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Abu Awwad D, Shafiq J, Delaney GP, Anacak Y, Bray F, Flores JA, Gondhowiardjo S, Minjgee M, Permata TBM, Pineda JC, Yusak S, Zubizarreta E, Yap ML. Current and projected gaps in the availability of radiotherapy in the Asia-Pacific region: a country income-group analysis. Lancet Oncol 2024; 25:225-234. [PMID: 38301690 DOI: 10.1016/s1470-2045(23)00619-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Cancer incidence and mortality is increasing rapidly worldwide, with a higher cancer burden observed in the Asia-Pacific region than in other regions. To date, evidence-based modelling of radiotherapy demand has been based on stage data from high-income countries (HIC) that do not account for the later stage at presentation seen in many low-income and middle-income countries (LMICs). We aimed to estimate the current and projected demand and supply in megavoltage radiotherapy machines in the Asia-Pacific region, using a national income-group adjusted model. METHODS Novel LMIC radiotherapy demand and outcome models were created by adjusting previously developed models that used HIC cancer staging data. These models were applied to the cancer case mix (ie, the incidence of each different cancer) in each LMIC in the Asia-Pacific region to estimate the current and projected optimal radiotherapy utilisation rate (ie, the proportion of cancer cases that would require radiotherapy on the basis of guideline recommendations), and to estimate the number of megavoltage machines needed in each country to meet this demand. Information on the number of megavoltage machines available in each country was retrieved from the Directory of Radiotherapy Centres. Gaps were determined by comparing the projected number of megavoltage machines needed with the number of machines available in each region. Megavoltage machine numbers, local control, and overall survival benefits were compared with previous data from 2012 and projected data for 2040. FINDINGS 57 countries within the Asia-Pacific region were included in the analysis with 9·48 million new cases of cancer in 2020, an increase of 2·66 million from 2012. Local control was 7·42% and overall survival was 3·05%. Across the Asia-Pacific overall, the current optimal radiotherapy utilisation rate is 49·10%, which means that 4·66 million people will need radiotherapy in 2020, an increase of 1·38 million (42%) from 2012. The number of megavoltage machines increased by 1261 (31%) between 2012 and 2020, but the demand for these machines increased by 3584 (42%). The Asia-Pacific region only has 43·9% of the megavoltage machines needed to meet demand, ranging from 9·9-40·5% in LMICs compared with 67·9% in HICs. 12 000 additional megavoltage machines will be needed to meet the projected demand for 2040. INTERPRETATION The difference between supply and demand with regard to megavoltage machine availability has continued to widen in LMICs over the past decade and is projected to worsen by 2040. The data from this study can be used to provide evidence for the need to incorporate radiotherapy in national cancer control plans and to inform governments and policy makers within the Asia-Pacific region regarding the urgent need for investment in this sector. FUNDING The Regional Cooperative Agreement for Research, Development and Training Related to Nuclear Science and Technology for Asia and the Pacific (RCA) Regional Office (RCARP03).
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Affiliation(s)
- Dania Abu Awwad
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jesmin Shafiq
- Collaboration for Cancer Outcomes, Research and Evaluation, Liverpool Hospital, Ingham Institute, University of New South Wales, Liverpool, NSW, Australia
| | - Geoffrey Paul Delaney
- Collaboration for Cancer Outcomes, Research and Evaluation, Liverpool Hospital, Ingham Institute, University of New South Wales, Liverpool, NSW, Australia
| | - Yavuz Anacak
- Department of Radiation Oncology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Freddie Bray
- Cancer Surveillance Branch, International Agency for Research on Cancer, Lyon, France
| | - Jerickson Abbie Flores
- Jose R Reyes Memorial Medical Center, Manila, Philippines; AC Sacred Heart Medical Center, Pampanga, Philippines
| | - Soehartati Gondhowiardjo
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; Department of Radiation Oncology, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia; Indonesian Radiation Oncology Society, South Jakarta, Indonesia
| | | | - Tiara Bunga Mayang Permata
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; Department of Radiation Oncology, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | | | | | - Eduardo Zubizarreta
- International Atomic Energy Agency, Vienna International Centre, Vienna, Austria
| | - Mei Ling Yap
- Collaboration for Cancer Outcomes, Research and Evaluation, Liverpool Hospital, Ingham Institute, University of New South Wales, Liverpool, NSW, Australia; The George Institute for Global Health, University of New South Wales, Barangaroo, NSW, Australia; Macarthur Cancer Therapy Centres, Western Sydney University, Campbelltown, NSW, Australia.
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Sabbagh A, Weiss J, Tawk B, Mohammed MA, Abdulbaki H, Moraes FY, Grover S, Yap ML, Zubizarreta E, Lievens Y, Rodin D, Mohamad O. Hypofractionation Adoption in Prostate Cancer Radiotherapy: Results of an International Survey. JCO Glob Oncol 2023; 9:e2300046. [PMID: 37319396 PMCID: PMC10497301 DOI: 10.1200/go.23.00046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/22/2023] [Accepted: 04/14/2023] [Indexed: 06/17/2023] Open
Abstract
PURPOSE Hypofractionation is noninferior to conventional fractionation in the treatment of localized prostate cancer. Using results from the European Society of Radiation Oncology's (ESTRO) Global Impact of Radiotherapy in Oncology (GIRO) initiative survey on hypofractionation, this study identifies rates of adoption, facilitating factors, and barriers to adoption of hypofractionation in prostate cancer across World Bank income groups. MATERIALS AND METHODS The ESTRO-GIRO initiative administered an international, anonymous, electronic survey to radiation oncologists from 2018 to 2019. Physician demographics, clinical practice characteristics, and hypofractionation regimen use (if any) for several prostate cancer scenarios were collected. Responders were asked about specific justifications and barriers to adopting hypofractionation, and responses were stratified by World Bank income group. Multivariate logistic regression models were used to analyze variables associated with hypofractionation preference. RESULTS A total of 1,157 physician responses were included. Most respondents (60%) were from high-income countries (HICs). In the curative setting, hypofractionation was most often preferred in low- and intermediate-risk prostate cancers, with 52% and 47% of respondents reporting hypofractionation use in ≥50% of patients, respectively. These rates drop to 35% and 20% in high-risk prostate cancer and where pelvic irradiation is indicated. Most respondents (89%) preferred hypofractionation in the palliative setting. Overall, respondents from upper-middle-income countries and lower-middle- and low-income countries were significantly less likely to prefer hypofractionation than those from HICs (P < .001). The most frequently cited justification and barrier were availability of published evidence and fear of worse late toxicity, respectively. CONCLUSION Hypofractionation preference varies by indication and World Bank income group, with greater acceptance among providers in HICs for all indications. These results provide a basis for targeted interventions to increase provider acceptance of this treatment modality.
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Affiliation(s)
- Ali Sabbagh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Jessica Weiss
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Bouchra Tawk
- Clinical Cooperation Unit—Translational Radiation Oncology, National Center for Tumoral Diseases NCT Heidelberg, German Cancer Research Center (DKFZ), Heidelberg University Hospital, Heidelberg, Germany
| | - Mohammed A. Mohammed
- American University of Beirut Medical Center, Beirut, Lebanon
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Hasan Abdulbaki
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Fabio Y. Moraes
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston, ON, Canada
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mei Ling Yap
- Collaboration for Cancer Outcomes, Research and Evaluation (CCORE), Ingham Institute, UNSW Sydney, Liverpool, NSW, Australia
- Liverpool and Macarthur Cancer Therapy Centres, Western Sydney University, Campbelltown, NSW, Australia
- The George Institute for Global Health, UNSW Sydney, Newtown, NSW, Australia
| | | | - Yolande Lievens
- Ghent University Hospital and Ghent University, Ghent, Belgium
| | - Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, ON, Canada
| | - Osama Mohamad
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
- Department of Urology, University of California San Francisco, San Francisco, CA
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Mushonga M, Weiss J, Liu ZA, Nyakabau AM, Mohamad O, Tawk B, Moraes FY, Grover S, Yap ML, Zubizarreta E, Lievens Y, Rodin D. Hypofractionation in Breast Cancer Radiotherapy Across World Bank Income Groups: Results of an International Survey. JCO Glob Oncol 2023; 9:e2200127. [PMID: 36706350 PMCID: PMC10166450 DOI: 10.1200/go.22.00127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
PURPOSE Hypofractionated breast radiotherapy has been found to be equivalent to conventional fractionation in many clinical trials. Using data from the European Society for Radiotherapy and Oncology Global Impact of Radiotherapy in Oncology survey, we identified preferences for hypofractionation in breast cancer across World Bank income groups and the perceived facilitators and barriers to its use. MATERIALS AND METHODS An international, electronic survey was administered to radiation oncologists from 2018 to 2019. Demographics, practice characteristics, preferred hypofractionation regimen for specific breast cancer scenarios, and facilitators and barriers to hypofractionation were reported and stratified by World Bank income groups. Variables associated with hypofractionation were assessed using multivariate logistic regression models. RESULTS One thousand four hundred thirty-four physicians responded: 890 (62%) from high-income countries (HICs), 361 (25%) from upper-middle-income countries (UMICs), 183 (13%) from low- and lower-middle-income countries (LLMICs). Hypofractionation was preferred most frequently in node-negative disease after breast-conserving surgery, with the strongest preference reported in HICs (78% from HICs, 54% from UMICs, and 51% from LLMICs, P < .001). Hypofractionation for node-positive disease postmastectomy was more frequently preferred in LLMICs (28% from HICs, 15% from UMICs, and 35% from LLMICs, P < .001). Curative doses of 2.1 to < 2.5 Gy in 15-16 fractions were most frequently reported, with limited preference for ultra-hypofractionation, but significant variability in palliative dosing. In adjusted analyses, UMICs were significantly less likely than LLMICs to prefer hypofractionation across all curative clinical scenarios, whereas respondents with > 1 million population catchments and with intensity-modulated radiotherapy were more likely to prefer hypofractionation. The most frequently cited facilitators and barriers were published evidence and fear of late toxicity, respectively. CONCLUSION Preference for hypofractionation varied for curative indications, with greater acceptance in earlier-stage disease in HICs and in later-stage disease in LLMICs. Targeted educational interventions and greater inclusivity in radiation oncology clinical trials may support greater uptake.
