Radiotherapy Services Research Articles

Impact of War on Radiotherapy in Ukraine

The full-scale Russian invasion of Ukraine on February 24th, 2022 brought the largest humanitarian disaster to the heart of Europe since the World War II. Ukraine has lost tens of thousands of civilian lives, with approximately a third of the population displaced. The Russian army is deliberately damaging and destroying hospitals and clinics. This study describes the impact of the full-scale Russian invasion on the radiation therapy (RT) services in Ukraine. An annual survey was conducted by Grigoriev Institute for Medical Radiology, Kharkiv for the IAEA DIRAC database. The survey was sent to 41 RT centers in Ukraine requesting information on equipment, staffing, and patient volume. Due to the war conditions the data provided in the survey is limited. The information on operation of RT centers during the war collected by a Ukrainian Association of Medical Physicists representative is reported here as well. After the initial Russian invasion of Ukraine in 2014 and occupation of Crimea and parts of Donbas, Ukraine lost access to 7 RT centers with 18 external beam radiotherapy (EBRT) machines (17% of total). Just before the full-scale invasion in 2022, there were a total of 44 Co-60 machines (57%) and 33 linear accelerators (43%) in the unoccupied territories. As a result of the full-scale invasion of Ukraine in 2022, almost all RT centers suspended operation in the first weeks of war. The most challenging period for RT in Ukraine was in March when Kyiv (where 20 EBRT machines are located) was partially surrounded by the occupiers. The situation improved after Ukrainians liberated approximately half of total occupied territory. Currently, 2 additional RT centers are under occupation; 3 RT centers sustained heavy shelling and equipment damage. The response rate to the survey was 63%. Compared to 2021 data, in 2022, the number of radiation oncologists decreased by 7.8%, medical physicists by 7.3%, and therapists by 10.0%. The workload in the RT centers close to the combat zone almost halved, while increasing by 10 - 60% in the western and central Ukraine. The total number of patients treated with EBRT decreased by 11% and brachytherapy by 21%. Age of the RT equipment in Ukraine is shown in Table 1. Despite the ongoing war, Ukrainian cancer centers installed 3 new linear accelerators, with 14 linear accelerators pending installation. Radiotherapy in Ukraine sustained significant damages since the 2014 Russian invasion, which was exacerbated further by the full-scale invasion in 2022. To support the vitality and absorptive capacity of RT services in Ukraine, the democratic world can help by donating equipment, hardware, software, and participating in training of Ukrainian RT professionals as they transition to modern and high-quality RT care for Ukrainian cancer patients.

Evaluating Geographic Access to Radiotherapy Services in Canada

To identify jurisdictions and demographic factors associated with increased driving times to the nearest RT facility in Canada. RT facilities in Canada were identified using information obtained from the Canadian Association of Radiation Oncology and the IAEA Directory of Radiotherapy Centers. The 2021 Canadian census was used to determine demographic profiles for each dissemination area, the smallest geographic unit (target size 400-700 people) on which all census data is reported. Poor geographic access was defined as a driving time between a dissemination area and the closest RT facility exceeding 90 minutes as computed using the OpenStreetMap database. The association between province and poor geographic access was assessed using multivariable logistic regression adjusting for population density by decile. Demographic characteristics were subsequently introduced into the logistic regression to identify factors associated with poor access. A total of 51 radiotherapy centers and 57,937 dissemination areas were mapped. Median driving time to the closest RT facility was 23 minutes, and 13% of the population had poor access to RT. RT was least accessible in the three territories, whose residents had a median driving time of 1096 minutes. Among the provinces, Newfoundland had the longest median driving time of 91 minutes while Manitoba had the shortest median driving time of 20 minutes. On logistic regression with population density as a covariate, dissemination areas in Newfoundland (OR, 9.64 compared to Ontario; 95% CI, 8.3 to 11.2) and British Columbia (OR, 5.46; 95% CI, 5.03 to 5.93) had the highest odds of poor geographic access, whereas Ontario (reference) and PEI (OR, 0.49; 95% CI, 0.34 to 0.69) had the lowest odds. Inclusion of demographic variables in the logistic regression revealed that dissemination areas with higher median age (OR, 1.035 per year; 95% CI, 1.030 to 1.039), more males (OR, 1.033 per %; 95% CI, 1.021 to 1.045), lower income (OR, 1.030 per % low income status; 95% CI, 1.024 to 1.035), increased aboriginal representation (OR, 1.050 per %; 95% CI, 1.045 to 1.054), fewer visible minorities (OR, 0.979 per %; 95% CI, 0.973 to 0.985), fewer immigrants (OR, 0.934 per %; 95% CI, 0.927 to 0.941), and lower attainment of postsecondary education (OR, 0.976 per %; 95% CI, 0.972 to 0.979) were associated with poorer access to RT. Approximately 13% of Canadians have a driving time exceeding 90 minutes to the closest RT facility. Geographic access to RT varied by province and dissemination areas with higher median age, low socioeconomic status, a greater proportion of males, and higher aboriginal populations were associated with poorer access. Our study identified deficiencies in access to existing RT facilities, and its results may inform planning efforts for locations of new facilities in Canada.

