International Journal of
Radiation Oncology biology
physics
www.redjournal.org
EDITORIAL
The Challenge of Global Radiation Therapy: An IAEA Perspective Eduardo Rosenblatt, MD,* Oscar Acun˜a,y and May Abdel-Wahab * *Division of Human Health and yDepartment of Technical Cooperation, International Atomic Energy Agency, Vienna, Austria Received Nov 26, 2014, and in revised form Dec 2, 2014. Accepted for publication Dec 2, 2014.
Radiation therapy is an essential component of cancer care, with 50% to 60% of patients needing radiation therapy at some point. In spite of this, resources are limited in many areas around the world (1). As of 2014, 36 countries have no available radiation therapy units, leading cancer patients in those countries to deplete their financial resources to be treated abroad or, more commonly, to go without treatment. Even when radiation therapy is available, the resources are often insufficient for the number of cancer patients in need of care. Most high-income countries have at least 1 radiation therapy unit available for every 250,000 people, whereas in nearly 20 low-to-middle-income countries (LMIC), each available radiation therapy unit must provide services for more than 5 million people, sometimes reaching as high as 1 machine for 20 million people or more. However, the issue of global access to radiation therapy is more complex and is not just limited to challenges of equipment availability. In some countries, radiation therapy services may be available, but economic or geographic barriers may prevent access to treatment. In others, barriers such as inadequate staffing, the acquisition of unsuitable equipment, or poor equipment maintenance can leave cancer patients without proper access to treatment. Until LMIC can acquire the proper capacity for providing radiation therapy, millions of cancer patients throughout the world will remain deprived of an important modality of cancer cure and palliation. The International Atomic Energy Agency (IAEA) was created in 1957 in response to the deep fears and expectations resulting from the discovery of nuclear energy (2). This technology can be used either for nonpeaceful uses or
as a practical and useful tool. Radiation therapy is such a tool, and the IAEA has a long history and broad countryspecific experience in addressing radiation therapy needs around the world. Through this experience the IAEA understands that it is essential to count on the collaboration and commitment of local governments for the successful installation and operation of radiation therapy units in countries that need them. Countries and their governments have differing priorities at any given time. In the area of health, these priorities may not necessarily be cancer treatment or radiation therapy but may range from food and water shortages, malnutrition, communicable disease outbreaks, insect pests, and sanitation to natural disasters and conflict or war situations. IAEA projects have the highest chance of success when governments give high priority to the delivery of high-quality cancer care to their citizens and are prepared to invest in this area. All activities, including procurement, building and installations, and hiring and training of staff will then be strongly supported and facilitated by the government. Most low-income countries are unable to meet their radiation therapy needs without external support and therefore require nongovernmental organizations or international organizations to operate as a multipartner task force. Understanding the specific national setup for the provision of health care services is very important. A single indicator, such as the total number of radiation therapy departments or teletherapy machines per million population, may give an approximate indication of the status of radiation therapy in a country. However, it does not
Reprint requests to: Dr Eduardo Rosenblatt, MD, Applied Radiation Biology and Radiotherapy, Division of Human Health, International
Atomic Energy Agency, Wagramer Strasse 5, PO Box 100, Vienna A1400, Austria. Tel: (0043) 1-2600-21669; E-mail: [email protected]
Int J Radiation Oncol Biol Phys, Vol. 91, No. 4, pp. 687e689, 2015 0360-3016/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2014.12.008
688
Rosenblatt et al.