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Affiliation(s)
- Melinda Mushonga
- Sally Mugabe Central Hospital, Harare, Zimbabwe.,Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Jessica Weiss
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Zhihui Amy Liu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Anna-Mary Nyakabau
- Department of Oncology, Faculty of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Osama Mohamad
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Bouchra Tawk
- German Cancer Research Consortium, Core Site Heidelberg, German Cancer Research Center, Heidelberg, Germany.,Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine and Heidelberg University Hospital, Heidelberg, Germany
| | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston, Ontario, Canada
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, United States; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mei Ling Yap
- Collaboration for Cancer Outcomes, Research and Evaluation (CCORE), Ingham Institute, UNSW Sydney, Liverpool, Australia.,Liverpool and Macarthur Cancer Therapy Centres, Western Sydney University, Campbelltown, Australia.,School of Public Health, Faculty of Medicine and Health, University of Sydney, Campbelltown, Australia
| | | | - Yolande Lievens
- Ghent University Hospital and Ghent University, Ghent, Belgium
| | - Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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Wilson BE, Oar A, Rodin D, Bray F, Ferlay J, Polo A, Borras JM, Bourque JM, Malik M, Ynoe de Moraes F, Lievens Y, Stevens LM, Zubizarreta E, Yap ML. Radiotherapy prioritization in 143 national cancer control plans: Correlation with radiotherapy machine availability, geography and income level. Radiother Oncol 2022; 176:83-91. [PMID: 36113775 DOI: 10.1016/j.radonc.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/24/2022] [Accepted: 09/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND In 2015, the Global Task Force on Radiotherapy for Cancer Control (GTFRCC) called for 80% of National Cancer Control Plans (NCCP) to include radiotherapy by 2020. As part of the ongoing ESTRO Global Impact of Radiotherapy in Oncology (GIRO) project, we assessed whether inclusion of radiotherapy in NCCPs correlates with radiotherapy machine availability, national income, and geographic region. METHODS A previously validated checklist was used to determine whether radiotherapy was included in each country's NCCP. We applied the CCORE optimal radiotherapy utilisation model to the GLOBOCAN 2020 data to estimate the demand for radiotherapy and compared this to the International Atomic Energy Agency (IAEA) Directory of Radiotherapy Centres (DIRAC) supply data, stratifying by income level and world region. World regions were defined according to the IAEA. FINDINGS Complete data (including GLOBOCAN 2020, DIRAC and NCCP) was available for 143 countries. Over half (55%, n = 79) included a radiotherapy-specific checklist item within the plan. Countries which included radiotherapy services planning in their NCCP had a higher median number of machines (1.68 vs 0.75 machines/1000 patients needing radiotherapy, p < 0.001). There was significant regional and income-level heterogeneity in the inclusion of radiotherapy-related items in NCCPs. Low-income and Asia-Pacific countries were least likely to include radiation oncology services planning in their NCCP (p = 0.06 and p = 0.003, respectively). Few countries in the Asia-Pacific (18.6%) had a plan to develop or maintain radiation services, compared to 57% of countries in Europe. INTERPRETATION Only 55% of current NCCPs included any information regarding radiotherapy, below the GTFRCC's target of 80%. Prioritisation of radiotherapy in NCCPs was correlated with radiotherapy machine availability. There was regional and income-level heterogeneity regarding the inclusion of specific radiotherapy checklist items in the NCCPs. Ongoing efforts are needed to promote the inclusion of radiotherapy in future iterations of NCCPs in order to improve global access to radiation treatment. FUNDING No direct funding was used in this research.
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Affiliation(s)
- Brooke E Wilson
- Collaboration for Cancer Outcomes, Research and Evaluation, South-West Clinical School, University of New South Wales, Liverpool, NSW, Australia; Department of Oncology, Queens University, Kingston, Ontario, Canada.
| | - Andrew Oar
- Icon Cancer Centre, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Danielle Rodin
- Global Cancer Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Freddie Bray
- Cancer Surveillance Branch, International Agency for Cancer Research, Lyon, France
| | - Jacques Ferlay
- Cancer Surveillance Branch, International Agency for Cancer Research, Lyon, France
| | - Alfredo Polo
- Applied Radiation Biology and Radiotherapy Section, International Atomic Energy Agency, Vienna, Austria
| | - Josep M Borras
- Department of Clinical Sciences and IDIBELL, University of Barcelona, Barcelona, Spain
| | - Jean-Marc Bourque
- Division of Radiation Oncology, University of Ottawa, Ottawa, Ontario, Canada; Radiation Oncology, Montreal University Hospital Centre, Montreal, Canada
| | - Monica Malik
- Department of Radiation Oncology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | | | - Yolande Lievens
- Radiation Oncology Department, Ghent University Hospital and Ghent University, Ghent, Belgium
| | - Lisa M Stevens
- Programme of Action for Cancer Therapy, International Atomic Energy Agency, Vienna, Austria
| | - Eduardo Zubizarreta
- Applied Radiation Biology and Radiotherapy Section, International Atomic Energy Agency, Vienna, Austria
| | - Mei Ling Yap
- Collaboration for Cancer Outcomes, Research and Evaluation, South-West Clinical School, University of New South Wales, Liverpool, NSW, Australia; Liverpool Cancer Centre and Macarthur Cancer Therapy Centre, Western Sydney University, Campbelltown, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; The George Institute for Global Health, UNSW Sydney, Newtown, New South Wales, Australia
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Hande V, Chopra S, Kalra B, Abdel-Wahab M, Kannan S, Tanderup K, Grover S, Zubizarreta E, Rubio JAP. Point-A vs. volume-based brachytherapy for the treatment of cervix cancer: A meta-analysis. Radiother Oncol 2022; 170:70-78. [PMID: 35259419 PMCID: PMC10042219 DOI: 10.1016/j.radonc.2022.02.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/28/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND & PURPOSE To report disease-free survival (DFS) for volume-based and point-A based brachytherapy (BT) in locally advanced cervical cancer. MATERIALS & METHODS We conducted a meta-analysis of studies assessing the effects of point-A and volume-based brachytherapy on 3-year DFS. Studies including stage I-IVA cervical cancer patients were included if standard treatment of concomitant chemo-radiotherapy and high-dose- or pulsed dose rate BT was delivered. The primary outcome was 3-year DFS, and secondary outcomes were 3-year local control (LC), 3-year overall survival (OS) and late toxicity. A random-effects subgroup meta-analysis was done. RESULTS In total, 5499 studies were screened, of which 24 studies with 5488 patients were eligible. There was significant heterogeneity among point-A studies (1538 patients) (I2 = 82%, p < 0.05) relative to volume-based studies (3950 patients) (I2 = 58, p = 0.01). The 3-year DFS for point-A and volume-based studies were 67% (95% CI 60%-73%) and 79% (95% CI 76%-82%) respectively (p = 0.001). Three-year LC for point-A and volume-based studies were 86% (95% CI 81%-90%) and 92% (91%-94%) respectively (p = 0.01). The difference in 3-year OS (72% vs. 79%, p = 0.12) was not statistically significant. The proportion of prospectively enrolled patients was 23% for point-A studies and 33% for volume-based studies. There was no difference in late grade 3 or higher gastrointestinal (3% vs. 4%, p = 0.76) genitourinary toxicities (3% vs. 3% p = 0.45) between the two groups. CONCLUSION Volume-based BT results in superior 3-year DFS and 3-year LC. In the absence of randomized trials, this meta-analysis provides the best evidence regarding transition to 3D planning.
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Affiliation(s)
- Varsha Hande
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India; Applied Radiation Biology and Radiotherapy Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India.
| | - Babusha Kalra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - May Abdel-Wahab
- Applied Radiation Biology and Radiotherapy Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Sadhana Kannan
- Department of Epidemiology and Clinical Trials Unit, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhaba National Institute, Navi Mumbai, India
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Surbhi Grover
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, United States; Botswana-UPenn Partnership, Gaborone, Botswana
| | - Eduardo Zubizarreta
- Applied Radiation Biology and Radiotherapy Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Jose Alfredo Polo Rubio
- Applied Radiation Biology and Radiotherapy Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria.
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Yap M, Wilson B, Oar A, Borras J, Bourque J, Lievens Y, Moraes F, Malik M, Polo A, Rodin D, Romero Y, Stevens L, Zubizarreta E. MO-0056 The prioritisation of radiotherapy in National Cancer Control Plans: a global study. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)02289-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Scott A, Polo A, Zubizarreta E, Aidoo C, Milosevic M, Rodin D. Access to Radiotherapy in Ghana: A Geospatial Analysis. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Elmore SNC, Polo A, Bourque JM, Pynda Y, van der Merwe D, Grover S, Hopkins K, Zubizarreta E, Abdel-Wahab M. Radiotherapy resources in Africa: an International Atomic Energy Agency update and analysis of projected needs. Lancet Oncol 2021; 22:e391-e399. [PMID: 34478675 DOI: 10.1016/s1470-2045(21)00351-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 06/01/2021] [Accepted: 06/11/2021] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
- Shekinah N C Elmore
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Harvard Radiation Oncology Program, Boston, MA, USA
| | - Alfredo Polo
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Jean-Marc Bourque
- Division of Radiation Oncology, University of Ottawa, Ottawa, ON, Canada; Department of Medicine, McGill University, Montreal, QC, Canada
| | - Yaroslav Pynda
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | | | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Kirsten Hopkins
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Eduardo Zubizarreta
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - May Abdel-Wahab
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria.
