Closing the Cancer Divide Through Ubuntu: Information and Communication Technology-Powered Models for Global Radiation Oncology

Democratizing FLASH Radiotherapy

FLASH radiotherapy (RT) is emerging as a potentially revolutionary advancement in cancer treatment, offering the potential to deliver RT at ultra-high dose rates (>40 Gy/s) while significantly reducing damage to healthy tissues. Democratizing FLASH RT by making this cutting-edge approach more accessible and affordable for healthcare systems worldwide would have a substantial impact in global health. Here, we review recent developments in FLASH RT and present perspective on further developments that could facilitate the democratizing of FLASH RT. These include upgrading and validating current technologies that can deliver and measure the FLASH radiation dose with high accuracy and precision, establishing a deeper mechanistic understanding of the FLASH effect, and optimizing dose delivery conditions and parameters for different types of tumors and normal tissues, such as the dose rate, dose fractionation, and beam quality for high efficacy. Furthermore, we examine the potential for democratizing FLASH radioimmunotherapy leveraging evidence that FLASH RT can make the tumor microenvironment more immunogenic, and parallel developments in nanomedicine or use of smart radiotherapy biomaterials for combining RT and immunotherapy. We conclude that the democratization of FLASH radiotherapy represents a major opportunity for concerted cross-disciplinary research collaborations with potential for tremendous impact in reducing radiotherapy disparities and extending the cancer moonshot globally.

Artificial Intelligence-Based Radiotherapy Contouring and Planning to Improve Global Access to Cancer Care

PURPOSE

Increased automation has been identified as one approach to improving global cancer care. The Radiation Planning Assistant (RPA) is a web-based tool offering automated radiotherapy (RT) contouring and planning to low-resource clinics. In this study, the RPA workflow and clinical acceptability were assessed by physicians around the world.

METHODS

The RPA output for 75 cases was reviewed by at least three physicians; 31 radiation oncologists at 16 institutions in six countries on five continents reviewed RPA contours and plans for clinical acceptability using a 5-point Likert scale.

RESULTS

For cervical cancer, RPA plans using bony landmarks were scored as usable as-is in 81% (with minor edits 93%); using soft tissue contours, plans were scored as usable as-is in 79% (with minor edits 96%). For postmastectomy breast cancer, RPA plans were scored as usable as-is in 44% (with minor edits 91%). For whole-brain treatment, RPA plans were scored as usable as-is in 67% (with minor edits 99%). For head/neck cancer, the normal tissue autocontours were acceptable as-is in 89% (with minor edits 97%). The clinical target volumes (CTVs) were acceptable as-is in 40% (with minor edits 93%). The volumetric-modulated arc therapy (VMAT) plans were acceptable as-is in 87% (with minor edits 96%). For cervical cancer, the normal tissue autocontours were acceptable as-is in 92% (with minor edits 99%). The CTVs for cervical cancer were scored as acceptable as-is in 83% (with minor edits 92%). The VMAT plans for cervical cancer were acceptable as-is in 99% (with minor edits 100%).

CONCLUSION

The RPA, a web-based tool designed to improve access to high-quality RT in low-resource settings, has high rates of clinical acceptability by practicing clinicians around the world. It has significant potential for successful implementation in low-resource clinics.

Cancer in sub-Saharan Africa: a Lancet Oncology Commission

In sub-Saharan Africa (SSA), urgent action is needed to curb a growing crisis in cancer incidence and mortality. Without rapid interventions, data estimates show a major increase in cancer mortality from 520 348 in 2020 to about 1 million deaths per year by 2030. Here, we detail the state of cancer in SSA, recommend key actions on the basis of analysis, and highlight case studies and successful models that can be emulated, adapted, or improved across the region to reduce the growing cancer crises. Recommended actions begin with the need to develop or update national cancer control plans in each country. Plans must include childhood cancer plans, managing comorbidities such as HIV and malnutrition, a reliable and predictable supply of medication, and the provision of psychosocial, supportive, and palliative care. Plans should also engage traditional, complementary, and alternative medical practices employed by more than 80% of SSA populations and pathways to reduce missed diagnoses and late referrals. More substantial investment is needed in developing cancer registries and cancer diagnostics for core cancer tests. We show that investments in, and increased adoption of, some approaches used during the COVID-19 pandemic, such as hypofractionated radiotherapy and telehealth, can substantially increase access to cancer care in Africa, accelerate cancer prevention and control efforts, increase survival, and save billions of US dollars over the next decade. The involvement of African First Ladies in cancer prevention efforts represents one practical approach that should be amplified across SSA. Moreover, investments in workforce training are crucial to prevent millions of avoidable deaths by 2030. We present a framework that can be used to strategically plan cancer research enhancement in SSA, with investments in research that can produce a return on investment and help drive policy and effective collaborations. Expansion of universal health coverage to incorporate cancer into essential benefits packages is also vital. Implementation of the recommended actions in this Commission will be crucial for reducing the growing cancer crises in SSA and achieving political commitments to the UN Sustainable Development Goals to reduce premature mortality from non-communicable diseases by a third by 2030.

