Radiotherapy resources in Africa: an International Atomic Energy Agency update and analysis of projected needs

The number of patients with cancer in Africa has been predicted to increase from 844 279 in 2012 to more than 1·5 million in 2030. However, many countries in Africa still lack access to radiotherapy as a part of comprehensive cancer care. The objective of this analysis is to present an updated overview of radiotherapy resources in Africa and to analyse the gaps and needs of the continent for 2030 in the context of the UN Sustainable Development Goals. Data from 54 African countries on teletherapy megavoltage units and brachytherapy afterloaders were extracted from the Directory for Radiotherapy Centres, an electronic, centralised, and continuously updated database of radiotherapy centres. Cancer incidence and future predictions were taken from the GLOBOCAN 2018 database of the International Agency for Research on Cancer. Radiotherapy need was estimated using a 64% radiotherapy utilisation rate, while assuming a machine throughput of 500 patients per year. As of March, 2020, 28 (52%) of 54 countries had access to external beam radiotherapy, 21 (39%) had brachytherapy capacity, and no country had a capacity that matched the estimated treatment need. Median income was an important predictor of the availability of megavoltage machines: US$1883 (IQR 914-3269) in countries without any machines versus $4485 (3079-12480) in countries with at least one megavoltage machine (p=0·0003). If radiotherapy expansion continues at the rate observed over the past 7 years, it is unlikely that the continent will meet its radiotherapy needs. This access gap might impact the ability to achieve the Sustainable Development Goals, particularly the target to reduce preventable, premature mortality by a third, and meet the target of the cervical cancer elimination strategy of 90% with access to treatment. Urgent, novel initiatives in financing and human capacity building are needed to change the trajectory and provide comprehensive cancer care to patients in Africa in the next decade.

Global Radiotherapy: Current Status and Future Directions-White Paper

Recognizing the increase in cancer incidence globally and the need for effective cancer control interventions, several organizations, professional bodies, and international institutions have proposed strategies to improve treatment options and reduce mortality along with minimizing overall incidence. Despite these efforts, an estimated 9.6 million deaths in 2018 was attributed to this noncommunicable disease, making it the second leading cause of death worldwide. Left unchecked, this will further increase in scale, with an estimated 29.5 million new cases and 16.3 million deaths occurring worldwide in 2040. Although it is known and generally accepted that cancer services must include radiotherapy, such access is still very limited in many parts of the world, especially in low- and middle-income countries. After thorough review of the current status of radiotherapy including programs worldwide, as well as achievements and challenges at the global level, the International Atomic Energy Agency convened an international group of experts representing various radiation oncology societies to take a closer look into the current status of radiotherapy and provide a road map for future directions in this field. It was concluded that the plethora of global and regional initiatives would benefit further from the existence of a central framework, including an easily accessible repository through which better coordination can be done. Supporting this framework, a practical inventory of competencies needs to be made available on a global level emphasizing the knowledge, skills, and behavior required for a safe, sustainable, and professional practice for various settings. This white paper presents the current status of global radiotherapy and future directions for the community. It forms the basis for an action plan to be developed with professional societies worldwide.

Pre-procedural high-pitch coronary CT angiography assessment of patients undergoing transcatheter aortic valve implantation (TAVI) without patient-specific adjustment: analysis of diagnostic performance

AIM

To evaluate the ability to assess the coronary arteries using pre-procedural computed tomography (CT; high-pitch mode) in patients referred for transcatheter aortic valve implantation (TAVI).

METHODS AND MATERIALS

CT and invasive coronary angiography (ICA) were performed pre-TAVI in 100 patients (46 women; 79 ± 5.9 years). CT was performed in prospectively ECG-triggered high-pitch mode after intravenous administration of 70 ml iodinated contrast medium. Image quality was assessed using a four-point scale (graded 0-3). Significant coronary artery stenosis (≥50% diameter) was graded as either present or absent by one observer and in one-third of patients by two observers independently. ICA was the standard of reference. Results were reported per segment and per patient.

RESULTS

Twenty-two percent of patients had known coronary artery disease (CAD). In two cases, a coronary anomaly was detected. Diagnostic image quality (grade 1-3) was achieved in 30.3% of segments. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 75%, 80.5%, 16%, and 98.5%, respectively. Significant coronary stenosis could be ruled out completely in all segments in three patients. The interrater agreement per patient was excellent (kappa = 1).

