The Lancet Oncology CommissionExpanding global access to radiotherapy
Introduction
In 2012, 14·1 million new cases of cancer were reported worldwide (figure 1A), and this number is projected to reach 24·6 million by 2030.1 8·2 million cancer deaths were recorded in 2012, and this figure is projected to rise to 13·0 million by 2030, when most of the deaths will occur in low-income and middle-income countries,2 (where, in 2012, cancer became a leading cause of death and disability).3 Beyond the human suffering, cancer imposes an enormous economic burden worldwide—US$2 trillion in 2010.4
Radiotherapy is a fundamental component of effective cancer treatment and control.5 It is estimated that about half of cancer patients would benefit from radiotherapy for treatment of localised disease, local control, and palliation.6 Yet this crucial component of the response to cancer has been largely absent from global health discourse, and has received limited domestic and international funding. Even in high-income countries, radiotherapy has frequently been used suboptimally despite facilities being available. As a result, there is a worldwide shortfall of radiotherapy services, with more than 90% of the population in low-income countries lacking access to radiotherapy.7 The growing burden of cancer will place increased demand on the already- scarce radiotherapy services worldwide.
Much has been written about the need for a comprehensive approach to population-based cancer control. In 2011, the UN General Assembly committed to prevention and control of non-communicable diseases (NCDs).8 In 2013, WHO member states agreed at the World Health Assembly to develop comprehensive NCD global monitoring framework targets to reduce by 2025 premature mortality from cardiovascular and chronic respiratory diseases, cancers, and diabetes by 25% relative to their 2010 levels.9, 10 At least 1·5 million deaths from cancer will need to be prevented each year to achieve the so-called 25 by 25 target,11 but global efforts to control cancer are woefully inadequate so far,12, 13 especially in low-income and middle-income countries, which have only 5% of the resources but 80% of the global cancer burden.14 The 25 by 25 target cannot be achieved by prevention alone. Managing cancer requires both effective preventive measures to reduce future burden of disease, and health-care systems that provide accurate diagnosis and high-quality multimodality treatment. Such multimodality treatment should include radiotherapy, surgery, drugs, and access to palliative and supportive care. However, persistent underinvestment in radiotherapy resources with resulting unnecessary deaths shows that this clinical service is frequently forgotten when planning cancer control systems. Investment in radiotherapy is crucial and an imperative in low-income and middle-income countries15 if unnecessary cancer deaths and suffering are to be avoided. Thus, with WHO's focus on access to cancer drugs,16 global access to surgery,17 and access to palliative care,18 we thought it timely to be concerned about the gap in access to radiotherapy, and consider the economic case for investment in radiotherapy.
Radiotherapy is perceived as a complex treatment. A misleading assumption is that its deployment in poorer nations is not feasible, but nothing could be further from the truth. Radiotherapy can be effectively standardised and delivered irrespective of socioeconomic, political, and cultural context.19, 20, 21, 22 Here, we present new evidence to show that radiotherapy is affordable and feasible, and can be safely and consistently deployed in low-income and middle-income countries. Our report will show the health and economic benefits of investing in radiotherapy in these nations. Investment in radiotherapy is timely for many reasons, including evidence from The Lancet Commission on Investing in Health23 showing the benefits of investing in health to achieve convergence in health outcomes between low-income countries and upper-middle-income countries, the momentum for investing in low-income and middle-income countries to expand surgery,24 and the UN resolution on sustainable development, which recognises that “universal health coverage is a key instrument to enhancing health, social cohesion and sustainable human and economic development”.25
This Commission presents new analyses that quantify coverage of radiotherapy services worldwide and by country. It also includes new estimates for the future burden of cancer to 2035 and the projected demand for radiotherapy services by country and globally from 2015 to 2035, to ascertain the scale-up of radiotherapy services needed. Provision of high-quality, safe, effective, timely, efficient, equitable, and patient-centred26 radiotherapy services is particularly important because service quality critically affects cancer outcomes.27, 28, 29 Our analysis also includes health systems investments needed to create an enabling environment for delivery of high-quality radiotherapy services in low-income and middle-income countries.
Investment in radiotherapy necessitates an important set of skills and resources. We project the financial, human, and physical resources needed to address the worldwide shortfall in radiotherapy services. Here, we calculate the financial resources and investment needed to expand coverage of radiotherapy in low-income and middle-income countries between 2015 and 2035, and estimate health and economic benefits of investing in radiotherapy. Finally, we describe the opportunities that could be created by innovations in science, human resources, and financing, and discuss the importance of leadership that could help to develop an inclusive response. We conclude by identifying a series of actions that should underpin the global efforts to scale up coverage of radiotherapy in low-income and middle-income countries.