reflect patient access or the quality of the service. A country may have many radiation therapy departments, but most of them may be in the private sector. Conversely, a national insurance system may allow all citizens to choose their radiation therapy providers based on their relative ability to pay. Private centers in developing countries often have agreements with the public sector (ministry of health or social security system) to provide services to public-sector patients. These scenarios would allow different access to radiation therapy within the populations served. The IAEA works in cooperation with its Member States’ governments to agree on each country’s priorities and needs in the area of nuclear applications, including radiation therapy. A prerequisite to establish countries’ priorities and needs is dialogue between the IAEA and all national stakeholders. The IAEA provides imPACT missions through the Programme of Action for Cancer Therapy (PACT). Such reviews provide an evaluation of a country’s readiness to implement cancer control programs, an assessment of the national cancer burden, and provision of recommendations on developing national cancer control capacity. Subsequent activities are based on the national development plans, country-specific analyses, and lessons learned from the experience of past cooperation. These activities ensure effective partnerships and mobilization of resources to integrate radiation medicine within a comprehensive national cancer control approach. The IAEA contributes to the promotion of radiation therapy through the Division of Human Health by providing quality assurance programs (eg QUATRO, QUANUM, QUADRIIL) (3-5), educational activities, conferences, and research programs, including multiinstitutional multinational randomized trials, and through support delivered through the Technical Cooperation (TC) Program and the Division of PACT. The TC projects follow a planning cycle that comprises submission of project concepts by Member States, screening of these concepts, subsequent project design, and finally program approval by the Board of Governors of the IAEA and assignment of resources for their implementation. The planning cycle takes 2 years. At the time of writing this article, the IAEA has received requests from its Member States for 25 national radiation therapy projects and 20 regional projects to be implemented in the 2016 to 2017 cycle. In 2013, 28.6% of the total TC fund was dedicated to health-related projects (6). Between 1983 and 2013, the Technical Cooperation Fund invested $289.6 million in cancer and radiation therapy projects worldwide (Fig. 1). By region, the investment in 2012 to 2013 was $7.1 million for Africa, $3.1 million for Asia and the Pacific, $10 million for Europe, $6 million for Latin America, and $0.06 million for interregional projects. A typical IAEA radiation therapy project normally includes human resource capacity building, expert advice, and
International Journal of Radiation Oncology Biology Physics
the provision of equipment as a package that incorporates, in addition to a teletherapy machine, an imaging system, a treatment planning system including software, record and verify (R&V) system, a range of immobilization and fixation devices, and dosimetry and quality assurance equipment (7). For the human resource component, the project always includes the training of a full team, including radiation oncologists, medical physicists, radiation therapists, and occasionally maintenance engineers and nurses. The project additionally includes 1 or more national training events (training course or workshop) in which the Agency brings lecturers to the country to train a local team in a specific technique. Projects that involve the delivery of expensive imaging or radiation therapy equipment are very carefully designed and include a preparatory procurement plan that takes into account the existing regulatory safety aspects, numbers of staff, and their training needs. With regard to equipment, the Agency often relies on cost-sharing agreements with governments. Equipment is procured through a transparent tendering process in which the technical specifications are presented to several international manufacturers. The final decision is made by a procurement committee on the basis of the best-value principle. The Agency does not usually deliver secondhand or refurbished equipment. In countries where the IAEA has assisted with the establishment of a first radiation therapy center, it has been found to have had a multiplying effect by promoting further expansion, acquisition of new equipment, and training of staff, culminating in the establishment of additional radiation therapy centers. On several occasions, the involvement of the IAEA in a radiation therapy project facilitated input by donors willing to support this form of cancer therapy. A massive investment of resources in equipment would be a simplistic approach to the problem. There is also a need for a sufficient number of qualified professionals to operate radiation therapy equipment effectively and safely (8). As a matter of policy, the IAEA does not deliver radiation sources to countries that do not have an adequate radiation safety infrastructure. In addition to these activities, in 2009 the IAEA established the Advisory Group on increasing access to Radiotherapy Technology (AGaRT) in low-income and middle-income countries under PACT to further address the shortfall of radiation therapy services in LMICs. AGaRT acts as a neutral facilitator to bring together major radiation therapy equipment suppliers with radiation therapy users in LMICs and has initiated a dialogue process to ensure that the unique radiation therapy requirements of LMICs can be met by the technology available. AGaRT provides an unprecedented platform to review and recommend affordable and suitable radiation therapy packages and solutions adapted to the needs of developing countries. An estimation of the level of resources required to meet the need for radiation therapy services on a global scale, and an action plan for the mobilization of such resources, is
Volume 91 Number 4 2015
The Challenge of Global Radiation Therapy
689
Disbursements in USD 1980-2013 750000
71000000
Interregional
83000000
Africa Asia and the Pacific Europe Latin America
70000000 63000000
Disbursements in USD 1980-2013 90000000 83000000 80000000 70000000
71000000
70000000 63000000 60000000
50000000
Disbursements in USD
40000000
30000000
20000000
10000000 750000
0 Interregional
Africa
Asia and the Pacific
Europe
Latin America
Fig. 1. International Atomic Energy Agency technical cooperation disbursements for projects in cancer/radiation therapy between 1980 and 2013. USD Z United States dollars. an important and necessary step. However, the installation and operation of radiation therapy centers around the world has to be approached on a country-by-country basis, assessing, facing, and solving the individual countries’ issues. Priority can be given to the 36 low-income countries that do not have any radiation therapy capacity today.
