Inr J. Rodmwn Oncolog,’ Bml Phw Vol. Printed in the US A. All rights reserved.
I’). pp. 1257-1261
Copyright
0360.3016190 $3.00 t .OO CC 1990 Pergamon Press plc
??Special Feature: Developing Countries
AN OVERVIEW OF THE SITUATION IN RADIOTHERAPY WITH EMPHASIS ON THE DEVELOPING COUNTRIES G. P. HANSON,’
J. STJERNSWARD,’ ‘WHO, Geneva,
M. NOFAL~
Switzerland;
AND
and *IAEA, Vienna,
F. DUROSINMI-ETTI~ Austria
Radiotherapy services are closely linked to the level of medical care which, in turn, is an important component of the overall health care program, with its development related to social, economic, and educational factors. As a basis for understanding the situation regarding adequate coverage of the population by radiotherapy services, general information about the world population (currently 5 billion), age distribution, frequency of cancer occurrence, and causes of death is presented. For an appreciation of the obstacles that must be overcome, the situation with regard to Gross National Product (GNP), transfer of economic resources, and per capita expenditures for health services is shown. For example, in the developing world, most countries spend less than 5% of their GNP for health, and on a macro scale at least 20 billion U.S. dollars per year are being transferred from the poor nations of the southern hemisphere to the northern hemisphere. Information about the wide range of population coverage with radiotherapy resources and the trend regarding high-energy radiotherapy machines is presented. For example, in North America (USA) there are six high-energy machines for each one million persons, and each machine is used to treat about 230 new patients per year. In other parts of the world, such as large areas of Africa and South-East Asia, there may only be one high-energy radiotherapy machine for 20 to 40 million people, and one machine may be used to treat more than 600 new patients per year. Many cancer patients have no access to radiotherapy services. When estimates of the need for radiotherapy services in the developing world as a consequence of cancer incidence are compared with the current health expenditures, it is concluded that a combined effort of national authorities, donor and financial institutions, professional and scientific societies, and international organizations is required. The knowledge, skills, and technology are available in many excellent radiotherapy centers throughout the world. The key issues are priority and the commitment of sufficient resources. Radiotherapy services, World population, Developing countries.
year 20 10 it will be nearly 7 billion. As shown in Table 1 most of the people of the world will live in less developed areas (9). The composition of the world population is moving toward a higher median age, and the elderly population, which is defined as those 65 years of age or older, is increasing steadily in both the more developed areas and the less developed areas. Currently about I out of every 17 persons is age 65 or more and by the year 2025 nearly 1 out of every 10 persons will be elderly (8, 12, 13).
INTRODUCTION
Radiotherapy, or radiation oncology as a more comprehensive term, is a medical speciality and hence its development within a country or region is closely linked to the level of medical care. In turn, medical care is an important component in the overall health care program and its level of development is closely related to social, economic, and educational factors. Therefore, in presenting this overview of the situation regarding radiotherapy, it is necessary to consider the corresponding situation and trends which tend to promote or constrain its use within the health care system.
Economic transition In many countries of the developing world, economic growth has been declining during the past decade, unemployment has increased, and, as a consequence, alienation, delinquency, and violence have increased. The economic trend as expressed by the per capita Gross National Product for industrialized and developing countries is shown in Table 2 (10). The distribution of countries by WHO Region with per capita GNP of more
DISCUSSION
Demographic situation According to the United Nations, the population of the world passed the 5 billion level in 1987; by the year 2000 the world’s population will be over 6 billion and by the
Reprint requests to: G. P. Hanson, Radiation Medicine, Health Organization, I2 I I Geneva 27, Switzerland.
Accepted
World 1257
for publication
24 May 1990.
1258
I. J. Radiation Oncology 0 Biology 0 Physics
November 1990, Volume 19, Number 5
Table 1.
World: population (millions)
Year 1970 1980 1990 2000 2010 2020
More developed areas: population (millions)
3683 4453 5248 6127 6995 7806
ings (e.g., 27% for Africa in 1984) is required to service debts. “In 1979, a net of $40 billion flowed from the northern hemisphere to the developing nations of the south. Today that flow has been reversed. Taking everything into account-loans, aid, repayments of interests and capitalthe southern world is now transferring at least $20 billion a year to the northern hemisphere.” (UNICEF, State of the World’s Children, Report, 1989 (10)). This net economic transfer of $20 billion would be even higher, perhaps as high as $60 billion per year, if the effective transfer of resources resulting from the reduction in prices for raw materials could be quantified.
