Radiotherapy infrastructure and human resources in Europe - Present status and its implications for 2020

Radiotherapy (RT) is required for nearly half of the newly diagnosed cancer patients. To optimise the quality and availability of RT, guidelines have been proposed by European Society for Radiotherapy and Oncology-QUAntification of Radiation Therapy Infrastructure And Staffing Needs (ESTRO-QUARTS) and the International Atomic Energy Agency (IAEA). This study evaluates the present status of RT capacity in Europe and the projected needs by 2020 as per these recommendations. Thirty-nine of the 53 countries, listed in Europe by the UN Statistical Division, whose cancer incidences, teletherapy and human resources were available in the Global Cancer Incidence, Mortality and Prevalence (GLOBOCAN), International Agency for Research on Cancer (IARC) and DIrectory of RAdiotherapy Centres (DIRAC) (IAEA) databases were evaluated. A total of 3550 teletherapy units (TRT), 7017 radiation oncologists (RO), 3685 medical physicists (MP) and 12,788 radiotherapy technologists (RTT) are presently available for the 3.44 million new cancer cases reported annually in these countries. The present infrastructure and human resources in RT are estimated to provide RT access to 74.3% of the patients requiring RT. The current capacity in TRT, RO, MP and RTT when compared with recommended guidelines has a deficit of 25.6%, 18.3%, 22.7% and 10.6%, respectively. Thus, to respond to requirements by 2020, the existing capacity needs to be augmented by an additional 1698 TRTs, 2429 ROs, 1563 MPs and 2956 RTTs. With an imminent rise in cancer incidence, multifaceted strategic planning at national and international levels within a coordinated comprehensive cancer control programme is highly desirable to give adequate access to all patients who require radiotherapy across Europe. Specific steps to address this issue at national and continental levels involving all major stakeholders are proposed

Radiotherapy infrastructure and human resources in Switzerland : Present status and projected computations for 2020

PURPOSE: The purpose of this study was to evaluate the present status of radiotherapy infrastructure and human resources in Switzerland and compute projections for 2020. MATERIALS AND METHODS: The European Society of Therapeutic Radiation Oncology "Quantification of Radiation Therapy Infrastructure and Staffing" guidelines (ESTRO-QUARTS) and those of the International Atomic Energy Agency (IAEA) were applied to estimate the requirements for teleradiotherapy (TRT) units, radiation oncologists (RO), medical physicists (MP) and radiotherapy technologists (RTT). The databases used for computation of the present gap and additional requirements are (a) Global Cancer Incidence, Mortality and Prevalence (GLOBOCAN) for cancer incidence (b) the Directory of Radiotherapy Centres (DIRAC) of the IAEA for existing TRT units (c) human resources from the recent ESTRO "Health Economics in Radiation Oncology" (HERO) survey and (d) radiotherapy utilization (RTU) rates for each tumour site, published by the Ingham Institute for Applied Medical Research (IIAMR). RESULTS: In 2015, 30,999 of 45,903 cancer patients would have required radiotherapy. By 2020, this will have increased to 34,041 of 50,427 cancer patients. Switzerland presently has an adequate number of TRTs, but a deficit of 57 ROs, 14 MPs and 36 RTTs. By 2020, an additional 7 TRTs, 72 ROs, 22 MPs and 66 RTTs will be required. In addition, a realistic dynamic model for calculation of staff requirements due to anticipated changes in future radiotherapy practices has been proposed. This model could be tailor-made and individualized for any radiotherapy centre. CONCLUSION: A 9.8 % increase in radiotherapy requirements is expected for cancer patients over the next 5 years. The present study should assist the stakeholders and health planners in designing an appropriate strategy for meeting future radiotherapy needs for Switzerland

Teleradiotherapy network: applications and feasibility for providing cost-effective comprehensive radiotherapy care in low- and middle-income group countries for cancer patients

Globally, new cancer cases will rise by 57% within the next two decades, with the majority in the low- and middle-income countries (LMICs). Consequently, a steep increase of about 40% in cancer deaths is expected there, mainly because of lack of treatment facilities, especially radiotherapy. Radiotherapy is required for more than 50% of patients, but the capital cost for equipment often deters establishment of such facilities in LMICs. Presently, of the 139 LMICs, 55 do not even have a radiotherapy facility, whereas the remaining 84 have a deficit of 61.4% of their required radiotherapy units. Networking between centers could enhance the effectiveness and reach of existing radiotherapy in LMICs. A teleradiotherapy network could enable centers to share and optimally utilize their resources, both infrastructure and staffing. This could be in the form of a three-tier radiotherapy service consisting of primary, secondary, and tertiary radiotherapy centers interlinked through a network. The concept has been adopted in some LMICs and could also be used as a "service provider model," thereby reducing the investments to set up such a network. Teleradiotherapy networks could be a part of the multipronged approach to address the enormous gap in radiotherapy services in a cost-effective manner and to support better accessibility to radiotherapy facilities, especially for LMICs

