I think the major take-home point I’m trying to bring today is that when you are looking at radiotherapy assets for your country that you’ve got to take into account not simply what the coolest, newest, highest technology piece of equipment may be but you’ve got to look at the discrete needs of the country in terms of its cancer population, you’ve got to look at your discrete needs of the country in terms of its power grid, in terms of its availability of trained people to use that equipment and in terms of the supply chain that can get spare parts to you if things break.

Let’s take an example: we’re hearing here from places like Africa, places like Nepal. What would be a typical example of what you’re talking about?

If you were a low or middle income country in Africa, for instance, and you were engaged in getting, for instance, a proton centre because protons are the newest thing in the US and they’re building them in Japan, all over, the issue is not simply the fact that your country might have a tough time affording a proton centre but it would be much better served to be buying far more reasonable technology that would affect far more of its people.

Isn’t some of that obvious already?

Sure it is but the bottom line is that there’s a lot of pressure on governments, on financial institutions, to not seem to be backwards or to be at the mercy of some of the vendors that have a lot of money that they use for marketing. It’s very difficult for many governments to try and prioritise where they’re going to spend their healthcare dollars.

Of course, some of the basic radiotherapy techniques have been responsible for tremendous advances against cancer in the past already.

That is certainly true.

Could you name to me which are the most useful techniques that you must have as a basic?

I think in most cases of low and middle income countries you need to have a basic radiotherapy system in place if for nothing else then palliation of advanced cancer, pain relief, relief of large masses that are causing patients a loss of function. Palliation will be the first thing on the agenda for many, many low and middle income countries. Once there’s an infrastructure that allows for earlier detection and prevention of the type of things that we’re talking about here in this conference, then we can move to more targeted therapies for cure of many cancers. But first off you have to look after those patients who have no curative option but are in significant suffering.

OK, so what is the infrastructure that is needed in order to start looking at curative therapy?

The infrastructure is not simply things like a stable power grid, the infrastructure is a technology based population that will allow you to have trained people there to not only use the equipment but fix the equipment. Then you also need a steady stream of spare parts because the more sophisticated the technology you use the more frequently it breaks and so you need to be able to get the pieces and get it fixed so it’s not broken for long.

And how should you get guidance? If you’re in a low and middle income country how should you get guidance on this? Because if it’s just imposed from outside or from the government then there could be problems, couldn’t there?

There certainly are in most cases where things get imposed by people who may not have the proper understanding. I think that there are lots of NGOs that are available that may be up to speed on… My bias is that any time things are imposed upon a group of people who are trying to provide healthcare you’re going to have a suboptimal result. There are many NGOs and other groups that can provide support of the way that this conference does.

So how should you get that guidance of what to do? Should you go and ask doctors, ask the patients, what?

I think what you need to do is ask the physicians and get physicians engaged from other parts of the world that have an understanding of your specific needs in terms not only of your patient population but of your technical infrastructure.

And how do you actually raise awareness in order to actually get the correct sort of emphasis on radiotherapy techniques?

There are NGOs such as this one that provide support to governmental organisations.

How much difference can you make to cancer care in the community by having good curative radiotherapy systems in place and also the palliative ones?

First of all what you have to do is get something in place and something that will remain in place. So if you get any piece of radiotherapy equipment and it breaks after a year and you never fix it you’ve only had a year’s worth of use of that equipment. But you need to have a piece of equipment in there that’s functional and that will be used continuously and upgraded and updated and replaced when needed. When you get onto that, when you get that momentum, if I may, that’s when I think you can really start making forward strides in your country.

In Indiana you’re using proton therapy, you’re using IMRT, lots of image-guided systems that sound wonderful. It sounds almost as if you could more or less cure anything but what is happening in the rest of the world?

Much of the rest of the world wants protons, for instance, these days. The issue is that protons are for really a discrete set of patients. There is a further advanced technique called carbon ion therapy which is even for a more unique set of patients. It’s much more expensive and so rather than everybody going off in terms of protons or carbon ions we would, as a globe, be better suited by having a limited number of these way advanced things that everybody could have access to, should they need it.

What about training of doctors though and education generally?

Education generally you need specific experience to work with protons and to work with carbon ions. The vast majority of trained radiation oncologists all over the world are perfectly capable of working with, say, the old cobalt machines and the modern linear accelerators with or without multileaf collimation and four dimensional imaging and things like this.