References 1. Zubizarreta EH, Fidarova E, Healy B, et al. Need for radiotherapy in low and middle income countries: The silent crisis continues. Clin Oncol, http://dx.doi.org/10.1016/j.clon2014.10.006; 2014 Nov 15. 2. Fisher D. History of the International Atomic Energy Agency: The first 40 years. Vienna: 1997.
3. International Atomic Energy Agency. Comprehensive audits of radiotherapy practices: A tool for quality improvement, (QUATRO). Vienna: IAEA; 2007. 4. International Atomic Energy Agency. Quality management audits in nuclear medicine practices (QUANUM). Vienna: IAEA; 2008. 5. International Atomic Energy Agency. Comprehensive clinical audits of diagnostic radiology practices: A tool for quality improvement (QUADRIIL). Vienna: IAEA; 2010. 6. IAEA Technical Cooperation Report 2013. Report by the Director General. Vienna: IAEA; July 2014. 7. International Atomic Energy Agency. Setting up a radiotherapy programme: Clinical, medical physics, radiation protection and safety aspects. Vienna: IAEA; 2008. 8. Abdel-Wahab M, Rosenblatt E, Holmberg O, et al. Safety in radiation oncology: The role of international initiatives by the International Atomic Energy Agency. J Am Col Radiol 2011;8:789-794.
Radiation Oncology biology
physics
www.redjournal.org
EDITORIAL
The Challenge of Global Radiation Therapy: An IAEA Perspective Eduardo Rosenblatt, MD,* Oscar Acun˜a,y and May Abdel-Wahab * *Division of Human Health and yDepartment of Technical Cooperation, International Atomic Energy Agency, Vienna, Austria Received Nov 26, 2014, and in revised form Dec 2, 2014. Accepted for publication Dec 2, 2014.
Radiation therapy is an essential component of cancer care, with 50% to 60% of patients needing radiation therapy at some point. In spite of this, resources are limited in many areas around the world (1). As of 2014, 36 countries have no available radiation therapy units, leading cancer patients in those countries to deplete their financial resources to be treated abroad or, more commonly, to go without treatment. Even when radiation therapy is available, the resources are often insufficient for the number of cancer patients in need of care. Most high-income countries have at least 1 radiation therapy unit available for every 250,000 people, whereas in nearly 20 low-to-middle-income countries (LMIC), each available radiation therapy unit must provide services for more than 5 million people, sometimes reaching as high as 1 machine for 20 million people or more. However, the issue of global access to radiation therapy is more complex and is not just limited to challenges of equipment availability. In some countries, radiation therapy services may be available, but economic or geographic barriers may prevent access to treatment. In others, barriers such as inadequate staffing, the acquisition of unsuitable equipment, or poor equipment maintenance can leave cancer patients without proper access to treatment. Until LMIC can acquire the proper capacity for providing radiation therapy, millions of cancer patients throughout the world will remain deprived of an important modality of cancer cure and palliation. The International Atomic Energy Agency (IAEA) was created in 1957 in response to the deep fears and expectations resulting from the discovery of nuclear energy (2). This technology can be used either for nonpeaceful uses or
as a practical and useful tool. Radiation therapy is such a tool, and the IAEA has a long history and broad countryspecific experience in addressing radiation therapy needs around the world. Through this experience the IAEA understands that it is essential to count on the collaboration and commitment of local governments for the successful installation and operation of radiation therapy units in countries that need them. Countries and their governments have differing priorities at any given time. In the area of health, these priorities may not necessarily be cancer treatment or radiation therapy but may range from food and water shortages, malnutrition, communicable disease outbreaks, insect pests, and sanitation to natural disasters and conflict or war situations. IAEA projects have the highest chance of success when governments give high priority to the delivery of high-quality cancer care to their citizens and are prepared to invest in this area. All activities, including procurement, building and installations, and hiring and training of staff will then be strongly supported and facilitated by the government. Most low-income countries are unable to meet their radiation therapy needs without external support and therefore require nongovernmental organizations or international organizations to operate as a multipartner task force. Understanding the specific national setup for the provision of health care services is very important. A single indicator, such as the total number of radiation therapy departments or teletherapy machines per million population, may give an approximate indication of the status of radiation therapy in a country. However, it does not
