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Section II Techniques, Modalities, and Modifiers in Radiation Oncology

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80% prediction limit

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Figure 28.3.  Megavoltage machines per million population ver- sus gross national income per capita on a log-log scale. Countries are divided by income more than US $12,000 (high income) and then by region: Africa, Latin America (LA), Eastern Europe (EE), and Asia. The solid line is a linear regression line and dotted lines are the 80% confidence limit. The vertical dotted line represents the cutoff for high income. (From Levin V, Tatsuzaki H. Radiotherapy services in countries in transition: gross national income per capita as a significant factor. Radiother Oncol 2002;63:147–150, with per- mission from Elsevier.)

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The most pertinent elements of access to radiation therapy in developing countries are discussed here. Availability of equipment and personnel for radiation ther- apy are common limiting factors in developing countries. Less than 5% of global medical spending on cancer is in developing countries. 29 This is despite developing countries containing over 80% of the world’s population 4 and almost 80% of the world’s premature death, disability, and ill health from cancer. 2 Insufficient medical training programs make it difficult to address the lack of key personnel for radiation oncology. 30–33 ,34 International Atomic Energy Agency (IAEA) data suggest that developing countries only have about a third of the world’s 12,206 megavoltage radiation therapy units despite an esti- mated need for between double and triple the current num- ber. 35 There are currently 23 countries with populations over 1 million with no known machines, mostly in Africa. 35 The greatest limitations in machine supply are strongly associated with low national economic status (Fig. 28.3). 36 Given the expected rise in cancer incidence in LMCs, these large mismatches between need and availability will only increase if current machine supply is not improved. In addition to machine availability, one must also consider the need for other physical resources. These include clinical space, bunkers, other equipment (brachytherapy, simulation, immobilization, treatment planning, beam modification, dosimetry, quality assurance), a reliable power supply for linear accelerators, and the availability of parts (and technical support) for machine maintenance and repair. 37 The state of radiation therapy resources varies between developing countries and regions. 31,32,36,38 Some selected exam- ples are provided for illustration. In 1999, Levin et al. 38 docu- mented the availability and distribution of radiation therapy equipment in Africa. Only 22 of 56 countries in Africa were con- fidently known to have megavoltage radiation therapy facilities. In total, more than 400 million Africans had effectively no access to radiation therapy. Although machine supply has since modestly increased, there are still dramatic shortfalls in machine supply in Sub-Saharan Africa. 35 In the Asia and Pacific Region, Tatsuzaki and Levin 31 found an 82-fold variation in the number of megavoltage machines per million population for 1999. China’s and India’s machine supply has increased in recent years, though capacity is still well below what is needed to treat all patients (Table 28.1). 3,35,39 Workforce resources vary considerably between countries, and

most countries have less than two radiation oncologists per 1,000 incident cancers annually. 3 , 33 , 35 More physicists are required if radiotherapy capacity is to expand in the Asia Pacific region. 33 In the era of multidisciplinary cancer therapy, for instance, for head and neck squamous cell carcinoma, availability of other elements of diagnosis and therapy such as surgical oncol- ogy, medical oncology, oncology nursing, pathology, radiology, rehabilitation, supportive care, and palliative care are all important to effective cancer management. 40 Without adequate pathology and radiology, it is not possible to effectively diagnose cancer and distinguish curative from palliative cases. The need for surgical capacity is especially noted, given its central role in curative treatment of the most common cancers globally, espe- cially in their early stages. Access to palliative care, including pain control for moderate to severe pain, is also a major issue. The World Health Organization (WHO) estimates 5 billion peo- ple live in countries with limited or no access to narcotic anal- gesics and other controlled substances, with an estimated 5.5 million patients with terminal cancer dying each year without adequate treatment. 41 Spatial accessibility refers to the geographic accessibility of medical treatments. Available information suggests spatial accessibility is a major issue in LMCs. 35 ,42 With radiation ther- apy centers often in large cities, rural populations may face substantial financial challenges when traveling into cities for the duration of radiation treatment. Acceptability of available options can impact an individu- al’s willingness to take advantage of services and adhere to recommended therapies. For example, a small study from Cameroon found beliefs, fears, cultural factors, and awareness were among explanations for delay in seeking medical atten- tion for cancer. 43 Values surrounding effects of pelvic radiation treatment on fertility, loss of hair with some chemotherapy, and anatomic changes associated with surgery such as mastec- tomy are some potential factors in need of further description and quantification in developing countries. Culturally appro- priate cancer control plans sensitive to a region’s social and political concerns are needed, including initiatives to overcome stigma and improve awareness. 44 Affordability of radiation therapy and other forms of cancer therapy are a major concern in LMCs. 45 Households often have limited or no health insurance coverage, especially in low- income and lower middle-income countries and more often