0360.301b/YO S3.M + .XJ Copynghf Cc)1990 Pergamon Press plc
Im J Radioiron Oncology Bml Phys, Vol. 19. pp. 1261-1270 Printed in the U.S.A. All rights reserved.
??Special Feature: Developing Countries
SITUATION
OF RADIOTHERAPY
IN LATIN AMERICA
L. C. CALMON TEIXEIRA, Associate
Professor,
Federal
University
of Bahia, Head, Radiotherapy
M.D.
Department,
Hospital
Aristides,
Maltez, Bahia, Brazil
A survey to evaluate situation of radiotherapy in Latin America was conducted. Consultation was made with representatives of 10 countries, resulting in the responses of 5. These five countries represent around 80% and 81%, respectively, from the total area and population of South America. Situation of equipment, modem facilities, and human resources is analyzed. A Cobalt machine is the basic megavoltage equipment in Latin America; half of the total number, however, is of old units with very low output sources. Linacs represent one-third of cobalt machines, the majority of low photon energy without electron capability. Treatment planning, localization, patient positioning, and immobilization are inadequade or of low quality in a high number of institutions. Teaching programs are insufficient or inexistent in certain areas. Late diagnosis and referral for treatment is a major problem for cancer control in Latin America. Hierarchization and regionalization of radiation therapy centers are indicated as a way to provide high quality services and teaching programs. In Latin America, lodging and facilities for transportation are essential to assure the continuity of radiation treatment and regular follow-up to patients from rural or distant areas. Cancer control, Radiotherapy,
Latin America.
INTRODUCTION
cancer centers. The assessment of the radiotherapy situation in all Latin America offers some difficulties. In 1972, the Panamerican Health Organization (Organizacion Panamericana de la Salud), in accordance with the government of Brazil, called a meeting in Rio de Janeiro to evaluate the situation of physics in radiation therapy. Only nine countries from all of Latin America attended the meeting. Table 2 presents information from this meeting concerning personnel and equipment (3). In 1983 a survey to evaluate the clinical aspects of quality assurance in radiotherapy was conducted by Luis Souhami from the National Cancer Institute (Instituto National de Cancer) of Brazil. From 46 institutions in 12 countries consulted, only 27 (58, 5%) in 9 countries answered the questionnaire. Some information from that survey (6) will be reproduced in this paper.
The incidence of cancer is rising in Latin America, where in some countries, neoplastic diseases appear as the second cause of death (4, 5, 7). It has been estimated by a group of experts that from 2000 to 3000 new cases of cancer per million inhabitants occur yearly in these countries (2). In Latin America, radiotherapy is an important cancer treatment method. It is well known that during the course of the disease, radiation therapy is applied to about 50% of the patients. In some sites, for example, cervical cancer, this percentage may be as high as 90%, if we consider radiotherapy as the only treatment modality or in combination with surgery (1). Consequently, it is critical for this part of the world to determine the present situation of radiotherapy and to identify other correlated problems that may affect the therapeutic result of cancer control. Very late diagnosis and referral for treatment is one of the most serious obstacles for control of cancer, as pointed out by Zaharia (9) and confirmed by our own published data (1) on cancer of the cervix (Table 1). Social and economic factors, the solution of which depends more upon political decisions than medical efforts, have been identified as being responsible for this situation and for the low percentage of patient follow-up in the majority of
METHODS
AND MATERIALS
The present evaluation is based on the replies of 5 out of the 10 countries consulted in South America. excluding Guianas and Suriname due to difficulties of contact. The five countries represent around 80% and 8 1% from the total area and population of South America, respectively
Presented at the 17th International Radiology Congress, Paris, July 1989. Reprint requests to: L. C. Calmon Teixeira. M.D. Departa-
mento de Radioterapia, Hospital Aristides Maltez, Av. D. Jo50 VI, no. 332, Brotas 41945, Salvador, Bahia, Brasil. Accepted for publication 24 May 1990. 126-t
I. J. Radiation Oncology 0 Biology0 Physics
1268
Table 1. Radiotherapy in Latin America: cervical cancer by clinical staging Stage
No. pts.
0
I II III and IV
85 276 366 1.152
Total
1.879
Table 3. Radiotherapy in Latin America: Equipment and facilities 1989 Cobalt machine Linac Simulator
(%) 4.5 14.6 19.4 61.3 I
Treatment planning system Physics equipment Physicist
80.7
100.0
Hospital A. Maltez, Salvador, Brazil, 1967/75. Total pts. = 1.994, without information 115.
