Radiotherapy in cancer Radiotherapy in cancer control in low control in low- - and and middle middle income countries middle middle-income countries income countries income countries
XRT in LMI countries XRT in LMI countries XRT in LMI countries XRT in LMI countries � What is LMI? � What is LMI? What is LMI? What is LMI? � Cancer in LMI Cancer in LMI � Need for XRT � Need for XRT Need for XRT Need for XRT � Cost and cost Cost and cost- -effectiveness effectiveness � Current state of XRT in LMI countries � Current state of XRT in LMI countries Current state of XRT in LMI countries Current state of XRT in LMI countries � Case studies Case studies • Breast • Breast Breast Breast • Cervix Cervix • Lung Lung Lung Lung
LMI countries LMI countries LMI countries LMI countries Income Income Gross National Income Gross National Income per person per year (US$) per person per year (US$) per person per year (US$) per person per year (US$) Low Low 765 765 Middle Middle 766 766 – – 9,385 9,385 High High 9,386 9,386
World Bank Incomes Upper middle income (34) Lower middle income (54) ( ) Low income (60) High income: OECD (24) High income: nonOECD (26)
Cancer in LMI countries Cancer in LMI countries Cancer in LMI countries Cancer in LMI countries � 10 million new cases by 2010 10 10 10 million new cases by 2010 illi illi b 2010 b 2010 � > 50% of all cancers occur in LMI > 50% of all cancers occur in LMI � 70% by 2020 70% by 2020
New cases of cancer New cases of cancer Globocan 2002
Radiotherapy Utilisation Radiotherapy Utilisation Radiotherapy Utilisation Radiotherapy Utilisation � 52% of all cancer patients need � 52% of all cancer patients need 52% of all cancer patients need 52% of all cancer patients need radiotherapy at least once radiotherapy at least once � 86% curative or adjuvant 86% curative or adjuvant 86% cu at 86% cu at e o e o adju a t adju a t � 20 20- -25% may need > 1 treatment episode 25% may need > 1 treatment episode � RTU likely to be higher � RTU likely to be higher RTU likely to be higher RTU likely to be higher • More advanced stage More advanced stage • Less surgical expertise Less surgical expertise g g p p
The need for radiotherapy The need for radiotherapy The need for radiotherapy The need for radiotherapy Iceland Canada Russia Estonia Latvia Latvia United Kingdom Lithuania Belarus Ireland Poland Germany Czech Republic Slovakia Ukraine Kazakhstan Hungary Moldova Mongolia France Romania United States Slovenia Croatia Bosnia and Herzegovina Serbia Bulgaria Georgia Albania Macedonia Uzbekistan Kyrgyzstan Armenia Azerbaijan Korea DPR Turkey Tajikistan Greece Portugal Korea Rep. Spain Malta China Japan Cyprus Syria Afghanistan Tunisia Lebanon Iraq Morocco Jordan Pakistan Kuwait Algeria Libya Egypt Qatar Saudi Arabia United Arab Emirates Bangladesh Mexico India Cuba Haiti Myanmar Dominican Republic Jamaica Mali Niger g Cape Verde Vietnam Guatemala Chad Yemen Eritrea Honduras Senegal El Salvador Sudan Nicaragua Thailand Burkina Faso Philippines Costa Rica Benin Ethiopia Nigeria Panama Sierra Leone Ghana Sri Lanka Cote D'Ivoire Cameroon Central African Republic Venezuela Liberia Malaysia Uganda Singapore Kenya Gabon Ecuador Indonesia Democratic Republic of the Congo Tanzania Peru Angola Zambia Malawi Brazil Bolivia % of cases requiring RT q g Madagascar Zimbabwe Mauritius Botswana P Paraguay Namibia Namibia Australia South Africa Uruguay 0 - 0.39 Chile Argentina 0.39 - 0.43 0.43 - 0.47 0 47 - 0 51 0.47 - 0.51 0.51 - 0.55 0.55 - 0.59 N. Taylor, IAEA 2005 0.59 - 1
Cancer cases needing XRT Cancer cases needing XRT Cancer cases needing XRT Cancer cases needing XRT Iceland Canada Russia Estonia Latvia United Kingdom Lithuania Belarus Ireland Poland Germany Czech Republic Slovakia Ukraine Kazakhstan Hungary Moldova Mongolia France Romania United States Slovenia Croatia Bosnia and Herzegovina Serbia Bulgaria Georgia Macedonia Albania Uzbekistan Kyrgyzstan Armenia Azerbaijan Korea DPR Turkey Tajikistan Greece Portugal Korea Rep. Spain Malta China Japan Cyprus Syria Tunisia Lebanon Afghanistan Iraq Morocco Jordan Pakistan Kuwait Algeria Libya Egypt Qatar Saudi Arabia United Arab Emirates Bangladesh Mexico India Cuba Haiti Myanmar Dominican Republic Jamaica Mali Niger Cape Verde Vietnam Guatemala Yemen Chad Eritrea Honduras Senegal El Salvador Sudan Thailand Nicaragua Burkina Faso Philippines Costa Rica Benin Nigeria Ethiopia Panama Sierra Leone Ghana Sri Lanka Cote D'Ivoire Cameroon Venezuela Liberia Central African Republic Malaysia Uganda Singapore Kenya Gabon Ecuador Indonesia Democratic Republic of the Congo Cancer Cases per Million Tanzania Peru Angola Population Requiring RT Zambia Malawi Brazil Bolivia Zimbabwe bab e Madagascar Mauritius Botswana Namibia Paraguay Australia South Africa Uruguay 0 - 200 Chile Argentina 200 - 800 800 - 1200 1200 - 1600 1600 - 2000 N. Taylor, IAEA 2005 2000 - 20000
Cost Cost Cost Cost Building Building Building Building 3% 3% 3% 3% Equipment Equipment 30% 30% Staff Staff 50% 50% Materials Materials 4% 4% Overheads Overheads Overheads Overheads 13% 13% 13% 13% Kesteloot K, Lievens Y, van der SE. Improved management of radiotherapy departments through accurate cost data. Radiother Oncol 2000; 55(3):251-262.