Which Criteria Should We use to Determine an Adequate Number of Linear Accelerators in Emerging Economy Countries

In the age of limited resources, knowing the number of linear accelerators (LINACS) is paramount for designing and planning comprehensive coverage for a population. As important guidelines for the actual prediction of the number of LINACS, a wide range of directions are found in the literature. These guidelines vary depending on total population size, cancer incidence, cancer types, fractions per year, and machine workload. Knowing which guidelines to use, and which one fits the population's needs, is key to the best utilization of resources. In Oman, we have a stable population with minimal rates of immigration/emigration. The current needs of LINACS are met so we have a unique opportunity to test some of these guidelines and see which one most accurately predicts the correct number needed. The results should help emerging economies use a similar approach in estimating their needs. This study was conducted to estimate the demand for radiotherapy services needed in Oman taking into consideration the most common methods and recommendations available in the literature. The calculation methods analyzed: COCIR - targets a density of 7 radiation therapy units per million; ESTRO/QUARTS - 1 LINAC per 400 patients/year or 1 LINAC per 180,000 persons; and IAEA method that uses a combination of cancer incidence, number of treatment fractions per cancer type, and machine workload. The population demographics with cancer incidence were extracted from the Oman Cancer Registry data 2019 (total number of cases and cancer types). For the density of LINAC units per million population, we used the 2019 population of 4.603 million. For the workload calculation, we used 4 fractions/hour in an 8-hour shift and 248 working days. The calculations included the total number of cancer cases, average number of fractions per year, machine workload, rate of patients receiving radiotherapy per cancer type, the optimal number of fractions per treatment course, retreatment rate, and radiotherapy utilization rate per cancer type. Based on most frequent cancer incidence (1,437 cases), the total number of fractions per year is 22,920. The workload of machines was 7,936 fractions/year. If calculations included total number of cancer types (2,039) and average number of fractions per patient based on average number of fractions per cancer site, the total number of fractions is 27,715. If the reirradiation ratio included the number of fractions per year, a total of 34,644 (25% increase). For the COCIR, ESTRO/QUARTS, and IAEA recommendations, the range is 2.8 to 32 of required LINACS for adequate coverage in Oman (respectively 32; 4 to 25; and 2.8). The analysis of recommended guidelines for calculating the required number of LINACS in Oman showed a wide range. While in practice we know currently the number of LINACS required for our population is 5, for emerging economies 1 LINAC per 400 patients/year, or the IAEA calculation methods are the closest approximation to the actual needs.

An Analysis of Delays in Treatment Time for Prostate Cancer Patients in Sub-Saharan Africa

Time interval from diagnosis of prostate cancer to treatment is an important predictor of survival outcomes for patients. These time intervals can be prolonged in resource-limited settings, such as those in Sub-Saharan Africa (SSA). The purpose of this project was to analyze the time interval between diagnosis and either hormonal or radiotherapy treatment for prostate cancer patients in Nigeria and Tanzania. The outcomes can inform the implementation of the recent Lancet Oncology Commission recommendations on increasing access to radiotherapy services in SSA to curb the growing cancer burden in the region. Data were extracted from electronic patient records at the NSIA-LUTH Cancer Center (NLCC) in Lagos, Nigeria and at the Ocean Road Cancer Institute (ORCI) in Dar Es Salaam, Tanzania. Included patients were prostate cancer patients who received hypofractionated radiotherapy (HFRT) at ORCI between January 6 - June 16, 2022, and either HFRT or conventionally fractionated radiotherapy (CFRT) at NLCC between February 1 - July 27, 2022. Simple descriptive statistics were used to calculate the mean time interval between the patient's date of diagnosis of prostate cancer and the start of hormonal or radiotherapy treatment. Time to hormonal therapy was collected for 23 ORCI patients and 28 NLCC patients. The mean time interval from date of diagnosis to start of hormonal therapy was 19.3 weeks for patients in Tanzania and 8.0 weeks for patients in Nigeria. Time to radiotherapy was collected for 23 ORCI patients and 50 NLCC patients. The mean time interval from date of diagnosis to start of radiotherapy was 59.13 weeks for patients in Tanzania and 48.5 weeks for patients in Nigeria. Prostate cancer patients in Nigeria and Tanzania experience significant delay in receiving hormonal and radiotherapy treatment, especially when compared to wait times in well-resourced countries. For example, a recent assessment of U.S. patients in the National Cancer Database who were diagnosed with prostate cancer between 2004-2015 revealed that the mean interval from diagnosis to definitive therapy (either surgery or some form of radiotherapy) was 11.3 weeks - significantly less than the mean times documented in our study of SSA patients (Cone et al., 2020). Additionally, patients in Tanzania experienced longer treatment delays compared to patients in Nigeria, highlighting potential disparities in access to care between SSA countries. These prolonged delay times are likely to negatively impact survival and represent an intervention opportunity to alleviate the cancer crisis in SSA.

