Brachytherapy Capacity for Management of Cervical Cancer in Low- and Middle-Income Countries: An Updated IAEA Database Analysis

Abstract

<h3>Purpose/Objective(s)</h3> Cervical cancer (ca-cx) is a leading cause of cancer death in women worldwide. Low and Middle-Income countries (LMICs) account for 90% of case mortalities annually. Treatment include surgery, RT +/- chemotherapy. RT consist of EBRT +/- brachytherapy (BT) or exclusive BT for stage IA. LMIC access to RT is crucial for the global control of ca-cx. However, most studies on RT capacity in LMICs have focused on EBRT. This study assesses progress in the BT capacity in LMICs. It analyzes the current demand and deficits based on the updated survey of global RT facilities and epidemiological trends of ca-cx. <h3>Materials/Methods</h3> We projected the 2022 incidence of ca-cx for each LMIC from GLOBOCAN, a database of global cancer registries maintained by the IACR. Using an optimal BT utilization (BTU) of 71.4%, we estimate the demand for BT in each LMIC. The BTU is the proportion of cases with BT indication. Evidence-based estimates informed BTU of 71.4% for ca-cx in LMICs. We obtained the number of BT units in each LMIC from the IAEA DIRAC. Per IAEA, an HDR unit can deliver 1,920 RT frx a year. Prior studies show an average of 3 frx per RT course for ca-cx in LMICs. The required BT for each LMIC was computed as (I * BTU * 3) / (1,920). Deficit was analyzed from available BT as of Feb 2022 and compared to 2014. <h3>Results</h3> 2022 anticipates 591,610 new ca-cx cases in 133 LMICs, for which 422,410 would require BT. 80 LMICs had BT, and 53 had none. There are 1,199 BT in all LMICs, a 198% increase from 402 in 2014 and exceeds the demand of 661 needed to control ca-cx. However, there was an inequitable geographic distribution & regional deficit. Sub-Sahara Africa (SSA) and East Asia /Pacific (EA/P) had deficit of 114 and 110 BT respectively. These regions meet only 36% and 47% of the needed BT. They have also had the slowest progress from 2014. An analysis at the economic level showed that low-income economies (LIEs) were more likely to have BT deficit. Only 3 of 27 LIEs meet full coverage. BT coverage in LIEs is 6.5% which pales in comparison to 279% and 168% for upper and lower-middle-income economies, respectively. <h3>Conclusion</h3> There is progress in BT access for ca-cx in LMICs from last decade. However, a regional deficit persists. The shortage is most dire in the LIEs located in the EA/P and SSA subcontinents. The findings of this study should be taken with some caution. The IAEA-DIRAC captures RT facilities worldwide but is self-reported data. Also, this study, like prior IAEA studies, analyzed with HDR-BT capacity. HDRs are more efficient than LDR which the available resource in some LMICs. There is a limited report of the BT specifications on DIRAC. Finally, ca-cx is not sole indication for BT, even though it is the main indication in LMICs. While previous analyses on BT capacity in LMICs have only utilized epidemiological data of ca-cx, a growing BT utilization for prostate and other gynecologic cancers should be noted. We, therefore, anticipate a slight decrease in our estimated capacities when all other indications are factored, although likely inconsequential.