So what’s the bottom line message that you would like to get over to improve cancer care all over the world without going for the latest fancy techniques that you yourself are quite an expert on?

I think that’s it, that our reach should not exceed our grasp in terms of what our patients need, in terms of what our healthcare workers can support and in terms of what our system infrastructure can provide in terms of spare parts and electricity and technology.

And do you think the sensible application of reasonable expenditure on radiotherapy that there can be a big impact in low and middle income countries?

Absolutely, absolutely.

And the overall aim is to improve cancer care all over the world, not just in rich countries but also in low and middle income countries, although all countries are represented here. But radiotherapy is really fancy. You in Indiana are doing proton therapy, you’re doing IMRT, all sorts of image guided things, things like carbon ions, amazing stuff. Why should low and middle income countries not get these techniques as well as all the rest?

I think the point is not that they should not get the techniques, I think the point is for most low and middle income countries that the overwhelming need is for a broader application of radiation that doesn’t require this high technology. You need a low technology asset that is used diffusely throughout the country to get to as many different patients as you can. When you start increasing the technology, proton, carbon, things like this, you decrease the number of centres that can provide it and you minimise the number of patients who can benefit from it and when you’re in a low or middle income country that is just beginning its move towards cancer care as a national goal, what you need to do, I think, is to start off with something more reasonable in terms of cost that you can diffuse more rapidly throughout the country.

Can you put some figures on it? What’s the cost of proton therapy equipment, as compared with more standard stuff?

So if you need an older cobalt machine you can buy a used cobalt machine, or some vendors are beginning to get newer cobalt machines, you can get one for probably about a million dollars. If you want a linear accelerator they’ll cost up to 4½ million dollars but they require significant training of your people, they require a significant spare parts pipeline.

And a proton machine?

The proton machine requires a cyclotron, it could easily be above a hundred million dollars. And carbon ions are even more expensive than that. The number of patients that protons and carbon ions treat is far, far smaller than what you’re going…

Right, the numbers of patients is how many, then, with the different techniques?

When you’re talking about a low or middle income country the vast majority of your radiotherapy requirements are going to be, sadly, for palliation for the first decade or so you’re going to be getting your arms around all the advanced cancers that are there.

But very important too.

Critically important but easily done with lower end machines. When you start talking about linear accelerators you can start talking about curing the patients and such. When you start talking about protons you’re dealing with a cadre of patients who for the most part are either the children or patients with advanced skull based tumours. So again you’re cutting down the number of patients who can benefit and really ratcheting up the costs.

And this needs to be keyed in with diagnostics as well, doesn’t it, because if you get a cancer earlier then you really do need the more refined techniques.

Absolutely, it’s got to be keyed into diagnostics, it’s got to be keyed into advances in chemotherapy and medical oncology, it’s got to be keyed in with advances in surgical oncology as well. All these things have got to proceed apace.

But doctors and governments and centres have reputations to maintain so they do need prestige as well. How do you counsel them to balance that?

It’s very difficult because when you start looking at institutional ego or governmental ego or any time in the sphere of whatever your group, whether it’s a school or a university or a country, moves they don’t want to be seen as lacking, they don’t want to be seen as a low or middle income country or they don’t want to be seen as the fourth most important university in that country. The issue is, though, that when you’re building a national infrastructure for cancer it’s better to start off and include all your people first rather than leap to a new technology that, by definition, will exclude a lot of your patients.

What’s the trick, though, in persuading people or developing a system whereby you gain prestige by treating the greatest number of patients and you get the right equipment. How do you enthuse organisations and individual doctors and patients.

It’s extraordinarily hard; by NGOs such as the one we’re dealing with today. But it’s very difficult when vendors come in and use all their marketing ploys.

Commercialism is a problem.

Oh, it’s an enormous trouble when they can just point across a border and say, ‘So and so has this.’

Everybody wants the latest model of automobile.

That’s right.

So what’s your bottom line message to doctors and organisations?

The bottom line message is you’ve got to look for the greatest needs of the most of your patients and right now in many low and middle income countries, if not most, you’re dealing with a system where radiotherapy is best used for palliation for the next decade or so until the infrastructure, the cancer system, can get its arms around advanced cancer. Then when we move into things like prevention or early detection and things like that then we can move towards a more advanced technology when the power grid can support it and when the pipeline system for spare parts can support it and when the people of that country are trained well enough to support it as well.