Expanding Access to Radiation Therapy: An Update on Brazil's Current Challenges and Opportunities

Real-world evidence for oncological outcomes after radiotherapy or surgery for T1a-T1b glottic squamous cell carcinoma: A population-based cohort study

BACKGROUND

Compare outcomes after surgery (S) or radiotherapy (RT) for T1a-T1b glottic squamous cell carcinoma (T1GSCC) in a population-based cohort study.

METHODS

Patients diagnosed with T1GSCC from 1999 to 2020 were identified from a public database. Clinical, demographic, and social data were extracted. Treatment and patient groups and subgroups were compared with log-rank test, Cox proportional test, and propensity-score matched (PSM).

RESULTS

Eight hundred and eighty-eight patients with T1GSCC were included in the study, with a median follow-up of 61 months. The 5- and 10-year overall survival (OS) S versus RT were 76% versus 71% and 60% versus 52% (p = 0.02), respectively. In the subgroup analysis, S was associated with better OS for T1b, male, and public service patients (p < 0.05). In the PSM cohort of S versus RT with 110 patients each, there was no significant difference in the OS, CSS, and LC.

CONCLUSIONS

T1GSCC has favorable outcomes with S or RT.

Breast and gynecologic cancers as a Brazilian health priority

OBJECTIVE

Cancer imposes a profound burden on low- and middle-income countries where 65% of the global cancer deaths occurred in 2020. The objective of the present review was to describe female cancer epidemiology in Brazil, barriers to prevention, screening, and treatment, and to propose strategies to a better control.

METHODS

For the process of literature search and scientific acquisition, we have utilized the terms "female cancer" AND "breast cancer," AND "cervical cancer" AND "endometrial cancer" AND "ovarian cancer" AND "Brazil" in PubMed. References of the articles included in this review were manually searched in order to identify relevant studies on the topic. The official Brazilian epidemiology data were extensively analyzed at the governmental site www.inca.gov.br.

RESULTS

Considering cases of breast and gynecologic cancers together, 105,770 new cases are expected to be diagnosed yearly, positioning female cancer as the highest cancer incidence in Brazil. Female breast cancer is the most common and the leading cause of death from cancer in the female population in all regions of Brazil, except in the North, where cervical cancer ranks first. Cervical cancer, a preventable disease, corresponds to the third-most common neoplasia in women, with higher incidences in the North and Northeast regions of Brazil. An upward trend has been observed in endometrial cancer incidence, a tendency that follows the increase of its two most common risk factors: population aging and obesity. Ovarian cancer currently occupies the eighth position among female cancers in Brazil, but it is the most lethal gynecologic cancer. The main strategies to reduce female cancer mortality rates are the reduction of inequalities in healthcare services and the early diagnosis of cases. The lack of a specific national cancer program results in a reactive and unplanned approach to healthcare provision, ultimately leading to suboptimal resource utilization and higher expenditure.

CONCLUSION

Analyzed together, breast and gynecologic cancers correspond to the leading cause of cancer in Brazil. A heterogeneous group, female cancer includes diseases with a high primary and secondary prevention potential. The organization of a female cancer program in Brazil prioritizing primary and secondary prevention strategies, such as adequate mammography screening and human papillomavirus vaccination coverage, could significantly improve female cancer control in the country.

Radiotherapy resources in Brazil (RT2030): a comprehensive analysis and projections for 2030

BACKGROUND

The demand for radiotherapy in Brazil is unfulfilled, and the scarcity of data on the national network hampers the development of effective policies. We aimed to evaluate the current situation, estimate demands and requirements, and provide an action plan to ensure access to radiotherapy for those in need by 2030.

METHODS

The Brazilian Society for Radiation Oncology created a task force (RT2030) including physicians, medical physicists, policy makers, patient advocates, and suppliers, all of whom were major stakeholders involved in Brazilian radiotherapy care. The group was further divided into seven working groups to address themes associated with radiotherapy care in Brazil. From March 1, 2019, to Aug 3, 2020, there were monthly meetings between the group's leaders and the Central Committee and six general meetings. First, a comprehensive search of all different national databases was done to identify all radiotherapy centres. Questionnaires evaluating radiotherapy infrastructure and human resources and assing the availability, distribution, capacity, and workload of resources were created and sent to the radioprotection supervisor of each centre. Results were analysed nationally and across the country's regions and health-care systems. A pre-planned review of available databases was done to gather data on active radiation oncology centres and the distribution of radiotherapy machines (linear accelerators [LINACs]) across Brazil. We used national population and cancer incidence projections, recommended radiotherapy usage from the medical literature, and national working patterns to project radiotherapy demands in 2030. An action plan was established with suggestions to address the gaps and meet the demands.