CONCLUSION

Relevant coronary findings can frequently be observed in high-pitch TAVI-planning CT. Despite the limitations of the technique and in patients referred to pre-TAVI evaluation (rapid heart rate, coronary calcifications, etc.), a valid evaluation of coronary arteries is possible in a considerable proportion of segments with a high NPV; however, few studies were completely free of motion artefacts to dependably exclude CAD using this technique in this challenging group of patients.

Shift in parasitic infections during the Corona pandemic: a hospital-based retrospective study

The Corona pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) calls on the Saudi government to take action to control the infection. The government closed borders, prohibited travel, limited outdoor movements, and told primary and secondary care facilities to reduce all regular non-urgent health services. It is not known whether these measures have impacted the prevalence of parasitic intestinal infections. This study has therefore been carried out to investigate this issue. Dataset of 217 stool samples submitted to the King Faisal Medical Complex (KFMC) Microbiology Laboratory in Taif, Saudi Arabia for parasitological examination during the pandemic (January-June 2020) and 649 samples submitted during the corresponding months of the previous year (January-June 2019) were extracted and analyzed. Overall, 24.1% (209/866) of samples were parasitespositives; 26.6% (173/649) before and 16.5% (36/217) during the pandemic, with 79% reduction. There was a significant difference in gender-parasitism between the two periods where the majority of parasitism were for males (p<0.001). Infections were frequent in patients aged 5- 14 years both before (84/649; 12.9%) and during (12/217; 5.5%) the pandemic, with significant difference observed between the two cohorts (p<0.002). Moreover, the majority of infected patients were non-Saudi (67.9%; 142/209), with a significant difference in nationality reported, (p=0.024). Protozoa were identified in 21.8% (189) of all samples investigated, of which, Blastocystis hominis, Entamoeba coli, Giardia lamblia, Entamoeba histolytica/dispar and Cryptosporidium species were identified in 6.1% (53), 5.4% (47), 5.0% (44), 2.8% (25), and 2.3% (20), respectively. Helminths were diagnosed in 2.3% (20/866) of samples. Eggs of hookworm, Ascaris, Taenia spp, and Hymenolepis nana were detected in 0.9% (8), 0.5% (5), 0.3% (3) and 0.4% (4), respectively. In parallel with our research hypothesis, a substantial decrease in the burden of intestinal parasitic infections was recorded with the lock-down measures taken during the Corona pandemic.

The timing and design of stereotactic radiotherapy approaches as a part of neoadjuvant therapy in pancreatic cancer: Is it time for change?

Stereotactic Radiotherapy (SRT) over 5-15 days can be interdigitated without delaying chemotherapy. Bridging chemotherapy may allow for extended intervals to surgery, potentially improving sterilization of surgical margins and overall survival. SRT for pancreatic adenocarcinoma should not be limited to the tumor, and should consider hypofractionated approaches to regional nodes.

Medical imaging and nuclear medicine: a Lancet Oncology Commission

The diagnosis and treatment of patients with cancer requires access to imaging to ensure accurate management decisions and optimal outcomes. Our global assessment of imaging and nuclear medicine resources identified substantial shortages in equipment and workforce, particularly in low-income and middle-income countries (LMICs). A microsimulation model of 11 cancers showed that the scale-up of imaging would avert 3·2% (2·46 million) of all 76·0 million deaths caused by the modelled cancers worldwide between 2020 and 2030, saving 54·92 million life-years. A comprehensive scale-up of imaging, treatment, and care quality would avert 9·55 million (12·5%) of all cancer deaths caused by the modelled cancers worldwide, saving 232·30 million life-years. Scale-up of imaging would cost US$6·84 billion in 2020-30 but yield lifetime productivity gains of $1·23 trillion worldwide, a net return of $179·19 per $1 invested. Combining the scale-up of imaging, treatment, and quality of care would provide a net benefit of $2·66 trillion and a net return of $12·43 per $1 invested. With the use of a conservative approach regarding human capital, the scale-up of imaging alone would provide a net benefit of $209·46 billion and net return of $31·61 per $1 invested. With comprehensive scale-up, the worldwide net benefit using the human capital approach is $340·42 billion and the return per dollar invested is $2·46. These improved health and economic outcomes hold true across all geographical regions. We propose actions and investments that would enhance access to imaging equipment, workforce capacity, digital technology, radiopharmaceuticals, and research and training programmes in LMICs, to produce massive health and economic benefits and reduce the burden of cancer globally.