Mobilising stakeholders to improve access to state-of-the-art radiotherapy in low- and middle-income countries

In an ongoing effort to improve access to state-of-the-art radiotherapy in low- and middle-income countries (LMICs), a joint symposium was organised by the non-governmental, non-profit organisation Medical physicists in diaspora for Africa e.V. (MephidA e.V.) in collaboration with the Germany-based Cameroon-German medical doctor’s association (Camfomedics e.V.) and the Harvard-based Global Health Catalyst summit. The goal of the symposium was to discuss the technical and structural challenges faced in African LMIC settings, re-evaluate strategies to overcome the shortfall of radiotherapy services and ameliorate the situation. The meeting brought together industry partners, including radiotherapy machine vendors and dosimetry solution providers, alongside public health, oncology and medical physics experts. This paper summarises the deliberations and recommendations based on the ongoing efforts including the use of information and communication technologies towards the provision of expert knowledge and telemedicine, the use of solar energy to avoid power outages and the use of high-end technology for enhanced quality assurance. We also present the experiences on the first linac installation at the Rwanda Military Hospital, the challenges faced in this LMIC as well as the patient’s demography, reflecting the reality in most sub-Saharan LMICs.

Using advanced information and communication technologies to advance oncology education in Africa

Background

Recent work has highlighted the tremendous potential of information and communication technologies (ICTs) in advancing global oncology education, research and care. The COVID-19 pandemic has made the development of effective approaches for online education even more crucial. Here we assessed the readiness, interest and potential models for effective implementation of ICT-powered oncology education in Africa.

Methods

Building on previous work by the African Organisation for Research and Training in Cancer (AORTIC), a survey was conducted to assess the electronic learning (e-Learning) readiness of oncology health professionals using an online self-assessment tool. Components of e-Learning readiness assessed include access to computers, Internet, appropriate bandwidth and interest. As a practical test model, an ICT resource-intensive radiation oncology training programme was implemented via the Global Oncology University (GO-U) collaborative education platform. An analysis of results, challenges and opportunities resulting from these is discussed for advancing online oncology education in Africa.

Results

The survey showed over 92% of health professionals have access to computers, laptops or other technology that can allow them to participate in online education. Over 45% of oncology health professionals have already participated in some form of online education. Interest in online education was over 93%. Models for effective online learning in oncology include synchronous and asynchronous short-term courses for continuous education and long-term degree and residency programmes. There was a significant increase in skills level following the collaborative radiation oncology training model used by the GO-U platform.

Conclusion

Africa has the capacity to implement successful e-Learning in oncology, which is consistent with findings in previous work such as the AORTIC. Greater investment by institutions and governments is needed in terms of resources and policy changes to facilitate the implementation of effective online oncology training. Purposeful engagement of diaspora oncology health professionals with relevant cultural backgrounds as with some current collaborative efforts is highly recommended in helping turn brain drain into brain circulation.

Hypofractionated Radiotherapy in African Cancer Centers

In the advent of the coronavirus disease (COVID-19) pandemic, professional societies including the American Society for Radiation Oncology and the National Comprehensive Cancer Network recommended adopting evidence-based hypofractionated radiotherapy (HFRT). HFRT benefits include reduction in the number of clinical visits for each patient, minimizing potential exposure, and reducing stress on the limited workforce, especially in resource-limited settings as in Low-and-Middle-Income Countries (LMICs). Recent studies for LMICs in Africa have also shown that adopting HFRT can lead to significant cost reductions and increased access to radiotherapy. We assessed the readiness of 18 clinics in African LMICs to adopting HFRT. An IRB-approved survey was conducted at 18 RT clinics across 8 African countries. The survey requested information regarding the clinic’s existing equipment and human infrastructure and current practices. Amongst the surveyed clinics, all reported to already practicing HFRT, but only 44% of participating clinics reported adopting HFRT as a common practice. Additionally, most participating clinical staff reported to have received formal training appropriate for their role. However, the survey data on treatment planning and other experience with contouring highlighted need for additional training for radiation oncologists. Although the surveyed clinics in African LMICs are familiar with HFRT, there is need for additional investment in infrastructure and training as well as better education of oncology leaders on the benefits of increased adoption of evidence-based HFRT during and beyond the COVID-19 era.

