Millions of Cancer Victims in Developing Countries Lack Access to Life-Saving Radiotherapy
Vienna, 26 June 2003 |
The number of cancer patients in the developing world will double to 10 million new cases annually by 2015 (World Cancer Report, World Health Organization, 2003), most of whom will have no access to the radiation therapy that could save or prolong their lives, and decrease their pain and suffering, the International Atomic Energy Agency (IAEA) says. Radiotherapy ranks with surgery as the most important methods of curing local cancer, according to the World Health Organization (WHO).
"A silent crisis in cancer treatment exists in developing countries and is intensifying every year," says Mohamed ElBaradei, IAEA Director General. "At least 50 to 60 percent of cancer victims in the developing world can benefit from radiotherapy that destroys cancerous tumours, but most developing countries do not have enough radiotherapy machines or sufficient numbers of specialized doctors and other health professionals."
Developing countries are home to 85 percent of the world population, but they have only about one-third of the total radiotherapy facilities, or some 2,200-radiation therapy machines. In contrast, the developed world has more than 4,500 treatment machines.
Some 15 African nations and several countries in Asia lack even one radiation therapy machine. Ethiopia, which has 60 million people, possesses just one such machine, provided by the IAEA. Other developing countries have very low ratios of machines per population, often one machine for several million people, versus a ratio of one machine per 250,000 inhabitants, which is typical of most developed countries.
Over the next decade, the IAEA estimates that at least $2.5 billion is needed to provide adequate treatment facilities in the developing world, half to purchase machines, and half to train the physicians and physicists required to ensure safe and effective treatment.
"We believe that treating cancer has to be made a global health care priority," says Dr. ElBaradei.
According to the WHO, some 6 million people died from cancer in 2000, the last year for which full results are available. Cancer deaths will increase to 10 million per year by 2020, according to latest estimates.
"The growing cancer crisis in the developing world can be traced to people living longer, changing lifestyles, unhygienic living conditions and other important factors," says Bhadrasain Vikram, MD, IAEA radiation oncologist in its Human Health Division. "This crisis is predictable and, to some degree preventable, depending on how well we start to manage it now."
Radiotherapy, also called radiation therapy, attacks cancer and other diseases with ionizing radiation, which deposits energy that injures or destroys malignant cells in tumour tissue. The genetic material of these cells is damaged, making it impossible for them to continue to reproduce. When the radiation is accurately aimed and delivered at the right doses the cancer cells are damaged irreparably while the adjacent normal cells are able to repair themselves and function properly.
Radiotherapy is used to treat localized solid tumours, such as cancers of the skin, mouth, larynx, brain, breast, prostate or uterine cervix. It can also be used to treat cancers of the blood-forming cells and lymphatic system such as lymphoma. Radiotherapy is often administered before surgery or after surgery to either facilitate surgery or consolidate surgical gains, and reduce local recurrence. The vast majority of the external beam radiotherapy in the developing world uses ionizing radiation from a cobalt-60 source. Another technique for delivering radiation to cancer cells is to place radioactive implants directly in a tumour or body cavity. This is called internal radiotherapy or brachytherapy. In this treatment, the radiation dose is concentrated in a small area, and the patient stays in the hospital for only a few hours or days. Internal radiotherapy is frequently used for cancers of the tongue, prostate, and cervix.
"There are insufficient facilities and qualified staff to adequately treat the victims of cancer in the developing world today," says Ana Maria Cetto, IAEA's Head of the Department of Technical Co-operation. "The IAEA supports the provision of radiotherapy equipment, training, quality assurance and maintenance in developing countries."
The IAEA says that because of the types of cancer more prevalent in the developing world, such as cervical cancer, and because the cancers are often diagnosed at later stages the vast majority of cancers in the developing world should be treated by radiation. Even for advanced cases where curative therapy may not always work, radiation is able to provide substantial pain relief.
To address this challenge, the IAEA is working with key partners such as WHO in establishing national cancer management programmes that include prevention, early diagnosis, treatment and palliative care. Studies show that in advanced countries with such programmes, the investment pays off - about 45 percent of all cancers are cured.
The IAEA works in partnership with the WHO on most of its cancer projects. The WHO works to address the full spectrum of the health-disease continuum from prevention to end-of-life care. The role of the IAEA in cancer control programs has grown rapidly as radiotherapy and nuclear imaging become increasingly important for the management of cancer.
IAEA programmes in some 80 countries around the world demonstrate the value of radiation therapy. The four main IAEA goals are:
- Mobilizing the required funding to bring machines and training for local specialists in the 15 African countries that do not have any and where the technology is sustainable
- Increasing the number of machines to enable people to access radiation therapy when they need it - to a far higher proportion than the present one machine for one million people;
- Increasing the utilization of existing machines by training more doctors and other health professionals in their safe and effective use.
