World Bank Incomes. Upper middle income (34) Lower middle income (54) Low income (60) High income: OECD (24) High income: nonoecd (26)

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1 Radiotherapy in cancer control in low- and middle-income income countries

2 XRT in LMI countries What is LMI? Cancer in LMI Need for XRT Cost and cost-effectiveness Current state of XRT in LMI countries Case studies Breast Cervix Lung

3 LMI countries Income Low 765 Gross National Income per person per year (US$) Middle 766 9,385 High 9,386

4 World Bank Incomes Upper middle income (34) Lower middle income (54) Low income (60) High income: OECD (24) High income: nonoecd (26)

5 Cancer in LMI countries 10 million new cases by 2010 >50% of all cancers occur in LMI 70% by 2020

6 New cases of cancer Globocan 2002

7 Radiotherapy Utilisation 52% of all cancer patients need radiotherapy at least once 86% curative or adjuvant a 20-25% 25% may need >1 treatment episode RTU likely to be higher More advanced stage Less surgical expertise

8 The need for radiotherapy Iceland Canada Russia United States Mexico Guatemala El Salvador Honduras Nicaragua Costa Rica Panama Cuba Haiti Jamaica Dominican Republic Venezuela Cape Verde Senegal United Kingdom Ireland Portugal Spain Morocco Mali France Algeria Burkina Faso Benin Sierra Leone Cote D'Ivoire Ghana Liberia Estonia Latvia Lithuania Belarus Poland Germany Czech Republic Slovakia Ukraine Hungary Moldova Romania Slovenia Bosnia Croatia and Herzegovina Serbia Bulgaria Albania Macedonia Tunisia Niger Malta Libya Chad Greece Nigeria Cameroon Central African Republic Egypt Sudan Turkey Cyprus Syria Lebanon Jordan Eritrea Ethiopia Georgia Armenia Azerbaijan Iraq Kuwait Qatar Saudi Arabia United Arab Emirates Yemen Kazakhstan Uzbekistan Afghanistan Tajikistan Pakistan Kyrgyzstan India Sri Lanka Bangladesh Myanmar China Mongolia Thailand Vietnam Philippines Korea DPR Korea Rep. Japan Malaysia Ecuador Uganda Kenya Gabon Democratic Republic of the Congo Singapore Indonesia Tanzania % of cases requiring RT Peru Bolivia Paraguay Brazil Angola Zambia Malawi Zimbabwe Namibia Botswana Madagascar Mauritius Chile Argentina Uruguay South Africa Australia N. Taylor, IAEA 2005

9 Cancer cases needing XRT Iceland Canada Russia Estonia Latvia United Kingdom Lithuania Ireland Belarus United States Mexico Portugal Spain Morocco France Algeria Poland Germany Czech Republic Slovakia Tunisia Hungary Moldova Romania Slovenia Croatia Bosnia and Herzegovina Serbia Bulgaria Macedonia Albania Malta Libya Greece Egypt Ukraine Turkey Cyprus Syria Lebanon Jordan Georgia Iraq Armenia Azerbaijan Kuwait Saudi Arabia Qatar United Arab Emirates Uzbekistan Kazakhstan Afghanistan Tajikistan Pakistan Kyrgyzstan Bangladesh China Mongolia Korea DPR Korea Rep. Japan Cuba India Jamaica Dominican Haiti Republic Mali Niger Myanmar Guatemala Honduras El Salvador Nicaragua Cape Verde Senegal Burkina Faso Chad Sudan Eritrea Yemen Thailand Vietnam Philippines Costa Rica Panama Venezuela Benin Sierra Leone Cote D'IvoireGhana Liberia Nigeria Cameroon Central African Republic Ethiopia Sri Lanka Malaysia Cancer Cases per Million Population Requiring RT Ecuador Peru Bolivia Brazil Uganda Kenya Gabon Democratic Republic of the Congo Tanzania Angola Zambia Malawi Zimbabwe Madagascar Mauritius Singapore Indonesia Paraguay Namibia Botswana South Africa Australia Chile Argentina Uruguay N. Taylor, IAEA 2005

10 Cost Building 3% Equipment 30% Staff 50% Materials 4% Overheads 13% Kesteloot K, Lievens Y, van der SE. Improved management of radiotherapy departments through accurate cost data. Radiother Oncol 2000; 55(3):

11 Cobalt Linac Machine $480,000 $1,800,000 Maintenance $1270 to $35,680 $3000 to $91,740 Cost per treatment $4.87 $11 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):

12 Current status of XRT 24/72 countries with > 1 million people had no XRT Average GNI/ cap US$300 GDP/capita US S$ 1,000s Europe Asia & Pacific Central America South America Africa straight line fit All Member States No. teletherapy units / million population

13 Cervix >80% new cases & deaths in LMI 50-60% of new cases die of cervix cancer 91-99% 99% need XRT Incidence Mortality M/I ratio Age standerdised (world d) rate per 100, high income countries upper-middle income countries low-middle income countries low income countries Mortality/Incide ence ratio*

14 Strategies to improve access Planning Investment Linkages Access to information Education about cancer Safety

15 Planning No one size fit s all plan casemix capabilities 100% 80% 70% Liver Ovary etc. 90% Leukaemia 60% 50% 40% 30% 20% 10% 0% East Africa Central Africa Northern Africa Southern Africa Western Africa all Africa Thyroid Testis Multiple myeloma Melanoma of skin Kidney etc. Corpus uteri Other Pharynx Pancreas Hodgkin's disease Colon/Rectum Brain, nervous system Nasopharynx Larynx Oral cavity Lung Stomach Bladder Non-Hodgkin lymphoma Oesophagus Prostate Cervix uteri Breast

16 Investment Equipment Staff Maintenance Source replacement

17 Linkages Many isolated departments Training CPD South South Exchanges Protocols Staff

18 Access to information Journals Cost Language g On-line access Meetings $/Gbyte/month US Africa

19 Education about cancer Medical students Radiation oncology staff Regional training centres Distance learning courses

20 Safety Inter-centre dosimetry Maintenance Common protocols Source security

21 Conclusions Cancer is a major problem in LMI Radiotherapy is essential and viable Cobalt is preferred Planning Investment Linkages Information Education Safety PACT