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Abdel-Wahab M, Gondhowiardjo SS, Rosa AA, Lievens Y, El-Haj N, Polo Rubio JA, Prajogi GB, Helgadottir H, Zubizarreta E, Meghzifene A, Ashraf V, Hahn S, Williams T, Gospodarowicz M. Global Radiotherapy: Current Status and Future Directions-White Paper. JCO Glob Oncol 2021; 7:827-842. [PMID: 34101482 PMCID: PMC8457786 DOI: 10.1200/go.21.00029] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- May Abdel-Wahab
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Soehartati S Gondhowiardjo
- Radiotherapy Department, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas of Indonesia, Jakarta, Indonesia
| | - Arthur Accioly Rosa
- Radiation Oncology, Hospital Portugues, Hospital Sao Rafael, Salvador, Brazil
| | | | - Noura El-Haj
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | | | | | - Herdis Helgadottir
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Eduardo Zubizarreta
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Ahmed Meghzifene
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Varisha Ashraf
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Stephen Hahn
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Tim Williams
- South Florida Proton Therapy Institute, Delray Beach, FL
| | - Mary Gospodarowicz
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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Murgic J, Jaksic B, Prpic M, Kust D, Bahl A, Budanec M, Prgomet Secan A, Franco P, Kruljac I, Spajic B, Babic N, Kruslin B, Zovak M, Zubizarreta E, Rosenblatt E, Fröbe A. Comparison of hypofractionation and standard fractionation for post-prostatectomy salvage radiotherapy in patients with persistent PSA: single institution experience. Radiat Oncol 2021; 16:88. [PMID: 33980277 PMCID: PMC8115388 DOI: 10.1186/s13014-021-01808-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/18/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Hypofractionated post-prostatectomy radiotherapy is emerging practice, however with no randomized evidence so far to support it's use. Additionally, patients with persistent PSA after prostatectomy may have aggressive disease and respond less well on standard salvage treatment. Herein we report outcomes for conventionally fractionated (CFR) and hypofractionated radiotherapy (HFR) in patients with persistent postprostatectomy PSA who received salvage radiotherapy to prostate bed. METHODS Single institution retrospective chart review was performed after Institutional Review Board approval. Between May 2012 and December 2016, 147 patients received salvage postprostatectomy radiotherapy. PSA failure-free and metastasis-free survival were calculated using Kaplan-Meier method. Cox regression analysis was performed to test association of fractionation regimen and other clinical factors with treatment outcomes. Early and late toxicity was assessed using Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0. RESULTS Sixty-nine patients who had persistent PSA (≥ 0.1 ng/mL) after prostatectomy were identified. Median follow-up was 67 months (95% CI 58-106 months, range, 8-106 months). Thirty-six patients (52.2%) received CFR, 66 Gy in 33 fractions, 2 Gy per fraction, and 33 patients (47.8%) received HFR, 52.5 Gy in 20 fractions, 2.63 Gy per fraction. Forty-seven (68%) patients received androgen deprivation therapy (ADT). 5-year PSA failure- and metastasis-free survival rate was 56.9% and 76.9%, respectively. Thirty patients (43%) experienced biochemical failure after salvage radiotherapy and 16 patients (23%) experienced metastatic relapse. Nine patients (13%) developed metastatic castration-resistant disease and died of advanced prostate cancer. Median PSA failure-free survival was 72 months (95% CI; 41-72 months), while median metastasis-free survival was not reached. Patients in HFR group were more likely to experience shorter PSA failure-free survival when compared to CFR group (HR 2.2; 95% CI 1.0-4.6, p = 0.04). On univariate analysis, factors significantly associated with PSA failure-free survival were radiotherapy schedule (CFR vs HFR, HR 2.2, 95% CI 1.0-4.6, p = 0.04), first postoperative PSA (HR 1.02, 95% CI 1.0-1.04, p = 0.03), and concomitant ADT (HR 3.3, 95% CI 1.2-8.6, p = 0.02). On multivariate analysis, factors significantly associated with PSA failure-free survival were radiotherapy schedule (HR 3.04, 95% CI 1.37-6.74, p = 0.006) and concomitant ADT (HR 4.41, 95% CI 1.6-12.12, p = 0.004). On univariate analysis, factors significantly associated with metastasis-free survival were the first postoperative PSA (HR 1.07, 95% CI 1.03-1.12, p = 0.002), seminal vesicle involvement (HR 3.48, 95% CI 1.26-9.6,p = 0.02), extracapsular extension (HR 7.02, 95% CI 1.96-25.07, p = 0.003), and surgical margin status (HR 2.86, 95% CI 1.03-7.97, p = 0.04). The first postoperative PSA (HR 1.04, 95% CI 1.00-1.08, p = 0.02) and extracapsular extension (HR 4.24, 95% CI 1.08-16.55, p = 0.04) remained significantly associated with metastasis-free survival on multivariate analysis. Three patients in CFR arm (8%) experienced late genitourinary grade 3 toxicity. CONCLUSIONS In our experience, commonly used hypofractionated radiotherapy regimen was associated with lower biochemical control compared to standard fractionation in patients with persistent PSA receiving salvage radiotherapy. Reason for this might be lower biological dose in HFR compared to CFR group. However, this observation is limited due to baseline imbalances in ADT use, ADT duration and Grade Group distribution between two radiotherapy cohorts. In patients with persistent PSA post-prostatectomy, the first postoperative PSA is an independent risk factor for treatment failure. Additional studies are needed to corroborate our observations.
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Affiliation(s)
- Jure Murgic
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
| | - Blanka Jaksic
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
| | - Marin Prpic
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
- School of Dental Medicine, University of Zagreb, Gunduliceva 5, 10000, Zagreb, Croatia
| | - Davor Kust
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
| | - Amit Bahl
- University Hospitals Bristol NHS Foundation Trust, Marlborough Street, Bristol, BS13NU, UK
| | - Mirjana Budanec
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
| | - Angela Prgomet Secan
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
| | - Pierfrancesco Franco
- Department of Translational Medicine, University of Eastern Piedmont, 28100, Novara, Italy
- Department of Radiation Oncology, 'Maggiore della Carità' University Hospital, 28100, Novara, Italy
| | - Ivan Kruljac
- Department of Endocrinology, Diabetes and Metabolic Diseases "Mladen Sekso", University Hospital Center Sestre Milosrdnice, University of Zagreb School of Medicine, Vinogradska 29, 10000, Zagreb, Croatia
| | - Borislav Spajic
- Department of Urology, University Hospital Center Sestre Milosrdnice, 10000, Zagreb, Croatia
| | - Nenad Babic
- Department of Radiology, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
| | - Bozo Kruslin
- Ljudevit Jurak Department of Pathology and Cytology, Sestre Milosrdnice University Hospital Centre, Vinogradska 29, 10000, Zagreb, Croatia
| | - Mario Zovak
- Department of Surgery, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
| | - Eduardo Zubizarreta
- Division of Human Health, International Atomic Energy Agency (IAEA), Wagramer Str. 5, 1220, Vienna, Austria
| | - Eduardo Rosenblatt
- Division of Human Health, International Atomic Energy Agency (IAEA), Wagramer Str. 5, 1220, Vienna, Austria
| | - Ana Fröbe
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia.
- School of Dental Medicine, University of Zagreb, Gunduliceva 5, 10000, Zagreb, Croatia.
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12
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Guedes de Castro D, Braun AC, Calsavara VF, Melo Gondim GR, Gobo Silva ML, Chen MJ, Fogaroli RC, Ramos H, Coelho TM, Scintini Herbst AC, Abdallah EA, Yu LS, Fidarova E, Zubizarreta E, Assis Pellizzon AC, Domingos Chinen LT. Prospective Assessment of the Association Between Circulating Tumor Cells and Control of Brain Disease After Focal Radiation Therapy of Breast Cancer Brain Metastases. Adv Radiat Oncol 2021; 6:100673. [PMID: 33912738 PMCID: PMC8071730 DOI: 10.1016/j.adro.2021.100673] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/20/2021] [Accepted: 01/27/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose Predicting the risk of early distant brain failure (DBF) is in demand for management decisions in patients who are candidates for local treatment of brain metastases. This study aimed to analyze the association between circulating tumor cells (CTCs) and brain disease control after stereotactic radiation therapy/radiosurgery (SRT) for breast cancer brain metastasis (BCBM). Methods and Materials We prospectively assessed CTCs before (CTC1) and 4 to 5 weeks after (CTC2) SRT and their relationship with the number of new lesions (NL) suggestive of BCBM before SRT. CTC were quantified and analyzed by immunocytochemistry to evaluate the expression of the proteins COX2, EGFR, ST6GALNAC5, NOTCH1, and HER2. Distant brain failure-free survival (DBFFS), the primary endpoint, diffuse DBFFS (D-DBFFS), and overall survival were estimated. Analysis for DBF within 6 months, with death as competing risk, was performed. Results Patients were included between 2016 and 2018. CTCs were detected in all 39 patients before and in 34 of 35 patients after SRT. After median follow-up of 16.6 months, median DBFFS, D-DBFFS, and overall survival were 15.3, 14.1, and 19.5 months, respectively. DBF at 6 months was 40% with CTC1 ≤0.5 and 8.82% with CTC1 >0.5 CTC/mL (P = .007), and D-DBF at 6 months was 40% with CTC1 ≤0.5 and 0 with CTC1 >0.5 CTC/mL (P = .005) and 25% with NL/CTC1 >6.8 and 2.65% with NL/CTC1 ≤6.8 (P = .063). On multivariate analysis, DBFFS was inferior with CTC1 ≤0.5 (hazard ratio, 8.27; 95% confidence interval, 2.12-32.3; P = .002), and D-DBFFS was inferior with CTC1 ≤0.5 (hazard ratio, 10.22; 95% confidence interval, 1.99-52.41; P = .005). Protein expression was not associated with outcomes. Conclusions These data suggest that CTC1 and NL/CTC1 may have a role as a biomarker of early diffuse DBF and as a subsequent guide between focal or whole-brain radiation therapy in patients with BCBM.
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Prajogi GB, Loreti G, Zubizarreta E, Merwe D. Role of the IAEA in education and training of radiotherapy professionals in Asia Pacific. J Med Imaging Radiat Oncol 2021; 65:431-435. [DOI: 10.1111/1754-9485.13143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/28/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Gregorius Ben Prajogi
- Applied Radiation Biology and Radiotherapy Section Division of Human Health Department of Nuclear Sciences and Applications International Atomic Energy Agency Vienna Austria
| | - Giorgia Loreti
- Dosimetry and Medical Radiation Physics Section Division of Human Health Department of Nuclear Sciences and Applications International Atomic Energy Agency Vienna Austria
| | - Eduardo Zubizarreta
- Applied Radiation Biology and Radiotherapy Section Division of Human Health Department of Nuclear Sciences and Applications International Atomic Energy Agency Vienna Austria
| | - Debbie Merwe
- Dosimetry and Medical Radiation Physics Section Division of Human Health Department of Nuclear Sciences and Applications International Atomic Energy Agency Vienna Austria
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Rodin D, Tawk B, Mohamad O, Grover S, Moraes FY, Yap ML, Zubizarreta E, Lievens Y. Hypofractionated radiotherapy in the real-world setting: An international ESTRO-GIRO survey. Radiother Oncol 2021; 157:32-39. [PMID: 33453312 DOI: 10.1016/j.radonc.2021.01.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/21/2020] [Accepted: 01/03/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Multiple large trials have established the non-inferiority of hypofractionated radiotherapy compared to conventional fractionation. This study will determine real-world hypofractionation adoption across different geographic regions for breast, prostate, cervical cancer, and bone metastases, and identify barriers and facilitators to its use. MATERIALS AND METHODS An anonymous, electronic survey was distributed from January 2018 through January 2019 to radiation oncologists through the ESTRO-GIRO initiative. Predictors of hypofractionation were identified in univariable and multivariable regression analyses. RESULTS 2316 radiation oncologists responded. Hypofractionation was preferred in node-negative breast cancer following lumpectomy (82·2% vs. 46·7% for node-positive; p < 0.001), and in low- and intermediate-risk prostate cancer (57·5% and 54·5%, respectively, versus 41·2% for high-risk (p < 0.001)). Hypofractionation was used in 32·3% of cervix cases in Africa, but <10% in other regions (p < 0.001). For palliative indications, hypofractionation was preferred by the majority of respondents. Lack of long-term data and concerns about local control and toxicity were the most commonly cited barriers. In adjusted analyses, hypofractionation was least common for curative indications amongst low- and lower-middle-income countries, Asia-Pacific, female respondents, small catchment areas, and in centres without access to intensity modulated radiotherapy. CONCLUSION Significant variation was observed in hypofractionation across curative indications and between regions, with greater concordance in palliation. Using inadequate fractionation schedules may impede the delivery of affordable and accessible radiotherapy. Greater regionally-targeted and disease-specific education on evidence-based fractionation schedules is needed to improve utilization, along with best-case examples addressing practice barriers and supporting policy reform.