Less developed areas: population (millions)
1047 1136 1209 1276 1331 1377
2636 3317 4040 485 I 5664 6429
Table 2. Trend in per capita gross national product US $
for industrialized
and developing countries: 1960- 1985 Industrialized countries
Year 1960 1970 1980 1986
Health situation For organizational purposes, WHO has six Regional Offices which each serve from 11 to 44 countries with population distributions as shown in Table 4. Few of these countries in the developing world are able to spend as much as 5% of their GNP for their health needs, as shown in Table 5 (14). Although accurate information on the causes of illness and death is not available, it is estimated that about 50 million people die each year from the major causes of death as shown in Table 6 (15). In 1980, neoplasms accounted for 19% of deaths in developed countries and for 5% in developing countries. By the year 2025 when the population distribution in the developing countries will more nearly resemble that of the developed countries, the
Developing countries
5,000 7,000 9,000 10,000
300 400 500 500
than US $500 and less than US $500 is shown in Table 3 (14). Many developing countries have reduced imports drastically to service debts that had accumulated prior to a worldwide recession that began in the early 1980’s. In many developing areas, a large portion of the export earn-
Table 3. GNP per capita (US$): distribution Number
of countries
South-East Asia
Americas
of countries,
by WHO region
in WHO region
Europe
Eastern Mediterranean
Western Pacific
Total
GNP
Africa
Less than $500 $500 and more
21 6
1 31
8 2
0 24
6 17
7 12
43 92
Subtotal
27
32
10
24
23
19
135
Total
44
34
11
34
23
20
166
Table 4. Number
Africa Number of countries Percent of world population Percent of population which is urban
Table 5. Percent
Africa 13
52
in WHO regions and percent
America
South-East Asia
of world’s population Eastern Mediterranean
Europe
Western Pacific
44 9
34 14
11 24
35 17
22 6
20 30
29
71
24
69
42
31
of countries
America
of countries
by WHO regions spending South-East Asia 10
at least 5% of Gross National
Europe 74
Product
Eastern Mediterranean 25
on health Western Pacific 62
1259
Radiotherapy in developing countries 0 G. P. HANSONet al.
estimated percent of death by major categories ( 1980)
Table 6. Worldwide
Cause
Developed countries
Developing countries
Infectious and parasitic diseases Neoplasms Circulatory diseases and certain degenerative diseases Conditions originating in the perinatal period Injury and poisoning All other and unknown causes All causes
World total
40 5
8 19
33 8
19
54
26
8 5
2 6
6 5
23 100
12 100
21 100
Table 7. Twelve selected cancers: frequency of occurrence throughout the world Rank I 2 3 4 5 6 7 8 9 IO
Males Lung Stomach Colon/rectum Mouth/pharynx Prostate Oesophagus Liver Bladder Lymphoma Leukaemia
Females
Both sexes
Breast Cervix Colon/rectum Stomach Corpus uteri Lung Ovary Mouth/pharynx Oesophagus Lymphoma
Stomach Lung Breast Colon/rectum Cervix Mouth /pharynx Oesophagus Liver Lymphoma Prostate
importance of cancer as a cause of death is expected to be about equal. Even now, more than one-half of all cancer patients are in the developing world. The total number of new patients is about 3,200,OOO per year, for which about 5% of the world’s cancer care resources are available. For example, in Africa south of the Sahara, but not including South Africa, there are no more than 75 cancer
specialists of any kind, of whom only about 20 are radiation oncologists. The frequency of occurrence among both sexes of cancer throughout the world was recently reported by Parkin et al. and is shown in Table 7 (5). Radiotherapy, alone or in conjunction with surgery or chemotherapy, has an important role in the treatment (curative or palliative) of most of these cancers. In developed countries, more than one-half of all cancer patients receive radiotherapy during the course of their illness. The frequency of radiotherapy, surgery, and other treatment methods such as chemotherapy and hormonotherapy for the most common cancer sites in an area with well-developed radiotherapy services is shown in Table 8 (16). Radiotheraplj situation Periodically, IAEA and WHO have made specific, concerted efforts to obtain information regarding the availability of radiotherapy services throughout the world and the Directory of High-Energy Radiotherapy Centers was published in 1970 and 1976 (2, 3). Additionally, information, primarily about radiotherapy centers with 6oCo teletherapy units, is available through the IAEA/WHO Postal Dose Intercomparison Programme for Radiotherapy Centers, which has been in operation continuously since 1969. Through this program during the period 19691987, approximately 2,000 dosimetric intercomparisons were made in 700 radiotherapy centers in 89 countries (7). The current situation regarding high-energy radiotherapy facilities (60Co or higher energy) in various regions of the world is shown in Table 9, and the trend ( 1970- 1989) in the availability of high energy radiotherapy machines is shown in Table 10. Some countries and areas of the world appear to have adequate, or even more than adequate, coverage with radiotherapy services. For example, in North America (USA) there are six high-energy radiation therapy machines for each one million of population, and each machine is used to treat about 230 new patients
