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Chapter 28 Radiation Oncology in the Developing World

is an important, and challenging, goal to meet. 47 ,85 Given the shortage of national funding for cancer care in poorer coun- tries, international private and public donor support and advo- cacy for tiered pricing will be notably important in improving access to cancer therapy. Planning.  Development of radiation therapy capacity can- not occur in isolation. Radiation therapy resources must be integrated into a broader context of multidisciplinary cancer care and cancer control and into a functional health system capable of tackling the double burden of communicable and noncommunicable diseases afflicting developing countries. 86 A national cancer control plan and collection of cancer regis- try and health data are central in organizing resources in an equitable and appropriate fashion. 87 Notably, the GTF.CCC has published an important resource for planning, advocacy, and priority setting entitled Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries. 88 Prevention (e.g., tobacco control, hepatitis B and HPV vac- cination) and early detection are crucial in reducing the burden of advanced cancers in developing countries. When early detection and prevention are combined with timely access to effective cancer therapy, there is great potential for dramati- cally reducing deaths from cancer in developing countries as well as minimizing national costs of cancer therapy. 47 Numerous relevant resources on cancer control and other noncommuni- cable diseases have been published online by the WHO, includ- ing a series of modules on cancer control planning, 89 and the Framework Convention on Tobacco Control. The IAEA plays a prominent role in quality assurance, safety standards, and dose calibration of radiation therapy equipment internationally. It has also been involved in numer- ous technical cooperation projects and radiation therapy clini- cal trials in developing countries. In 2004, the IAEA launched the Program of Action for Cancer Treatment (PACT) to widen the scope of its work in radiation therapy planning and capac- ity building. Its wide-ranging plan started with the development of sustainable demonstration radiation treatment sites in six countries throughout the developing world (Albania, Nicaragua, Sri Lanka, Tanzania, Vietnam, and Yemen). The PACT program situates the delivery of radiation therapy within a comprehen- sive framework including prevention, early detection, treat- ment, and palliation. Plans sensitive to the target country’s social and political situation are developed through local and international partnerships. Other IAEA initiatives for develop- ing countries include strengthening pediatric radiation oncol- ogy and quality audits. At a global level, breast cancer guidelines stratified by avail- ability of resources have been developed through the Breast Health Global Initiative. 90 This is a useful paradigm for devel- oping resource-appropriate and stepwise, scalable goals and guidelines for cancer care that is being adopted for other can- cers. 91 A related approach has been used by the IAEA to describe additional resource requirements, benefits, and risks for specific approaches in lung cancer treatment, including curative and palliative radiation. 92 Developing innovative means of organizing and funding cancer services is needed. The IAEA’s PACT program offers opportunities to identify successful models of service delivery and planning. A model of radiotherapy service provision utiliz- ing geographically dispersed telemedicine-linked sites with varying levels of capacity has also been proposed by an Indian group to maximize available resources. 93 Another concept that is being explored is utilizing community health workers and primary care to expand cancer-related service provision. Proposed activities are cancer prevention, early detection, some treatment (e.g., systemic therapy), palliation, and follow- up. 47 A social business model is one potential solution to financing radiation therapy services. 94 This is being explored as part of a Bangladesh initiative.

Capacity Building.  The importance of improving human resources for radiation oncology and oncology in gen- eral cannot be overstated given the global workforce short- age of trained health care professionals. Some initial efforts have been made in developing curricula and educational approaches specific to the discipline of radiation medicine. 95,96 The IAEA has been notably involved in these efforts. The issue of loss of trained staff from developing to developed countries is especially important to consider in developing educational programs. Urban regions in LMCs may have high-level exper- tise that can be utilized in developing national training pro- grams. A complementary approach is online training. This is the approach of the Virtual University for Cancer Control and Regional Training Network (VUCCnet) initiative in Africa. A growing number cancer centers, regional groups, and spe- cific nations have been involved in twinning projects build- ing capacity for cancer therapy in limited-resource countries. These initiatives have been particularly strong in pediatric oncology, with demonstrated success. 97,98 They provide an appealing means for broad participation in improving cancer control in developing countries. Numerous oncology societies in developed and developing countries support initiatives to build capacity in developing countries. The African Organization for Research and Training in Cancer (AORTIC) is an Africa-based collaboration with an advocacy, research, and training focus in cancer control for Africa. ESTRO, ASTRO, and a number of other radiation oncol- ogy societies support initiatives for education and capacity building in developing countries. ASCO has developed a num- ber of ongoing initiatives in training, mentoring, and continu- ing education of oncologists in developing countries, including translation by local editors of their flagship journal into 12 languages. 99 The U.S. National Cancer Institute Radiation Research Program is partnering with other oncology groups to develop a capacity-building Cancer Expert Corps. Regional and national initiatives are very important for improving the capacity to treat cancer in developing countries. For example, the Forum for Nuclear Cooperation in Asia (FNCA) organizes radiation therapy protocols in the Asian region for the common problems of cervical cancer and naso- pharyngeal cancer. 100 The FNCA involves Asian countries at a wide range of economic levels. At a national level, the Association of Radiation Oncologists of India (AROI) publishes a scientific journal and supports various educational and pro- fessional activities. 101 Quality.  Embedded within the themes of investment, planning, and capacity building is the implicit theme of struc- ture-related quality improvement. Process-related initiatives in quality are another very important part of ensuring optimal outcomes. These are often referred to indirectly (e.g., safety, effectiveness, patient-centeredness, timeliness, efficiency, equity). 51 Quality improvement relating to process and orga- nizational structure is important as it holds the potential for improving some outcomes more rapidly than other drivers of health, such as economic growth. 102 One important element of quality for radiation oncology in developing countries is safety, given the potential for unsafe treatment to negate any benefit of available treatment. 103 Safety includes the clinical process, the various elements of technical quality assurance, maintenance, worker safety, public safety, and source secu- rity. 104,105 Safety requires investment in appropriate dosimetry equipment, sufficiently trained human resources, and time for quality assurance activities. 105 Internal and external audits, peer review, regulation, accreditation, certification, checklists, adverse event reporting, common protocols, quality improve- ment, and independent checking are examples of interven- tions ensuring safety and quality assurance in radiation oncol- ogy. 64,106,107

Techniques, Modalities, and Modifiers in Radiation Oncology