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Affiliation(s)
- Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada.
| | - Bouchra Tawk
- German Cancer Research Consortium, Core Site Heidelberg, German Cancer Research Center, Heidelberg, Germany; Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine and Heidelberg University Hospital, Heidelberg, Germany
| | - Osama Mohamad
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, United States
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, United States; Perelman School of Medicine, University of Pennsylvania, Philadelphia, United States
| | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston, Canada
| | - Mei Ling Yap
- Collaboration for Cancer Outcomes, Research and Evaluation (CCORE), Ingham Institute, UNSW Sydney, Liverpool, Australia; Liverpool and Macarthur Cancer Therapy Centres, Western Sydney University, Campbelltown, Australia
| | | | - Yolande Lievens
- Ghent University Hospital and Ghent University, Ghent, Belgium
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15
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Vinnikov V, Hande MP, Wilkins R, Wojcik A, Zubizarreta E, Belyakov O. Prediction of the Acute or Late Radiation Toxicity Effects in Radiotherapy Patients Using Ex Vivo Induced Biodosimetric Markers: A Review. J Pers Med 2020; 10:E285. [PMID: 33339312 PMCID: PMC7766345 DOI: 10.3390/jpm10040285] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/02/2020] [Accepted: 12/11/2020] [Indexed: 12/14/2022] Open
Abstract
A search for effective methods for the assessment of patients' individual response to radiation is one of the important tasks of clinical radiobiology. This review summarizes available data on the use of ex vivo cytogenetic markers, typically used for biodosimetry, for the prediction of individual clinical radiosensitivity (normal tissue toxicity, NTT) in cells of cancer patients undergoing therapeutic irradiation. In approximately 50% of the relevant reports, selected for the analysis in peer-reviewed international journals, the average ex vivo induced yield of these biodosimetric markers was higher in patients with severe reactions than in patients with a lower grade of NTT. Also, a significant correlation was sometimes found between the biodosimetric marker yield and the severity of acute or late NTT reactions at an individual level, but this observation was not unequivocally proven. A similar controversy of published results was found regarding the attempts to apply G2- and γH2AX foci assays for NTT prediction. A correlation between ex vivo cytogenetic biomarker yields and NTT occurred most frequently when chromosome aberrations (not micronuclei) were measured in lymphocytes (not fibroblasts) irradiated to relatively high doses (4-6 Gy, not 2 Gy) in patients with various grades of late (not early) radiotherapy (RT) morbidity. The limitations of existing approaches are discussed, and recommendations on the improvement of the ex vivo cytogenetic testing for NTT prediction are provided. However, the efficiency of these methods still needs to be validated in properly organized clinical trials involving large and verified patient cohorts.
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Affiliation(s)
- Volodymyr Vinnikov
- S.P. Grigoriev Institute for Medical Radiology and Oncology, National Academy of Medical Science of Ukraine, 61024 Kharkiv, Ukraine
| | - Manoor Prakash Hande
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, MD9, 2 Medical Drive, Singapore 117593, Singapore;
| | - Ruth Wilkins
- Consumer and Clinical Radiation Protection Bureau, Health Canada, 775 Brookfield Road, Ottawa, ON K1A 1C1, Canada;
| | - Andrzej Wojcik
- Centre for Radiation Protection Research, MBW Department, Stockholm University, Svante Arrhenius väg 20C, Room 515, 10691 Stockholm, Sweden;
| | - Eduardo Zubizarreta
- Section of Applied Radiation Biology and Radiotherapy, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna International Centre, P.O. Box 100, 1400 Vienna, Austria;
| | - Oleg Belyakov
- Section of Applied Radiation Biology and Radiotherapy, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna International Centre, P.O. Box 100, 1400 Vienna, Austria;
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16
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Anacak Y, Zubizarreta E, Zaghloul M, Laskar S, Alert J, Gondhowiardjo S, Giselvania A, Correa-Villar R, Pedrosa F, Dorj B, Kamer S, Howard SC, Quintana Y, Ribeiro RC, Rosenblatt E, Hopkins K. The Practice of Paediatric Radiation Oncology in Low- and Middle-income Countries: Outcomes of an International Atomic Energy Agency Study. Clin Oncol (R Coll Radiol) 2020; 33:e211-e220. [PMID: 33250288 DOI: 10.1016/j.clon.2020.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/14/2020] [Accepted: 11/06/2020] [Indexed: 12/17/2022]
Abstract
AIMS Childhood cancer survival is suboptimal in most low- and middle-income countries (LMICs). Radiotherapy plays a significant role in the standard care of many patients. To assess the current status of paediatric radiotherapy, the International Atomic Energy Agency (IAEA) undertook a global survey and a review of practice in eight leading treatment centres in middle-income countries (MICs) under Coordinated Research Project E3.30.31; 'Paediatric radiation oncology practice in low and middle income countries: a patterns-of-care study by the International Atomic Energy Agency.' MATERIALS AND METHODS A survey of paediatric radiotherapy practices was distributed to 189 centres worldwide. Eight leading radiotherapy centres in MICs treating a significant number of children were selected and developed a database of individual patients treated in their centres comprising 46 variables related to radiotherapy technique. RESULTS Data were received from 134 radiotherapy centres in 42 countries. The percentage of children treated with curative intent fell sequentially from high-income countries (HICs; 82%) to low-income countries (53%). Increasing deficiencies were identified in diagnostic imaging, radiation staff numbers, radiotherapy technology and supportive care. More than 92.3% of centres in HICs practice multidisciplinary tumour board decision making, whereas only 65.5% of centres in LMICs use this process. Clinical guidelines were used in most centres. Practice in the eight specialist centres in MICs approximated more closely to that in HICs, but only 52% of patients were treated according to national/international protocols whereas institution-based protocols were used in 41%. CONCLUSIONS Quality levels in paediatric radiotherapy differ among countries but also between centres within countries. In many LMICs, resources are scarce, coordination with paediatric oncology is poor or non-existent and access to supportive care is limited. Multidisciplinary treatment planning enhances care and development may represent an area where external partners can help. Commitment to the use of protocols is evident, but current international guidelines may lack relevance; the development of resources that reflect the capacity and needs of LMICs is required. In some LMICs, there are already leading centres experienced in paediatric radiotherapy where patient care approximates to that in HICs. These centres have the potential to drive improvements in service, training, mentorship and research in their regions and ultimately to improve the care and outcomes for paediatric cancer patients.
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Affiliation(s)
- Y Anacak
- Ege University School of Medicine, Izmir, Turkey
| | | | - M Zaghloul
- National Cancer Institute, Cairo University, Cairo, Egypt; Children's Cancer Hospital, Cairo, Egypt
| | - S Laskar
- Tata Memorial Hospital, Mumbai, India
| | - J Alert
- Instituto de Oncología y Radiobiología, Habana, Cuba
| | - S Gondhowiardjo
- Faculty of Medicine, University of Indonesia/Dr Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - A Giselvania
- Faculty of Medicine, University of Indonesia/Dr Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | | | - F Pedrosa
- Instituto de Medicina Integral Prof. Fernando Figueira, Recife, Brazil
| | - B Dorj
- National Cancer Centre, Ulaanbaatar, Mongolia
| | - S Kamer
- Ege University School of Medicine, Izmir, Turkey
| | - S C Howard
- University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - R C Ribeiro
- St Jude Children's Research Hospital, Memphis, TN, USA
| | - E Rosenblatt
- International Atomic Energy Agency, Vienna, Austria
| | - K Hopkins
- International Atomic Energy Agency, Vienna, Austria.