Table 8. Frequency of radiotherapy and surgery Treatment
Cancer distribution Mouth, pharynx Sinus, larynx Skin, connective tissue Breast Cervix uteri Other female genital organs Bladder, kidney Lymphoma, leukemia Lung, bronchi Digestive tract All cancers
Radiotherapy alone (W) 59 68 52 16 59 11 38 26 35 1 21
Surgery plus radiotherapy (%)
Surgery alone (%)
Other (%)
None (%)
14 16 5 42 13 31 8 6 4 0.1 12
23 I 41 27 13 35 46 4 19 53 33
0.4 0.6 0.3 7 0.2 5 2 40 22 4 7
4 8 2 8 5 18 18 24 29 41 26
1. J. Radiation Oncology 0 Biology 0 Physics
1260
Table 9. High-energy
radiotherapy
November 1990, Volume 19, Number 5
resources
Table I 1. Radiotherapy resources in the USA, 1983
by WHO region, 1989
WHO region
Countries with high-energy radiotherapy facilities
Number of high-energy radiotherapy centres
Africa* Americas+ Eastern Mediterranean Europe* South-East Asia Western Pacific”
12 23 20 35 7 11
14 250 40 500 80 200
* Not + Not $ Not s;Not
including including including including
South Africa. USA and Canada. USSR. China.
per year. The situation in the USA is shown in Tables 11 and 12 (1, 11). In other parts of the world, such as large areas of Africa and South-East Asia, there may only be one high-energy radiotherapy machine for 20 to 40 million people, and one machine may be used to treat more than 600 new patients per year. Many cancer patients have no access to radiotherapy services. In its 1988 Report, the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) provided an estimate on the use of radiotherapy throughout the world. Because of the difficulty in obtaining data, non-uniform reporting methods, and unclear definitions, estimates were made based upon the correlation between population per physician and the medical use of radiation. The UNSCEAR world wide estimates of the radiation therapy situation by level of services are shown in Table 13 (1 l), and some specific examples of the radiation therapy experience and level of services are shown in Table 14. In 1986, Racoveanu estimated that radiotherapy facilities and specialized personnel are not available in 40% of the developing countries and are insufficient with regard to need in 60% of the developing countries (6).
Human resources Radiation therapists Medical physicists Radiotherapy technologists Dosimetrists Physical resources Facilities Cobalt-60 units Linacs and betatrons
CONCLUSION
Total number of high-energy machines
For a definitive
of radiotherapy
improvement
of the existing
situation
in most developing countries, a concerted
1976
WHO region Africa* Americas+ Eastern Mediterranean Europe* South-East Asia Western Pacific” including including including including
1,083 744 1,018
In an attempt to relate the need for radiotherapy services to the cancer incidence in the developing world, which ranges from 75 to 320 new cases per year per 100,000 population, Racoveanu also estimated that 1,400- 1,900 teletherapy machines and the appropriate number of specialists would be necessary for an acceptable coverage until the year 2000. The cost of the teletherapy machines alone was estimated to be US $350-475 million. When the cost of premises, training of staff, and dosimeters and other auxiliary equipment was added, the figures were at least doubled-to US $700-950 million. The economic data presented earlier in this paper clearly demonstrate that this level of investment is not possible within the current health budgets of developing countries. A partial solution to the dilemma could be to provide brachytherapy for treatment of certain cancers such as cervical cancer, as has been done in a pilot project in Egypt with the collaboration of IAEA and WHO, and which could possibly be extended for palliation of cancer of the esophagus (4). When incorporated in a well planned and coordinated cancer program, including early detection, training, proper management, application, and follow-up, this dedicated use of brachytherapy can provide a useful treatment method when external beam radiotherapy is not available. A standard equipment package costing about US $25,000 can provide treatment for 50 cervical cancer patients per year (two applications for each patient).