Practical considerations for prostate hypofractionation in the developing world

External beam radiotherapy is an effective curative treatment option for localized prostate cancer, the most common cancer in men worldwide. However, conventionally fractionated courses of curative external beam radiotherapy are usually 8-9 weeks long, resulting in a substantial burden to patients and the health-care system. This problem is exacerbated in low-income and middle-income countries where health-care resources might be scarce and patient funds limited. Trials have shown a clinical equipoise between hypofractionated schedules of radiotherapy and conventionally fractionated treatments, with the advantage of drastically shortening treatment durations with the use of hypofractionation. The hypofractionated schedules are supported by modern consensus guidelines for implementation in clinical practice. Furthermore, several economic evaluations have shown improved cost effectiveness of hypofractionated therapy compared with conventional schedules. However, these techniques demand complex infrastructure and advanced personnel training. Thus, a number of practical considerations must be borne in mind when implementing hypofractionation in low-income and middle-income countries, but the potential gain in the treatment of this patient population is substantial.

The Practice of Paediatric Radiation Oncology in Low- and Middle-income Countries: Outcomes of an International Atomic Energy Agency Study

AIMS

Childhood cancer survival is suboptimal in most low- and middle-income countries (LMICs). Radiotherapy plays a significant role in the standard care of many patients. To assess the current status of paediatric radiotherapy, the International Atomic Energy Agency (IAEA) undertook a global survey and a review of practice in eight leading treatment centres in middle-income countries (MICs) under Coordinated Research Project E3.30.31; 'Paediatric radiation oncology practice in low and middle income countries: a patterns-of-care study by the International Atomic Energy Agency.'

MATERIALS AND METHODS

A survey of paediatric radiotherapy practices was distributed to 189 centres worldwide. Eight leading radiotherapy centres in MICs treating a significant number of children were selected and developed a database of individual patients treated in their centres comprising 46 variables related to radiotherapy technique.

RESULTS

Data were received from 134 radiotherapy centres in 42 countries. The percentage of children treated with curative intent fell sequentially from high-income countries (HICs; 82%) to low-income countries (53%). Increasing deficiencies were identified in diagnostic imaging, radiation staff numbers, radiotherapy technology and supportive care. More than 92.3% of centres in HICs practice multidisciplinary tumour board decision making, whereas only 65.5% of centres in LMICs use this process. Clinical guidelines were used in most centres. Practice in the eight specialist centres in MICs approximated more closely to that in HICs, but only 52% of patients were treated according to national/international protocols whereas institution-based protocols were used in 41%.

CONCLUSIONS

Quality levels in paediatric radiotherapy differ among countries but also between centres within countries. In many LMICs, resources are scarce, coordination with paediatric oncology is poor or non-existent and access to supportive care is limited. Multidisciplinary treatment planning enhances care and development may represent an area where external partners can help. Commitment to the use of protocols is evident, but current international guidelines may lack relevance; the development of resources that reflect the capacity and needs of LMICs is required. In some LMICs, there are already leading centres experienced in paediatric radiotherapy where patient care approximates to that in HICs. These centres have the potential to drive improvements in service, training, mentorship and research in their regions and ultimately to improve the care and outcomes for paediatric cancer patients.

The Use of Health-Related Technology to Reduce the Gap Between Developed and Undeveloped Regions Around the Globe

Cancer is the second leading cause of death worldwide, with approximately 70% of the 9.6 million deaths per year occurring in low- and middle-income countries (LMICs), where there is critical shortage of human and material resources or infrastructure to deal with cancer. If the current trend continues, the burden of cancer is expected to increase to 22 million new cases annually by 2030, with 81% of new cases and almost 88% of mortality occurring in LMICs. Global health places a priority on improving health and reducing these disparities to achieve equity in health for all people worldwide. In today's hyper-connected world, information and communication technologies (ICTs) will increasingly play an integral role in global health. Here, we focus on how the use of health-related technology, specifically ICTs and artificial intelligence (AI), can help in closing the gap between high-income countries (HICs) and LMICs in cancer care, research, and education. Key examples are highlighted on the use of telemedicine and tumor boards, as well as other online resources that can be leveraged to advance global health.