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Taku N, Polo A, Zubizarreta E, Prasad R, Hopkins K. External Beam Radiotherapy in West Africa: 1979 - 2019. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.2444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Chan J, Friborg J, Zubizarreta E, van Eck J, Hanna T, Bourque J, Gaudet M, Dennis K, Olson R, Coleman C, Petersen A, Grau C, Abdel-Wahab M, Brundage M, Slotman B, Polo A. Geographic Accessibility to Radiotherapy in Canada and Greenland for Indigenous Populations: A Quantitative Approach to Highlighting Inequities and Exploring Solutions. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.2448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Polo Rubio J, Zubizarreta E, Lievens Y, Barton M, Rodin D, Jake V, Grover S, Abdel-Wahab M. OC-0077: Factors Associated with the Global Availability of Radiotherapy Services: an IAEA analysis. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)00103-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mir R, Kelly SM, Xiao Y, Moore A, Clark CH, Clementel E, Corning C, Ebert M, Hoskin P, Hurkmans CW, Ishikura S, Kristensen I, Kry SF, Lehmann J, Michalski JM, Monti AF, Nakamura M, Thompson K, Yang H, Zubizarreta E, Andratschke N, Miles E. Organ at risk delineation for radiation therapy clinical trials: Global Harmonization Group consensus guidelines. Radiother Oncol 2020; 150:30-39. [DOI: 10.1016/j.radonc.2020.05.038] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/12/2020] [Accepted: 05/24/2020] [Indexed: 12/25/2022]
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21
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Chan J, Zubizarreta E, van Eck JW, Hanna T, Bourque JM, Gaudet M, Dennis K, Olson R, Coleman CN, Abdel-Wahab M, Brundage M, Slotman B, Polo A. 33: Geographic Accessibility to Radiotherapy in Canada for Indigenous Populations: Highlighting The Inequities. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(20)30925-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Chan J, Friborg J, Zubizarreta E, van Eck JW, Hanna TP, Bourque JM, Gaudet M, Dennis K, Olson R, Coleman CN, Petersen AJ, Grau C, Abdel-Wahab M, Brundage M, Slotman B, Polo A. Examining geographic accessibility to radiotherapy in Canada and Greenland for indigenous populations: Measuring inequities to inform solutions. Radiother Oncol 2020; 146:1-8. [DOI: 10.1016/j.radonc.2020.01.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/22/2020] [Accepted: 01/27/2020] [Indexed: 12/15/2022]
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Chan J, Polo A, Zubizarreta E, Bourque JM, Hanna TP, Gaudet M, Dennis K, Brundage M, Slotman B, Abdel-Wahab M. Access to radiotherapy and its association with cancer outcomes in a high-income country: Addressing the inequity in Canada. Radiother Oncol 2019; 141:48-55. [PMID: 31575428 DOI: 10.1016/j.radonc.2019.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/03/2019] [Accepted: 09/07/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE Canada is a high-income country with universal healthcare. In international comparisons, its overall level of access to radiotherapy appears sufficient. However, challenges exist due to Canada's large geographic area and small population density. The association between access and cancer outcomes nationally has not yet been described. MATERIALS AND METHODS We quantified geographic accessibility for 2012 using the linear distance from each Canadian health region centroid to the nearest radiotherapy center. We used geospatial analytic techniques to detect clusters of age-standardized all-cancer mortality-to-incidence ratios (MIRs) across health regions, from 2010-2012. Global ordinary least squares (OLS) and geographically-weighted regression (GWR) were conducted to examine relationships between distance and MIR, adjusting for sociodemographic factors. RESULTS Median distance from health region centroid to nearest radiotherapy center was 101.73 km (range 1.14-2095.12). One cluster of worse outcomes (MIR range 0.45-0.88) involved most of northern Canada, with a second cluster of better outcomes (MIR range 0.40-0.41) in southern British Columbia. In both regression models, regions with longer distance to radiotherapy center (ß = 0.0001), increased smoking (ß = 0.002), and poorer food security (ß = -0.003) were significantly associated with worse outcomes (OLS R2 = 0.70, GWR R2 = 0.74). Distance remained independently associated with MIR for lung and colorectal cancer subgroups, but not breast and prostate. CONCLUSIONS A clear north-south discordance in cancer outcomes exists in Canada, with poorer outcomes in the north, while radiotherapy centers are concentrated along the south. Increased distance to radiotherapy, along with other sociodemographic and health-system factors, are associated with poorer cancer outcomes. Our study could be replicated, particularly in other high-income countries, to help identify national patterns and regional disparities in access and outcomes.
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Affiliation(s)
- Jessica Chan
- Division of Radiation Oncology, The Ottawa Hospital and the University of Ottawa, Canada; Division of Human Health, International Atomic Energy Agency, Vienna, Austria; Department of Radiation Oncology, Amsterdam UMC - Vrije University Medical Center, The Netherlands.
| | - Alfredo Polo
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Eduardo Zubizarreta
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Jean-Marc Bourque
- Division of Radiation Oncology, The Ottawa Hospital and the University of Ottawa, Canada; Division of Human Health, International Atomic Energy Agency, Vienna, Austria; Institute of Cancer Policy, Kings College London, United Kingdom
| | - Timothy P Hanna
- Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen's University, Kingston, Canada
| | - Marc Gaudet
- Division of Radiation Oncology, The Ottawa Hospital and the University of Ottawa, Canada
| | - Kristopher Dennis
- Division of Radiation Oncology, The Ottawa Hospital and the University of Ottawa, Canada
| | - Michael Brundage
- Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen's University, Kingston, Canada
| | - Ben Slotman
- Department of Radiation Oncology, Amsterdam UMC - Vrije University Medical Center, The Netherlands
| | - May Abdel-Wahab
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
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Chopra S, Mittal P, Viswanathan A, Tharavichitkul E, Zubizarreta E, Nout RA, Yap ML, Grover S, Rodin D, Rai B, Gondhowiardjo S, Shrivastava SK. Global Collaborations for Cervical Cancer: Can the East-West Alliance Facilitate Treatment for all? Clin Oncol (R Coll Radiol) 2019; 31:529-538. [PMID: 31229379 DOI: 10.1016/j.clon.2019.05.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/11/2019] [Accepted: 05/28/2019] [Indexed: 12/20/2022]
Abstract
Despite the advances in the primary prevention of cervical cancer, there is an absolute increase in the incidence of cervical cancer as a result of an increase in world population. A vast majority of patients in low and low-middle income countries continue to present at a locally advanced stage, necessitating treatment with chemoradiation and brachytherapy. There is a dearth of equipment and trained professionals for the treatment of cervical cancer, especially in low and low-middle income countries. There is an urgent need to improve treatment availability and develop better treatments. Worldwide trends, however, reveal a low number of therapeutic and innovative research trials in cervical cancer. The present article elucidates the existing challenges and provides solutions to improve outcomes. The proposed strategies hinge on strengthening collaborations for global advocacy.
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Affiliation(s)
- S Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi Mumbai, India; Homi Bhabha National Institute, Mumbai, India.
| | - P Mittal
- Homi Bhabha National Institute, Mumbai, India; Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - A Viswanathan
- Department of Radiation Oncology, Johns Hopkins University Medical Center, Baltimore, Maryland, USA
| | - E Tharavichitkul
- Division of Radiation Oncology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - E Zubizarreta
- Division of Human Health, International Atomic of Energy Agency - Vienna International Centre, Vienna, Austria
| | - R A Nout
- Department of Radiation Oncology, Leiden University Medical Center LUM, Leiden, the Netherlands
| | - M L Yap
- Collaboration for Cancer Outcomes, Research and Evaluation (CCORE), Ingham Institute, UNSW Sydney, Liverpool, New South Wales, Australia; Liverpool and Macarthur Cancer Therapy Centres, Western Sydney University, Campbelltown, New South Wales, Australia; School of Public Health, The University of Sydney, Camperdown, Australia
| | - S Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA; Botswana-UPENN Partnership, University of Botswana, Gaborone, Botswana
| | - D Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - B Rai
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S Gondhowiardjo
- Department of Radiotherapy, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - S K Shrivastava
- Department of Radiation Oncology, Apollo Hospital, Belapur, Navi Mumbai, India
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Dosanjh M, Aggarwal A, Pistenmaa D, Amankwaa-Frempong E, Angal-Kalinin D, Boogert S, Brown D, Carlone M, Collier P, Court L, Di Meglio A, Van Dyk J, Grover S, Jaffray D, Jamieson C, Khader J, Konoplev I, Makwani H, McIntosh P, Militsyn B, Palta J, Sheehy S, Aruah S, Syratchev I, Zubizarreta E, Coleman C. Developing Innovative, Robust and Affordable Medical Linear Accelerators for Challenging Environments. Clin Oncol (R Coll Radiol) 2019; 31:352-355. [DOI: 10.1016/j.clon.2019.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/08/2018] [Accepted: 01/15/2019] [Indexed: 12/21/2022]
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Rodin D, Burger EA, Atun R, Barton M, Gospodarowicz M, Grover S, Hanna TP, Jaffray DA, Knaul FM, Lievens Y, Zubizarreta E, Milosevic M. Scale-up of radiotherapy for cervical cancer in the era of human papillomavirus vaccination in low-income and middle-income countries: a model-based analysis of need and economic impact. Lancet Oncol 2019; 20:915-923. [PMID: 31151906 DOI: 10.1016/s1470-2045(19)30308-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 03/29/2019] [Accepted: 04/03/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND Radiotherapy is standard of care for cervical cancer, but major global gaps in access exist, particularly in low-income and middle-income countries. We modelled the health and economic benefits of a 20-year radiotherapy scale-up to estimate the long-term demand for treatment in the context of human papillomavirus (HPV) vaccination. METHODS We applied the Global Task Force on Radiotherapy for Cancer Control investment framework to model the health and economic benefits of scaling up external-beam radiotherapy and brachytherapy for cervical cancer in upper-middle-income, lower-middle-income, and low-income countries between 2015 and 2035. We estimated the unique costs of external-beam radiotherapy and brachytherapy and included a specific valuation of women's caregiving contributions. Model outcomes life-years gained and the human capital and full income net present value of investment. We estimated the effects of stage at diagnosis, radiotherapy delivery system, and simultaneous HPV vaccination (75% coverage) up to a time horizon set at 2072. FINDINGS For the period from 2015 to 2035, we estimated that 9·4 million women in low-income and middle-income countries required treatment with external-beam radiotherapy, of which 7·0 million also required treatment with brachytherapy. Incremental scale-up of radiotherapy in these countries from 2015 to meet optimal radiotherapy demand by 2035 yielded 11·4 million life-years gained, $59·3 billion in human capital net present value (-$1·5 billion in low-income, $19·9 billion in lower-middle-income, and $40·9 billion in upper-middle-income countries), and $151·5 billion in full income net present value ($1·5 billion in low-income countries, $53·6 billion in lower-middle-income countries, and $96·4 billion in upper-middle-income countries). Benefits increased with advanced stage of cervical cancer and more efficient scale up of radiotherapy. Bivalent HPV vaccination of 12-year-old girls resulted in a 3·9% reduction in incident cases from 2015-2035. By 2072, when the first vaccinated cohort of girls reaches 70 years of age, vaccination yielded a 22·9% reduction in cervical cancer incidence, with 38·4 million requiring external-beam radiotherapy and 28·8 million requiring brachytherapy. INTERPRETATION Effective cervical cancer control requires a comprehensive strategy. Even with HPV vaccination, radiotherapy treatment scale-up remains essential and produces large health benefits and a strong return on investment to countries at different levels of development. FUNDING None.