Table 10. Trend of availability of high-energy radiotherapy machines by WHO region
* Not + Not * Not g Not
2,199 1,067 3,648 438
6 166 30 811 55 442
7 198 48 998 84 648
20 500 60 1300 170 800
South Africa in 1970, 1976, and 1989. Canada and USA in 1970, 1976, and 1989. USSR in 1970, 1976, and 1989. China in 1970, 1976, and 1989.
Table 12. Megavoltage radiotherapy units in the USA
Year
Cobalt
1975 1978 1980 1983 1986
970 900 980 744 671
Linear accelerators and betatrons 407 606 801 1018 1294
New patients per unit 227 232 233 227 226
1261
Radiotherapy in developing countries 0 G. P. HANSON c’/ul. Table 13. Radiation Annual Level of services
I II 111 IV
Population (millions) 1300 1750 1220 730
therapy
procedures
Brachytherapy teletherapy
situation
by level of services
per million population Unsealed radionuclides
and
2400 600 100 50
Machines
Total
per million
number of
population
machines
400 100 16 8
effort, including a large capital investment in training, equipment, and structural facilities, is needed. In view of the changing demographic characteristics of the populations and the growing importance of cancer as a public health problem. national authorities need to devise comprehensive cancer programs which include public education for prevention, early detection, accurate diagnosis. multi-modality treatment (including radiotherapy), rehabilitation, and follow-up. A combined effort of national authorities, donor and financial institutions, professional and scientific societies, and international organizations such as IAEA. WHO. UICC, and UNDP could change the situation. To succeed. the current situation, which has prevailed for the last decade and which can be characterized as slow or no growth. and even deterioration, must be completely reversed. The key issues are priority and the commitment of sufficient resources. The knowledge, skills, and technology are available in many excellent radiotherapy centers in both the developed and the devel-
10 2.5 0.4 0.2
13000 4400 490 I50
oping countries, and through existing channels of intercould be transferred if the funding national cooperation were available.
Table 14. Radiation
Level of services 1 11 111 IV
therapy
experience
Country
Year
France USA Brazil Venezuela India Sudan Indonesia
1987 1981 1981 1981 1976 1985 1978
* Brachytherapy
and level of services
Annual procedures per million population* 2400 -600 -600 125 70 7
Machines per million population 8 10 2.5 2.4 0.5 0.3 -
and teletherapy.
REFERENCES I.
-I _.
3.
4.
5.
6.
7.
8.
Diamond, J.: Kramer, S.; Hanks, G. Trends in radiation therapy demographics-1974 to 1983. Int. J. Radiat. Oncol. Biol. Phys. 12:1673-1674: 1986. International Atomic Energy Agency. Directory of high-energy radiotherapy centers, 1970 edition. Vienna: IAEA: 1970. International Atomic Energy Agency. Directory of high-energy radiotherapy centers, 1976 edition. Vienna: IAEA; 1976. Mahfouz, M. M. The brachytherapy pilot project in Egypt. In: Proceedings of the Fifth International Symposium on the Planning of Radiological Departments, (ISPRAD V), Florence, 20-23 April 1988. Brescia: Clas International: 1988. Parkin, D. M.; Laara, A.; Muir, C. S. Estimates of the worldwide frequency of sixteen major cancers in 1980. Int. J. Cancer 41:184-197; 1988. Racoveanu, N. T. Radiotherapy in developing countriesconstraints and possible solutions. In: Radiotherapy in developing countries, Proceedings of a Symposium, Vienna, 1-5 September, 1986, organized by IAEA in cooperation with WHO. Vienna: IAEA; 1987. Svensson, H.; Hanson, G. P.; Zsdanszky, K. The IAEA/ WHO TL dosimetry service for radiotherapy centers 19691987: Acta Oncologica 29:46 l-467, Fast. 4: 1990. United Nations. World population prospects, estimates and projections as assessed in 1984. New York: United Nations: 1986.