Expanding Radiotherapy Access in Sub-Saharan Africa: An Analysis of Travel Burdens and Patient-Related Benefits of Hypofractionation

The purpose of this project was to examine the travel burdens for radiotherapy patients in Nigeria, Tanzania, and South Africa, and to assess the patient-related benefits of hypofractionated radiotherapy (HFRT) for breast and prostate cancer patients in these countries. The outcomes can inform the implementation of the recent Lancet Oncology Commission recommendations on increasing the adoption of HFRT in Sub-Saharan Africa (SSA) to enhance radiotherapy access in the region. Data were extracted from electronic patient records at the NSIA-LUTH Cancer Center (NLCC) in Lagos, Nigeria and the Inkosi Albert Luthuli Central Hospital (IALCH) in Durban, South Africa, from written records at the University of Nigeria Teaching Hospital (UNTH) Oncology Center in Enugu, Nigeria, and from phone interviews at Ocean Road Cancer Institute (ORCI) in Dar Es Salaam, Tanzania. Google Maps was used to calculate the shortest driving distance between a patient's home address and their respective radiotherapy center. QGIS was used to map the straight-line distances to each center. Descriptive statistics were used to compare transportation costs, time expenditures, and lost wages when using HFRT versus conventionally fractionated radiotherapy (CFRT) for breast and prostate cancer. All transportation- and wage-related cost data were contextualized within each country's monthly adjusted net national income (MANNI) per capita, as reported by 2020 data from the World Bank. Patients in Nigeria (n = 390) traveled a median distance of 24.0 km (interquartile range (IQR) = 238.5 km) to NLCC and 86.7 km (IQR = 87.3 km) to UNTH, patients in Tanzania (n = 23) traveled a median distance of 537.0 km (IQR = 587.5 km) to ORCI, and patients in South Africa (n = 412) traveled a median distance of 18.0 km (IQR = 15.0 km) to IALCH. Estimated transportation cost savings for breast cancer patients in Lagos and Enugu were 12,895 Naira and 7,369 Naira (20% and 11% of MANNI per capita), respectively, and for prostate cancer patients were 25,329 and 14,276 Naira (38% and 22% of MANNI per capita), respectively. Prostate cancer patients in Tanzania saved a median of 137,765 Shillings (78% of MANNI per capita) in transportation costs. Significant time expenditures - a relevant consideration for patient convenience - were also saved for ORCI patients, including a median of 80.0 hours (includes travel, treatment, and wait times). Mean transportation cost savings for patients in South Africa were 4,777 Rand (72% of MANNI per capita) for breast cancer and 9,486 Rand (143% of MANNI per capita) for prostate cancer. Cancer patients in SSA travel considerable distances to access radiotherapy services. HFRT decreases patient-related costs and time expenditures, which may increase radiotherapy access and alleviate the growing burden of cancer in the region.

Financial Implications of Evolving Breast Cancer Radiotherapy Treatment Protocols

Adjuvant radiotherapy for breast cancer represents a significant portion of radiotherapy (RT) treatments. The resource implications of evidence-based changes in treatment protocols must be defined to facilitate RT service planning. We designed a study to calculate the impact of past changes and create a model to allow prediction of costs implications for future changes. Changes in RT treatment (shown in table 1) in the past 3 years were identified in consultation with clinical staff and by reviewing institutional treatment guidelines. Resource and infrastructure costs were calculated for each protocol. Staff time was calculated using standard time slots where known (e.g., CT simulation appointment) and estimates based on discussion with staff (e.g., time to plan whole breast RT). Cost / Gy was calculated based on Linac cost of €2.5M, 10% annual service charge over 12-year lifetime, 2.7 patients treated / hour (verified institutional metric) and standard 2Gy fraction, giving €37.72 / Gy. We did not include facilities costs nor account for differing treatment outcomes. We collected relevant data on a consecutive 6-month sample (Jan - Jun 2019) of women receiving adjuvant RT for breast cancer (n = 224). Total costs were calculated by applying costs for each protocol change to the women in this cohort eligible for the changes. Protocol changes and costs are summarized in table 1. The use of DIBH for women <60 years receiving IMN RT (left and right sided) added a cost. The largest cost saving resulted from more selective tumor bed boost, a saving of €462,138. The potential impact of a 5-fraction boost for women with non-low risk DCIS was estimated. In the cohort analyzed, identified changes in adjuvant breast radiotherapy resulted in overall savings due to updated indications for boost and the implementation of ultra-hypofractionated radiotherapy. We are now analyzing the impact of introducing simultaneous integrated boost and partial breast radiotherapy.