Reprint requests to: Dr Eduardo Rosenblatt, MD, Applied Radiation Biology and Radiotherapy, Division of Human Health, International
Atomic Energy Agency, Wagramer Strasse 5, PO Box 100, Vienna A1400, Austria. Tel: (0043) 1-2600-21669; E-mail: [email protected]
Int J Radiation Oncol Biol Phys, Vol. 91, No. 4, pp. 687e689, 2015 0360-3016/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2014.12.008
688
Rosenblatt et al.
reflect patient access or the quality of the service. A country may have many radiation therapy departments, but most of them may be in the private sector. Conversely, a national insurance system may allow all citizens to choose their radiation therapy providers based on their relative ability to pay. Private centers in developing countries often have agreements with the public sector (ministry of health or social security system) to provide services to public-sector patients. These scenarios would allow different access to radiation therapy within the populations served. The IAEA works in cooperation with its Member States’ governments to agree on each country’s priorities and needs in the area of nuclear applications, including radiation therapy. A prerequisite to establish countries’ priorities and needs is dialogue between the IAEA and all national stakeholders. The IAEA provides imPACT missions through the Programme of Action for Cancer Therapy (PACT). Such reviews provide an evaluation of a country’s readiness to implement cancer control programs, an assessment of the national cancer burden, and provision of recommendations on developing national cancer control capacity. Subsequent activities are based on the national development plans, country-specific analyses, and lessons learned from the experience of past cooperation. These activities ensure effective partnerships and mobilization of resources to integrate radiation medicine within a comprehensive national cancer control approach. The IAEA contributes to the promotion of radiation therapy through the Division of Human Health by providing quality assurance programs (eg QUATRO, QUANUM, QUADRIIL) (3-5), educational activities, conferences, and research programs, including multiinstitutional multinational randomized trials, and through support delivered through the Technical Cooperation (TC) Program and the Division of PACT. The TC projects follow a planning cycle that comprises submission of project concepts by Member States, screening of these concepts, subsequent project design, and finally program approval by the Board of Governors of the IAEA and assignment of resources for their implementation. The planning cycle takes 2 years. At the time of writing this article, the IAEA has received requests from its Member States for 25 national radiation therapy projects and 20 regional projects to be implemented in the 2016 to 2017 cycle. In 2013, 28.6% of the total TC fund was dedicated to health-related projects (6). Between 1983 and 2013, the Technical Cooperation Fund invested $289.6 million in cancer and radiation therapy projects worldwide (Fig. 1). By region, the investment in 2012 to 2013 was $7.1 million for Africa, $3.1 million for Asia and the Pacific, $10 million for Europe, $6 million for Latin America, and $0.06 million for interregional projects. A typical IAEA radiation therapy project normally includes human resource capacity building, expert advice, and
International Journal of Radiation Oncology Biology Physics
the provision of equipment as a package that incorporates, in addition to a teletherapy machine, an imaging system, a treatment planning system including software, record and verify (R&V) system, a range of immobilization and fixation devices, and dosimetry and quality assurance equipment (7). For the human resource component, the project always includes the training of a full team, including radiation oncologists, medical physicists, radiation therapists, and occasionally maintenance engineers and nurses. The project additionally includes 1 or more national training events (training course or workshop) in which the Agency brings lecturers to the country to train a local team in a specific