Bridging radiotherapy gaps in Africa

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Published: 19 Dec 2017
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Dr Kirsten Hopkins - International Atomic Energy Agency, Vienna, Austria

Dr Hopkins speaks with ecancer at AORTIC 2017 about the availability of radiotherapy resources in West Africa.

With increasing demand, Dr Hopkins considers how gaps in maintenance and replacement of cobalt or LINAC units has increased pressure on what units are available.

She encourages further support of health systems to redevelop staffing and infrastructure of radiotherapeutics, and considers how operational units of the IAEA contribute.

 

The availability of radiotherapy resources in  West Africa, really since radiotherapy started there which was back in the early 1970s, what kind of machines they had there then in relation to the population, how they developed, how there’s been a change in machines. But also, very sadly, how actually at the moment the availability of radiotherapy per million people has come down which is very distressing and that’s operational radiotherapy machines.

Why has there been a decrease?

We’re going to present an observation and it possibly needs a little more clarifying. One immediate answer is that actually the population has gone up, so just to keep pace we needed to be expanding faster than we’ve done. But also, sadly, since the early 2000s many machines that existed between 2000 - 2005 have become non-functional. There may be various reasons for that, it may be lack of maintenance because maintenance contracts cost a lot of money and often aren’t taken but actually radiotherapy machines are very complex and they do need regular maintenance. It may in some cases be that the machines have just reached the end of their life and that there hasn’t been a realistic appreciation and forward planning for a replacement. Plus, back in the 1970s the choice was always for cobalt units which are more robust so when people had had those for a few decades they quite understandably changed to LinAcc technology. It’s not particularly wrong to do it but you have to bite the bullet about maintenance and about facing the fact that you’re going to have to replace them and that you will have downtime on them and that you need backup machines. But there might be several answers to that, it doesn’t necessarily mean put in some cobalt, it might mean that a mixture of cobalts and LinAccs might be a good thing for a department. Or you might say, no, we’ve made that transition, I want to use LinAccs but you do have to have a very realistic appreciation of the cost of keeping them going – human resources, maintenance contracts, servicing, maintenance and replacement, and it’s not for the faint hearted. It’s quite expensive.

What conclusion would you draw?

One conclusion, I have to say it’s very tragic at the moment. At the moment there are two countries in West Africa which had radiotherapy at the beginning of this millennium which we don’t have it now and that’s very sad. The actual availability of radiotherapy is lower and we should all regret that. We should look at the reasons for that and try to reverse it. Actually I would say that several of the countries involved are very much on the case about this; there are plans for replacing units that have become non-functional and getting radiotherapy started again. There is an appreciation as well of what I’m saying, that actually to make a service sustainable you have to address the fact that machines have to be maintained and replaced and actually personnel do as well. Unfortunately, you train a batch of radiation staff but they only stay for a certain amount of time so you have to have a realistic approach to replacing your staff. Even your infrastructure and buildings have to be repaired and renewed or expanded from time to time and changing.

But there are good data to show that there’s a good return from radiotherapy. It’s a very cost effective treatment. It addresses a lot of the malignancies that we see in this area. It can cure many of the cancers or it can contribute to the cure along, perhaps, with surgery and chemotherapy in some cases. Of all the patients cured of cancer 40% have radiotherapy as some or all of their treatment. It has enormous palliative benefit, it relieves suffering, it relieves pain, it relieves bleeding, it relieves pressure on the spinal cord so that people don’t get paralysed from malignancy. So actually it is a cost effective treatment but if you have a machine and it breaks down, it’s standing idle, it’s not going to help anyone. So if you’re going to do it take on the cost and commitment to really make it run.

Can you outline any other ways the IAEA helps cancer care?

The agency is committed to safe use of nuclear technology and that can actually be in the diagnosis of cancer as well as the treatment of cancer. We’re looking at diagnostic tools like gamma cameras and PET scanners. There’s also the impact missions, along with other partners, the WHO and several other partners, to go and look at the whole situation and advise, signpost where you can get help, developing a national cancer control plan.

We also maintain a lot of free to view online guidance documents; just about everything to do with nuclear technology, it will be there somewhere. But some of them are developing a national radiotherapy service: planning it, building your first radiotherapy centre. There’s another wonderful document that tells you how to design your centre, starting with do you own the land, do you have the title, is the title appropriate, is the ground sound enough and so on and leading until you’ve got a whole department. So there’s that.

The other thing that we do is that we run clinical research protocols recruiting centres in low and middle income countries. Part of the aim of that is the research question itself but it’s also a transfer of technology so as to help new centres to come in to the clinical trial world. Because initially if you’re new and untested you won’t be very attractive to a commercial sponsor for a trial or even a big multicentre organisation. We help people learn how to develop a protocol to be a coinvestigator then to put their trial through ethics and then perform it. So that helps people onto the bandwagon of actually doing research. Also centres in low and middle income countries have a lot of patients so actually there is a resource there which is very important. A lot of the world’s population lives in low and middle income countries so it’s important that research does go on there to answer the questions.

Of course occasionally there may be things like Ebola, not exactly my field, where you have to do the research there. So you shouldn’t ignore that part of the world, you should be actually training people so that when we do research the data is good and robust and answers the question.