Assessment of barriers to optimal cancer control in adult cancer treatment centres in Cameroon.

Approximately 20,745 new cases of cancer were registered annually with 13,199 (64%) deaths in 2020 in Cameroon. Despite the increasing cancer burden, there is a paucity of reliable data that can enhance decision-making for cancer control in Cameroon. This assessment was, therefore, designed to generate data that may enable stakeholders, policymakers and funders to make data-driven decisions on cancer control. We conducted a cross-sectional survey in July 2020, which enabled us to collect data on key cancer variables from six adult cancer treatment centres in Cameroon. The key components of the assessment included case detection, service availability, human resource capacity, cost of chemotherapy and radiotherapy, the safety of chemotherapy sessions, data systems, patient education, palliative care, funding for chemotherapy and chemotherapy stock. Data were compiled and analysed using Microsoft Excel 2016. Data from four of the 6 sites show that 1,636 new cases were recorded representing an annual case detection rate of 11.8%. All the six assessed facilities offered chemotherapy services, 5/6 (83.3%) offered surgery for cancers, while just 1 (16.7%) offered radiotherapy services. In addition, none offered nuclear medicine services for cancer care and treatment. Similarly, none of the facilities had the WHO-recommended number of human resources for optimal cancer care. Overall, there were only 6 medical oncologists, 2 surgical oncologists, 3 radiation oncologists and 14 oncology nurses providing services across the 6 cancer treatment centres. Treatment services are expensive for an average national, with a complete course of chemotherapy followed by radiotherapy costing ~XAF 1,240,000 (~$2,480). None of the survey facilities had a recommended safe biosafety cabinet and clean room for the preparation of chemotherapies, rendering the preparation of chemotherapies suboptimal and hazardous. Data collection tools were manual, relatively available and very different across all the surveyed sites and the interval for data collection and transmission was collectively undefined. Optimal cancer care in adult cancer treatment centres is limited by several health systems and socio-economic factors. The identification of these barriers has enabled the formulation of action-oriented interventions, leveraging on the recently adopted national strategy for the prevention and control of cancers in the country.

94 Evaluating Geographic Access to Radiotherapy Services in Canada

94 Evaluating Geographic Access to Radiotherapy Services in Canada

Cervical Cancer Progression in Patients Waiting for Radiotherapy Treatment at a Referral Center in Ethiopia: A Longitudinal Study

ABSTRACT Nonmetastatic cervical cancer is a highly curable malignancy, and radiotherapy (RT) remains the mainstay treatment. Early initiation is critical, and the optimal time to initiate RT for cure is 6 weeks, with a reported 15% decrease in 3-year overall survival for those who wait 40 days. There is considerable variation in the waiting time to initiate RT between countries, with a median time of 27.2 days in Ontario, Canada and 108 days in South Africa. Real-world evidence of cancer progression because of treatment delay is scarce in low-income countries. Ethiopia, a country of 120 million, had a single machine at Tikur Anbessa Specialized Hospital (TASH) until it acquired a linear accelerator very recently. This study aimed to assess the extent of delay in receiving RT and the effect of delay on the natural disease court in patients with cervical cancer treated at TASH. This study was conducted at TASH between January 2019 and May 2020 and evaluated patients at different time points before and after RT. All individuals who were diagnosed with cervical cancer (stage IIB to stage IVA) and booked for RT at TASH were included. Concurrent chemoradiotherapy was administered for cervical cancer with weekly cisplatin as a chemotherapy agent. A total of 115 patients were included in this study. The median time between pathologic diagnosis and booking RT was 19 days, and the median time from booking to RT initiation was 458 days. The total median time from diagnosis to treatment was 477 days, and the median time to disease progression was 51 days. During the waiting period for RT, the stage was reassessed for 105 patients. The number of patients in stage IIB, IIA, and IIIB decreased during this period, whereas the number of patients in stage IVA increased from 20 (17.4%) to 30 (26.1%), 2 (1.8%) developed distant metastasis to the lungs (stage IVB), and 37 died before receiving a phone call for RT. Of 115 patients booked to receive CCRT, only 9 (7.8%) received CCRT, 80 (69.9%) received a single shot of palliative RT due to disease progression, and 25 (21.7%) did not receive RT at all. The mean and median survival times were 20.1 months (95% confidence interval [CI], 18.3–22.7) and 21 months (95% CI, 18.3–23.8), respectively. Waiting time, stage at presentation, distant metastasis during the waiting time, hydronephrosis during the waiting time, and type of treatment were significantly associated with survival. Multivariate cox regression using these variables found that patients with stage IIIB were 2.2 times more likely to die than those with stage IIB (adjusted hazards ratio, 2.2; 95% CI, 1.07–4.48), and patients with stage IVA were 20.95 times more likely to die than patients with stage IIB (adjusted hazards ratio, 20.95; 95% CI, 6.26–70.03). Prolonged waiting time increased the mortality rate of cervical cancer by 2.9 (95% CI, 1.07–4.5). This study provides a significant advancement in our understanding of cervical cancer care in low-income countries. The median waiting time diagnosis to treatment was 477 days, whereas the median waiting period for disease progression was 51 days, resulting in unnecessary disease progression, change in treatment intent from curative to palliative, and increased mortality. These findings highlight the need to increase access to RT services in lower-income nations to reduce wait times and provide better cancer care.