9. United Nations. World population trends, population and development interrelations and population policies, 1983 Monitoring Report, Vol. 1, Population trends, and Vol. II. Monitoring. New York: U.N.; 1985. IO. United Nations Childrens Fund. The state of the world’s children, 1989. New York: Published for UNICEF by the Oxford University Press; 1989. I I. United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR). Sources, effects, and risks of ionizing radiation, 1988 UNSCEAR Report. New York: United Nations; 1988. 12. World Bank. World bank atlas 1987. Washington, DC: The World Bank; 1987. 13. World Bank. World development report 1987. Washington, DC: Published for the World Bank by Oxford University Press; 1987. 14. World Health Organization. Evaluation of the strategy for health for all by the year 2000. Volume I Global Review, Volume 2 African Region, Volume 3 Region of the Americas, Volume 4 South-East Asia Region. Volume 5 European Region, Volume 6 Eastern Mediterranean Region, Volume 7 Western Pacific Region. Geneva: World Health Organization: 1987. 15. World Health Organization. World health statistics annual 1984. Geneva: World Health Organization; 1984. of radiotherapy. 16. World Health Organization. Optimization Technical Report Series 644. Geneva: WHO: 1980.
I’). pp. 1257-1261
Copyright
0360.3016190 $3.00 t .OO CC 1990 Pergamon Press plc
??Special Feature: Developing Countries
AN OVERVIEW OF THE SITUATION IN RADIOTHERAPY WITH EMPHASIS ON THE DEVELOPING COUNTRIES G. P. HANSON,’
J. STJERNSWARD,’ ‘WHO, Geneva,
M. NOFAL~
Switzerland;
AND
and *IAEA, Vienna,
F. DUROSINMI-ETTI~ Austria
Radiotherapy services are closely linked to the level of medical care which, in turn, is an important component of the overall health care program, with its development related to social, economic, and educational factors. As a basis for understanding the situation regarding adequate coverage of the population by radiotherapy services, general information about the world population (currently 5 billion), age distribution, frequency of cancer occurrence, and causes of death is presented. For an appreciation of the obstacles that must be overcome, the situation with regard to Gross National Product (GNP), transfer of economic resources, and per capita expenditures for health services is shown. For example, in the developing world, most countries spend less than 5% of their GNP for health, and on a macro scale at least 20 billion U.S. dollars per year are being transferred from the poor nations of the southern hemisphere to the northern hemisphere. Information about the wide range of population coverage with radiotherapy resources and the trend regarding high-energy radiotherapy machines is presented. For example, in North America (USA) there are six high-energy machines for each one million persons, and each machine is used to treat about 230 new patients per year. In other parts of the world, such as large areas of Africa and South-East Asia, there may only be one high-energy radiotherapy machine for 20 to 40 million people, and one machine may be used to treat more than 600 new patients per year. Many cancer patients have no access to radiotherapy services. When estimates of the need for radiotherapy services in the developing world as a consequence of cancer incidence are compared with the current health expenditures, it is concluded that a combined effort of national authorities, donor and financial institutions, professional and scientific societies, and international organizations is required. The knowledge, skills, and technology are available in many excellent radiotherapy centers throughout the world. The key issues are priority and the commitment of sufficient resources. Radiotherapy services, World population, Developing countries.
year 20 10 it will be nearly 7 billion. As shown in Table 1 most of the people of the world will live in less developed areas (9). The composition of the world population is moving toward a higher median age, and the elderly population, which is defined as those 65 years of age or older, is increasing steadily in both the more developed areas and the less developed areas. Currently about I out of every 17 persons is age 65 or more and by the year 2025 nearly 1 out of every 10 persons will be elderly (8, 12, 13).
INTRODUCTION
Radiotherapy, or radiation oncology as a more comprehensive term, is a medical speciality and hence its development within a country or region is closely linked to the level of medical care. In turn, medical care is an important component in the overall health care program and its level of development is closely related to social, economic, and educational factors. Therefore, in presenting this overview of the situation regarding radiotherapy, it is necessary to consider the corresponding situation and trends which tend to promote or constrain its use within the health care system.