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Affiliation(s)
- Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre Toronto, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.
| | - Emily A Burger
- Center for Health Decision Science, Harvard University, Boston, MA, USA; Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Rifat Atun
- Department of Global Health and Population, Harvard University, Boston, MA, USA; Harvard T H Chan School of Public Health, and the Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Michael Barton
- Ingham Institute for Applied Medical Research, University of New South Wales Sydney, Liverpool, NSW, Australia
| | - Mary Gospodarowicz
- Radiation Medicine Program, Princess Margaret Cancer Centre Toronto, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Surbhi Grover
- Botswana-UPenn Partnership and Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy P Hanna
- Division of Cancer Care and Epidemiology, Cancer Research Institute and Department of Oncology, Queen's University, Kingston, ON, Canada
| | - David A Jaffray
- Radiation Medicine Program, Princess Margaret Cancer Centre Toronto, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Felicia M Knaul
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, FL, USA; Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | | | - Michael Milosevic
- Radiation Medicine Program, Princess Margaret Cancer Centre Toronto, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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Rodin D, Osama M, Tawk B, Grover S, Moraes F, Yap M, Zubizarreta E, Lievens Y. OC-0505 Evidence-based practice in the global setting: an international survey of hypofractionation. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)30925-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Chan J, Polo A, Abdel-Wahab M, Hirata D, Bourque J, Zubizarreta E. Access to Radiation Therapy among Indigenous Populations in Canada. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.1197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Rivera S, Petit C, Martin AN, Cacicedo J, Leaman O, Rosselot MCA, Lazaryan A, Akperov K, Sinaika V, Monestel R, Fröbe A, Kevlishvili G, Stojkovski I, Magsar B, Corovic M, Mahmood H, Alauddin Z, Barriga O, Lucas M, Palmu M, Zubizarreta E, Hopkins K, Eriksen J. Long-term impact on contouring skills achieved by online learning. An ESTRO-FALCON-IAEA study. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.1174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Chan J, Polo A, Abdel-Wahab M, Hirata D, Bourque J, Zubizarreta E. Disparities in Accessibility to Radiation Therapy in a High-Income Country: The Case of Canada. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.1196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Jacinto AA, Batalha Filho ES, Viana LDS, De Marchi P, Capuzzo RDC, Gama RR, Boldrini Junior D, Santos CR, Pinto GDJ, Dias JM, Canton HP, Carvalho R, Radicchi LA, Bentzen S, Zubizarreta E, Carvalho AL. Feasibility of concomitant cisplatin with hypofractionated radiotherapy for locally advanced head and neck squamous cell carcinoma. BMC Cancer 2018; 18:1026. [PMID: 30352576 PMCID: PMC6199702 DOI: 10.1186/s12885-018-4893-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 10/03/2018] [Indexed: 11/10/2022] Open
Abstract
Background The evolution of radiotherapy over recent decades has reintroduced the hypofractionation for many tumor sites with similar outcomes to those of conventional fractionated radiotherapy. The use of hypofractionation in locally advanced head and neck cancer (LAHNC) has been already used, however, its use has been restricted to only a few countries. The aim of this trial was to evaluate the safety and feasibility of moderate hypofractionated radiotherapy (HYP-RT) with concomitant cisplatin (CDDP). Methods This single-arm trial was designed to evaluate the safety and feasibility of HYP-RT with concomitant CDDP in LAHNC. Stage III and IV patients withnonmetastatic disease were enrolled. Patients were submitted to intensity modulatedradiation therapy, which comprised 55 Gy/20 fractions to the gross tumor and44–48 Gy/20 fractions to the areas of subclinical disease. Concomitant CDDPconsisted of 4 weekly cycles of 35 mg/m2. The primary endpoints were the treatment completion rate and acute toxicity. Results Twenty patients were enrolled from January 2015 to September 2016, and 12 (60%) were classified as unresectable. All patients completed the total dose of radiotherapy, and 19 patients (95%) received at least 3 of 4 cycles of chemotherapy. The median overall treatment time was 29 days (27–34). Grade 4 toxicity was reported twice (1 fatigue and 1 lymphopenia). The rates of grade 3 dermatitis and mucositis were 30% and 40%, respectively, with spontaneous resolution. Nasogastric tubes were offered to 15 patients (75%) during treatment; 4 patients (20%) needed feeding tubes after 2 months, and only 1 patient needed a feeding tube after 12 months. Conclusion HYP-RT with concomitant CDDP was considered feasible for LAHNC, and the rate of acute toxicity was comparable to that of standard concomitant chemoradiation. A feeding tube was necessary for most patients during treatment. Further investigation of this strategy is warranted. Trial registration ClinicalTrials, NCT03194061. Registered 21 Jun 2017 – Retrospectively registered.
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Affiliation(s)
- Alexandre Arthur Jacinto
- Department of Radiation Oncology, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, 14.784-400, Brazil.
| | | | - Luciano de Souza Viana
- Department of Medical Oncology, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, 14.784-400, Brazil
| | - Pedro De Marchi
- Department of Medical Oncology, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, 14.784-400, Brazil
| | - Renato de Castro Capuzzo
- Department of Head and Neck, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, 14.784-400, Brazil
| | - Ricardo Ribeiro Gama
- Department of Head and Neck, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, 14.784-400, Brazil
| | - Domingos Boldrini Junior
- Department of Head and Neck, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, 14.784-400, Brazil
| | - Carlos Roberto Santos
- Department of Head and Neck, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, 14.784-400, Brazil
| | - Gustavo Dix Junqueira Pinto
- Department of Medical Oncology, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, 14.784-400, Brazil
| | - Josiane Mourão Dias
- Department of Medical Oncology, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, 14.784-400, Brazil
| | - Heloisa Pelisser Canton
- Department of Radiation Oncology, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, 14.784-400, Brazil
| | - Raiany Carvalho
- Department of Head and Neck, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, 14.784-400, Brazil
| | - Lucas Augusto Radicchi
- Department of Radiation Oncology, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, 14.784-400, Brazil
| | - Soren Bentzen
- University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Eduardo Zubizarreta
- International Atomic of Energy Agency - Vienna International Centre, PO Box 100, A-1400, Vienna, Austria
| | - Andre Lopes Carvalho
- Department of Head and Neck, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, 14.784-400, Brazil
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Abstract
Background and context: Fifty-three countries are members of the Commonwealth. These countries span Africa, Asia, the Americas, Europe and the Pacific and are diverse - they are among the world's largest, smallest, richest and poorest countries. Thirty-one of these members are classified as small states - countries with a population size of 1.5 million people or less and larger member states that share similar characteristics with them. The Commonwealth Secretariat is planning to tackle the problem of cervical cancer in their low and middle member states (LMIC) through the project “Cervical Cancer in the Commonwealth: Collective Action”. There are 209,100 cervical cancer cases diagnosed per year in the Commonwealth, and in 167,300 cases radiotherapy treatment is indicated. Aim: To analyze the problem of cervical cancer in low and middle-income countries of the Commonwealth and to propose the first step for a collective action. Strategy/Tactics: The treatment of locally advanced cervical cancer includes radiotherapy (teletherapy and brachytherapy) plus concomitant chemotherapy. Cervical cancer has a high rate of curability if brachytherapy is added to teletherapy. We identified radiotherapy departments in Commonwealth LMIC with teletherapy but no brachytherapy and proposed the upgrade of these services to include brachytherapy as a first step. Program/Policy process: The evidence-based treatment of locally advanced cervical cancer is a combination of external beam radiotherapy with chemotherapy and brachytherapy. Brachytherapy has played a major role during many decades in the treatment of gynecologic cancer with good clinical results. EBRT combined with BT leads to superior survival for patients with cervix cancer as compared with EBRT alone, and additionally, MR image-guided BT further improves local control and survival. Countries with no access to BT may only offer palliative treatment to women diagnosed with locally advanced cervical cancer. Any curative attempt for these patients should include brachytherapy. The addition of brachytherapy to external beam radiotherapy in the treatment of cervical cancer is associated with a 12% increase in the 4-y overall survival rates and 13% increase in cause-specify survival. Brachytherapy can save at least 12% more cervical cancer lives than radiotherapy alone. These differences would be much bigger in LMIC because of the limited technology used for external beam radiotherapy. Outcomes: Each high dose rate (HDR) brachytherapy afterloader can treat up to 666 patients per year, of which 466 (70%) could be potentially cured. The capital costs for installing an HDR afterloader is around US$ 1 million, including equipment and building, the annual operating costs are US$ 473,000, and the costs of brachytherapy are US$ 710 per patient. In the lifetime of an HDR afterloader (10 years), 4660 patients could be cured per afterloader installed. What was learned: Brachytherapy saves lives!
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Affiliation(s)
| | - M. Lodge
- International Network for CancerTreatment and Research, Oxford, United Kingdom
| | | | - A. Polo
- International Atomic Energy Agency, Vienna, Austria
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Abdel-Wahab M, Paez D, Zubizarreta E, Polo A. Improving Access to Treatment of Gynecologic Cancers/Cervix Cancers. J Glob Oncol 2018. [DOI: 10.1200/jgo.18.70700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Aim and purpose: The session aims at outlining actions that the healthcare community can take to improve the current situation and inform cervix cancer control plans. Highlighting the need to address opportunities in the prevention and management of cervix cancer, the session will provide guidance on primary, secondary and tertiary prevention and management of cervix cancer and will discuss the role of radiotherapy, while showcasing examples of collaboration. Audiences: Healthcare professionals with a special interest in women's cancers/cervix cancer and healthcare services planning. Cancer care advocates and patients advocates Decision makers involved in the planning of health care services Stakeholders in LMICs Suggested panel participants: Cherian Varghese, WHO Topic “The UN Joint Global Programme on Cervical Cancer Prevention and Control” The speaker will present this important initiative that builds on the world's collective endeavors so that in a generation, death from cervical cancer ceases to be a public health issue. Kennedy Lishimpi Topic, “Case study: Zambia” Illustrate how Zambia went from having no radiotherapy facilities to being able to offer up-to-date treatment to cancer patients Lusaka, Zambia Ted Trimble, NCI Topic, “NCI Activities in Support of Cervical Cancer” To present the important initiatives of the NCI/NHI to tackle the burden of gynecologic cancers Bethesda, Maryland May Abdel-Wahab, IAEA Topic, “International Program Results on the Ground in Support of Cervical Cancer” The speaker will present available support cooperation, education and training, and the need for enhanced safety and quality and use an example of interventions in Africa.