technique. Projects that involve the delivery of expensive imaging or radiation therapy equipment are very carefully designed and include a preparatory procurement plan that takes into account the existing regulatory safety aspects, numbers of staff, and their training needs. With regard to equipment, the Agency often relies on cost-sharing agreements with governments. Equipment is procured through a transparent tendering process in which the technical specifications are presented to several international manufacturers. The final decision is made by a procurement committee on the basis of the best-value principle. The Agency does not usually deliver secondhand or refurbished equipment. In countries where the IAEA has assisted with the establishment of a first radiation therapy center, it has been found to have had a multiplying effect by promoting further expansion, acquisition of new equipment, and training of staff, culminating in the establishment of additional radiation therapy centers. On several occasions, the involvement of the IAEA in a radiation therapy project facilitated input by donors willing to support this form of cancer therapy. A massive investment of resources in equipment would be a simplistic approach to the problem. There is also a need for a sufficient number of qualified professionals to operate radiation therapy equipment effectively and safely (8). As a matter of policy, the IAEA does not deliver radiation sources to countries that do not have an adequate radiation safety infrastructure. In addition to these activities, in 2009 the IAEA established the Advisory Group on increasing access to Radiotherapy Technology (AGaRT) in low-income and middle-income countries under PACT to further address the shortfall of radiation therapy services in LMICs. AGaRT acts as a neutral facilitator to bring together major radiation therapy equipment suppliers with radiation therapy users in LMICs and has initiated a dialogue process to ensure that the unique radiation therapy requirements of LMICs can be met by the technology available. AGaRT provides an unprecedented platform to review and recommend affordable and suitable radiation therapy packages and solutions adapted to the needs of developing countries. An estimation of the level of resources required to meet the need for radiation therapy services on a global scale, and an action plan for the mobilization of such resources, is
Volume 91 Number 4 2015
The Challenge of Global Radiation Therapy
689
Disbursements in USD 1980-2013 750000
71000000
Interregional
83000000
Africa Asia and the Pacific Europe Latin America
70000000 63000000
Disbursements in USD 1980-2013 90000000 83000000 80000000 70000000
71000000
70000000 63000000 60000000
50000000
Disbursements in USD
40000000
30000000
20000000
10000000 750000
0 Interregional
Africa
Asia and the Pacific
Europe
Latin America
Fig. 1. International Atomic Energy Agency technical cooperation disbursements for projects in cancer/radiation therapy between 1980 and 2013. USD Z United States dollars. an important and necessary step. However, the installation and operation of radiation therapy centers around the world has to be approached on a country-by-country basis, assessing, facing, and solving the individual countries’ issues. Priority can be given to the 36 low-income countries that do not have any radiation therapy capacity today.
References 1. Zubizarreta EH, Fidarova E, Healy B, et al. Need for radiotherapy in low and middle income countries: The silent crisis continues. Clin Oncol, http://dx.doi.org/10.1016/j.clon2014.10.006; 2014 Nov 15. 2. Fisher D. History of the International Atomic Energy Agency: The first 40 years. Vienna: 1997.
3. International Atomic Energy Agency. Comprehensive audits of radiotherapy practices: A tool for quality improvement, (QUATRO). Vienna: IAEA; 2007. 4. International Atomic Energy Agency. Quality management audits in nuclear medicine practices (QUANUM). Vienna: IAEA; 2008. 5. International Atomic Energy Agency. Comprehensive clinical audits of diagnostic radiology practices: A tool for quality improvement (QUADRIIL). Vienna: IAEA; 2010. 6. IAEA Technical Cooperation Report 2013. Report by the Director General. Vienna: IAEA; July 2014. 7. International Atomic Energy Agency. Setting up a radiotherapy programme: Clinical, medical physics, radiation protection and safety aspects. Vienna: IAEA; 2008. 8. Abdel-Wahab M, Rosenblatt E, Holmberg O, et al. Safety in radiation oncology: The role of international initiatives by the International Atomic Energy Agency. J Am Col Radiol 2011;8:789-794.
