Due to low cancer awareness in developing countries, an estimated 80% of all patients with cancer have advanced stage disease at initial presentation. Even if detected at an earlier stage, however, there is inadequate access to treatment to cure or manage pain for cancer patients.
The need for radiotherapy is much greater in developing countries due to late-stage presentations and the types of cancer that predominate. Access to radiotherapy, however, is severely limited:
- While at least 55% of all cancers in Africa have an indication for radiotherapy, facilities are available in only 23 of Africa’s 53 countries, reaching less than 5% of the (total African) population.
- Africa has less than 2% of all radiotherapy cancer centres globally and is home to approximately 15% of the world's population, demonstrating the dire need to improve the availability of radiotherapy.
While African countries will account for over a million new cancer cases a year, the lack of resources and basic infrastructure mean that most Africans have no access to cancer screening, early diagnosis, treatment or palliative care.
One of our students David Evans, told us about his experiences on an oncology placement. David was fortunate to work in one of the only cancer institutes in Tanzania, and had an incredible learning experience.
"The staff are very friendly and are obviously doing the best they can with very limited resources. I've yet to experience the cobalt-60 machines in action but hopefully that will come in the near future. Today was spent in (HDR) Brachytherapy treating stage 3 and 4 cervix patients. Despite a team of people, due to the technology they have they are only able to treat 3 people per day per machine. After insertion, orthogonal films are taken, developed, and scanned before the planning can begin. 2D dose distributions are then planned while the patient is lying waiting on the bed. The whole procedure seemed to take 2-3 hours, after which the patient was sent home (or to where they are staying) without any recovery time but with pain relief medication.
The past two days have been incredibly interesting as I got to see patients being treated on the external beam machines. Despite treating huge numbers of patients per machine the pace of African life means things seem to move very slowly and calmly, but then again there are no boxes of chocolates so I suppose it all evens out. Most of the radiographers I have seen do not wear TLDs because they say they only get exchanged every couple of years so they don’t see the point. Despite daily QA checks I’m not sure how happy I’d be without my TLD and radiation alarm keeping me safe from the lump of cobalt-60 sitting in the head of the machine.
The most complicated treatment I have seen so far has been a 6 year old girl being treated for an retinoblastoma, but even this was only 3 fields and there was no immobilisation or shielding for the contra-lateral eye. Most of the other treatments have been ant and post parallel opposed pairs. Apart from some head and neck patients there is no immobilisation other than a head rest and there are no treatment plans – radiographers set the field size and exposure time from the treatment sheet and then simply set up by eye, based on external physical landmarks or steri-strips stuck on the patient’s skin on the first day of treatment. For over 75% of patients there is no further imaging after diagnosis and only the most complicated cases are imaged on the simulator.
This week has seen a visit from the head of the physics department from Inkosi Albert Luthuli Central Hospital in Durban acting on behalf of the IAEA. He has been as surprised as I was by some of the techniques being used here and together with the local head of physics a plan has been drawn up to simulate most, if not all patients, and improve immobilisation and skin markers.
One of the cobalt machines has been out of action for nearly a week now, meaning that there is currently only one radiotherapy machine in the entire country. As they work from 8am to 10pm already, there is no possibility of treating more patients on the one working machine so patients are simply not treated. Breaks in treatment of up to 2 weeks are not uncommon due to machine breakdowns, often in very advanced and aggressive cancers.
I've spent the week split between the one working treatment unit and oncologist's clinics. Today I saw the effect of machine breakdowns when five women had their treatment intent changed from radical to palliative because so many of their appointments had to be canceled, unfortunately the radiobiological benefit has been irreversibly lost.
On the plus side, for the first time since I arrived I saw a cervix patient treated with a 4-field brick technique rather than the normal ant and post parallel opposed pair. On the down side, one of the lateral lasers does not work and the isocentre markers were plasters stuck to the patient's skin.
I only saw one patient being treated with a head shell in the entire time I was there. They had been used previously but the department did not have the budget to order any more. They had 15 left but they were being reserved for 'VIPs', so all the other head and neck patients were treated without any immobilisation."