(including Guianas and Suriname). Consultation was made with representatives of radiotherapy societies or cancer government institutions through telephone or per-
sonal contact in four countries and by mail in six others. The results of this contact form the basis of this paper. Data concerning South America as a whole were provided by Carlos E. Almeida, Ph.D., from National Nuclear Energy Comission (Comissao National de Energia Nuclear), Brazil.
RESULTS Analysis of material Table 3 presents a summary of the Latin American situation concerning megavoltage units, modem facilities, and physicist availability. Practically all radiotherapy services have conventional roentgentherapy equipment. Despite the number of megavoltage machines, note that fewer than 60% of the centers have no physicist and are not provided with minimum equipment for dosimetry. This agrees with a published survey (see Table 4) reporting that 52.0% and 53.5% of the institutions in Latin America have a deficit in the number of physicists and dosimetrists; 35.5% have a deficit of radiotherapists and in 92.5 institutions the number of technologists is adequate (6). In general, training programs for radiotherapists and physicists (residence) are scheduled for 3 and 2 years, but the number of institutions with these training programs is small.
Table 2. Radiotherapy in Latin America: Equipment and human resources situation in 1972 Country
Co 60*
Linac*
Brazil Argentina Venezuela Chile Peru
45 44 12 9 5
10 1 -
* Installed and in installation. + Full and part time. OPAS (3).
Radiotherapist+ 114 100 26 18 16
November 1990, Volume 19, Number 5
Physicist+ 33 13 3 1 0
-300 -100 ~20 (some others home made) lO Mev Simulators Treatment planning system Remote after loading (Selectron) Gynecologic manual after loading Dosimetry equipment Radiotherapist Physicist Radiotherapy centers
- 110 -55 50 5 -8 -4 0
(+ 15 to be delivered) (+3 to be delivered) (+ 1 to be delivered) (+2 to be delivered) ($4 to be delivered) (f7 to be delivered) (2 to be delivered)
>90% of the centers >80% of the centers -250 -175 -209
The situation of radiotherapy in Latin America reflects social-economic dissimilarities: that is, there are a very small number of large and sophisticated radiation therapy centers in a few developed geographical areas versus a high number of small centers in less developed regions. Consequently, we cannot report on “optimal standards” as a rule and even minimal standards can be difficult to meet by an expressive number of centers. There is an evident insufficiency of well-trained personnel: radiotherapists, physicists, and dosimetrists. Teaching programs for radiation therapy, physics, technology, and dosimetry are insufficient or nonexistent in certain areas. There is a significant number of old telecobalt machines; many units operate at an S.S.D. shorter than 80 cm and others have a very low output source. The majority of Linacs operate in the range of 4 to 6 Mev (photons) without electron capability. Treatment planning, localization, patient positioning, and immobilization are inadequate or of low quality in a high number of institutions. The patient follow-up percentage is low. Late diagnosis and referral for
Table 9. Radiotherapy
in Latin America:
Cobalt machine Linac System: Gynecologic manual after loading (Cs) Radiotherapy centers Radiotherapist
Table 10. Radiotherapy Table 7. Radiotherapy
in Latin America:
Cobalt machine Linac Simulators Treatment planning system Dosimetry equipment Physicist Radiotherapist Radiotherapy centers
Argentina -80 -12 -5 -2 ? -60 -150 -90
1989
Cobalt machine Linac Simulator Treatment planning system Brachytherapy (gynec.) Radiotherapist Physicist Radiotherapy centers Radiotherapist training Physicist training
Venezuela
1989
12 (public centers) 10 (4-6 Mev)
>90% of the centers - 12 (ali public) -40
in Latin America:
Peru 1989
- 11 (3 NCI) 1 (NCI) 1 (NCI) 1 (NCI) - 100% of the centers -18 5 (3 full time) 8 (5 in Lima) 3 years 2 years
1270
1.J.
Radiation Oncology 0 Biology 0 Physics
treatment is a major problem for cancer control in Latin America. Recommendations Hierarchization and regionalization of radiation therapy centers are indicated as a way to provide high quality services and teaching programs at a reasonable cost. Large and small centers should be strategically distributed according to the peculiarities of each region or country. Telecobalt units still remain as the basic equipment for de-
November 1990, Volume 19, Number 5
veloping areas of Latin America. High energy Linacs with electron capability are recommended for large regional centers. The substitution of old or inadequate (shorter than 80 cm S.S.D.) Cobalt machines and low output radioactive sources must be encouraged. Training programs and refresher courses for all personnel involved with radiotherapy must be stimulated. In Latin America, lodging and facilities for transportation are essential to assure the continuity of radiation treatment and regular follow-up to patients from rural or distant areas.