Novel Pilot Curriculum for International Education of Lymphoma Management Using E-Contouring

PURPOSE

The International Lymphoma Radiation Oncology Group (ILROG) published consensus guidelines on the management of Hodgkin disease (HD) and nodal non-Hodgkin lymphoma (NHL), which became the most downloaded articles from International Journal of Radiation Oncology, Biology, and Physics. E-contouring workshops allow for interactive didactic sessions, allowing participants to see case-based contouring in real time. A pilot 1-hour curriculum was developed with the objective of reviewing ILROG guidelines for HD and NHL management with incorporation of e-contouring tools. This represents the first international education intervention in Spanish using e-contouring with a pre- and postintervention questionnaire.

METHODS

A 1-hour presentation was prepared in Spanish reviewing the ILROG recommendations for HD and NHL. The review was followed by the author's demonstration of contour creation using patients with HD and NHL prepared for the American Society for Radiation Oncology's 2015 e-contouring lymphoma session. A five- question evaluation was prepared and administered before and after intervention. A two-tailed paired t test was performed to evaluate any significant change in test value before and after intervention.

RESULTS

A total of nine quizzes were collected before and after the intervention. The average test score before the intervention was 75.6%, and the average test score after the intervention was 86.7% ( P = .051). Four students scored 100% on both the pre- and postintervention evaluations, and no student had a decrease in score from pre- to postintervention evaluation. The topic with the lowest score tested dose consideration.

CONCLUSION

A substantial but nonsignificant improvement in test evaluation was seen with this pilot curriculum. This pilot intervention identified obstacles for truly interactive didactic sessions that, when addressed, can lead to fully developed interactive didactic sessions.

Telehealth in radiation oncology at the Townsville Cancer Centre: Service evaluation and patient satisfaction

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Telehealth serviced a range of ages, cancer diagnoses and treatment intents.

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Tele-radiation oncology consultations reduced travel and time burden for patients.

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Patients reported an overall high level of satisfaction with telehealth consultation.

Purpose

Telehealth (TH) in Radiation Oncology at Townsville Cancer Centre (TCC) was implemented in July 2011 to provide cancer care closer to home to the regional and rural population. The aim of this study was to describe the service use and patient satisfaction.

Materials and methods

A retrospective audit of records was conducted for patients treated at TCC between July 2011 and December 2015. Data included patient demographics, diagnosis and treatment. Results of a patient satisfaction survey were summarised through descriptive statistics.

Results

A total of 1530 TH consultations were provided to 833 patients. 311 patient charts were audited (615 TH, 650 in-person, 151 phone consultations). Median distance from TCC to satellites was 327.3 km (21.6 to 1130.1). 71% were male and median age was 65 (23–94 years). Cancer diagnoses included prostate (32%), breast (12%) and head and neck (10%). 60% of patients underwent radiation therapy for curative intent, 22% palliative and 18% did not undergo treatment. 106 patients participated in the satisfaction survey (231 patients invited, response rate of 46%), with the overall positive response mainly attributed to advantages in travel and time savings. 54.7% of patients selected TH as their preference for future consultations, 34.9% indicated a mix of TH and in-person consultations, and only 1 patient (0.9%) indicating in-person only.

Conclusion

TH enables the delivery of radiation oncology consultations to rural and regional patients, with an overall high level of patient satisfaction. Patients welcomed the model for benefits of travel and time savings. Future directions include engaging with specialist, rural medical staff and patients to maximize access.

The pervasive crisis of diminishing radiation therapy access for vulnerable populations in the United States, part 1: African-American patients

Introduction

African Americans experience the highest burden of cancer incidence and mortality in the United States and have been persistently less likely to receive interventional care, even when such care has been proven superior to conservative management by randomized controlled trials. The presence of disparities in access to radiation therapy (RT) for African American cancer patients has rarely been examined in an expansive fashion.

Methods and materials

An extensive literature search was performed using the PubMed database to examine studies investigating disparities in RT access for African Americans.

