Challenges in building radiotherapy capacity: A longitudinal study evaluating eight years of the Brazilian radiotherapy expansion plan

BACKGROUND

In 2012, the Brazilian government launched a radiotherapy (RT) expansion plan (PER-SUS) to install 100 linear accelerators. This study assesses the development of this program after eight years.

METHODS

Official reports from the Ministry of Health (MoH) were reviewed. RT centres projects status, timeframes, and cost data (all converted to US dollars) were extracted. The time analysis was divided into seven phases, and for cost evaluation, there were five stages. The initial predicted project time (IPPT) and costs (estimated by the MoH) for each phase were compared between the 18 operational RT centres (able to treat patients) and 30 non-operational RT centres using t-tests, ANOVA, and the Mann-Whitney U. A p-value < 0.05 indicates statistical significance.

RESULTS

A significant delay was observed when comparing the IPPT with the overall time to conclude each 48 RT centres project (p < 0.001), with considerable delays in the first five phases (p < 0.001 for all). Moreover, the median time to conclude the first 18 operational RT centres (77.4 months) was shorter compared with the 30 non-operational RT centres (94.0 months), p < 0.001. The total cost of 48 RT services was USD 82,84 millions (mi) with a significant difference in the per project median total cost between 18 operational RT centres, USD1,34 mi and 30 non-operational RT centres USD2,11 mi, p < 0.001. All phases had a higher cost when comparing 30 non-operational RT centres to 18 operational RT centres, p < 0.001. The median total cost for expanding existing RT centres was USD1,30 mi versus USD2,18 mi for new RT services, p < 0.0001.

CONCLUSION

After eight years, the PER-SUS programs showed a substantial delay in most projects and their phases, with increased costs over time.

POLICY SUMMARY

Our findings indicate a need to act to increase the success of this plan. This study may provide a benchmark for other developing countries trying to expand RT capacity.

Radiotherapy Resources in Latin America and the Caribbean: An International Atomic Energy Agency Analysis of Current and Projected Needs

PURPOSE/OBJECTIVE(S)

The inequitable access to radiotherapy (RT) is recognized to be a complex undertaking that will require sustained work identifying gaps and mobilizing efforts to fill in those gaps. Data can support policy-makers as they embark on programs to reduce premature mortality from cancer in their countries and regions. The purpose of this analysis is to identify the current gaps and needs in Latin America and the Caribbean (LAC).

MATERIALS/METHODS

We created a database of 41 countries in LAC using open-source data, including data on population size (UN Department of Economic and Social Affairs data), gross national income per capita (GNIPC) (World Bank Data), current and projected cancer incidence and mortality (Globocan 2020). The International Atomic Energy Agency (IAEA) Directory of Radiotherapy Centers (DIRAC) was used to identify the number and operational status of megavoltage (MV) teletherapy machines (Cobalt-60 and Linear Accelerators LINACs) and brachytherapy facilities (HDR and LDR). To calculate current and projected gaps in external beam RT (EBRT) facilities, we matched DIRAC data with Globocan cancer incidence data for 2020 and projections for 2025 and 2030 while applying a 64% optimal EBRT utilization rate (taking into account re-treatment). For brachytherapy, analysis took into account both HDR and LDR capacity and was primarily focused on needs based on current and projected incidence of cervical cancer cases in LAC.

RESULTS

EBRT was available in 32 (76%) of 41 countries. There were 742 RT centers in 32 countries with a total of 1131 MV units. Average coverage in 2022 based on an optimal utilization rate of 64% was 64%. LINACs accounted for 87% of the total MV units and Cobalt-60 capacity decreased to 13% of total teletherapy capacity compared to capacity in 2018. Most countries clustered in the same range of GNIPC to teletherapy units per 1000 cases, however outliers were most notable in the Caribbean. The median GNIPC was $6340 and the median MV units per 1000 cancer cases were 1.4. The current deficit in MV units is estimated at 672 megavoltage units and projected to be 2455 units by 2030 representing more than double the current capacity. 28 out of 41 countries (68%) had brachytherapy including 279 installed services, both HDR and LDR. At a 75% optimal utilization rate of brachytherapy in locally advanced cervical cancer, the current brachytherapy capacity in LAC could treat 108,420 patients with cervical cancer/year, which meets the current needs in the region albeit with significant inequity in distribution of resources.

CONCLUSION

There is 15% improvement in the current EBRT capacity in LAC compared to 2018. However, there is still shortage of at least 672 extra units needed. By 2030, the need for MV units will be double the current capacity. The current brachytherapy capacity meets needs albeit with inequitable distribution across the region primarily in the Caribbean.

