A Zimbabwean perspective on radiotherapy in care and training

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Published: 22 Nov 2017
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Dr Ntokozo Ndlovu - University of Zimbabwe, Harare, Zimbabwe

Dr Ndlovu speaks with ecancer at AORTIC 2017 about radiotherapy in Zimbabwe.

She describes the essential role of training and education in developing availability of radiotherapy, and the essential role of radiotherapy in a multidisciplinary approach to tackling cancer.

Dr Ndlovu also considers the costs and benefits of cobalt radiotherapy, noting a lack of new evidence to support cobalt technology and associated skin reactions.

At this meeting I am presenting on the experience that we’ve had over three decades in training of radiotherapy professionals in Zimbabwe which is of importance, not only just for Zimbabwe but for the whole continent of Africa.

What have you learnt over these 30 years?

The most important lesson I could say we have learnt is that self-sufficiency in training of these professionals is very important because there is a global shortage of radiotherapy professionals. As such, you cannot depend on somebody else really doing it for you. So in developing programmes to train radiation oncologists, radiotherapy technicians, medical physicists, it actually helps to make sure that you can offer quality cancer treatments and serve the cancer population in your country.

What do you do with a multidisciplinary approach?

It’s really part of the function of the training institutions. So as a prerequisite to actually training a whole, quite professional person who can do radiotherapy treatments you need to have all those disciplines in place and functional. So the multidisciplinary interactions that we have at our centre cover specialties like gynaecology, internal medicine, ear nose and throat surgery, general surgery. We also have pathologists, diagnostic radiologists who do participate at these meetings. Also we’re actually involved in multidisciplinary tumour boards which we do electronically over the internet such as the AFRONET. We are involved in the AFRONET project which is an IAEA programme where we actually have tumour board meetings via video conferencing with other nationals from other countries in Africa and others.

Any advice for other countries?

The important lesson is that with what you have you can actually do a lot and having that self-sufficiency in training of these professionals means you can actually easily expand. Recently we have expanded our radiotherapy service from what was quite basic to now centres that can actually deliver a very good standard of treatment for the sake of our patients and our professionals are able to actually carry out these treatments very well.

What type of machines do you use?

In my centre, we have two centres in Zimbabwe, and in the centre that I practice in we have three linear accelerators, we have one digital conventional simulator, we have one CT wide bore dedicated oncology CT simulator. We also have treatment planning systems, oncology information systems as well as two high dose rate brachytherapy machines.

What’s your opinion on cobalt radiotherapy?

I think I’ve opinionated enough on that in my lifetime and what I hope is that the experience I have had in all the years that I have opinionated is that there will still perhaps be for those people who feel that cobalt therapy has a role, perhaps they are right in a way. You have to have that confidence that you are able to sustain high technology in terms of the maintenance of it and in terms of the staff actually being confident in actually doing what the high technology comes with. And also having that vision of expansion, of introducing new things and then, of course, if that is who you are then it’s OK to go into linear accelerators in cobalt therapy. But when we talk about it scientifically, there are many points that I could bring up but one of the points that I can easily think of right now is that when you look at the evidence, because if we are going to practise evidence-based medicine, when you look at the evidence there’s hardly any new evidence that is based on cobalt therapy. If one therefore is going to be practising evidence-based medicine it means you still have to extrapolate back . You have to extrapolate that evidence back to cobalt, in which case it may not really apply.

Also the need for linear accelerators in Africa, we treat a lot of pelvic tumours, in my centre it’s mainly cancer of the cervix. When you look at cancer of the cervix patients I had an opportunity when I was in training to use cobalt therapy on cancer of the cervix patients. They developed severe skin reactions and most of the time these skin reactions develop after the patient has gone back home at the end of the treatment. So when you consider that our patients have to travel long distances to come for the treatment if a patient develops such a reaction when they are back there in the rural areas you will not be there to guide them, you will not be there to treat them. I am glad that in my institution that’s now a thing of the past. We have very minimum skin reactions with linear accelerators and if that is just one thing that would make me say, ‘I’ll go for a linear,’ I’ll do that.

Can you tell me about the challenges surrounding radiotherapy in Zimbabwe?

We are a developing country so some of the challenges that are faced by other developing countries we do face. Of course I spoke about training of radiation oncology professionals, we still need to expand, we’re not yet there. So our population coverage is not as per recommended standard, we still don’t have one machine per million people and for us to reach there we still have to train more personnel, we still have to build more centres. I spoke about the distances that the patients have to travel, that’s a challenge because when patients have to travel long distances to get to us and stay with us for several weeks, which is what happens when someone is having radiotherapy, it might not be ideal. It would be ideal if they could have that treatment in their own home environment. So there are all those issues that still need to be dealt with.