Radiotherapy in cancer Radiotherapy in cancer control in lowcontrol in low-- and and

middlemiddle income countriesincome countriesmiddlemiddle--income countriesincome countries

XRT in LMI countriesXRT in LMI countriesXRT in LMI countriesXRT in LMI countries

What is LMI?What is LMI?What is LMI?What is LMI?Cancer in LMICancer in LMINeed for XRTNeed for XRTNeed for XRTNeed for XRTCost and costCost and cost--effectivenesseffectivenessCurrent state of XRT in LMI countriesCurrent state of XRT in LMI countriesCurrent state of XRT in LMI countriesCurrent state of XRT in LMI countriesCase studiesCase studies•• Breast Breast •• Breast Breast •• CervixCervix•• LungLungLungLung

LMI countriesLMI countriesLMI countriesLMI countries

IncomeIncome Gross National Income Gross National Income per person per year (US$)per person per year (US$)per person per year (US$)per person per year (US$)

Low Low 765765

MiddleMiddle 766 766 –– 9,3859,385

HighHigh 9,3869,386

World Bank IncomesUpper middle income (34)Lower middle income (54)( )Low income (60)High income: OECD (24)High income: nonOECD (26)

Cancer in LMI countriesCancer in LMI countriesCancer in LMI countriesCancer in LMI countries

10 illi b 201010 illi b 201010 million new cases by 201010 million new cases by 2010

>50% of all cancers occur in LMI>50% of all cancers occur in LMI

70% by 202070% by 2020

New cases of cancer New cases of cancer

Globocan 2002

Radiotherapy UtilisationRadiotherapy UtilisationRadiotherapy UtilisationRadiotherapy Utilisation

52% of all cancer patients need 52% of all cancer patients need 52% of all cancer patients need 52% of all cancer patients need radiotherapy at least onceradiotherapy at least once86% curative or adjuvant86% curative or adjuvant86% cu at e o adju a t86% cu at e o adju a t2020--25% may need >1 treatment episode25% may need >1 treatment episodeRTU likely to be higherRTU likely to be higherRTU likely to be higherRTU likely to be higher•• More advanced stageMore advanced stage•• Less surgical expertiseLess surgical expertiseg pg p

The need for radiotherapyThe need for radiotherapyThe need for radiotherapy The need for radiotherapy

Russia

Latvia

Iceland

Estonia

Canada

Uzbekistan

United States

United Kingdom

United Arab Emirates

Ukraine

Turkey

Tunisia

Tajikistan

SyriaSpain

Slovenia

Slovakia

Serbia

Saudi Arabia

Romania

Qatar

Portugal

Poland

Pakistan

NigerMyanmar

Morocco

MongoliaMoldova

Mexico

Malta

Mali

Macedonia

Lithuania

Libya

Lebanon

Latvia

Kyrgyzstan

Kuwait

Korea Rep.

Korea DPR

Kazakhstan

Jordan

Japan

Jamaica

Ireland

Iraq

India

Hungary

Haiti

Greece

Germany

Georgia

France

Egypt

Dominican Republic

Czech Republic

Cyprus

Cuba

Croatia

China

BulgariaBosnia and Herzegovina

Belarus

Bangladesh

AzerbaijanArmenia

Algeria

Albania

Afghanistan

Zimbabwe

Zambia

Yemen Vietnam

Venezuela

Uganda

Thailand

Tanzania

Sudan

Sri Lanka

Singapore

Sierra Leone

Senegal

Philippines

Peru

P

Panama Nigeria

g

Nicaragua

Namibia

Mauritius

Malaysia

Malawi

Madagascar

Liberia

KenyaIndonesia

HondurasGuatemala

Ghana

Gabon

Ethiopia

EritreaEl Salvador

EcuadorDemocratic Republic of the Congo

Cote D'IvoireCosta Rica

Chad

Central African Republic

Cape Verde

Cameroon

Burkina Faso

Brazil

Botswana

Bolivia

Benin

Angola

% of cases requiring RT

Uruguay

South Africa

Paraguay Namibia

Chile

Australia

Argentina

q g

0 - 0.390.39 - 0.430.43 - 0.470 47 - 0 51

N. Taylor, IAEA 2005

0.47 - 0.510.51 - 0.550.55 - 0.590.59 - 1

Cancer cases needing XRTCancer cases needing XRTCancer cases needing XRTCancer cases needing XRT

Russia

Iceland

Canada

Uzbekistan

United States

United Kingdom

United Arab Emirates

Ukraine

Turkey

Tunisia

Tajikistan

SyriaSpain

Slovenia

Slovakia

Serbia

Saudi Arabia

Romania

Qatar

Portugal

Poland

PakistanMorocco

MongoliaMoldova

Mexico

Malta

Macedonia

Lithuania

Libya

Lebanon

Latvia

Kyrgyzstan

Kuwait

Korea Rep.

