About two and half years ago the Board of UICC approved the creation of the Global Task Force for Radiotherapy for Cancer Control, trying to address the questions of how we can close the gap in access to radiotherapy around the world. We then worked very hard over two years and just this spring we became the Lancet Oncology Commission on Radiotherapy and produced the report that was published in Lancet Oncology in September this year.
Fundamentally there is a great need for cancer treatment in the world. We all know that there’s a great increase in cancer cases around the world projected to occur in the next twenty years and most of this increase will be in low and middle income countries. These countries really don’t have well-functioning health systems and are very ill prepared to face it. When we talk about cancer control we usually talk about prevention, tobacco control, vaccination, diagnosis, palliative care, especially in the places with poor health systems. So radiotherapy never comes up as a priority to talk about and that’s why the task force. Because, for example, in Africa there are at least 30 countries with zero access to radiotherapy and some countries that have access have two to three machines for populations of 40-60 million people with a two year waiting list which is basically translated as no access for the population and radiotherapy being used only for palliation. The palliative role of radiotherapy is very, very important but it doesn’t extend survival and doesn’t save lives.
So what the Task Force concentrated on is the use of radiotherapy to actually contribute to the cure of cancer and extend survival and save lives. So what we did, we calculated how much would it take to close the gap in access throughout the world, both in low income countries, middle income countries and high income countries by 2035. The reason for the twenty year time period is because it takes time; it takes time to scale up radiotherapy, to build new facilities, to train the workforce and to implement the programme, so it’s unrealistic to do it faster than that. However, we know that the number of new cancer cases by 2035 will be much more than now – it will be over 24 million new cancer cases. So we calculated this gap up until 2035.
It is well-known what the benefit of radiotherapy in cancer is, there are a number of studies suggesting that on average about 50% of patients who are diagnosed with cancer will benefit from radiotherapy. So what we did is we calculated the number of years lives saved with radiotherapy for the top ten countries in the world, so the top ten countries in frequency where radiotherapy is used, even though in liver cancer it’s not used we took it into account. We then calculated what would be the survival, five year survival, of patients without radiotherapy, treated without radiotherapy or other modalities, and with radiotherapy. By calculating this gap we could actually calculate the number of years lives saved if you had equal world access to radiotherapy around the world and that number was very, very high. We’ve calculated that by 2035 we would be at least 27 million life years saved if you had good access to radiotherapy.
Then we calculated how much would it cost to scale up. We obviously used the numbers of average cost of equipment, average cost of building the facility, cost of training people, up until 2035 and we actually concluded that for the whole world it would be $184 billion, that’s to scale up by 2035. That cost in low income countries, however, would be only $26.6 billion, which considering it’s a twenty year timeframe is not an insurmountable number.
Then we went further and using well accepted investment framework calculations, the same calculations that were done to look at the cost-benefit of treatment of HIV, malaria, TB and other diseases, we calculated if we saved lives and if people remained active and contributed to the workforce or just being alive, contributing to society, what would be the economic return on investment? We were pleasantly surprised that this economic benefit was actually quite large. It amounted to about $100 billion if you used the efficiency model. So we first of all calculated the nominal model where we used the equipment twelve hours a day, we replaced equipment every twelve years, we produced staffing ratios and practices that are common in high income countries. We then said if you did mass purchase of equipment, if you operated the equipment longer, if you replaced the equipment less frequently, if you were more efficient with the use of equipment what would be that benefit and that benefit, that return on investment, is usually much greater. We think that the efficiency model is quite feasible, especially in low income countries.
It was very interesting to know that when you looked at the cost of setting up the radiotherapy equipment, in high income countries most of the cost is human resources, in low income countries, as you could expect, it’s cost of equipment. So if we can lower the cost of equipment, considering that the human resources are much less expensive, operating costs are much less expensive in low income countries, scaling up radiotherapy is quite feasible.
So despite a high upfront cost, this would save the government in the long run?
Yes, this is becoming more and more the tenant of looking at healthcare. In our countries healthcare is looked always as an expense. All the ministries say that the health ministries should spend less money, we should spend less money on healthcare, but nobody up until now actually looked at the economic benefit of people living longer. I think it has been found that improving the life expectancy in the population actually produces the benefit in terms of national GDP so healthy countries become wealthy countries. That could be probably translated for individual diseases and individual interventions. Obviously there are many assumptions that you make along the way – you make assumptions about quality of care, you make assumptions about utilisation. We know, for example, that although the optimal utilisation calculated, utilisation of radiotherapy, may be 50% in some high income countries it’s about 35% or 29%. So I think that you look at the ideal model and you calculate benefit knowing that probably you’re going to achieve 80% or less of this benefit.
Where would this money come from?
I think that data can be used by WHO, by governments, by industry. It’s really a motivation to lower the cost of equipment and treatment and to push for starting to close the gap. Because by many countries radiotherapy is considered to be something too complicated, too expensive, too difficult to set up so people set up treatments for cancer and eliminate radiotherapy as one of the elements of treatment. What we’ve tried to show is that it’s not only beneficial in terms of saving year lives but it’s also affordable in the long term, but it does need an initial outlay of funds and money to establish the facilities because, unlike some other aspects of healthcare, without the treatment facility of machinery you just can’t do it. Therefore setting up these centres with equipment is very important.
The other important thing that we found is that it will require a huge increase in human resources and trained people. The radiotherapy does require a multi-professional approach, we need radiation oncologists, cancer specialists who know how to use radiotherapy. We need medical physicists; in many countries medical physics is not an accepted health profession and we need to change that parameter to say they are a health profession, medical physicists. And then radiation technologists. So absolutely thousands and thousands of experts need to be trained and it’s also a call to action to universities, to professional organisations, to scale up the education effort and also simplify the education effort. Medical education right now has a very odd system: there are barriers in credentialing, there are barriers in how many years it takes to produce an expert, but there are some initial efforts to do competency based education where you can just learn what you need to do and enter the workforce much earlier than in high income countries.
So there are many challenges and we made suggestions in the report of how to overcome these challenges.
What form would this training take?
Probably a combination of online and practical, a combination of partnerships, a combination of short-term exchanges, combinations of people from low income countries going to middle income countries but also vice versa, reverse learning, and basically new models of collaboration and teaching.
We’ve put out a call to action, one specific call to action that we’ve put out is it’s very difficult to scale up radiotherapy everywhere all at the same time. We believe that each country should have a cancer centre of excellence with radiotherapy. Clearly radiotherapy is only part of our treatment of cancer. In order for radiotherapy to be effective you need to have accurate cancer diagnosis, you need to have assessment of extent of disease with imaging and you need to have surgery and chemotherapy because most of the patients with cancer these days do require a multi-modality effort. So although our report talks about radiotherapy, we do recognise that the environment and the ecosystem for radiotherapy needs to have all the other elements of cancer present in order for radiotherapy to achieve its benefit. It also needs to have an ecosystem that has an adequate power supply, adequate facilities, transportation and other non-medical elements to produce the desired effects.
