Huge Shortfall in Radiotherapy, Investment Would Save Lives

Liam Davenport

September 26, 2015

VIENNA — There is a huge shortfall in the provision of radiotherapy, which is essential for the cure and palliation of many cancers, warn experts in a review that suggests major investment could reap huge benefits.

"The building of radiotherapy capacity will require large initial investment," commented Mary K. Gospodarowicz, MD, clinical department head, Princess Margaret Cancer Centre, University Health Network, Montreal, Canada, and co-chair of the Union for International Cancer Control Global Task Force on Radiotherapy for Cancer Control.

"However, the treatment [radiotherapy] is more cost-effective than chemotherapy and surgery for treating cancer, and the health and economic benefits will be realized in just 10 to 15 years," she said in a statement.

"To justify the investment, we only need to look at the remarkable progress made in tackling the enormous challenges of HIV/AIDS and malaria. This gives us the hope and confidence that the same success can be achieved with cancer control and radiotherapy," Dr Gospodarowicz said.

The huge shortfall in radiotherapy services is revealed in a new report presented here at European Cancer Congress (ECC) 2015 and published simultaneously in Lancet Oncology as part of a commission on access to cancer services.

Although up to 60% of cancer patients will require radiotherapy at some point, currently only 40% to 60% worldwide have access to radiotherapy services, the report notes.

Even in some higher-income countries, there is inadequate access to radiotherapy facilities and equipment, and services are virtually absent in some low-income countries.

The review indicates that worldwide investment to increase radiotherapy services, particularly in low- and middle-income countries (LIMCs), would not only yield almost 27 million life-years but also bring net economic benefits of $278 to $365 billion worldwide during the next 20 years.

From left to right: Dr Philippe Poortmans, Dr David Collinridge (editor of Lancet Oncology), and Dr Rifat Atun

"There is a widespread misconception that the costs of providing radiotherapy put it beyond the reach of all but the richest countries," commented lead author Rifat Atun, MD, professor of global health systems at Harvard University and director of Global Health Systems Cluster at the Harvard T. H. Chan School of Public Health, in Boston, Massachusetts, in a statement.

"Nothing could be further from the truth. Our work for this commission clearly shows that not only can this essential service be deployed safely and high-quality treatment delivered in low- and middle-income countries, but that scale-up of radiotherapy capacity is a feasible and highly cost-effective investment."

Philip Poortmans, MD, PhD, professor of radiation oncology at Radboud University, Nijmegen, the Netherlands, and president of the European Society for Radiotherapy and Oncology, said in a press briefing that he is "extremely happy" with the commission and congratulated everyone involved.

Dr Philip Poortmans

He said: "It's clear that most of the gain, at first sight, can be obtained in the low- and middle-income countries, and I often compare it with the 80/20 principle: for 80% of the benefits, you need 20% of the investments, and then for the last 20% of the benefits, you need 80% of the investment."

"So it's clear that with a relatively small investment, you can scale up radiation therapy worldwide."

He added: "What's so important with this work is that it's not just the needs based on evidence-based guidelines but also what is the return on investment."

"We should, of course, take a look at the financial figures. That's the way we can probably convince the politicians to go ahead, but we should also look at the individual patients, of course. It's quality of life, it's life span that can be hugely increased."

Substantial Shortfall in Provision

On the basis of available data, it was estimated that from 50% to 60% of cancer patients will need radiotherapy at some point. That means that by 2035, more than 12 million cancer patients worldwide would benefit from radiotherapy, requiring a total of 204 million fractions of radiotherapy.

There is currently a substantial shortfall in the provision of radiotherapy services, with only 40% to 60% of cancer patients estimated to have access to radiotherapy services.

The authors say that there has been a lack of investment in radiotherapy services worldwide, with the result that even in high-income countries, such as Canada, Australia, and the United Kingdom, "the numbers of radiotherapy facilities, equipment, and trained staff are inadequate."

It is estimated that in low-income countries, up to 90% of cancer patients do not have access to radiotherapy. For example, in sub-Saharan Africa, radiotherapy services are almost completely lacking.

In some countries, such as Brazil, facilities are centralized in large urban areas, creating geographical barriers to access, and in others, equipment has not been deployed or cannot be used owing to a lack of maintenance.

Estimates of Capacity

To examine the levels of investment required to achieve full access to radiotherapy worldwide, the researchers carried out a series of analyses.

They constructed a nominal model of essential equipment and elements of a radiotherapy facility, as well as its layout and size, to determine the capital and construction costs for a high- quality radiotherapy service.

Personnel costs were calculated from the results of a questionnaire sent to members of the Global Task Force for Radiotherapy for Cancer Control, along with information gathered from public databases. Training costs, aside from undergraduate and continuing education costs, were determined for radiotherapy professionals.

Operational costs for radiotherapy facilities were also calculated. Such costs included those for human resources, maintenance, consumables, and overhead costs, such as those required for immobilization devices, nursing supplies, cleaning, facility maintenance, heating, cooling, and general administration.

Current treatment capacity was assessed using data from the International Atomic Energy Agency's Directory of Radiotherapy Centres registry and the European Society for Radiotherapy and Oncology's Health Economics in Radiation Oncology database.

The team also examined future facility, equipment, and staffing needs by using incidence and fractionation data per country, divided into four gross-national-income groups on the basis of assumed standard of two treatment machines per department at 12 treatment hours per day and four fractions per hour.

Investment Needed

Scaling up radiotherapy services on the basis of a standard nominal model to allow full access for all patients by 2035 would require an overall investment of $26.6 billion in low-income countries, $62.6 billion in lower-middle-income countries, and $94.8 billion in upper-middle-income countries, giving a total of $184.0 billion across all LMICs.

With efficiency improvements, the required investment would be $14.1 billion in low-income, $33.3 billion in lower-middle-income, and $49.4 billion in upper-middle-income countries, at a total of $96.8 billion.

The researchers calculate that the scale-up of radiotherapy capacity would result in 26.9 million life-years being saved in LMICs during the lifetime of the patients.

This net investment would lead to a net worldwide economic benefit with the standard nominal model of $278.1 billion by 2035, at $265.2 million in low-income countries, $38.5 billion in lower- middle-income countries, and $239.3 billion in upper-middle-income countries.

With efficiency improvements, the net economic benefit would be $365.4 billion, at $12.8 billion in low-income countries, $67.7 billion in lower-middle-income countries, and $284.7 billion in upper-middle-income countries.

Six Key Targets

To achieve the scale-up of radiotherapy services, the authors set out six key targets, the first three of which to be delivered by 2020:

  • Comprehensive cancer plans that include radiotherapy in 80% of countries

  • Each LMIC to create one new center for treatment and training

  • Radiotherapy services to be included in universal health coverage plans in 80% of LMICs

The remaining three targets are to be delivered by 2025:

  • A 25% increase in radiotherapy capacity

  • 7500 radiation oncologists, 2000 radiotherapy radiographers, and 6000 medical physicists to be trained in LMICs

  • An up-front investment of $46 billion to establish radiotherapy infrastructure and training in LMICs

Dr Atun emphasized: "The time has come to agree and implement immediate actions to tackle the global shortfall in radiotherapy services and the crisis of access to this highly effective treatment."

For the authors of the study published in Lancet Oncology, relevant financial relationships are listed in that article.

European Cancer Congress (ECC) 2015: Abstract LBA2. Presented September 26, 2015.

Lancet Oncol. 2015;16:1153-86. Abstract

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