- Establishing good clinical and safety practices in radiotherapy institutions.
"The IAEA has been stepping up its efforts as the coming crisis in cancer management in the developing world has become more acute," says Dr. ElBaradei. "Greater support from the international community is needed so that effective cancer treatment is more widely available in the less advantaged nations of the world."
Ethiopia -- Cancer of the cervix is among the most common forms of cancer in Ethiopian women. It is usually fatal because of late detection and the scarcity of treatment facilities. Cervical cancer mostly affects Ethiopian women over 30 years old and peaks in the 40-45 year old age group. Cervical cancer strikes Ethiopian women at more than four times the average incidence in developed countries where routine screening (such as PAP smear) provides early detection, which usually yields to simple and effective radiation treatment.
Genet A., an Ethiopian woman, is an example of a person whose life was saved by radiotherapy. When she was 34 years old, she began to feel sick all the time. She went to a regional hospital in Ethiopia's southern city of Awasa, where, four months after she had first noticed her health problem, she was diagnosed with invasive cervical cancer.
Doctors told her that she had less than two years to live without treatment. She worried about the fate of her two young sons, believing she would soon die. In July 2001, Genet boarded a bus in Awasa and traveled 300 kilometers (180 miles) north to the nation's capital of Addis Ababa. She had been referred by her local hospital to Dr. Bogale Solomon, director of the Black Lion Hospital Radiotherapy Department.
The centre opened in 1997, a joint project between the Ethiopian Government and the IAEA. In its first four years, the facility has treated 1,300 patients, with the number of patients per month growing steadily, and with a growing waiting list.
Seven days after Genet began her 30-day treatment, the symptoms that alerted doctors to her condition stopped.
Genet has joined a group of patients, mostly other women, who attend the clinic daily as outpatients. These patients are exposed to small doses of radiation, lasting one to two minutes, a process known as fractionation, which best spares healthy cells. The treatment entails directing multiple beams of radiation from outside the body at the tumour. The radiotherapy machine being used is Chinese-made and its radioactive source is cobalt-60, first used therapeutically 50 years ago.
Her chances of being cured are good, says Dr. Bogale, an internist and Ethiopia's sole radiation oncologist. "Although her disease was too advanced to be operated on, she's an early case," he explained. "The cancer hadn't spread out of the pelvis region."
Women make up about 70 per cent of the patients at the centre, and cancer of the cervix is the most common disease comprising over one-third of all female patients treated. The incidence of cervical cancer is high all across sub-Saharan Africa, Latin America and Asia, where infection with the human papilloma virus (HPV) is blamed for its proliferation. The main factors include poor hygiene linked to poverty. Recently, the spread of HIV (the virus that causes AIDS) may have also increased the risk of getting cervical cancer, and other cancers such as lymphoma and Karposi's sarcoma.
Unfortunately, many of the patients referred to the Black Lion Hospital are not diagnosed until the disease is far advanced. Nevertheless 50 percent of patients treated there four years ago are still alive, Dr. Bogale said.
"Although there is an increasing prevalence of cancer in developing countries there is a lack of awareness of the seriousness of the growing cancer management crisis," says Victor Levin, head of the IAEA section of Applied Radiation Biology and Radiotherapy. "The perception that there is less chance of getting cancer in developing countries is proving increasingly false," Levin says.
With help from the IAEA, modern radiotherapy facilities have been set up for the first time in several African countries, including Ghana, Ethiopia, Namibia, and Uganda. Second radiotherapy centers have been added in Nigeria and Sudan. Countries currently receiving assistance to initiate radiotherapy services include Angola, Yemen and Zambia.
Sri Lanka -- The incidence of most kinds of cancer is rising rapidly in Sri Lanka, the island nation of 19 million people formerly known as Ceylon, located off the southeast coast of India.
In 2002 alone, almost 25,000 new and treated cases of cancer were recorded, more than a 100 percent increase over comparable figures for 1992.
In the cancer wards of Kandy General Hospital in the central region of the country, the lines of patients seeking radiotherapy treatment from the facilities' two cobalt therapy units reach into the hundreds every day.
"Across Sri Lanka, we are witnessing a rapid rise in adult cancers of all types," explains Sarath Wattegama, MD, the chief radiation oncologist at Kandy General. "The incidence of adult cancers - such as breast and cervical cancer in women and lung, throat and stomach cancer in men - and the demand for adequate radiotherapy services are accelerating steadily."
Kandy General Hospital covers five of Sri Lanka's nine provinces, including seven million people. "Our cancer unit has just 70 beds for patients," explains Dr. Wattegama. "Meanwhile, more than 100 outpatients visit the clinic every day, so there is a desperate over demand for both treatment and patient support services." Pressed by the growing demand, Dr. Wattegama and his assistants can only afford a few minutes for each patient for diagnosis, treatment and follow-up.
