ASTRO 2016: Unmet Need for Radiation Therapy Found Among Nearly Half of Eligible Cancer Patients in Nine Developing Countries

Key Points

  • The median optimal radiation therapy utilization for all countries was 52%. Optimal utilization rates ranged from a low of 47% for Costa Rica to a high of 56% for Tunisia.
  • The median actual radiation therapy utilization rate was 28%, with a much broader range than for optimal utilization. The lowest rates of utilization were in Ghana (9%) and the Philippines (10.3%), while the highest utilization rates were in Tunisia (46%) and Uruguay (37%).
  • Ghana and the Philippines had the highest levels of unmet need, at 82.3 and 80.5%, respectively. In the majority of cases in Romania (57.6% and Serbia (54%), radiation therapy is not utilized, though indications for it exist. Costa Rica and Tunisia had the lowest levels of unmet need, at 25.5% and 18%, respectively.

Although approximately 50% of cancer patients in developing countries need radiation therapy to treat their disease, up to half of these patients do not have access to it, according to research presented by Rosenblatt et al at the 58th Annual Meeting of the American Society for Radiation Oncology (ASTRO). Examining nine middle-income countries, researchers found that between 18% and 82% of patients who can benefit from radiation therapy in these countries do not receive the treatment.

Researchers at the International Atomic Energy Agency conducted this project to assess levels of optimal and actual radiation therapy utilization and calculated unmet radiation therapy need in developing countries. This study is the first scientific analysis of radiation therapy utilization in middle-income countries.

Study Details

Findings reflect data from nine countries, including Costa Rica, Ghana, Malaysia, the Philippines, Romania, Serbia, Slovenia, Tunisia, and Uruguay. Optimal and actual radiation therapy utilization rates were determined for each country. The optimal radiation therapy utilization rate is the proportion of all newly diagnosed cases of cancer who have an indication for radiation therapy at least once in their lifetime. An indication for radiation therapy was defined as a clinical scenario for which radiation therapy is recommended as the treatment of choice because there is evidence of its superiority to alternative modalities and/or no treatment (eg, better survival, local control, or quality of life profiles). In clinical situations where radiation therapy was equivalent to other treatment options, all comparable modalities were included in the model, and a subsequent sensitivity analysis was conducted to determine the proportion of these patients who indicated for radiation therapy.

Indications for radiation therapy for each cancer site were derived from treatment guidelines published by reputed national and international organizations. An evidence-based computation model was used based on data from high income countries, and researchers developed optimal radiation therapy utilization models for each cancer site by combining clinical scenarios and epidemiological data. The distribution of tumor types for each country was obtained from Globocan-2012, and patients were counted only once even if they subsequently developed repeated indications radiation therapy.

Actual radiation therapy utilization rate was calculated dividing the total number of new cases of cancer treated with radiation therapy for the first time in 2012 (“new RT cases”), by the total number of new cases of cancer diagnosed in the same year (“incident cases”). The total number of new RT cases for each country was reported to the research team by the individual country coordinators who gathered the data from their own center, and all other radiation therapy centers in their respective countries. Incident cases were obtained from cancer incidence data from Globocan-2012.

The case-mix for each country was determined by prospectively registering 300 consecutive patients receiving radiation therapy at a leading radiation therapy center in each country and by capturing detailed data on patient, tumor, and treatment characteristics from this sample.

Analysis Findings

The median optimal radiation therapy utilization for all countries was 52%. Optimal utilization rates ranged from a low of 47% for Costa Rica to a high of 56% for Tunisia. Differences in optimal utilization rates are attributable to varying incidence rates of cancer types in each country.

Median actual radiation therapy utilization rate was roughly half of optimal utilization, suggesting that nearly half of cancer patients across these nine countries combined may not be receiving adequate care for their disease. The median actual radiation therapy utilization rate was 28%, with a much broader range than for optimal utilization. The lowest rates of utilization were in Ghana (9%) and the Philippines (10.3%), while the highest utilization rates were in Tunisia (46%) and Uruguay (37%).

Actual radiation therapy utilization rates were lower than optimal utilization rates for all nine countries, with the smallest difference in Tunisia and the widest gap in Ghana at nearly 43 percentage points. Median level of unmet need was 47% for all countries combined.

Ghana and the Philippines had the highest levels of unmet need, at 82.3% and 80.5%, respectively. In the majority of cases in Romania (57.6%) and Serbia (54%), radiation therapy is not utilized, though indications for it exist. Costa Rica and Tunisia had the lowest levels of unmet need, at 25.5% and 18%, respectively. Unmet need in radiation therapy utilization indicates that the treatment is not administered when needed.

“Access to radiation therapy remains limited in low- and middle-income countries,” said Elena Fidarova, MD, a researcher at the International Atomic Energy Agency in Vienna and co-author of the study. “In Ghana and the Philippines, for example, about 8 in 10 cancer patients who need radiation therapy will not receive needed treatment. To eradicate this disparity, efforts should be made to improve access to radiation therapy. National radiation therapy strategy with realistic short-, mid- and long-term goals should be developed and incorporated into comprehensive national cancer control plans. Existing obstacles to radiation therapy access should be systematically addressed in the planning phase.”

The unmet need was particularly substantial (in the order of 80%) in countries with limited resources and a large population. The number of teletherapy machines per 1,000 cancer cases ranged from a high of 1.3 in Tunisia to a low of 0.19 in Ghana. The strong correlation between the actual radiation therapy utilization rates and the number of teletherapy machines per 1,000 cancer cases/year in each country confirms that, although other access factors may be at play, availability of radiation therapy machines is an important factor in radiation therapy utilization.

“Our findings strongly support the call for action from the Lancet Oncology Commission, which requires a worldwide effort to expand global access to radiation therapy,” said Dr. Fidarova. “Differences between optimal and actual radiation therapy utilization rates and the high percentage of unmet radiation therapy need likely stem from a number of complex reasons, although inadequate capacity for radiation therapy is the most obvious factor. As obstacles in access to existing radiation therapy services, such as inadequate referral patterns, affordability of treatment, and geographical distribution of centers, differ by country, so does the ideal mix of solutions.”

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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