle-income countries). Our results provide compelling evidence that investment in radiotherapy not only enables treatment of large numbers of cancer cases to save lives, but also brings positive economic benefits.

A review of the clinical experience in pulsed dose rate brachytherapy

Pulsed dose rate (PDR) brachytherapy is a treatment modality that combines physical advantages of high dose rate (HDR) brachytherapy with the radiobiological advantages of low dose rate brachytherapy. The aim of this review was to describe the effective clinical use of PDR brachytherapy worldwide in different tumour locations. We found 66 articles reporting on clinical PDR brachytherapy including the treatment procedure and outcome. Moreover, PDR brachytherapy has been applied in almost all tumour sites for which brachytherapy is indicated and with good local control and low toxicity. The main advantage of PDR is, because of the small pulse sizes used, the ability to spare normal tissue. In certain cases, HDR resembles PDR brachytherapy by the use of multifractionated low-fraction dose.