REFERENCES 1. Calmon Teixeira, L. C. A radioterapia no cancer do co10 uterino: estado atual. In: Pinotti, J. S., Teixeira, L. C., eds. Oncologia ginecologica e mamaria, Vol. 2. Campinas: UNICAMP: 1988:68. 2. Organism0 Intemacional de Energia Atomica, Organization Mundial de la Salud. Organizaci6n de 10s Servicios de Radioterapia. Genebra: Serie de Informes Tecnicos; 1966:328. 3. Organizaci6n Panamericana de la Salud. Grupo de estudio sobre el adiestramiento de personal en fisica aphcada a la radioterapia. Document0 No. RAD/Can 1. Washington, DC; 1973. 4. Organization Panamericana de la Salud. Las condiciones de salud en las Americas, 1965-I 968. Washington, DC: Publication Cientifica; 1979:207.
5. Sociedad de Lucha Contra el Cancer. Nucleo de Quito. Cancer en Quito; Primer anuario 1985. Quito; 1987:9. 6. Souhami, L. Quality assurance in radiation therapy; clinical aspects. Int. J. Radiat. Oncol. Biol. Phys. IO(SuppI. 1):6972; 1984. 7. Waterhouse, J. A. A epidemiologia do cancer ambiental e riscos de cancer. In: Montoro, A. F., Nogueira, D. P., eds., Meio ambiente e cancer. Sao Paula: T. A. Queiroz Ed.; 1983:18. 8. Withers. H. R., Peters, L. J. Biologic aspects of radiation therapy. In: Fletcher, G. H., ed., Textbook of radiotherapy, 3 edition. Philadelphia: Lea and Febiger; 1980: 116-I 17. 9. Zaharia. M. Latin American experience. Int. J. Radiat. Oncol. Biol. Phys. lO(Suppl. 1):161-162: 1984.
Im J Radioiron Oncology Bml Phys, Vol. 19. pp. 1261-1270 Printed in the U.S.A. All rights reserved.
??Special Feature: Developing Countries
SITUATION
OF RADIOTHERAPY
IN LATIN AMERICA
L. C. CALMON TEIXEIRA, Associate
Professor,
Federal
University
of Bahia, Head, Radiotherapy
M.D.
Department,
Hospital
Aristides,
Maltez, Bahia, Brazil
A survey to evaluate situation of radiotherapy in Latin America was conducted. Consultation was made with representatives of 10 countries, resulting in the responses of 5. These five countries represent around 80% and 81%, respectively, from the total area and population of South America. Situation of equipment, modem facilities, and human resources is analyzed. A Cobalt machine is the basic megavoltage equipment in Latin America; half of the total number, however, is of old units with very low output sources. Linacs represent one-third of cobalt machines, the majority of low photon energy without electron capability. Treatment planning, localization, patient positioning, and immobilization are inadequade or of low quality in a high number of institutions. Teaching programs are insufficient or inexistent in certain areas. Late diagnosis and referral for treatment is a major problem for cancer control in Latin America. Hierarchization and regionalization of radiation therapy centers are indicated as a way to provide high quality services and teaching programs. In Latin America, lodging and facilities for transportation are essential to assure the continuity of radiation treatment and regular follow-up to patients from rural or distant areas. Cancer control, Radiotherapy,
Latin America.
INTRODUCTION
cancer centers. The assessment of the radiotherapy situation in all Latin America offers some difficulties. In 1972, the Panamerican Health Organization (Organizacion Panamericana de la Salud), in accordance with the government of Brazil, called a meeting in Rio de Janeiro to evaluate the situation of physics in radiation therapy. Only nine countries from all of Latin America attended the meeting. Table 2 presents information from this meeting concerning personnel and equipment (3). In 1983 a survey to evaluate the clinical aspects of quality assurance in radiotherapy was conducted by Luis Souhami from the National Cancer Institute (Instituto National de Cancer) of Brazil. From 46 institutions in 12 countries consulted, only 27 (58, 5%) in 9 countries answered the questionnaire. Some information from that survey (6) will be reproduced in this paper.