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Affiliation(s)
| | - D. Paez
- International Atomic Energy Agency, Vienna, Austria
| | | | - A. Polo
- International Atomic Energy Agency, Vienna, Austria
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Paez D, Zubizarreta E, Abdel-Wahab M, Polo A. Activities of the International Atomic Energy Agency in the Field of Cervical Cancer. J Glob Oncol 2018. [DOI: 10.1200/jgo.18.70200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background and context: In 2012, 560,000 women were diagnosed with cervical cancer (CXCA) worldwide and 266,000 women died of the disease: 86% of cases and 88% of deaths occurred in low- and middle-income countries (LMICs), and two thirds of the cases are locally advanced. For locally advanced CXCA the evidence-based treatment is a combination of external beam radiotherapy with chemotherapy and brachytherapy. Five-year overall survival for all stages combined ranges between 60%-69%, depending on the case-mix and the treatment modalities used. Countries with no access to radiotherapy may only offer palliative treatment to women diagnosed with locally advanced cervical cancer. Any curative attempt for these patients should include the two components of radiotherapy: concomitant radio-chemotherapy and brachytherapy. Radiotherapy is also a cost-effective treatment modality. Aim: To show the contribution and impact of the International Atomic Energy Agency (IAEA) to the improvement of results of CXCA in LMICs. Strategy/Tactics: Through its various programs, such as the Technical Cooperation programs, the Human Health program and the Program of Action for Cancer Therapy, the IAEA is committed to address these disproportionate geographic incidence and mortality rates introducing, expanding and improving radiotherapy services, working with partners such as WHO to improve cancer diagnosis, treatment, care, and control through collective action in these countries. Program/Policy process: During the last six decades, the IAEA has helped in addressing the growing cancer burden, delivering cancer-related assistance to LMICs, with financial and in-kind support from member states, donors and partners. The IAEA assistance has been primarily facilitated through the deployment of robust radiotherapy and nuclear medicine programs, coordinated research activities, documentation system and quality assurance program. This has enabled many member states to establish safe and effective diagnostic imaging and radiation therapy capacity to provide treatment and higher quality care to many of their cancer patients. The Program of Action for Cancer Therapy (PACT) is the IAEA's umbrella program for combating cancer and builds upon the above experience in radiation medicine expertise and technology. The WHO-IAEA Joint Program enable LMI member states to introduce, expand and improve their cancer treatment capacities and therapeutic effectiveness by integrating radiotherapy into a comprehensive national cancer control program. Outcomes: The IAEA provides tools for improving the practice of radiation medicine around the world. A fully implemented department (megavoltage and afterloading units, trained staff and quality assurance procedures in place) can treat up to 666 new CXCA cases per year, of which around 70% (466) can be cured. What was learned: Investing in radiotherapy can save lives!
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Affiliation(s)
- D. Paez
- International Atomic Energy Agency, Vienna, Austria
| | | | | | - A. Polo
- International Atomic Energy Agency, Vienna, Austria
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Pistenmaa DA, Dosanjh M, Amaldi U, Jaffray D, Zubizarreta E, Holt K, Lievens Y, Pipman Y, Coleman CN. Changing the global radiation therapy paradigm. Radiother Oncol 2018; 128:393-399. [DOI: 10.1016/j.radonc.2018.05.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/23/2018] [Accepted: 05/23/2018] [Indexed: 02/08/2023]
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Rosenblatt E, Fidarova E, Ghosh S, Zubizarreta E, Unterkirhere O, Semikoz N, Sinaika V, Kim V, Karamyan N, Isayev I, Akbarov K, Lomidze D, Bondareva O, Tuzlucov P, Zardodkhonova M, Tkachev S, Kislyakova M, Alimov J, Pidlubna T, Barton M, Mackillop W. Quality of radiotherapy services in post-Soviet countries: An IAEA survey. Radiother Oncol 2018; 127:171-177. [PMID: 29705501 DOI: 10.1016/j.radonc.2018.03.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/18/2018] [Accepted: 03/28/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND The quality of radiotherapy services in post-Soviet countries has not yet been studied following a formal methodology. The IAEA conducted a survey using two sets of validated radiation oncology quality indicators (ROIs). METHODS Eleven post-Soviet countries were assessed. A coordinator was designated for each country and acted as the liaison between the country and the IAEA. The methodology was a one-time cross-sectional survey using a 58-question tool in Russian. The questionnaire was based on two validated sets of ROIs: for radiotherapy centres, the indicators proposed by Cionini et al., and for data at the country level, the Australasian ROIs. RESULTS The overall response ratio was 66.3%, but for the Russian Federation, it was 24%. Data were updated on radiotherapy infrastructure and equipment. 256 radiotherapy centres are operating 275 linear accelerators and 337 Cobalt-60 units. 61% of teletherapy machines are older than ten years. Analysis of ROIs revealed significant differences between these countries and radiotherapy practices in the West. Naming, task profile and education programmes of radiotherapy professionals are different than in the West. CONCLUSIONS Most countries need modernization of their radiotherapy infrastructure coupled with adequate staffing numbers and updated education programmes focusing on evidence-based medicine, quality, and safety.
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Affiliation(s)
- Eduardo Rosenblatt
- Div. of Human Health, International Atomic Energy Agency, Vienna, Austria.
| | - Elena Fidarova
- Div. of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Sunita Ghosh
- Cancer Biostatistics, Univ. of Alberta, Edmonton, Canada
| | | | - Olga Unterkirhere
- Div. of Human Health, International Atomic Energy Agency, Vienna, Austria
| | | | - Valery Sinaika
- N.N. Alexandrov National Cancer Center of Belarus, Minsk, Belarus
| | - Viktor Kim
- Kazakhstan Research Institute of Oncology and Radiology, Almaty, Kazakhstan
| | | | - Isa Isayev
- National Center of Oncology, Baku, Azerbaijan
| | | | - Darejan Lomidze
- Tbilisi State Medical University, HTMC, University Clinic, Tbilisi, Georgia
| | | | | | | | - Sergey Tkachev
- N.N. Blokhin National Medical Research Center of Oncology, Russian Federation
| | | | - Jamshid Alimov
- National Research Center of Oncology, Tashkent, Uzbekistan
| | | | - Michael Barton
- Ingham Institute for Applied Medical Research, UNSW, Sydney, Australia
| | - William Mackillop
- Queen's University, Division of Cancer Care & Epidemiology, Kingston, Ontario, Canada
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Hendry J, Jones G, Mahantshetty U, Sarria G, da Motta N, Fidarova E, Abdel-Wahab M, Prasad R, Polo A, Zubizarreta E. Radiobiological Analysis of Outcomes Using External Beam Radiotherapy Plus High Dose-Rate Brachytherapy (4x7 Gy or 2x9 Gy) for Cervical Cancer in a Multi-Institution Trial. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Parkes J, Hess C, Burger H, Anacak Y, Ahern V, Howard SC, Elhassan M, Ahmed S, Ghalibafian M, Abbasi AN, Qureshi BM, Zaghloul M, Zubizarreta E, Bey P, Davidson A, Bouffet E, Esiashvili N. Recommendations for the treatment of children with radiotherapy in low- and middle-income countries (LMIC): A position paper from the Pediatric Radiation Oncology Society (PROS-LMIC) and Pediatric Oncology in Developing Countries (PODC) working groups of the International Society of Pediatric Oncology (SIOP). Pediatr Blood Cancer 2017; 64 Suppl 5. [PMID: 29297617 DOI: 10.1002/pbc.26903] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/31/2017] [Accepted: 11/02/2017] [Indexed: 02/06/2023]
Abstract
Pediatric radiotherapy is a critical part of pediatric oncology protocols and the quality of the radiotherapy may determine the future quality of life for long-term survivors. Multidisciplinary team decision making provides the basis for high-quality care. However, delivery of high-quality radiotherapy is dependent on resources. This article provides guidelines for delivery of good quality radiation therapy in resource-limited countries based on rational procurement and maintenance planning, protocol development, three-dimensional planning, quality assurance, and adequate staff numbers and training.
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Affiliation(s)
- Jeannette Parkes
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Clayton Hess
- Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Hester Burger
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Yavuz Anacak
- Ege University School of Medicine, Izmir, Turkey
| | - Verity Ahern
- Crown Princess Cancer Center, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Scott C Howard
- University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Moawia Elhassan
- National Cancer Institute, University of Gezira, Wad Medani, Sudan
| | - Soha Ahmed
- Children's Cancer Hospital Egypt (CCHE), National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mithra Ghalibafian
- MAHAK Pediatric Cancer Treatment and Research Center (MPCTRC), Tehran, Iran
| | | | | | - Mohamed Zaghloul
- Children's Cancer Hospital Egypt (CCHE), National Cancer Institute, Cairo University, Cairo, Egypt
| | | | | | - Alan Davidson
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | | | - Natia Esiashvili
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
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Lievens Y, Gospodarowicz M, Grover S, Jaffray D, Rodin D, Torode J, Yap ML, Zubizarreta E. Global impact of radiotherapy in oncology: Saving one million lives by 2035. Radiother Oncol 2017; 125:175-177. [DOI: 10.1016/j.radonc.2017.10.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 10/20/2017] [Indexed: 10/18/2022]
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40
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Izewska J, Coffey M, Scalliet P, Zubizarreta E, Santos T, Vouldis I, Dunscombe P. Improving the quality of radiation oncology: 10years' experience of QUATRO audits in the IAEA Europe Region. Radiother Oncol 2017; 126:183-190. [PMID: 28988660 DOI: 10.1016/j.radonc.2017.09.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 08/14/2017] [Accepted: 09/13/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE The IAEA has developed a methodology for comprehensive quality audits of radiotherapy practices called Quality Assurance Team for Radiation Oncology (QUATRO). This study explores the factors that impacted quality of care among QUATRO audited centres in the IAEA Europe Region. MATERIALS AND METHODS The 31 QUATRO reports collected over 10years include extensive data describing the quality of radiotherapy at the audited centres. A coding key was developed to aggregate and review these data in terms of recommendations for improvement and positive findings (commendations). RESULTS Overall 759 recommendations and 600 commendations were given. Eight centres recognized as centres of competence differed from other centres mostly because they operated complete quality management systems and were adequately staffed. Other centres had excessive staff workloads and many gaps in the process of care. Insufficient equipment levels were prevalent. Patient centredness, communication, dosimetry, quality control and radiation protection were frequently commended by QUATRO. CONCLUSIONS This analysis points to barriers to quality care such as insufficient staffing, education/training, equipment and lack of quality management. It highlights the correlation between the human resources availability and quality of care. It has also identified common action items for enhancing quality of radiotherapy programmes in the Region.
