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Chapter 28 Radiation Oncology in the Developing World

oping countries, commonly cancer, cardiovascular dis- ease, chronic lung disease, and mental illness, impose a major strain on current resources and health care models. Challenges to the structure of cancer control and radiation therapy in limited-resource settings may also include insuffi- cient priority of cancer control among some gov- ernments and donor agen- cies with many competing priorities. Other issues may include political or social instability, conflict, corrup- tion, and fragmented ser- vice provision. The process of health care refers to what occurs while care is provided. For radiation oncology, this includes technical ele- ments of quality assur- ance, treatment prescrip- tion, treatment planning, and treatment delivery. It

Table 28.1  Megavoltage Machine Supply AND cancer burden in 17 Asia Pacific Countries

2010 Per Capita Gross National Income ($US)

Population (Millions) 2010

Incident Cancers 2010

Megavoltage (MV) Machines 2011

Incident Cancers per MV Machine

Country

Myanmar

n.a. 640

48.0

69,952 150,271 147,738 119,374 1,001,749 4,603 82,468 25,802 309,582 118,601 2,978,386

6

11,659 10,018 3,358 3,730 2,100 2,302 2,749 2,150 9,105 1,797 1,958 1,563 1,659

Bangladesh

148.7 173.6

15 44 32

Pakistan Vietnam

1,050 1,100 1,340 1,890 2,050 2,290 2,580 4,210 4,260 7,900 19,890 29,050 a 40,920 42,150 43,740 a

87.9

India

1,224.6

477

Mongolia Philippines Sri Lanka Indonesia

2.8

2

93.3 20.9

30 12 34 66

239.9

Thailand

69.1

China

1,348.9

1,521

Malaysia

28.4 48.2

34,386 179,187 21,080 14,495 637,963 112,023

22

Korea, Rep New Zealand

108

4.4 5.1

25 12

843

Singapore

1,208

Japan

126.5 22.3

905 131

705 855

Australia

Total

3,692.6

6,007,660

3,442

n.a., not available. a 2009 data. As a simple estimate, countries with more than 1,000 new cancers annually per radiation machine most likely have a short- fall of radiation machines. 2010 gross national income per capita information provided by the World Bank Group (Atlas method), http:// data.worldbank.org/about/country-classifications. 2010 population data from the World Population Prospects 2010 revision, http://esa. un.org/unpd/wpp/index.htm. Projected cancer incidence in 2010 from GLOBOCAN 2008, http://globocan.iarc.fr/. Reported number of megavoltage radiation machines from Directory of Radiotherapy Centers (DIRAC) August 2011, http://www-naweb.iaea.org/nahu/dirac/ default.shtm.

among the poor in LMCs. 46, 47 This is notable as cancer-related public health care may be inadequate or nonexistent. The cost of travel to the nearest cancer center can itself be another major financial obstacle, and costs of staying for the length of radia- tion treatment in another location can mean lost income and more cost to the patient and family. 45 A family may lose addi- tional income due to caregiver absence from work. 45,48 Awareness of the basic cancer principles and the value of cancer screening and early detection may limit timely access to cancer services for the public in LMCs. A large Union for International Cancer Control (UICC) survey of multiple LMCs found substantial lack of awareness of common preventable causes of cancer and found that a quarter or more of respon- dents in Asia and Africa did not think cancer could be cured. 49 Limited awareness of principles of cancer diagnosis and appro- priate referral among nonspecialist health care workers may be further limiting factors for access to cancer treatment. Health care worker training in oncologic principles may be extremely basic or insufficient in some cases. 50 Key dimensions of quality are described by the Institute of Medicine as safety, effectiveness, patient-centeredness, timeli- ness, efficiency, and equity. 51 Quality can be assessed through consideration of a health system’s structure, process, and out- comes. 52 Elements of structure are physical resources, human resources, and organizational structure. Limitations in physical and human resources in LMCs have already been described. The access issues that relate to late presentation and failure to receive indicated treatment arguably have the greatest impact on outcomes and quality of radiation therapy in developing countries. Quality may be further degraded by the inequitable access of the few available resources between country and city, rich and poor. The organizational structure of health care in developing countries has historically revolved around communicable dis- ease, nutritional deficiencies, and child and maternal health. The additional burden of noncommunicable disease in devel- Quality of Radiation Oncology in Developing Countries

also includes the integration of multidisciplinary services needed alongside radiation oncology for effective cancer man- agement. A major process issue in some countries is system- related delay in diagnosis. 53,54 This probably contributes to high rates of advanced disease at presentation. System-related diagnostic delay can relate to weak or nonexistent referral sys- tems or limited resources for diagnosis. It is compounded by patient-related delay in seeking medical attention due to previ- ously described access issues. 55 The additional impact on delay due to waiting times for radiation following radiation oncology consultation requires further characterization in LMCs. The technical process of radiotherapy is a vital element of quality. For this reason, the IAEA and WHO have maintained a postal dose audit program using thermoluminescent devices (TLDs). A report focusing on measurements from developing countries found acceptable results, with most machines cali- brated within the ± 5% dose acceptance limit. Sixteen percent of machines registered measurements outside this range in the first round of testing, with 93% measuring dose within 5% of the standard after the second round. 56 Notably, a dosimetric audit in Latin America and the Caribbean suggested an asso- ciation between on-duty medical physics support and accept- able TLD results. 57 This emphasizes the importance of ade- quate staffing to a radiation department’s quality assurance process. Current reports are too limited to comment on the quality of general patterns of the radiation oncology clinical process in regions of the developing world. There are most certainly specific opportunities for gains. Taking advantage of hypofrac- tionation to increase throughput where there is supportive evidence has not always occurred, as one survey on patterns of palliative radiation for bone metastasis in Africa suggests. 58 Implementation of multidisciplinary decision making among oncologists in LMCs is important but not always present. 59,60 Treatment refusal or nonadherence by patients can be a major problem in some cases and is an important area for quality improvement where it exists. 42,48,61 Audits of the clinical deci- sion-making and the treatment-planning process may provide a useful means of ensuring patient safety, improving pro- cesses, and creating opportunities for continuing educa- tion. 62 ,63 This is particularly important with the introduction of

Techniques, Modalities, and Modifiers in Radiation Oncology