C b lt C b lt Cobalt Cobalt Li Li Linac Linac Machine Machine $480,000 $480,000 $1,800,000 $1,800,000 Maintenance $1270 to $1270 to $3000 to $3000 to Maintenance $91,740 $91,740 $35,680 $35,680 Cost per Cost per $4.87 $4.87 $11 $11 treatment treatment Van Der Giessen PH, Alert J, Badri C, Bistrovic M, Deshpande D, Kardamakis D et al. Multinational assessment of some operational costs of teletherapy. Radiother Oncol. 2004;71(3):347-55.
Current status of XRT Current status of XRT Current status of XRT Current status of XRT � 24/ 72 countries with > 1 million � 24/ 72 countries with > 1 million 24/ 72 countries with > 1 million 24/ 72 countries with > 1 million people had no XRT people had no XRT � Average GNI/ cap US$300 Average GNI/ cap US$300 e age G e age G / cap US$300 / cap US$300 All Member States 100.000 Europe Asia & Pacific Central America 10.000 South America S$ 1,000s Africa straight line fit GDP/capita US 1.000 0.0100 0.1000 1.0000 10.0000 100.0000 0.100 0.010 No. teletherapy units / million population
Cervix Cervix Cervix Cervix � > 80% new cases & deaths > 80% new cases & deaths in LMI in LMI in LMI in LMI � 50 50- -60% of new cases die of 60% of new cases die of cervix cancer cervix cancer � 91 91- -99% need XRT 99% need XRT Incidence Mortality M/I ratio 100 100 1 0 1.0 0 d) rate per 100, 000 80 0.8 ence ratio* 60 0.6 standerdised (world Mortality/Incide 40 0.4 20 0.2 Age s 0 0.0 high income upper-middle low-middle low income countries income income countries countries countries
Strategies to improve access Strategies to improve access Strategies to improve access Strategies to improve access � Planning � Planning Planning Planning � Investment Investment � Linkages Linkages Li k Li k � Access to information Access to information � Education about cancer Education about cancer � Safety � Safety Safety Safety
Planning Planning Planning Planning � No “one size fit’s all” plan � No one size fit s all plan No “one size fit’s all” plan No one size fit s all plan • casemix casemix 100% Liver • capabilities • capabilities capabilities capabilities Ovary etc. 90% Leukaemia Thyroid 80% Testis Multiple myeloma Melanoma of skin 70% Kidney etc. Corpus uteri 60% Other Pharynx Pancreas 50% Hodgkin's disease Colon/Rectum Brain, nervous system 40% Nasopharynx Larynx 30% Oral cavity Lung 20% Stomach Bladder N Non-Hodgkin lymphoma H d ki l h 10% Oesophagus Prostate 0% Cervix uteri East Central Northern Southern Western all Africa Breast Africa Africa Africa Africa Africa
Investment Investment Investment Investment � Equipment � Equipment Equipment Equipment � Staff Staff � Maintenance � Maintenance Maintenance Maintenance � Source Source replacement replacement replacement replacement
Linkages Linkages Linkages Linkages � Many isolated departments � Many isolated departments Many isolated departments Many isolated departments � Training Training � CPD CPD � South South – – South South � Exchanges Exchanges • Protocols • Protocols Protocols Protocols • Staff Staff
Access to information Access to information Access to information Access to information $/Gbyte/month � Journals � Journals Journals Journals 2000 • Cost Cost 1800 • Language Language g g g g 1500 • On On- -line access line access � Meetings Meetings 1000 500 500 20 0 0 US Africa
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