Closing the gap in Indigenous Australian cancer care: Initiatives to foster cultural safety and improve access to radiation therapy

IntroductionAboriginal and Torres Strait Islander peoples receive a poorer cancer prognosis compared to non-Indigenous Australians. Indigenous access to cancer care is limited by several factors, including differences in cultural understanding surrounding cancer and distrust of mainstream health institutions. It is believed that radiation therapy is being under-utilised by the Indigenous community. In response, several strategies were implemented to increase presentation and attendance by Indigenous Australians at a rural, private radiation therapy practice. MethodsA local Indigenous health service, Traditional Owners and Elders and the clinic's Reconciliation Action Plan Working Group were consulted to implement initiatives to reduce barriers to engaging in healthcare. One of these initiatives involved community consultation to select a culturally safe, Indigenous word to name one of the clinic's linear accelerators. Indigenous patient referrals into the clinic were tracked using an oncology information system. It is expected that by implementing several culturally safe strategies, there would be an increase in utilisation of the radiation therapy service and therefore, a decrease in Indigenous cancer burden across the local region. If strategies were yielding positive outcomes, there would be scope to implement these at other sites across a broader monitored network. ResultsCurrently, service utilisation is being monitored to determine whether initiatives have been successful. Initial data evaluation has been conducted and results are showing increased service utilisation by the Indigenous community. ConclusionWork has been undertaken to implement strategies to improve cultural safety and improve access to radiation therapy for Indigenous cancer patients. Preliminary results show an increase in the number of presentations to the clinic for radiation therapy treatment.

Radiotherapy service amidst COVID-19: Experience from Tertiary Referral Hospital in Semarang, Indonesia.

Several changes in hospital policies took place to mitigate the spread of Coronavirus disease 2019 (COVID-19). However, the patient's perception to these abrupt changes in medical services is not known. This study analyzed the quality of radiotherapy service during the COVID-19 pandemic and the patient's perception of them. This descriptive study will qualitatively assess cancer patient perception of the quality of radiotherapy service during COVID-19 pandemic. Willing participants were given a questionnaire that explore two major aspects: the patient's general knowledge of COVID-19 and their perception of radiotherapy service during the pandemic. The 145 participants of this study were generally well-informed about the significance of COVID-19 pandemic. Most respondents claimed to adequately practice preventive measures and put high regards in personal protective equipment (PPE) worn by them and healthcare workers for their safety. Their level of trust to all healthcare workers remained high and identified hospital announcements (television, brochures) educated them the most in regards to the relationship of COVID-19 and cancer. The changes in hospital policies and radiation oncology service in our institution were well-received by the study population. Despite the majority of respondents were afraid and anxious of being infected of COVID-19 while undergoing treatment, only a minority of them contemplated to delay or completely stop going for treatment. By adhering to major guidelines and adjustments of local resources, the delivery of radiotherapy service can remain consistent during the pandemic.