Upgrading of Kandy General's cancer treatment facilities and services began in 1998, with $260,000 in project assistance from the IAEA Technical Co-operation Programme. The IAEA supplied a lowdose-rate brachytherapy system to treat cervical cancers, a fully equipped radiation measurement laboratory and a workshop to produce immobilization devices. The government purchased two teletherapy units to provide external beam-directed therapy. The hospital computerized tomography (CT) and magnetic resonance imaging (MRI) scanners have been linked to a newly acquired Treatment Planning System, which is operated by an IAEA trained medical physicist.
"We run 120-150 patients through this treatment facility every day," explains Mr. H.M.S. Herath, the principal medical physicist at Kandy General. "That's roughly twice as many patients per machine as they would treat in Australia or Singapore." With support from the IAEA, Mr. Herath received specialized training in operating the software that accurately calculates the location and intensity of gamma radiation targeting cancerous tumours.
Mr. C. is a 45-year-old former fish vendor who is a recent beneficiary of Kandy's radiation therapy. He was selling fish door-to-door until nine months ago when he was diagnosed with a brain tumour. In fact, when he arrived semiconscious for an examination it appeared that he had lung cancer and that the malignant cells had already gone into his brain. Had it not been for radiotherapy, he probably would not be alive today. Following radiation treatments, Mr. C. is now in stable condition, but too weak to work. Sitting on the porch of his house in a village outside Kandy, Mr. C. knows, although belatedly, that cigarette smoking was the cause of his lung cancer. In a wooden shed next to his simple house, his wife and two children earn extra income by selling groceries and homemade pastries to neighbours.
Brazil -- The incidence of cancer in Brazil has been rising steadily in recent decades and cancer now is the second leading cause of death in the country, after circulatory diseases, according to the Pan American Health Organization (PAHO). Among Brazilian men, the most common cancer deaths are caused by cancers of the lung, stomach and prostate. Among women, the leading cancer deaths are from malignancies of the breast, lungs and cervix. Indeed, almost 231,000 women die every year in the Americas because of cervical cancer, according to PAHO. More than three fourths of those deaths occur in developing countries.
In order to address the cancer threat, Brazil's Ministry of Health purchased 15 modern linear accelerator cancer treatment machines in 2002 at a total cost of $15 million, which will be set up in cities around the country as part of a national programme to provide hospitals with advanced technologies for treatment.
The IAEA is providing expert advice and training on advanced techniques for shaping the radiation doses to conform with tumours for more effective treatment. The Agency is also implementing quality assurance and quality control procedures for the operation of these machines, as well as training in the technique known as "dynamic wedge" therapy in all radiation oncology departments in Brazil.
The public hospital, A.C. Camargo, in Sao Paulo, will provide the basic infrastructure and a linear accelerator capable of performing dynamic therapy. Appropriate dosimetric equipment required for these improved services is also provided by the IAEA.
Croatia -- The IAEA has been involved in upgrading radiotherapy for the treatment of cancer in most countries of Eastern Europe and the former Soviet Union. Since 1997, the IAEA has trained over 500 specialists from this region alone in specific radiation therapy skills.
Cancer rates in Croatia have been rising steadily in recent years: each year there are roughly 15,000 new cases.
The IAEA started its work in Croatia in 1997, with the objective to improve radiotherapy services and practices in various hospitals, mostly in the capital of Zagreb.
The projects include:
- Improving radiotherapy services and practices in the treatment of cancers at three medical centres in Zagreb by providing complementary equipment and training; and
- Extending the use of positron emission tomography (PET), a new imaging technique that is being increasingly used in developed countries, for the evaluation of cancer patients before and after treatment.
In Africa, the IAEA is working with 22 countries: Egypt, Tunisia, Kenya, Tanzania, Zimbabwe, Algeria, Libya, Morocco, South Africa, Gabon, Senegal, Cameroon, Madagascar and Mauritius, Ghana, Ethiopia, Namibia, Uganda, Nigeria, Sudan, Angola, Yemen and Zambia.
In Europe, the IAEA is working with 27 countries: Albania, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Estonia, Georgia, Greece, Hungary, Latvia, Lithuania, Malta, Poland, Portugal, Republic of Moldova, Romania, Russian Federation, Serbia and Montenegro, Slovakia, Slovenia, the former Yugoslav Republic of Macedonia, Turkey, and Ukraine.
In Asia, the IAEA is working with 17 countries: China, Singapore, Philippine, Korea, Thailand, Vietnam, Malaysia, Mongolia, New Zealand, Pakistan, Sri Lanka, Australia, India, Japan, Bangladesh, Indonesia and Myanmar.