Concurrent chemoradiotherapy vs. radiotherapy alone in locally advanced cervix cancer: a systematic review and meta-analysis

The efficacy of concurrent chemoradiotherapy (CTRT) in locally advanced cervix cancer (LACC, stages IIB-IVA) is contentious. This is due to the variable extent of therapeutic benefit reported in different randomized clinical trials and meta-analyses that usually include all stages of cervix cancer. A systematic review and meta-analysis was therefore conducted to evaluate the efficacy of concurrent CTRT over radiotherapy (RT) alone, predominantly in LACC for the key endpoints; complete response (CR), long-term loco-regional control (LRC), overall survival (OS), grade III/IV acute and late toxicities. Six databases namely - PubMed, EMBASE, SCOPUS, Web of Science, Google Scholar and Cochrane library were explored and supplemented by hand-searching. Only prospective randomized trials conducted in LACC between concurrent CTRT and RT alone with no surgical interventions were included. Fourteen English language articles from 1788 citations were shortlisted for the final analysis. Of the 2445 patients evaluated (CTRT: n=1217; RT: n=1228), 95.7% had LACC and 96% had a squamous cell histology. Eight studies used cisplatin alone, 4 had cisplatin-based combination chemotherapy (CT) while 2 used mitomycin-C, either alone or in combination. CTRT improved the CR (+10.2%, p=0.027), LRC (+8.4%, p<0.001) and OS (+7.5%, p<0.001) over RT alone. However a 10.4% higher incidence of grade III/IV acute toxicities (p<0.001) was also evident with CTRT. Late toxicities in both groups were equivalent. Subgroup analysis and meta-regression did not reveal any significant advantage in outcomes between the 3 CTRT regimens. Thus, although concurrent CTRT provides conclusive therapeutic benefit over RT alone in LACC, the choice of CT agents should be based on their cost-effectiveness and the anticipated expenses for the management of any associated acute toxicities. This assumes importance particularly in resource-constrained low-middle-income countries with the highest burden of LACC, where majority of the patients meet the treatment costs as out-of-pocket expenses

"HEATPAC" - a phase II randomized study of concurrent thermochemoradiotherapy versus chemoradiotherapy alone in locally advanced pancreatic cancer

BACKGROUND: Pancreatic cancer has a dismal prognosis with 5-year overall survival rate of around 5%. Although surgery is still the best option in operable cases, majority of the patients who present in locally advanced stages are deemed inoperable. Novel approaches are therefore needed for the management of around 80% of these inoperable locally advanced pancreatic cancers (LAPC). Hyperthermia (39-43 °C) is a potent radiosensitizer and further enhances the action of gemcitabine, also a known radiosensitizer. Thus through triple sensitization, a combination of hyperthermia, radiotherapy and gemcitabine could be expected to improve the therapeutic outcomes in LAPC. METHODS: This phase II randomized trial, HEATPAC in unresectable LAPC, explores the feasibility and efficacy of concurrent thermochemoradiotherapy (HTCTRT) over chemoradiotherapy (CTRT) alone with pre- and post-intervention FOLFIRINOX at standard dosage and schedule. Following 4 cycles of neoadjuvant FOLFIRINOX, patients with no metastasis and absence of gross peritoneal carcinomatosis would be randomized to either (a) control arm: concurrent CTRT with gemcitabine (400 mg/m2, weekly ×6) or (b) study arm: locoregional hyperthermia (weekly ×6 during radiotherapy) with concurrent CTRT (same as in control arm). All patients would receive simultaneous-integrated boost intensity-modulated radiation therapy to doses of 56Gy and 50.4Gy to the gross and clinical target volumes respectively delivered in 28 fractions over 5.5 weeks. Deep locoregional hyperthermia would be administered weekly and monitored with real-time intraduodenal multisensor thermometry probe. A temperature of 40-43 °C for 60 min would be aimed for each hyperthermia session. On completion of CTRT/HTCTRT, patients of both groups would receive an additional 8 cycles of FOLFIRINOX. DISCUSSION: The expected 1-year baseline overall survival with CTRT alone is considered as 40%. With HTCTRT, a survival advantage of +20% is expected. Considering α = 0.05 and β = 0.80 for sample size computation, a total of 86 patients would be equally randomized into the two treatment groups. This phase II study if found to be safe and effective, would form the basis of a future phase III randomized study. TRIAL REGISTRATION: The trial has been registered with the ClinicalTrials.gov ( NCT02439593 ). The study has been approved by the Ethical Commissions of Basel and Zurich and is open for patient recruitment