Global access to radiotherapy for cancer control

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Published: 12 Dec 2016
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Dr Mary Gospodarowicz - Princess Margaret Cancer Centre, Toronto, Canada

Dr Gospodarowicz speaks with ecancertv at the 2016 World Cancer Congress about the Global Task Force for Expanded Access to Cancer Care and Control, and her work with increasing the availability of radiotherapy in low and middle income countries. 

She describes the essential benefit to patients of radiotherapy as a treatment modality, and the economic benefit to society through longer survival of citizens.

Considering proton therapy, which was discussed further at the Proton Therapy Congress, Dr Gospodarowicz sees it as a useful tool, but not an immediate replacement for most radiotherapy.

More than five years ago, I was involved in the Global Task Force for Cancer Care and Control that were set up by Felicia Knaul at the Harvard Global Equity Initiative. That task force addressed the gap, the equity gap that exists between high income and low and middle income countries in access to care and cancer control.

There was such a huge scope of discussions that by the time you dealt with prevention and screening and early detection that the treatment was treated very superficially, without detail. Radiotherapy is a highly sophisticated treatment for cancer but wasn’t discussed in depth. So I got an idea that that was a very effective way of looking at the issue. Under the auspices of UICC in 2013 we set up the Global Task Force for Radiotherapy for Cancer Control to basically examine what it would take to close the gap that exists between high income countries and low and middle income countries.

We were very lucky to have a lot of information: IAEA has a registry of all the equipment in the world. It’s not a perfect registry but it’s more information that exists about access to surgery than in any other specialty so we used that. There is also a lot of scholarly work that has been done in Australia by Michael Barton, in Canada by Bill Mackillop, Scott Tyldesley, on the optimal utilisation of radiotherapy. So we used this data, we also collaborated with IARC to give us projections of cancer cases, specific cancers, the top ten cancers, and  the growth and incidence and prevalence over the last twenty years. What we found that, regardless of the state of GNI or economy, about 50% of cancer patients benefit from radiotherapy potentially and should be treated with radiotherapy. If you do that you actually save an amazing number of lives.

Now, there are some assumptions and the assumptions are that you work in an environment that has diagnostics, that has surgery, that has adjuvant chemotherapy so it’s not radiotherapy alone to create benefit. But without radiotherapy you wouldn’t realise that benefit even if the other modalities were present. So, we calculated the benefit in terms of years lives gained over the next twenty years if there is a linear scale-up of facilities. But then we went further and with the help of Rifat Atun who was the first author on The Lancet commission report that was published in Lancet Oncology last September, we’ve calculated what would be the economic benefit of this scale-up and we were pleasantly surprised. Radiotherapy is not an inexpensive treatment modality but because the investment lasts for many, many years and each treatment unit can treat thousands of patients, actually the economic benefit of lives saved and people then contributing to the economy returning to work, or even contributing to society by being around by being alive and contributing, is actually huge.

So we were very pleased with the results, we were very pleased with the reception of the report of the global task force. The task force is closed but we are looking forward to see what we can do further. So, at this meeting actually tomorrow we are having a meeting with ESTRO, with the European Society for Radiation Oncology, to see how we can create a partnership that would look at how to help the implementation of radiotherapy in low and middle income countries further.

What are your thoughts on proton therapy vs radiotherapy?

I think that there’s a misconception that proton therapy will replace or is a next step. It is part of the suite of our armamentarium radiotherapy. We have brachytherapy that is local application of radiotherapy; there is linear accelerators cobalt megavoltage radiotherapy and proton radiotherapy has an advantage in certain specific situations because it has less of the exit dose. But there has been a number of analyses by governments, for example there is a Dutch report and there was a UK report, that looks at what proportion of patients would actually benefit from proton therapy and at the present time that number is somewhere between 14-17%. So, to date, up until today, there is no suggestion that proton therapy should actually replace the rest of the radiotherapy armamentarium.

Proton therapy is a very useful technology but it doesn’t need to be introduced for everybody immediately. It’s evolving technology so the precision is improving - there is pencil beam scanning, there’s image guided proton therapy and the cost is going down. When these two things happen it will be more affordable but recently there has been a paediatric radiotherapy consensus group formed looking at what proportion of children with cancer should have proton therapy because it’s more beneficial to reduce late effects which are really important in children and certainly the consensus was that it was not 100%.