Building a sustainable future: Closing the gap in radiotherapy and brachytherapy resources to achieve the sustainable development agenda 2030 goals for cervical cancer control in Africa

AbstractThough radiation therapy services have been launched or expanded in several countries, there have also existed brief or seemingly ongoing infrastructure gaps. The purpose of this health policy study is to provide an overview of the radiation therapy resources available in Africa and to assess how well they align with the agenda 2030 goals, with a specific focus on the role of radiation therapy (both radiotherapy and brachytherapy) in reducing the incidence of cervical cancer. The study consulted publicly accessible datasets to gather information on each nation's radiation therapy equipment, cervical cancer mortality and incidence, gross domestic product (GDP), gross national income (GNI) and population size. This information was used to generate a final dataset for analysis across various African nations, identifying any gaps or areas where improvement is needed. We compared the external beam units (or brachytherapy afterloaders) and unmet needs across nations that had access to either external beam radiation therapy or brachytherapy using a straightforward linear regression. R studio was used for the statistical analysis. Africa's overall unmet need for radiotherapy service was 71.5%. Megavoltage units per cancer incidence and megavoltage units per million population had a strong significant association with economic status (GDP [r2 = 0.83; p &lt; .001]: and GNP [r = 0.83; p &lt; .001]). Additionally, the unmet cervical cancer needs based on the available brachytherapy capacity is about 60%. Interestingly, there was a strong correlation between cervical cancer incidence and brachytherapy capacity. Overall, the study provides valuable insights that can inform policy and decision‐making related to the provision of radiation therapy services in Africa. We expect that international organisations, African Union entities and governments will utilise the Directory of Radiotherapy Centres (DIRAC) initiative as a blueprint for establishing benchmarks and invest in radiotherapy and brachytherapy services in Africa.

Status of Government-Funded Radiotherapy Services in Nigeria.

Access to radiotherapy (RT) is now one of the stark examples of global cancer inequities. More than 800,000 new cancer cases require potentially curative or palliative RT services in Africa, arguably <15% of these patients currently have access to this important service. For a population of more than 206 million, Nigeria requires a minimum of 280 RT machines for the increasing number of cancer cases. Painfully, the country has only eight Government-funded RT machines. This study aimed to evaluate the status of the eight Government-funded RT services in Nigeria and their ability to deliver effective RT to their patients. A survey addressing 10 critical areas was used to assess the eight Government-funded RT services in Nigeria. Unfortunately, six of the eight centers (75%) surveyed have not treated patients with RT because they do not have functioning teletherapy machines in 2021. Only two RT centers have the capability of treating patients using advanced RT techniques. There is no positron emission tomography-computed tomography scan in any of the Government-funded RT centers. The workforce capacity and infrastructure across the eight centers are limited. All of the centers lack residency training programs for medical physicists and radiation therapy technologists resulting in very few well-trained staff. As the Nigerian Government plans for the new National Cancer Control Plan, there is an urgent need to scale up access to RT by upgrading the RT equipment, workforce, and infrastructure to meet the current needs of Nigerian patients with cancer. Although the shortfall is apparent from a variety of RT-capacity databases, this detailed analysis provides essential information for an implementation plan involving solutions from within Nigeria and with global partners.

Abstract 53: Implementing Equitable Cancer Support Program: Lessons From Cervical Cancer Chemotherapy Access Program (C3AP)

Abstract Purpose: There is an inverse relationship between diagnosis to initiation of treatment interval and outcome of cancer treatment. A significant number of diagnosed cervical cancer patients don’t receive timely treatment in low resource settings. The Cervical Cancer Chemotherapy Access Program (C3AP) is one of End Cervical Cancer Nigeria Initiative’s interventions to IMProve Access to Cervical Cancer Treatment (IMPACT) in low resource settings. This report provides documentary evidence of the evolution of the implementation of the C3AP and highlights best practices that can be scaled up. Methods: The C3AP was conceptualized to increase the proportion of diagnosed cervical cancer patients that receive timely treatment by exploring adjuvant and neoadjuvant role of chemotherapy in the management of cervical cancer patients in settings where access to radiotherapy services can not be guaranteed. We instituted Plan Do Study and Act (PDSA) quality improvement cycle for the C3AP and used RE-AIM framework to study the implementation processes to be acted upon as part of the PDSA quality improvement process towards improving reach of the program. Results: The C3AP supported treatment of only 4 patients over the reporting period of 5months. Poor referral to the program is a major hurdle the program is battling. Only 2(17%) of the 12 confirmed cases of cervical cancer diagnosed in the facility within the 5month study period were able to access chemoradiation, suggesting a missed opportunity for 6/10(60%) that couldn’t afford chemoradiation. The program evolved over a PDSA cycle to eliminate social eligibility in the criteria to access the support thereby able to shorten application -support interval to same day with potential positive impact on prognosis. Conclusion: Providing equitable support for indigent cancer patients should be beyond the emotion to help humanity. We recommend the use of structured quality improvement for all programs providing support to indigent cancer patients to ensure implementation fidelity. Citation Format: Qudus Lawal, Kasimu Umar Adoke, Jummai Jimeta Tuko, Aminu Magashi Garba, Ishak K. Lawal. Implementing Equitable Cancer Support Program: Lessons From Cervical Cancer Chemotherapy Access Program (C3AP) [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 53.