FINDINGS

The database search yielded 279 centres with an active radiotherapy registry. After applying predefined exclusion criteria, 263 centres were identified that provided external beam radiotherapy machines with or without brachytherapy. All 263 operational centres answered the questionnaires sent on Dec 9, 2019, which were then returned between Jan 1 and June 30, 2020. There were 409 therapy machines, 646 radiation oncologists, 533 physicists, and 230 989 patients undergoing radiotherapy (150 628 [65·2%] in the public health-care system and 80 937 [35·0%] in private). The mean annual occupation rate was 566 patients per treatment machine (SD 250). The number of residents per treatment machine ranged from 258 333 to 1 800 000. Technology availability varied considerably among regions and systems. In 2030, 639 994 new cancer cases are expected, which will require 332 797 radiotherapy courses. Therefore, 530 LINACs, 1079 radiation oncologists, and 1060 medical physicists will be needed.

INTERPRETATION

The expected increase in cancer incidence in the coming years will probably increase the disparities in cancer care and the burden for Brazilian patients. We provide a roadmap of the current situation and the particularities of the Brazilian radiotherapy network, which can serve as a starting point for cancer policy planning to improve this scenario.

FUNDING

Accuray, BRAINLAB, Elekta, IBA, ONE medical solution, SUN NUCLEAR corporation, VARIAN, and ZIGMA.

Deep inspiration breath hold: dosimetric benefits to decrease cardiac dose during postoperative radiation therapy for breast cancer patients

Background

Postoperative radiation therapy (RT) is the standard treatment for almost all patients diagnosed with breast cancer. Even with modern RT techniques, parts of the heart may still receive higher doses than those recommended by clinically validated dose limit restrictions, especially when the left breast is irradiated. Deep inspiration breath hold (DIBH) may reduce irradiated cardiac volume compared to free breathing (FB) treatment. This study aimed to evaluate the dosimetric impact on the heart and left anterior descending coronary artery (LAD) in FB and DIBH RT planning in patients with left breast cancer.

Materials and methods

A retrospective cohort study of women diagnosed with left-sided breast cancer submitted to breast surgery followed by postoperative RT from 2015 to 2019. All patients were planned with FB and DIBH and hypofractionated dose prescription (40.05 Gy in 15 fractions).

Results

68 patients were included in the study. For the coverage of the planned target volume evaluation [planning target volume (PTV) eval] there was no significant difference between the DIBH versus FB planning. For the heart and LAD parameters, all constraints evaluated favored DIBH planning, with statistical significance. Regarding the heart, median V16.8 Gy was 2.56% in FB vs. 0% in DIBH (p < 0.001); median V8.8 Gy was 3.47% in FB vs. 0% in DIBH (p < 0.001) and the median of mean heart dose was 1.97 Gy in FB vs. 0.92 Gy in DIBH (p < 0.001). For the LAD constraints D2% < 42 Gy, the median dose was 34.87 Gy in FB versus 5.8 Gy in DIBH (p < 0.001); V16.8 Gy < 10%, the median was 15.87% in FB versus 0% in DIBH (p < 0.001) and the median of mean LAD dose was 8.13Gy in FB versus 2.92Gy in DIBH (p < 0.001).

Conclusions

The DIBH technique has consistently demonstrated a significant dose reduction in the heart and LAD in all evaluated constraints, while keeping the same dose coverage in the PTV eval.

Radiotherapy activity in the COVID 19 pandemic: Brazil's operational national-level study

PURPOSE

During the COVID-19 pandemic, patients with cancer are at increased risk of not having timely diagnosis and access to cancer treatment. The present study evaluated the COVID-19 pandemic impact on radiotherapy activity in Brazil.

METHODS

A national-level study was performed to evaluate the RT utilization for prostate, breast, head & neck (HN), Gynecology (GYN), Gastrointestinal (GI), lung cancers, and bone/brain metastases. The data on the RT executed was extracted from the Brazilian Ministry of Health database. The NON-COVID period was considered the control group, and the comparison groups were COVID-2020 (without vaccine) and COVID-2021 (with vaccine).

RESULTS

We collected the data of 238,355 procedures executed on three periods. Significant difference in the RT utilization between NON-COVID and COVID-2020 were observed for prostate cancer, bone and brain metastases (-12.3 %, p = 0.02, +24 %, p = 0.02 and +14 %, p = 0.04, respectively). Comparing 2 equivalents months from NON-COVID-2019 (ref), COVID-2020, and COVID-2021, a significant increase was identified for bone and brain metastases (2020 +21 %, and 2021 +32 %), and (2020 +20 %, and 2021 +14 %). A stable drop occurred for prostate cancer (2020 -11 % and 2021 -10 %), and a variation was observed for breast (2020 +8 %, and 2021 -1 %) and lung cancer (2020 +10 %, and 2021 -3 %). For other cancers, non-significant changes were observed when comparing 2020 and 2021.

CONCLUSION

The RT activity was heterogeneously affected with a substantial increase for bone and brain metastases and a meaningful decline for prostate cancer.

POLICY SUMMARY

With a significant increase in the use of palliative radiotherapy for bone and brain metastases and a meaningful reduction in curative radiotherapy for prostate cancer, we hope these findings can help governments, RT services, medical communities, and other stakeholders develop strategies to mitigate the impact of the present and future pandemics. Finally, despite the changes imposed by the COVID pandemic, it is imperative to enhance screening, increase cancer diagnosis at an early stage, and improve access to all cancer treatments, including radiotherapy.