Korea DPR

Kazakhstan

Jordan

Japan

Ireland

Iraq

India

Hungary

Greece

Germany

Georgia

France

Estonia

Egypt

Czech Republic

Cyprus

Cuba

Croatia

China

BulgariaBosnia and Herzegovina

Belarus

Bangladesh

AzerbaijanArmenia

Algeria

Albania

Afghanistan

Zimbabwe

Zambia

Yemen Vietnam

Venezuela

Uganda

Thailand

Tanzania

Sudan

Sri Lanka

Singapore

Sierra Leone

Senegal

Philippines

Peru

PanamaNigeria

Niger

Nicaragua

Myanmar

Mali

Malaysia

Malawi

Madagascar

Liberia

Kenya

Jamaica

Indonesia

Honduras

Haiti

Guatemala

Ghana

Gabon

Ethiopia

EritreaEl Salvador

Ecuador

Dominican Republic

Democratic Republic of the Congo

Cote D'Ivoire

Costa Rica

Chad

Central African Republic

Cape Verde

Cameroon

Burkina Faso

Brazil

Bolivia

Benin

AngolaCancer Cases per Million Population Requiring RT

bab e

Uruguay

South Africa

Paraguay Namibia

Mauritius

Chile

Botswana

Australia

Argentina0 - 200200 - 800800 - 1200

N. Taylor, IAEA 20051200 - 16001600 - 20002000 - 20000

CostCostCostCost

BuildingBuilding 3%3%BuildingBuilding 3%3%

EquipmentEquipment 30%30%

StaffStaff 50%50%

MaterialsMaterials 4%4%

OverheadsOverheads 13%13%OverheadsOverheads 13%13%

Kesteloot K, Lievens Y, van der SE. Improved management of radiotherapy departments through accurate cost data. Radiother Oncol 2000; 55(3):251-262.

C b ltC b lt LiLiCobaltCobalt LinacLinac

MachineMachine $480,000$480,000 $1,800,000$1,800,000

MaintenanceMaintenance $1270 to $1270 to $35,680$35,680

$3000 to $3000 to $91,740 $91,740

Cost per Cost per treatmenttreatment

$4.87$4.87 $11$11

Van Der Giessen PH, Alert J, Badri C, Bistrovic M, Deshpande D, Kardamakis D et al. Multinational assessment of some operational costs of teletherapy. Radiother Oncol. 2004;71(3):347-55.

Current status of XRTCurrent status of XRTCurrent status of XRTCurrent status of XRT

24/72 countries with > 1 million 24/72 countries with > 1 million 24/72 countries with > 1 million 24/72 countries with > 1 million people had no XRTpeople had no XRTAverage GNI/ cap US$300 Average GNI/ cap US$300 e age G / cap US$300e age G / cap US$300

All Member States100.000

Europe

10.000

S$ 1

,000

s

Asia & Pacif ic

Central America

South America

Africa

straight line f it

0.100

1.0000.0100 0.1000 1.0000 10.0000 100.0000

GD

P/ca

pita

US

0.010

No. teletherapy units / million population

CervixCervixCervixCervix>80% new cases & deaths >80% new cases & deaths in LMIin LMIin LMIin LMI5050--60% of new cases die of 60% of new cases die of cervix cancercervix cancer

1000 1 0

Incidence Mortality M/I ratio

9191--99% need XRT99% need XRT

60

80

100

d) ra

te p

er 1

00, 0

000.6

0.8

1.0

ence

rat

io*

20

40

stan

derd

ised

(wor

ld

0.2

0.4

Mor

talit

y/In

cide

0

high incomecountries

upper-middleincome

countries

low-middleincome

countries

low incomecountries

Age

s

0.0

Strategies to improve accessStrategies to improve accessStrategies to improve accessStrategies to improve access

PlanningPlanningPlanningPlanningInvestmentInvestmentLi kLi kLinkagesLinkagesAccess to informationAccess to informationEducation about cancerEducation about cancerSafetySafetySafetySafety

PlanningPlanningPlanningPlanning

No “one size fit’s all” planNo “one size fit’s all” planNo one size fit s all planNo one size fit s all plan•• casemixcasemix•• capabilitiescapabilities

100%LiverOvary etc.•• capabilitiescapabilities

70%

80%

90% LeukaemiaThyroidTestisMultiple myelomaMelanoma of skinKidney etc.

40%

50%

60%Corpus uteriOther PharynxPancreasHodgkin's diseaseColon/RectumBrain, nervous system

20%

30%

NasopharynxLarynxOral cavityLungStomachBladderN H d ki l h

0%

10%

EastAfrica

CentralAfrica

NorthernAfrica

SouthernAfrica

WesternAfrica

all Africa

Non-Hodgkin lymphomaOesophagusProstateCervix uteriBreast

InvestmentInvestmentInvestmentInvestment

EquipmentEquipmentEquipmentEquipmentStaffStaffMaintenanceMaintenanceMaintenanceMaintenanceSource Source replacementreplacementreplacementreplacement

LinkagesLinkagesLinkagesLinkages

Many isolated departmentsMany isolated departmentsMany isolated departmentsMany isolated departmentsTrainingTrainingCPDCPDSouth South –– SouthSouthExchangesExchanges•• ProtocolsProtocols•• ProtocolsProtocols•• Staff Staff

Access to informationAccess to informationAccess to informationAccess to information

JournalsJournals $/Gbyte/monthJournalsJournals•• CostCost•• LanguageLanguage

18002000

g gg g•• OnOn--line accessline access

MeetingsMeetings

1500

500

1000

200

500

0US Africa

Education about cancerEducation about cancerEducation about cancerEducation about cancer

Medical studentsMedical studentsMedical studentsMedical studentsRadiation oncology staffRadiation oncology staff•• Regional training centresRegional training centresRegional training centresRegional training centres

Distance learning coursesDistance learning courses

SafetySafetySafetySafety

InterInter--centre dosimetrycentre dosimetryInterInter centre dosimetrycentre dosimetryMaintenance Maintenance Common protocolsCommon protocolsCommon protocolsCommon protocolsSource security Source security

ConclusionsConclusionsConclusionsConclusionsCancer is a major problem in LMICancer is a major problem in LMIj pj pRadiotherapy is essential and viableRadiotherapy is essential and viableCobalt is preferredCobalt is preferredPl iPl iPlanningPlanningInvestmentInvestmentLinkagesLinkagesLinkagesLinkagesInformationInformationEducation Education Education Education SafetySafetyPACTPACT