IAEA consultancy meeting on low-dose radiation for patients and population

This paper reports on the IAEA's Consultancy Meeting on "low-dose radiation for patients and population -Science, Technology and Society (STS) concepts for communication and perception among medical doctors and stakeholders-", which was held on October 21 and 22, 2020. The meeting consisted of seven presentation sessions, with a total of 27 presentations and 39 participants from seven countries. The meeting focused on various areas including environmental, food, and personal dosimetry;radiation and other secondary health effects after nuclear disasters;communication between medical professionals and patients or residents;and medical education on nuclear accidents. This meeting was convened to discuss STS perspectives related to nuclear emergencies, to share the findings of the Fukushima Health Management Survey and the current situation in Fukushima with international experts. The meeting confirmed the importance of coordinated recovery of affected areas and global preparedness in the aftermath of nuclear accidents.

Multivessel versus culprit-only PCI in STEMI patients with multivessel disease: meta-analysis of randomized controlled trials

Background

Previous randomized controlled trials (RCTs) indicated a benefit of multivessel percutaneous coronary intervention (PCI) compared to culprit vessel-only PCI in ST-elevation myocardial infarction (STEMI) without cardiogenic shock.

Purpose

To perform a pairwise meta-analysis of RCTs, already including the recently published COMPLETE (The Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI) trial, comparing multivessel PCI and culprit vessel-only PCI in STEMI patients without cardiogenic shock.

Methods

We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase for randomized controlled trials (RCTs) comparing multivessel PCI with culprit vessel-only PCI in STEMI patients without cardiogenic shock and multivessel coronary artery disease. Only RCTs reporting mortality or myocardial reinfarction after at least 6 months following randomization were included. Hazard ratios (HRs) were pooled using random-effect models.

Results

Nine RCTs were included in the final analysis. In total, 523 (8.3%) of 6,314 patients suffered the combined primary endpoint of death or non-fatal reinfarction. This primary endpoint was significantly reduced with multivessel PCI compared to culprit vessel-only PCI (HR 0.63, 95% confidence interval [CI] 0.43–0.93; p=0.03). This finding was driven by a reduction of non-fatal reinfarction (HR 0.64, 95% CI 0.52–0.79; p=0.001), whereas no significant reduction of all-cause death (HR 0.77, 95% CI 0.44–1.35; p=0.28) or cardiovascular death (HR 0.64, 95% CI 0.37–1.11; p=0.09) was observed.

Conclusion

In STEMI patients without cardiogenic shock multivessel PCI reduced the risk of death or non-fatal reinfarction compared to culprit vessel-only PCI.

Funding Acknowledgement

Type of funding source: None

Addressing Global Inequities in Positron Emission Tomography-Computed Tomography (PET-CT) for Cancer Management: A Statistical Model to Guide Strategic Planning

Background

According to the World Health Organization (WHO), non-communicable diseases are responsible for 71% of annual global mortality. National governments and international organizations are increasingly considering medical imaging and nuclear medicine access data in strategies to address epidemiologic priorities. Our objective here was to develop a statistical model to assist countries in estimating their needs for PET-CT systems for the management of specific cancer types.

Material/Methods

We introduce a patient-centered statistical model based on country-specific epidemiological data, PET-CT performance, and evidence-based clinical guidelines for PET-CT use for cancer. The output of the model was integrated into a Bayesian model to rank countries or world regions that would benefit the most from upscaling PET-CT scanners.

Results

We applied our model to the IMAGINE database, recently developed by the International Atomic Energy Agency (IAEA). Our model indicates that at least 96 countries should upscale their PET-CT services and more than 200 additional PET-CT scanners would be required to fulfill their needs. The model also provides quantitative evidence indicating that low-income countries would benefit the most from increasing PET-CT provision. Finally, we discuss several cases in which the standard unit [number of scanners]/[million inhabitants] to guide strategic planning or address inequities is misleading.

Conclusions

Our model may help in the accurate delineation and further reduction of global inequities in access to PET-CT scanners. As a template, the model also has the potential to estimate the costs and socioeconomic impact of implementing any medical imaging modality for any clinical application.

Understanding High-Dose, Ultra-High Dose Rate, and Spatially Fractionated Radiation Therapy

The National Cancer Institute's Radiation Research Program, in collaboration with the Radiosurgery Society, hosted a workshop called Understanding High-Dose, Ultra-High Dose Rate and Spatially Fractionated Radiotherapy on August 20 and 21, 2018 to bring together experts in experimental and clinical experience in these and related fields. Critically, the overall aims were to understand the biological underpinning of these emerging techniques and the technical/physical parameters that must be further defined to drive clinical practice through innovative biologically based clinical trials.

Correction to: Nuclear medicine services after COVID-19: gearing up back to normality

The authors P. Orellana and N. El-Haj were inadvertently deleted in the original paper.