Hypofractionated radiotherapy recommendations for localized prostate cancer in Brasil

OBJECTIVE

Several prospective randomized trials have shown that hypofractionation has the same efficacy and safety as the conventional fractionation in the treatment of localized prostate cancer. There are many benefits of hypofractionation, including a more convenient schedule for the patients and better use of resources, which is especially important in low- and middle-income countries like Brasil. Based on these data, the Brazilian Society of Radiotherapy (Sociedade Brasileira de Radioterapia) organized this consensus to guide and support the use of hypofractionated radiotherapy for localized prostate cancer in Brasil.

METHODS

The relevant literature regarding moderate hypofractionation (mHypo) and ultra-hypofractionation (uHypo) was reviewed and discussed by a group of experts from public and private centers of different parts of Brasil. Several key questions concerning clinical indications, outcomes and technological requirements for hypofractionation were discussed and voted. For each question, consensus was reached if there was an agreement of at least 75% of the panel members.

RESULTS

The recommendations are described in this article.

CONCLUSION

This initiative will assist Brazilian radiation oncologists and medical physicists to safely treat localized prostate cancer patients with hypofractionation.

The Financial Impact on Reimbursement of Moderately Hypofractionated Postoperative Radiation Therapy for Breast Cancer: An International Consortium Report

AIMS

Moderately hypofractionated breast irradiation has been evaluated in several prospective studies, resulting in wide acceptance of shorter treatment protocols for postoperative breast irradiation. Reimbursement for radiation therapy varies between private and public systems and between countries, impacting variably financial considerations in the use of hypofractionation. The aim of this study was to evaluate the financial impact of moderately hypofractionated breast irradiation by reimbursement system in different countries.

MATERIALS AND METHODS

The study was designed by an international group of radiation oncologists. A web-questionnaire was distributed to representatives from each country. The participants were asked to involve the financial consultant at their institution.

RESULTS

Data from 13 countries from all populated continents were collected (Europe: Denmark, France, Italy, the Netherlands, Spain, UK; North America: Canada, USA; South America: Brazil; Africa: South Africa; Oceania: Australia; Asia: Israel, Taiwan). Clinicians and/or departments in most of the countries surveyed (77%) receive remuneration based on the number of fractions delivered to the patient. The financial loss per patient estimated resulting from applying moderately hypofractionated breast irradiation instead of conventional fractionation ranged from 5-10% to 30-40%, depending on the healthcare provider.

CONCLUSION

Although a generalised adoption of moderately hypofractionated breast irradiation would allow for a considerable reduction in social and economic burden, the financial loss for the healthcare providers induced by fee-for-service remuneration may be a factor in the slow uptake of these regimens. Therefore, fee-for-service reimbursement may not be preferable for radiation oncology. We propose that an alternative system of remuneration, such as bundled payments based on stage and diagnosis, may provide more value for all stakeholders.

Chemoradiotherapy With or Without Surgery for Esophageal Squamous Cancer According to Hospital Volume

PURPOSE

Esophageal squamous cell cancer (ESCC) is still associated with a dismal prognosis. However, surgical series have shown that high-volume hospitals have better outcomes and that the impact of center volume on definitive chemoradiotherapy (dCRT) or CRT plus surgery (CRT + S) remains unknown.

METHODS

We performed a retrospective analysis of patients with locally advanced stage II-III (non-T4) ESCC treated with dCRT or CRT + S in São Paulo state, Brazil. Descriptive variables were assessed with the χ² test after categorization of hospital volume (high-volume [HV] center, top 5 higher volume, or low-volume [LV] center). Overall survival (OS) was assessed with Kaplan-Meier curves, log-rank tests, and Cox proportional hazards. Finally, an interaction test between each facility's treatments was performed.

RESULTS

Between 2000 and 2013, 1,347 patients were analyzed (77% treated with dCRT and 65.7% in HV centers) with a median follow-up of 23.7 months. The median OS for dCRT was 14.1 months (95% CI, 13.3 to 15.3 months) and for CRT + S, 20.6 months (95% CI, 16.1 to 24.9 months). In the multivariable analysis, dCRT was associated with worse OS (hazard ratio [HR], 1.38; 95% CI, 1.19 to 1.61; P < .001) compared with CRT + S. HV hospitals were associated with better OS (HR, 0.82; 95% CI, 0.71 to 0.94; P = .004) compared with LV hospitals. Importantly, CRT + S superiority was restricted to HV hospitals (dCRT v CRT + S: HR, 1.56; 95% CI, 1.29 to 1.89; P < .001), while in LV hospitals, there was no statistically significant difference (HR, 1.23; 95% CI, 0.88 to 1.43; P = .350), with a significant interaction test (P_interaction = .035).

CONCLUSION

Our data show that CRT + S is superior to dCRT in the treatment of ESCC exclusively in HV hospitals, which favors the literature trend to centralize the treatment of ESCC in HV centers.