Economic transition In many countries of the developing world, economic growth has been declining during the past decade, unemployment has increased, and, as a consequence, alienation, delinquency, and violence have increased. The economic trend as expressed by the per capita Gross National Product for industrialized and developing countries is shown in Table 2 (10). The distribution of countries by WHO Region with per capita GNP of more
DISCUSSION
Demographic situation According to the United Nations, the population of the world passed the 5 billion level in 1987; by the year 2000 the world’s population will be over 6 billion and by the
Reprint requests to: G. P. Hanson, Radiation Medicine, Health Organization, I2 I I Geneva 27, Switzerland.
Accepted
World 1257
for publication
24 May 1990.
1258
I. J. Radiation Oncology 0 Biology 0 Physics
November 1990, Volume 19, Number 5
Table 1.
World: population (millions)
Year 1970 1980 1990 2000 2010 2020
More developed areas: population (millions)
3683 4453 5248 6127 6995 7806
ings (e.g., 27% for Africa in 1984) is required to service debts. “In 1979, a net of $40 billion flowed from the northern hemisphere to the developing nations of the south. Today that flow has been reversed. Taking everything into account-loans, aid, repayments of interests and capitalthe southern world is now transferring at least $20 billion a year to the northern hemisphere.” (UNICEF, State of the World’s Children, Report, 1989 (10)). This net economic transfer of $20 billion would be even higher, perhaps as high as $60 billion per year, if the effective transfer of resources resulting from the reduction in prices for raw materials could be quantified.
Less developed areas: population (millions)
1047 1136 1209 1276 1331 1377
2636 3317 4040 485 I 5664 6429
Table 2. Trend in per capita gross national product US $
for industrialized
and developing countries: 1960- 1985 Industrialized countries
Year 1960 1970 1980 1986
Health situation For organizational purposes, WHO has six Regional Offices which each serve from 11 to 44 countries with population distributions as shown in Table 4. Few of these countries in the developing world are able to spend as much as 5% of their GNP for their health needs, as shown in Table 5 (14). Although accurate information on the causes of illness and death is not available, it is estimated that about 50 million people die each year from the major causes of death as shown in Table 6 (15). In 1980, neoplasms accounted for 19% of deaths in developed countries and for 5% in developing countries. By the year 2025 when the population distribution in the developing countries will more nearly resemble that of the developed countries, the
Developing countries
5,000 7,000 9,000 10,000
300 400 500 500
than US $500 and less than US $500 is shown in Table 3 (14). Many developing countries have reduced imports drastically to service debts that had accumulated prior to a worldwide recession that began in the early 1980’s. In many developing areas, a large portion of the export earn-
Table 3. GNP per capita (US$): distribution Number
of countries
South-East Asia
Americas
of countries,
by WHO region
in WHO region
Europe
Eastern Mediterranean
Western Pacific
Total
GNP
Africa
Less than $500 $500 and more
21 6
1 31
8 2
0 24
6 17
7 12
43 92
Subtotal
27
32
10
24
23
19
135
Total
44
34
11
34
23
20
166
Table 4. Number
Africa Number of countries Percent of world population Percent of population which is urban
Table 5. Percent
Africa 13
52
in WHO regions and percent
America
South-East Asia
of world’s population Eastern Mediterranean
Europe
Western Pacific
44 9
34 14
11 24
35 17
22 6
20 30
29
71
24
69
42
31
of countries
America
of countries
by WHO regions spending South-East Asia 10
at least 5% of Gross National
Europe 74
Product
Eastern Mediterranean 25
on health Western Pacific 62
1259
Radiotherapy in developing countries 0 G. P. HANSONet al.