Abstract 86: The Status of Government-Funded Radiotherapy Centres in Nigeria

Abstract Purpose: Access to radiotherapy (RT) is now one of the stark examples of global cancer inequities. Over 800,000 new cancer cases require potentially curative or palliative RT services in Africa, arguably less than 15% of these patients currently have access to this important service. For a population of over 200 million, Nigeria requires a minimum of 280 RT machines for the increasing number of cancer cases. Painfully the country has only 8 government-funded radiotherapy machines. This study aimed to evaluate the status of the eight (8) Government-funded RT centres in Nigeria regarding RT equipment, workforce and infrastructure to quantify their ability to deliver effective RT to their patients. Methods: A survey addressing ten (10) critical areas was used to assess the eight (8) Government-funded RT centres in Nigeria. Results: Unfortunately, 6 of the 8 centres (75%) surveyed have not treated patients with RT over the last 2 years because they do not have functioning teletherapy machines. Only 2 RT centres have the capability of treating patients using advanced RT techniques. There is no PET-CT scan in any of the Government-funded RTcentres. The workforce capacity and infrastructure across the 8 centres are limited. All of the centres lack residency training programmes for medical physicists and radiation therapy technologists (RTTs) resulting in very few well-trained staff. Conclusion: As the Nigeria government plans for the new National Cancer Control Plan, there is an urgent need to scale up access to radiotherapy by upgrading the RT equipment, workforce and infrastructure to meet the current needs of Nigerian cancer patients. While the shortfall is apparent from a variety of radiotherapy-capacity data bases, this detailed analysis provides essential information for an implementation plan involving solutions from within Nigeria and with global partners. Citation Format: Runcie C.W. Chidebe, Chinedu S. Aruah, Tochukwu C. Orjiakor, Fatima Uba, Uchechukwu N Shagaya, Charles Ugwanyi, Aisha A Umar, Taofeeq Ige, Obinna C. Asogwa, Oiza T Ahmadu, Musa Ali-Gombe, Alabi Adewumi, Vitalis C. Okwor, Mutiu A Jimoh, Basheer Bello, Lucy O. Eriba, Yusuf A. Ahmed, Awwal Bisalla, Ukamaka Itanyi, Ramatallah A Balogun, Suleiman Alabi, David Pistenmaa, Coleman C. Norman, Dosanjh Manjit. The Status of Government-Funded Radiotherapy Centres in Nigeria [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 86.

Systematic Review and Meta-analysis of the Association Between Radiation Therapy Treatment Volume and Patient Outcomes

Evidence of a volume-outcome association in cancer surgery has shaped the centralization of cancer services; however, it is unknown whether a similar association exists for radiation therapy.The objective of this study was to determine the association between radiation therapy treatment volume and patient outcomes. This systematic review and meta-analysis included studies that compared outcomes of patients who underwent definitive radiation therapy at high-volume radiation therapy facilities (HVRFs) versus low-volume facilities (LVRFs). The systematic review used Ovid MEDLINE and Embase. For the meta-analysis, a random effects model was used. Absolute effects and hazard ratios (HRs) were used to compare patient outcomes. The search identified 20 studies assessing the association between radiation therapy volume and patient outcomes. Seven of the studies looked at head and neck cancers (HNCs). The remaining studies covered cervical (4), prostate (4), bladder (3), lung (2), anal (2), esophageal (1), brain (2), liver (1), and pancreatic cancer (1). The meta-analysis demonstrated that HVRFs were associated with a lower chance of death compared with LVRFs (pooled HR, 0.90; 95% CI, 0.87- 0.94). HNCs had the strongest evidence of a volume-outcome association for both nasopharyngeal cancer (pooled HR, 0.74; 95% CI, 0.62-0.89) and nonnasopharyngeal HNC subsites (pooled HR, 0.80; 95% CI, 0.75-0.84), followed by prostate cancer (pooled HR, 0.92; 95% CI, 0.86-0.98). The remaining cancer types showed weak evidence of an association. The results also demonstrate that some centers defined as HVRFs are undertaking very few procedures per annum (<5 radiation therapy cases per year). An association between radiation therapy treatment volume and patient outcomes exists for most cancer types. Centralization of radiation therapy services should be considered for cancer types with the strongest volume-outcome association, but the effect on equitable access to services needs to be explicitly considered.