The incidence of cancer is rising in Latin America, where in some countries, neoplastic diseases appear as the second cause of death (4, 5, 7). It has been estimated by a group of experts that from 2000 to 3000 new cases of cancer per million inhabitants occur yearly in these countries (2). In Latin America, radiotherapy is an important cancer treatment method. It is well known that during the course of the disease, radiation therapy is applied to about 50% of the patients. In some sites, for example, cervical cancer, this percentage may be as high as 90%, if we consider radiotherapy as the only treatment modality or in combination with surgery (1). Consequently, it is critical for this part of the world to determine the present situation of radiotherapy and to identify other correlated problems that may affect the therapeutic result of cancer control. Very late diagnosis and referral for treatment is one of the most serious obstacles for control of cancer, as pointed out by Zaharia (9) and confirmed by our own published data (1) on cancer of the cervix (Table 1). Social and economic factors, the solution of which depends more upon political decisions than medical efforts, have been identified as being responsible for this situation and for the low percentage of patient follow-up in the majority of
METHODS
AND MATERIALS
The present evaluation is based on the replies of 5 out of the 10 countries consulted in South America. excluding Guianas and Suriname due to difficulties of contact. The five countries represent around 80% and 8 1% from the total area and population of South America, respectively
Presented at the 17th International Radiology Congress, Paris, July 1989. Reprint requests to: L. C. Calmon Teixeira. M.D. Departa-
mento de Radioterapia, Hospital Aristides Maltez, Av. D. Jo50 VI, no. 332, Brotas 41945, Salvador, Bahia, Brasil. Accepted for publication 24 May 1990. 126-t
I. J. Radiation Oncology 0 Biology0 Physics
1268
Table 1. Radiotherapy in Latin America: cervical cancer by clinical staging Stage
No. pts.
0
I II III and IV
85 276 366 1.152
Total
1.879
Table 3. Radiotherapy in Latin America: Equipment and facilities 1989 Cobalt machine Linac Simulator
(%) 4.5 14.6 19.4 61.3 I
Treatment planning system Physics equipment Physicist
80.7
100.0
Hospital A. Maltez, Salvador, Brazil, 1967/75. Total pts. = 1.994, without information 115.
(including Guianas and Suriname). Consultation was made with representatives of radiotherapy societies or cancer government institutions through telephone or per-
sonal contact in four countries and by mail in six others. The results of this contact form the basis of this paper. Data concerning South America as a whole were provided by Carlos E. Almeida, Ph.D., from National Nuclear Energy Comission (Comissao National de Energia Nuclear), Brazil.
RESULTS Analysis of material Table 3 presents a summary of the Latin American situation concerning megavoltage units, modem facilities, and physicist availability. Practically all radiotherapy services have conventional roentgentherapy equipment. Despite the number of megavoltage machines, note that fewer than 60% of the centers have no physicist and are not provided with minimum equipment for dosimetry. This agrees with a published survey (see Table 4) reporting that 52.0% and 53.5% of the institutions in Latin America have a deficit in the number of physicists and dosimetrists; 35.5% have a deficit of radiotherapists and in 92.5 institutions the number of technologists is adequate (6). In general, training programs for radiotherapists and physicists (residence) are scheduled for 3 and 2 years, but the number of institutions with these training programs is small.
Table 2. Radiotherapy in Latin America: Equipment and human resources situation in 1972 Country
Co 60*
Linac*
Brazil Argentina Venezuela Chile Peru
45 44 12 9 5
10 1 -
* Installed and in installation. + Full and part time. OPAS (3).