estimated percent of death by major categories ( 1980)
Table 6. Worldwide
Cause
Developed countries
Developing countries
Infectious and parasitic diseases Neoplasms Circulatory diseases and certain degenerative diseases Conditions originating in the perinatal period Injury and poisoning All other and unknown causes All causes
World total
40 5
8 19
33 8
19
54
26
8 5
2 6
6 5
23 100
12 100
21 100
Table 7. Twelve selected cancers: frequency of occurrence throughout the world Rank I 2 3 4 5 6 7 8 9 IO
Males Lung Stomach Colon/rectum Mouth/pharynx Prostate Oesophagus Liver Bladder Lymphoma Leukaemia
Females
Both sexes
Breast Cervix Colon/rectum Stomach Corpus uteri Lung Ovary Mouth/pharynx Oesophagus Lymphoma
Stomach Lung Breast Colon/rectum Cervix Mouth /pharynx Oesophagus Liver Lymphoma Prostate
importance of cancer as a cause of death is expected to be about equal. Even now, more than one-half of all cancer patients are in the developing world. The total number of new patients is about 3,200,OOO per year, for which about 5% of the world’s cancer care resources are available. For example, in Africa south of the Sahara, but not including South Africa, there are no more than 75 cancer
specialists of any kind, of whom only about 20 are radiation oncologists. The frequency of occurrence among both sexes of cancer throughout the world was recently reported by Parkin et al. and is shown in Table 7 (5). Radiotherapy, alone or in conjunction with surgery or chemotherapy, has an important role in the treatment (curative or palliative) of most of these cancers. In developed countries, more than one-half of all cancer patients receive radiotherapy during the course of their illness. The frequency of radiotherapy, surgery, and other treatment methods such as chemotherapy and hormonotherapy for the most common cancer sites in an area with well-developed radiotherapy services is shown in Table 8 (16). Radiotheraplj situation Periodically, IAEA and WHO have made specific, concerted efforts to obtain information regarding the availability of radiotherapy services throughout the world and the Directory of High-Energy Radiotherapy Centers was published in 1970 and 1976 (2, 3). Additionally, information, primarily about radiotherapy centers with 6oCo teletherapy units, is available through the IAEA/WHO Postal Dose Intercomparison Programme for Radiotherapy Centers, which has been in operation continuously since 1969. Through this program during the period 19691987, approximately 2,000 dosimetric intercomparisons were made in 700 radiotherapy centers in 89 countries (7). The current situation regarding high-energy radiotherapy facilities (60Co or higher energy) in various regions of the world is shown in Table 9, and the trend ( 1970- 1989) in the availability of high energy radiotherapy machines is shown in Table 10. Some countries and areas of the world appear to have adequate, or even more than adequate, coverage with radiotherapy services. For example, in North America (USA) there are six high-energy radiation therapy machines for each one million of population, and each machine is used to treat about 230 new patients
Table 8. Frequency of radiotherapy and surgery Treatment
Cancer distribution Mouth, pharynx Sinus, larynx Skin, connective tissue Breast Cervix uteri Other female genital organs Bladder, kidney Lymphoma, leukemia Lung, bronchi Digestive tract All cancers
Radiotherapy alone (W) 59 68 52 16 59 11 38 26 35 1 21
Surgery plus radiotherapy (%)
Surgery alone (%)
Other (%)
None (%)
14 16 5 42 13 31 8 6 4 0.1 12
23 I 41 27 13 35 46 4 19 53 33
0.4 0.6 0.3 7 0.2 5 2 40 22 4 7
4 8 2 8 5 18 18 24 29 41 26
1. J. Radiation Oncology 0 Biology 0 Physics
1260
Table 9. High-energy
radiotherapy
November 1990, Volume 19, Number 5
resources
Table I 1. Radiotherapy resources in the USA, 1983
by WHO region, 1989
WHO region
Countries with high-energy radiotherapy facilities
Number of high-energy radiotherapy centres
Africa* Americas+ Eastern Mediterranean Europe* South-East Asia Western Pacific”
12 23 20 35 7 11
14 250 40 500 80 200
* Not + Not $ Not s;Not
including including including including
South Africa. USA and Canada. USSR. China.
per year. The situation in the USA is shown in Tables 11 and 12 (1, 11). In other parts of the world, such as large areas of Africa and South-East Asia, there may only be one high-energy radiotherapy machine for 20 to 40 million people, and one machine may be used to treat more than 600 new patients per year. Many cancer patients have no access to radiotherapy services. In its 1988 Report, the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) provided an estimate on the use of radiotherapy throughout the world. Because of the difficulty in obtaining data, non-uniform reporting methods, and unclear definitions, estimates were made based upon the correlation between population per physician and the medical use of radiation. The UNSCEAR world wide estimates of the radiation therapy situation by level of services are shown in Table 13 (1 l), and some specific examples of the radiation therapy experience and level of services are shown in Table 14. In 1986, Racoveanu estimated that radiotherapy facilities and specialized personnel are not available in 40% of the developing countries and are insufficient with regard to need in 60% of the developing countries (6).
