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Section II Techniques, Modalities, and Modifiers in Radiation Oncology

technology at new locations. For example, initial experience with this approach in a new radiation therapy center in an Asian developing country found suboptimal management in 52% of cases. 62 Adverse event rates in developing countries treating with radiation are largely unknown. A report examining the risk profile of radiation therapy for the WHO could not identify any detailed reports of adverse events from Africa or Asia. 64 It is important to highlight the need for adverse event recording and reporting for the purpose of patient safety and quality improvement for all countries utilizing radiation therapy. Finally, quality of radiation oncology in developing coun- tries relates to outcomes. Of all cancer outcomes, there is the most information on survival. Generally, overall survival for cancer patients is lower, and sometimes dramatically so, for populations in developing countries. In a large multinational series from the International Agency for Research on Cancer (IARC), 5-year age-standardized relative survival for cervix cancer was 79% in Seoul, South Korea, but 46% in Mumbai, India; 22% in The Gambia; and only 13% in Kampala, Uganda. 65 Similarly, for breast cancer, survival rates ranged from 90% in Hong Kong SAR to 13% in The Gambia. When absolute survival was stratified by extent of disease, in many cases, treatment outcomes were still inferior in regions with less developed health services compared to regions with more developed services (e.g., local and regional extent breast cancer and larynx cancer). This may reflect access and quality issues in diagnosis, treatment, and follow-up and/or limitations of the available data. Radiation therapy has been shown to be cost-effective in numerous developed world settings. 66 ,67–68 A study by the Breast Health Global Initiative (BHGI) suggests that a com- prehensive breast cancer program involving early detection and treatment, including radiotherapy, can be cost-effective in developing world settings. 69 Notably, the BHGI study found that it was more cost-effective to invest in early detection in addition to comprehensive cancer therapy resources for breast cancer than in cancer therapy resources alone. This finding reflects the ability of early detection to increase the chances of cure due to earlier stage presentation and to some degree the lower cost of treating earlier stage versus locally advanced dis- ease. In other situations, preventing cancer reduces the num- ber of patients needing treatment, which can also impact on overall cost of therapy for a population. In addition to cost-effectiveness, the actual cost of deliver- ing interventions must be taken into account when planning. Though per-patient costs of radiation can be quite low com- pared to other modalities given the long usage cycle of mega- voltage radiotherapy units, large up-front costs can serve as a major deterrent to establishing services. Unfortunately, there is little context-specific information on the economics of cancer therapies in developing countries. One exception is an IAEA- supported study demonstrating wide variation in the cost of delivering a fraction of radiation between a sample of units in developing and developed countries. 70 For the costs consid- ered, the median cost per fraction delivered by a cobalt machine was less than half that for linear accelerators. Cost variation was most associated with radiation machine cost and machine usage for linear accelerators, and for cobalt machines, machine cost, usage, and personnel cost. Undoubtedly, applications of various radiation therapy techniques and modern equipment will yield opportunities to maximize the cost–benefit ratio of radiation treatment in developing countries. Hypofractionation yields opportunities to treat more patients with the same supply of equipment. 71 Economics of Radiation Therapy in Developing Countries

Hypofractionation for cervical cancer and lung cancer are examples of identified areas for research. 72–74 Investigation of brachytherapy or intraoperative radiation therapy (IORT) may provide means of delivering adjuvant treatments rapidly. High– dose-rate (HDR) brachytherapy markedly increases patient throughput (e.g., for cervical cancer) compared to low–dose- rate (LDR) brachytherapy per machine. 75 An IAEA study of accelerated radiation therapy for head and neck cancer in developing countries suggests an opportunity for increasing effectiveness of treatment without increasing departmental resources, though with increased, but tolerable, acute toxicity. 76 There has been some debate about the relative merits of cobalt-60 versus linear accelerator technology for limited resource settings. The ideal mix of machines will change depending on site-specific considerations and future market dynamics. Regarding the latter, development of lower-cost entry-level linear accelerators and, on the other hand, increases in costs of new and more sophisticated cobalt equipment would affect decision making. 77 It is useful to remember that quality assurance costs, maintenance costs, and associated personnel requirements of cobalt machines are estimated to be substan- tially less than for linear accelerators and reliability is generally higher. 70,77 Translating Knowledge into Action Recognized priorities for action fall into six categories: (a) advo- cacy, (b) investment, (c) planning, (d) capacity building, (e) qual- ity, and (f) research. 47,77–82 The varying resources, priorities, and disease burden seen in countries at different stages of develop- ment mean that there is no single solution that will apply in all cases. 81 In low-income countries with extreme resource limi- tations, a strategy focusing on cost-effective prevention, rais- ing awareness of cancer within the population, monitoring of process and outcomes, good palliative care, and focused early detection and treatment goals would be a reasonable starting point. 83 Advocacy.  An international coalition to support cancer control and cancer care in developing countries is emerging. The UICC plays an important role as an umbrella organiza- tion for advocacy. Other groups range from international agen- cies (e.g., IAEA, WHO, IARC), to national organizations (e.g., U.S. National Cancer Institute), to professional groups (e.g., American Society for Radiation Oncology [ASTRO], European Society for Radiotherapy and Oncology [ESTRO], American Society of Clinical Oncology [ASCO], International Organization for Medical Physics [IOMP]), to nongovernmental organiza- tions (NGOs) (e.g., Lance Armstrong Foundation, International Network for Cancer Treatment and Research [INCTR], Axios International, AfrOx, American Cancer Society), to academic institutions and hospitals (e.g., the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries [GTF.CCC] convened by Harvard, St. Jude Children’s Research Hospital). Through the advocacy of the UICC and many other partners (e.g., NCD Alliance), the Political Declaration 84 of the United Nations High-Level Meeting on the Prevention and Control of Non-communicable Diseases (September 19–20, 2011) was an important acknowledgment by governments of the global problem of cancer and other non- communicable diseases. It was also a substantial step toward specific and concerted action by the international community. Investment.  The advocacy and work of the many cancer control groups range from local to global, and from grassroots to high-level agencies. All approaches are extremely impor- tant for generating the political will to invest in cancer control. Particularly in middle-income countries, incorporation of can- cer care into public health insurance for those living in poverty