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Affiliation(s)
- Joanna Izewska
- International Atomic Energy Agency, Vienna International Centre, Vienna, Austria.
| | - Mary Coffey
- Discipline of Radiation Therapy, School of Medicine, Trinity Centre for Health Sciences, St. James' Hospital, Dublin, Ireland
| | - Pierre Scalliet
- Department of Radiotherapy, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Eduardo Zubizarreta
- International Atomic Energy Agency, Vienna International Centre, Vienna, Austria
| | - Tania Santos
- International Atomic Energy Agency, Vienna International Centre, Vienna, Austria
| | - Ioannis Vouldis
- International Atomic Energy Agency, Vienna International Centre, Vienna, Austria
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41
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Prasad R, Zubizarreta E, Healy B, Hopkins K, Wahab MA. Radiotherapy in South Asia: Infrastructure, Human Resource Capacity, and Future Needs. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.06.1587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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42
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Van Dyk J, Zubizarreta E, Lievens Y. Cost evaluation to optimise radiation therapy implementation in different income settings: A time-driven activity-based analysis. Radiother Oncol 2017; 125:178-185. [PMID: 28947098 DOI: 10.1016/j.radonc.2017.08.021] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/12/2017] [Accepted: 08/25/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND With increasing recognition of growing cancer incidence globally, efficient means of expanding radiotherapy capacity is imperative, and understanding the factors impacting human and financial needs is valuable. MATERIALS AND METHODS A time-driven activity-based costing analysis was performed, using a base case of 2-machine departments, with defined cost inputs and operating parameters. Four income groups were analysed, ranging from low to high income. Scenario analyses included department size, operating hours, fractionation, treatment complexity, efficiency, and centralised versus decentralised care. RESULTS The base case cost/course is US$5,368 in HICs, US$2,028 in LICs; the annual operating cost is US$4,595,000 and US$1,736,000, respectively. Economies of scale show cost/course decreasing with increasing department size, mainly related to the equipment cost and most prominent up to 3 linacs. The cost in HICs is two or three times as high as in U-MICs or LICs, respectively. Decreasing operating hours below 8h/day has a dramatic impact on the cost/course. IMRT increases the cost/course by 22%. Centralising preparatory activities has a moderate impact on the costs. CONCLUSIONS The results indicate trends that are useful for optimising local and regional circumstances. This methodology can provide input into a uniform and accepted approach to evaluating the cost of radiotherapy.
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Affiliation(s)
| | | | - Yolande Lievens
- Radiation Oncology Department, Ghent University Hospital and Ghent University, Belgium
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43
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Barton M, Zubizarreta E, Gospodarowicz M. Radiotherapy in Low- and Middle-income Countries. What Can We Do Differently? Clin Oncol (R Coll Radiol) 2017; 29:69-71. [DOI: 10.1016/j.clon.2016.11.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/15/2016] [Indexed: 12/31/2022]
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44
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van der Merwe D, Van Dyk J, Healy B, Zubizarreta E, Izewska J, Mijnheer B, Meghzifene A. Accuracy requirements and uncertainties in radiotherapy: a report of the International Atomic Energy Agency. Acta Oncol 2017; 56:1-6. [PMID: 27846757 DOI: 10.1080/0284186x.2016.1246801] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Radiotherapy technology continues to advance and the expectation of improved outcomes requires greater accuracy in various radiotherapy steps. Different factors affect the overall accuracy of dose delivery. Institutional comprehensive quality assurance (QA) programs should ensure that uncertainties are maintained at acceptable levels. The International Atomic Energy Agency has recently developed a report summarizing the accuracy achievable and the suggested action levels, for each step in the radiotherapy process. Overview of the report: The report seeks to promote awareness and encourage quantification of uncertainties in order to promote safer and more effective patient treatments. The radiotherapy process and the radiobiological and clinical frameworks that define the need for accuracy are depicted. Factors that influence uncertainty are described for a range of techniques, technologies and systems. Methodologies for determining and combining uncertainties are presented, and strategies for reducing uncertainties through QA programs are suggested. The role of quality audits in providing international benchmarking of achievable accuracy and realistic action levels is also discussed. RECOMMENDATIONS The report concludes with nine general recommendations: (1) Radiotherapy should be applied as accurately as reasonably achievable, technical and biological factors being taken into account. (2) For consistency in prescribing, reporting and recording, recommendations of the International Commission on Radiation Units and Measurements should be implemented. (3) Each institution should determine uncertainties for their treatment procedures. Sample data are tabulated for typical clinical scenarios with estimates of the levels of accuracy that are practically achievable and suggested action levels. (4) Independent dosimetry audits should be performed regularly. (5) Comprehensive quality assurance programs should be in place. (6) Professional staff should be appropriately educated and adequate staffing levels should be maintained. (7) For reporting purposes, uncertainties should be presented. (8) Manufacturers should provide training on all equipment. (9) Research should aid in improving the accuracy of radiotherapy. Some example research projects are suggested.
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Affiliation(s)
- Debbie van der Merwe
- Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | | | - Ben Mijnheer
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
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45
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Rosenblatt E, Prajogi GB, Barton M, Fidarova E, Eriksen JG, Haffty B, Millar BA, Bustam A, Zubizarreta E, Abdel-Wahab M. Need for Competency-Based Radiation Oncology Education in Developing Countries. ACTA ACUST UNITED AC 2017. [DOI: 10.4236/ce.2017.81006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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46
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Rosenblatt E, Fidarova E, Zubizarreta E, Barton M, MacKillop W, Jones G, Cordero L, Yarney J, Lim G, Gan J, Cernea V, Stojanovic-Rundic S, Strojan P, Kochbati L, Quarneti A. Radiation Therapy Utilization in Middle-Income Countries. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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47
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Rodin D, Hanna T, Burger E, Zubizarreta E, Yap M, Barton M, Atun R, Knaul F, Van Dyk J, Lievens Y, Gospodarowicz M, Jaffray D, Milosevic M. Global Access to Radiation Therapy for Cervical Cancer: The Cost of Inaction. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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48
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Rodin D, Hanna TP, Burger E, Zubizarreta E, Yap ML, Barton M, Atun R, Knaul F, Van Dyk J, Lievens Y, Gospodarowicz M, Jaffray D, Milosevic M. 11: Global Access to Radiotherapy for Cervical Cancer: The Cost of Inaction. Radiother Oncol 2016. [DOI: 10.1016/s0167-8140(16)33410-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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49
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Abstract
PURPOSE The global incidence of cancer is rising, particularly in low- and middle-income countries. Radiotherapy is an important cancer treatment in the curative and palliative setting. We aimed to estimate the global demand for and supply of radiotherapy megavoltage machines (MVMs) and assess the changes in supply and demand during the past decade. MATERIALS AND METHODS Cancer incidences for 27 cancer types in 184 countries were extracted from the International Agency for Research on Cancer GLOBOCAN database. The Collaboration for Cancer Outcomes Research and Evaluation radiotherapy utilization rate (RTU) model was used to estimate the number of patients in each country with an indication for radiotherapy for each cancer type and estimate the demand for MVMs. The radiotherapy supply data were accessed from Directory of Radiotherapy Centres database maintained by the International Atomic Energy Agency. RESULTS RTU varied by country, from 32% in Mongolia to 59% in Comoros. The average optimal world RTU was 50%, equating to 7 million people in 2012 who would benefit from radiotherapy. There remains a deficit of more than 7,000 machines worldwide. During the past decade, the gap between radiotherapy demand and supply has widened in low-income countries. CONCLUSION RTU varies significantly between countries. Approximately half of all patients with cancer worldwide should receive radiotherapy; however, more than 2 million people are unable to access it because of a lack of MVMs. Low- and middle-income countries are particularly disadvantaged by this deficit.
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Affiliation(s)
- Mei Ling Yap
- Mei Ling Yap and Michael Barton, Ingham Institute for Applied Medical Research, University of New South Wales Australia, Liverpool, New South Wales, Australia; Eduardo Zubizarreta, International Atomic Energy Agency, Vienna, Austria; and Freddie Bray and Jacques Ferlay, International Agency for Research on Cancer, Lyon, France
| | - Eduardo Zubizarreta
- Mei Ling Yap and Michael Barton, Ingham Institute for Applied Medical Research, University of New South Wales Australia, Liverpool, New South Wales, Australia; Eduardo Zubizarreta, International Atomic Energy Agency, Vienna, Austria; and Freddie Bray and Jacques Ferlay, International Agency for Research on Cancer, Lyon, France
| | - Freddie Bray
- Mei Ling Yap and Michael Barton, Ingham Institute for Applied Medical Research, University of New South Wales Australia, Liverpool, New South Wales, Australia; Eduardo Zubizarreta, International Atomic Energy Agency, Vienna, Austria; and Freddie Bray and Jacques Ferlay, International Agency for Research on Cancer, Lyon, France
| | - Jacques Ferlay
- Mei Ling Yap and Michael Barton, Ingham Institute for Applied Medical Research, University of New South Wales Australia, Liverpool, New South Wales, Australia; Eduardo Zubizarreta, International Atomic Energy Agency, Vienna, Austria; and Freddie Bray and Jacques Ferlay, International Agency for Research on Cancer, Lyon, France
| | - Michael Barton
- Mei Ling Yap and Michael Barton, Ingham Institute for Applied Medical Research, University of New South Wales Australia, Liverpool, New South Wales, Australia; Eduardo Zubizarreta, International Atomic Energy Agency, Vienna, Austria; and Freddie Bray and Jacques Ferlay, International Agency for Research on Cancer, Lyon, France
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50
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Atun R, Jaffray DA, Barton MB, Bray F, Baumann M, Vikram B, Hanna TP, Knaul FM, Lievens Y, Lui TYM, Milosevic M, O'Sullivan B, Rodin DL, Rosenblatt E, Van Dyk J, Yap ML, Zubizarreta E, Gospodarowicz M. Expanding global access to radiotherapy. Lancet Oncol 2015; 16:1153-86. [PMID: 26419354 DOI: 10.1016/s1470-2045(15)00222-3] [Citation(s) in RCA: 620] [Impact Index Per Article: 68.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 08/01/2015] [Accepted: 08/03/2015] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Rifat Atun
- Harvard TH Chan School of Public Health, Harvard University, Cambridge, MA, USA.
| | - David A Jaffray
- Princess Margaret Cancer Centre, Toronto, ON, Canada; TECHNA Institute, University Health Network, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Michael B Barton
- Ingham Institute for Applied Medical Research, University of New South Wales, Liverpool, NSW, Australia
| | - Freddie Bray
- International Agency for Research on Cancer, Lyon, France
| | - Michael Baumann
- Department of Radiation Oncology, Medical Faculty and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Bhadrasain Vikram
- National Cancer Institute, US National Institutes of Health, Bethesda, MD, USA
| | - Timothy P Hanna
- Ingham Institute for Applied Medical Research, University of New South Wales, Liverpool, NSW, Australia; Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | - Felicia M Knaul
- Harvard Global Equity Initiative, Harvard University, Cambridge, MA, USA; Harvard Medical School, Harvard University, Cambridge, MA, USA
| | - Yolande Lievens
- Ghent University Hospital, Ghent, Belgium; Ghent University, Ghent, Belgium
| | - Tracey Y M Lui
- TECHNA Institute, University Health Network, Toronto, ON, Canada
| | | | - Brian O'Sullivan
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Danielle L Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | | | - Jacob Van Dyk
- Department of Medical Biophysics, Western University, London, ON, Canada
| | - Mei Ling Yap
- Ingham Institute for Applied Medical Research, University of New South Wales, Liverpool, NSW, Australia
| | | | - Mary Gospodarowicz
- Princess Margaret Cancer Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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