Radiotherapist+ 114 100 26 18 16
November 1990, Volume 19, Number 5
Physicist+ 33 13 3 1 0
-300 -100 ~20 (some others home made) lO Mev Simulators Treatment planning system Remote after loading (Selectron) Gynecologic manual after loading Dosimetry equipment Radiotherapist Physicist Radiotherapy centers
- 110 -55 50 5 -8 -4 0
(+ 15 to be delivered) (+3 to be delivered) (+ 1 to be delivered) (+2 to be delivered) ($4 to be delivered) (f7 to be delivered) (2 to be delivered)
>90% of the centers >80% of the centers -250 -175 -209
The situation of radiotherapy in Latin America reflects social-economic dissimilarities: that is, there are a very small number of large and sophisticated radiation therapy centers in a few developed geographical areas versus a high number of small centers in less developed regions. Consequently, we cannot report on “optimal standards” as a rule and even minimal standards can be difficult to meet by an expressive number of centers. There is an evident insufficiency of well-trained personnel: radiotherapists, physicists, and dosimetrists. Teaching programs for radiation therapy, physics, technology, and dosimetry are insufficient or nonexistent in certain areas. There is a significant number of old telecobalt machines; many units operate at an S.S.D. shorter than 80 cm and others have a very low output source. The majority of Linacs operate in the range of 4 to 6 Mev (photons) without electron capability. Treatment planning, localization, patient positioning, and immobilization are inadequate or of low quality in a high number of institutions. The patient follow-up percentage is low. Late diagnosis and referral for
Table 9. Radiotherapy
in Latin America:
Cobalt machine Linac System: Gynecologic manual after loading (Cs) Radiotherapy centers Radiotherapist
Table 10. Radiotherapy Table 7. Radiotherapy
in Latin America:
Cobalt machine Linac Simulators Treatment planning system Dosimetry equipment Physicist Radiotherapist Radiotherapy centers
Argentina -80 -12 -5 -2 ? -60 -150 -90
1989
Cobalt machine Linac Simulator Treatment planning system Brachytherapy (gynec.) Radiotherapist Physicist Radiotherapy centers Radiotherapist training Physicist training
Venezuela
1989
12 (public centers) 10 (4-6 Mev)
>90% of the centers - 12 (ali public) -40
in Latin America:
Peru 1989
- 11 (3 NCI) 1 (NCI) 1 (NCI) 1 (NCI) - 100% of the centers -18 5 (3 full time) 8 (5 in Lima) 3 years 2 years
1270
1.J.
Radiation Oncology 0 Biology 0 Physics
treatment is a major problem for cancer control in Latin America. Recommendations Hierarchization and regionalization of radiation therapy centers are indicated as a way to provide high quality services and teaching programs at a reasonable cost. Large and small centers should be strategically distributed according to the peculiarities of each region or country. Telecobalt units still remain as the basic equipment for de-
November 1990, Volume 19, Number 5
veloping areas of Latin America. High energy Linacs with electron capability are recommended for large regional centers. The substitution of old or inadequate (shorter than 80 cm S.S.D.) Cobalt machines and low output radioactive sources must be encouraged. Training programs and refresher courses for all personnel involved with radiotherapy must be stimulated. In Latin America, lodging and facilities for transportation are essential to assure the continuity of radiation treatment and regular follow-up to patients from rural or distant areas.
REFERENCES 1. Calmon Teixeira, L. C. A radioterapia no cancer do co10 uterino: estado atual. In: Pinotti, J. S., Teixeira, L. C., eds. Oncologia ginecologica e mamaria, Vol. 2. Campinas: UNICAMP: 1988:68. 2. Organism0 Intemacional de Energia Atomica, Organization Mundial de la Salud. Organizaci6n de 10s Servicios de Radioterapia. Genebra: Serie de Informes Tecnicos; 1966:328. 3. Organizaci6n Panamericana de la Salud. Grupo de estudio sobre el adiestramiento de personal en fisica aphcada a la radioterapia. Document0 No. RAD/Can 1. Washington, DC; 1973. 4. Organization Panamericana de la Salud. Las condiciones de salud en las Americas, 1965-I 968. Washington, DC: Publication Cientifica; 1979:207.
5. Sociedad de Lucha Contra el Cancer. Nucleo de Quito. Cancer en Quito; Primer anuario 1985. Quito; 1987:9. 6. Souhami, L. Quality assurance in radiation therapy; clinical aspects. Int. J. Radiat. Oncol. Biol. Phys. IO(SuppI. 1):6972; 1984. 7. Waterhouse, J. A. A epidemiologia do cancer ambiental e riscos de cancer. In: Montoro, A. F., Nogueira, D. P., eds., Meio ambiente e cancer. Sao Paula: T. A. Queiroz Ed.; 1983:18. 8. Withers. H. R., Peters, L. J. Biologic aspects of radiation therapy. In: Fletcher, G. H., ed., Textbook of radiotherapy, 3 edition. Philadelphia: Lea and Febiger; 1980: 116-I 17. 9. Zaharia. M. Latin American experience. Int. J. Radiat. Oncol. Biol. Phys. lO(Suppl. 1):161-162: 1984.