IMPACT OF COVID-19 ON RADIATION ONCOLOGY IN PAKISTAN

The survey study was conducted in the Radiology Departments of different centers in Pakistan from June 2020 to October 2020 to assess the impact of COVID-19 on radiation therapy in Pakistan. Data about courses in external beam radiography and attendees were extracted from the hospital record. The percentage change in radiotherapy activity for each month between June to October 2020 was calculated and individually compared from June 2019 to October 2019. Results showed that lockdown was significantly associated with a reduction in radiotherapy courses (P&lt;.0001). The mean weekly number of radiotherapy courses decreased by 108 (-19.9%) in June 2020 from 543±170 in June 2019. The largest reduction in radiotherapy courses after the lockdown was reported in non-melanoma skin cancer and prostate cancer. Data analysis showed that radiation therapy services fell significantly at the onset of COVID-19. Cancers whose treatment can be safely delayed were most affected. On the other hand, cancers in which radiotherapy offered an alternative to surgery had seen a rise in treatment courses.

Expanding radiotherapy access in Sub-Saharan Africa: an analysis of travel burdens and patient-related benefits of hypofractionation.

The purpose of this project was to examine the travel burdens for radiotherapy patients in Nigeria, Tanzania, and South Africa, and to assess the patient-related benefits of hypofractionated radiotherapy (HFRT) for breast and prostate cancer patients in these countries. The outcomes can inform the implementation of the recent Lancet Oncology Commission recommendations on increasing the adoption of HFRT in Sub-Saharan Africa (SSA) to enhance radiotherapy access in the region. Data were extracted from electronic patient records at the NSIA-LUTH Cancer Center (NLCC) in Lagos, Nigeria and the Inkosi Albert Luthuli Central Hospital (IALCH) in Durban, South Africa, from written records at the University of Nigeria Teaching Hospital (UNTH) Oncology Center in Enugu, Nigeria, and from phone interviews at Ocean Road Cancer Institute (ORCI) in Dar Es Salaam, Tanzania. Google Maps was used to calculate the shortest driving distance between a patient's home address and their respective radiotherapy center. QGIS was used to map the straight-line distances to each center. Descriptive statistics were used to compare transportation costs, time expenditures, and lost wages when using HFRT versus conventionally fractionated radiotherapy (CFRT) for breast and prostate cancer. Patients in Nigeria (n=390) traveled a median distance of 23.1km to NLCC and 86.7km to UNTH, patients in Tanzania (n=23) traveled a median distance of 537.0km to ORCI, and patients in South Africa (n=412) traveled a median distance of 18.0km to IALCH. Estimated transportation cost savings for breast cancer patients in Lagos and Enugu were 12,895 Naira and 7,369 Naira, respectively and for prostate cancer patients were 25,329 and 14,276 Naira, respectively. Prostate cancer patients in Tanzania saved a median of 137,765 Shillings in transportation costs and 80.0 hours (includes travel, treatment, and wait times). Mean transportation cost savings for patients in South Africa were 4,777 Rand for breast cancer and 9,486 Rand for prostate cancer. Cancer patients in SSA travel considerable distances to access radiotherapy services. HFRT decreases patient-related costs and time expenditures, which may increase radiotherapy access and alleviate the growing burden of cancer in the region.

A personal perspective on the development and future of cone-beam CT for image-guided radiotherapy.

The development of cone-beam CT guided radiotherapy has transformed radiation oncology in the 20 years since it was first released commercially. The technological pace of change has spurred a massive transformation in our daily clinical practice, forced us to evolve our approach to multi- and inter-disciplinary collaboration, and enabled new treatment paradigms. Further progress in integrating quantitative CT in these robotic platforms promises to do even more by "burying the complexity" of radiotherapy and leveraging the expanding digital fabric that uses machine learning approaches to bring semi-automated expertise to bear on the issues of expertise and quality. This is the only way we will be able to respond to the massive global shortfall in high-quality radiotherapy services across the globe.

Resource Allocations for Common Radiation Oncology Procedures

Radiation Oncology is a complex, resource-intensive discipline. The complexity of the radiation oncology treatment process has increased significantly in recent years with the introduction of more advanced imaging, planning, and treatment delivery technology and enhanced use of multidisciplinary care paths. We conducted a multi-institutional study to estimate the average time by functional unit for a wide range of modern radiation oncology treatment regimens. Structured process mapping was performed for 24 treatment categories, and average time estimates for 6 functional groups were obtained for each process step through consultation with the full clinical team at each institution. Six geographically dispersed institutions participated in the study. Significant effort was invested in aggregate data analysis and clarification of assumptions. The findings show significant variability in the resources expended for many treatment categories as well as the distribution of workload between functional units. Major factors in the variability include the rate of adoption of hypofractionation in external beam therapy, adoption of automation tools and standardization, and the transition to multimodality image-based planning in brachytherapy. The data obtained from this study may be useful in designing institution-specific staffing models appropriate to the scope of radiation therapy services provided at each institution.