Section snippets
Part 1: Magnitude and distribution of cancers worldwide
In 2012, five cancers—lung (1·8 million cases), breast (1·7 million), colorectal (1·4 million), prostate (1·1 million), and stomach (0·95 million)—comprised almost half the total incidence of cancer worldwide,1 and caused 53% of the 8·2 million cancer deaths (figure 1A). However, there is variation in the scale and profile of cancer between and within countries. Type and incidence of cancers vary according to levels of the Human Development Index (HDI)30—a measure of education, life expectancy,
Part 2: The changing profile of cancer and the burden in 2030
When levels of socioeconomic development increase, cancer emerges along with other NCDs as a major source of morbidity and mortality as part of a late- stage epidemiological transition, displacing infectious diseases and malnutrition.2, 32 Cancer is now the leading cause of early death worldwide.33 Societal and economic transitions have partly brought about the increasing risk of several common cancers, via changes in reproductive patterns (a risk factor for breast cancer), tobacco consumption
Part 3: Shortfall in radiotherapy services
Estimation of the exact proportion of new cancer cases that will need radiotherapy is complex, in view of the variable patterns of cancer presentation and limited information on the current proportion of patients receiving radiotherapy. During the past 20 years, several investigators6, 38, 39, 40 have developed evidence-based estimates of desirable radiotherapy use on the basis of the indications for radiotherapy in clinical practice guidelines and the distribution of cancers and different
Part 4: Barriers to access for radiotherapy services
Worldwide, a lack of investment has led to severe limitations in access to radiotherapy. Even in high-income countries, such as Canada,55 Australia,56 and the UK,57 numbers of radiotherapy facilities, equipment, and trained staff are inadequate. There is an almost-complete absence of radiotherapy facilities in most countries in sub-Saharan Africa.7, 54, 58, 59 In countries with adequate or almost-adequate treatment capacity, facilities tend to be centralised in large urban centres, creating
Part 5: Role of radiotherapy for cancer treatment and palliative care
Radiotherapy has been used for treatment of cancer for more than 100 years.73, 74 Shortly after the discovery of x-rays, both low-energy x-rays and radium sources were used for treatment of superficial tumours.73 Regression of tumours was often noted, but so were radiation side-effects or toxic effects. With growing experience and knowledge of the effects of radiation on normal tissues and tumours—which led to the use of fractionation, careful dose calculation, and better targeting—radiotherapy
Elements of radiotherapy
Delivering radiotherapy involves several steps that involve various technologies (figure 7). These steps are not always in the same order or done by the same professionals. They include assessment of the patient (by a radiation oncologist), imaging for treatment preparation (by a radiation technologist), target volume delineation (by a radiation oncologist) and critical structure determination (by a radiation technologist or radiation oncologist), treatment plan development (by a dosimetrist or
Part 7: Return on investment
Investment frameworks have been used to make a case for investing in HIV,99, 100, 101 maternal and child health,102 and, more broadly, in public health and health care.23 They typically provide a conceptual outline for estimation of health, economic, and social benefits of health investments, with a defined timescale, evidence on cost-effective interventions, and contextual factors that determine the realisation of the full impact of benefits.99, 100, 101, 102
In the investment framework for
Part 8: Enabling environment and contextual readiness
To optimise the benefits, radiotherapy has to be deployed for the appropriate patients, in early-stage disease, and when indicated in combination with other treatment modalities. Patients must first be identified and then assessed to determine the best management plan. This process starts with accurate diagnosis (typically with biopsy followed by histopathological assessment, which might include immunohistochemistry and molecular and cytogenetic testing), followed by disease staging, before
Part 9: Scale-up of radiotherapy
The global gap in access to radiotherapy needs urgent action. This sense of urgency should be balanced against a need for careful resource-planning and responsible investment of scarce resources, especially in low-income countries. Examples of successful investments around the world suggest that to build appropriate and effective radiotherapy services more than financial investment is needed: an enabling policy environment is crucial to scaling up and sustaining radiotherapy services.
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Part 10: Obligation to innovate
Innovations are needed to expand radiotherapy services worldwide by accelerating adoption of existing technologies and creation of new technologies to address diverse needs. Innovations are also needed to develop new service models that remove impediments to efficient and effective care delivery, and improve financing, communication, and advocacy to mobilise support and gain the confidence of decision makers.
The global shortage of radiotherapy professionals is a major barrier to expanding
Part 11: Strengthening leadership and accountability
Despite radiotherapy being a critical component of cancer treatment, it is all but absent from global health and development discourse. Several distinct global actions have created a favourable environment for expanding radiotherapy services to improve cancer treatment, care, and control through collective action.
In 2004, the Programme of Action for Cancer Therapy (PACT)—a multipartner initiative led by the IAEA and WHO—highlighted the need for, and sought to stimulate investment in,
Part 12: Call to action
Radiotherapy is a crucial and inseparable component of comprehensive cancer treatment and care. For many of the most common cancers in low-income and middle-income countries, including lung, breast, cervical, and head and neck cancer, radiotherapy is essential for effective treatment. In high-income countries, radiotherapy could be used in more than half of cancer cases to cure localised disease, palliate symptoms, or control incurable disease. Without radiotherapy, patients will die and suffer
References (190)
- et al.
Global cancer transitions according to the Human Development Index (2008–2030): a population-based study
Lancet Oncol
(2012) - et al.
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010
Lancet
(2012) - et al.
Estimating the demand for radiotherapy from the evidence: a review of changes from 2003 to 2012
Radiother Oncol
(2014) - et al.
Need for radiotherapy in low and middle income countries—the silent crisis continues
Clin Oncol (R Coll Radiol)
(2015) Decisive action to end apathy and achieve 25×25 NCD targets
Lancet
(2014)- et al.
Cancer in the 25×25 non-communicable disease targets
Lancet
(2014) - et al.
Expansion of cancer care and control in countries of low and middle income: a call to action
Lancet
(2010) Bringing radiation therapy to underserved nations: an increasingly global responsibility in an ever-shrinking world
Int J Radiat Oncol Biol Phys
(2014)WHO resolution on access to palliative care
Lancet Oncol
(2014)- et al.
Implementation of a high-dose-rate brachytherapy program for carcinoma of the cervix in Senegal: a pragmatic model for the developing world
Int J Radiat Oncol Biol Phys
(2014)