Results

A total of 55 studies were found, spanning 11 organ systems. Disparities in access to RT for African Americans were most prominently study in cancers of the breast (23 studies), prostate (7 studies), gynecologic system (5 studies), and hematologic system (5 studies). Disparities in RT access for African Americans were prevalent regardless of organ system studied and often occurred independently of socioeconomic status. Fifty of 55 studies (91%) involved analysis of a population-based database such as Surveillance, Epidemiology and End Result (SEER; 26 studies), SEER-Medicare (5 studies), National Cancer Database (3 studies), or a state tumor registry (13 studies).

Conclusions

African Americans in the United States have diminished access to RT compared with Caucasian patients, independent of but often in concert with low socioeconomic status. These findings underscore the importance of finding systemic and systematic solutions to address these inequalities to reduce the barriers that patient race provides in receipt of optimal cancer care.

ASTRO's Advances in Radiation Oncology: Success to date and future plans

ASTRO's Advances in Radiation Oncology was launched as a new, peer-reviewed scientific journal in December 2015. More than 200 manuscripts have been submitted and 97 accepted for publication as of May 2017. As Advances enters its second year of publication, we have chosen to highlight subjects that will transform the way we practice radiation oncology in special issues or ongoing series: immunotherapy, biomedical analytics, and social media. A teaching case report contest for North American radiation oncology residents will be launched at American Society of Radiation Oncology 2017 to encourage participation in scientific publication by trainees early in their careers. Recognizing our social mission, Advances will also begin a series of articles devoted to highlighting the growing disparities in access to radiation oncology services in vulnerable populations in North America. We wish to encourage the American Society of Radiation Oncology membership to continue its support of the journal through high-quality manuscript submission, participation in the peer review process, and highlighting important manuscripts through sharing on social media.

Challenges and Prospects for Providing Radiation Oncology Services in Africa

There are considerable challenges to meeting the demands of the impending cancer crisis in Africa. These include a rising incidence of cancer and cancer-related deaths, equipment and maintenance costs, and deficits in human resources and training. Addressing these issues would be crucial to tackling the increasing burden of cancer on the continent. Innovations in technology and collaborative efforts within the global oncology community have created promising solutions for establishing quality cancer care in Africa and eradicating the massive disparities that currently exist. A multifaceted approach that establishes access to quality radiation oncology services is needed to curtail this alarming trend. In this article, we describe the current status of radiotherapy services in Africa, barriers and opportunities to improve this integral component of comprehensive cancer care.

A Roadmap and Cost Implications of Establishing Comprehensive Cancer Care Using a Teleradiotherapy Network in a Group of Sub-Saharan African Countries With No Access to Radiation Therapy

PURPOSE

To propose a roadmap and explore the cost implications of establishing a teleradiotherapy network to provide comprehensive cancer care and capacity building in countries without access to radiation therapy.

METHODS AND MATERIALS

Ten low-income sub-Saharan countries with no current radiation therapy facilities were evaluated. A basic/secondary radiation therapy center (SRTC) with 2 teletherapy, 1 brachytherapy, 1 simulator, and a treatment planning facility was envisaged at a cost of 5 million US dollars (USD 5M). This could be networked with 1 to 4 primary radiation therapy centers (PRTC) with 1 teletherapy unit, each costing USD 2M. The numbers of PRTCs and SRTCs for each country were computed on the basis of cancer incidence, assuming that a PRTC and SRTC could respectively treat 450 and 900 patients annually.

RESULTS

An estimated 71,215 patients in these countries will need radiation therapy in 2020. Stepwise establishment of a network with 99 PRTCs and 28 SRTCs would result in 155 teletherapy units and 96% access to radiation therapy. A total of 310 radiation oncologists, 155 medical physicists, and 465 radiation therapy technologists would be needed. Capacity building could be undertaken through telementoring by networking to various international institutions and professional societies. Total infrastructure costs would be approximately USD 860.88M, only 0.94% of the average annual gross domestic product of these 10 countries. A total of 1.04 million patients could receive radiation therapy during the 15-year lifespan of a teletherapy unit for an investment of USD 826.69 per patient. For the entire population of 218.32 million, this equates to USD 4.11 per inhabitant.

CONCLUSION

A teleradiotherapy network could be a cost-contained innovative health care strategy to provide effective comprehensive cancer care through resource sharing and capacity building. The network could also be expanded to include other allied specialties. The proposal calls for active coordination between all national and international organizations backed up by strong geopolitical commitment and action from all stakeholders.