Human resources Radiation therapists Medical physicists Radiotherapy technologists Dosimetrists Physical resources Facilities Cobalt-60 units Linacs and betatrons
CONCLUSION
Total number of high-energy machines
For a definitive
of radiotherapy
improvement
of the existing
situation
in most developing countries, a concerted
1976
WHO region Africa* Americas+ Eastern Mediterranean Europe* South-East Asia Western Pacific” including including including including
1,083 744 1,018
In an attempt to relate the need for radiotherapy services to the cancer incidence in the developing world, which ranges from 75 to 320 new cases per year per 100,000 population, Racoveanu also estimated that 1,400- 1,900 teletherapy machines and the appropriate number of specialists would be necessary for an acceptable coverage until the year 2000. The cost of the teletherapy machines alone was estimated to be US $350-475 million. When the cost of premises, training of staff, and dosimeters and other auxiliary equipment was added, the figures were at least doubled-to US $700-950 million. The economic data presented earlier in this paper clearly demonstrate that this level of investment is not possible within the current health budgets of developing countries. A partial solution to the dilemma could be to provide brachytherapy for treatment of certain cancers such as cervical cancer, as has been done in a pilot project in Egypt with the collaboration of IAEA and WHO, and which could possibly be extended for palliation of cancer of the esophagus (4). When incorporated in a well planned and coordinated cancer program, including early detection, training, proper management, application, and follow-up, this dedicated use of brachytherapy can provide a useful treatment method when external beam radiotherapy is not available. A standard equipment package costing about US $25,000 can provide treatment for 50 cervical cancer patients per year (two applications for each patient).
Table 10. Trend of availability of high-energy radiotherapy machines by WHO region
* Not + Not * Not g Not
2,199 1,067 3,648 438
6 166 30 811 55 442
7 198 48 998 84 648
20 500 60 1300 170 800
South Africa in 1970, 1976, and 1989. Canada and USA in 1970, 1976, and 1989. USSR in 1970, 1976, and 1989. China in 1970, 1976, and 1989.
Table 12. Megavoltage radiotherapy units in the USA
Year
Cobalt
1975 1978 1980 1983 1986
970 900 980 744 671
Linear accelerators and betatrons 407 606 801 1018 1294
New patients per unit 227 232 233 227 226
1261
Radiotherapy in developing countries 0 G. P. HANSON c’/ul. Table 13. Radiation Annual Level of services
I II 111 IV
Population (millions) 1300 1750 1220 730
therapy
procedures
Brachytherapy teletherapy
situation
by level of services
per million population Unsealed radionuclides
and
2400 600 100 50
Machines
Total
per million
number of
population
machines
400 100 16 8
effort, including a large capital investment in training, equipment, and structural facilities, is needed. In view of the changing demographic characteristics of the populations and the growing importance of cancer as a public health problem. national authorities need to devise comprehensive cancer programs which include public education for prevention, early detection, accurate diagnosis. multi-modality treatment (including radiotherapy), rehabilitation, and follow-up. A combined effort of national authorities, donor and financial institutions, professional and scientific societies, and international organizations such as IAEA. WHO. UICC, and UNDP could change the situation. To succeed. the current situation, which has prevailed for the last decade and which can be characterized as slow or no growth. and even deterioration, must be completely reversed. The key issues are priority and the commitment of sufficient resources. The knowledge, skills, and technology are available in many excellent radiotherapy centers in both the developed and the devel-
10 2.5 0.4 0.2
13000 4400 490 I50
oping countries, and through existing channels of intercould be transferred if the funding national cooperation were available.
Table 14. Radiation
Level of services 1 11 111 IV
therapy
experience
Country
Year
France USA Brazil Venezuela India Sudan Indonesia
1987 1981 1981 1981 1976 1985 1978
* Brachytherapy
and level of services
Annual procedures per million population* 2400 -600 -600 125 70 7
Machines per million population 8 10 2.5 2.4 0.5 0.3 -
and teletherapy.
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