Analysis of electromyographic muscles activity of gait in healthy subjects with and without AFO developed for patients with hemiparesis

The aim of the present study was to analyze the electromyographic (EMG) signals of the rectus femoris (RF), vastus lateralis (VL), tibialis anterior (TA) and soleus (SO) muscles in young healthy adults with and without the use of an experimental ankle-foot-orthosis (AFO) designed for patients with hemiparesis. Twenty-eight individuals with an average age of 22 +/- 3.63 years participated in the study. An electromyograph, surface electrodes and two force plates were used. There was a non-significant increase in the TA activity with the use of the AFO (6.04 +/- 2.81) when compared to non-use (5.91 +/- 2.49) (p > 0.5); the same was true for the other muscles evaluated. There was a positive correlation (r = 0.37) between TA and SO activity (p < 0.05). The results demonstrate that the AFO did not affect the gait pattern of healthy young adults.

[High blood pressure in children and adolescents: determinant factors]

OBJECTIVE: To review the state of prevalence of hypertension in childhood and the importance of its possible determinants. METHODS: Analysis of the literature concerned with eleven possible determinant factors - experimental design, internal and external validity. RESULTS AND CONCLUSIONS: Central body fat pattern seems to be a risk factor, while heart rate and tracking would be true markers of future hypertension. Social class, biological maturation, race, sodium intake and genetic factors have not yet been validated through unbiased studies.

[Perception on and registration of alcohol abuse and alcohol-related diseases at a university general hospital]

BACKGROUND

The high frequency of alcohol related problems highlights the importance of its approach. The association of both the alcohol-abuse and alcohol related diseases has been pointed in the literature and are often the main reason for hospitalization. Physicians use different tools to detect abusive drinkers, and one of them is the CAGE-test, validated by Mayfield et al. in 1974.

OBJECTIVES

To study the association between the result of the CAGE-test and the perception and registration of alcohol abuse by the medical staff and the nurses in charge of inpatients of Hospital de Clínicas de Porto Alegre, southern Brazil.

MATERIAL AND METHOD

The design involved three phases. First, the application of the CAGE-test to the 385 eligible patients. Second, review of all 51 CAGE-positive patients' records as well the controlled evaluation of 51 randomized CAGE-negative patients, to seek alcoholic habits and alcohol-related diseases. Third, interview with the medical staff to find out their perception about these subjects.

RESULTS

We found 51 patients CAGE-positive (prevalence = 13%). When evaluated through the registration and through a standardized interview, medical staff and nurses were not aware of more than half of CAGE-positive patients. No significant differences were found between medical staff registration and perception; the prevalence of alcohol related diseases was the same for both: 26 and 27% (p = .861). The prevalence of alcohol related diseases was higher among CAGE-positive patients (p = .0003).

CONCLUSIONS

In spite of the high prevalence among our patients, alcohol abuse is not pursued by our health teams as it should be. As for the future, there is reason to envision a continuing alcoholism rapprochement.

Maintenance of prolactin (PRL) binding sites in rat liver cells in suspension culture: effect of PRL and of inhibitors of various cellular functions

An in vitro method to study the regulation of PRL receptors has been established using adult rat liver cells cultured in a continuous suspension in L-15 medium. PRL binding averaged 28.2 +/- 1.8% of the added labeled hormone per 10(6) cells in freshly isolated liver cells prepared from female rats treated with 17 beta-estradiol. When these cells were incubated at 37 C, binding rapidly declined by 50% at 10 h and 90% at 48 h. This rapid decline could be counteracted by the inclusion of ovine PRL (50 nM), which maintained initial PRL receptor levels up to 48 h of culture. Higher concentrations of PRL (2.5 microM) induced a rapid down-regulation, apparent at 2 and 10 h of culture. Cycloheximide (50 micrograms/ml) induced a slight diminution of control PRL receptor levels and partially reversed the effect of 50 nM PRL. Approximately 60% of the PRL receptors were resistant to the effect of cycloheximide. On the other hand, actinomycin D (10 micrograms/ml) had no effect on PRL receptor levels in control and only a very slight effect in PRL-treated cells. Dinitrophenol, which blocks metabolic oxidation, also partially reversed the effect of 50 nM PRL although it was without any significant effect on control levels. Chloroquine (100 microM) and colchicine (1 microM) failed to alter PRL binding either in the absence or presence of 50 nM PRL. Our results suggest that the existence of regulatory factors occurring in vivo, which are absent in the culture medium, could be responsible for the decline in PRL receptor levels in the control hepatocytes. PRL itself could be one of these factors. On the other hand, and in agreement with the putative actions of the drugs utilized, the mechanism of the PRL-induced maintenance of receptor levels appears to lie in part with an effect on receptor synthesis at the translational (ribsomal) level but to be independent of the internalization or of lysosomal degradation.

Interaction of prolactin (PRL) binding sites with PRL receptor antibodies in rat liver cells in suspension culture: effect of inhibitors of cellular functions

We have recently demonstrated that prolactin is able to maintain the level of in receptors in cultured rat hepatocytes. This effect could be modulated by various inhibitors of cellular functions. We report here that an antibody developed against a partially purified prolactin receptor preparation can mimic this effect of the hormone (although to a lesser extent) and that drugs can modulate it in a similar manner. In particular, cycloheximide (50 micrograms/mL), which reduced basal receptor levels by approximately 40%, totally reversed the maintenance induced by the antireceptor serum. Actinomycin D (10 micrograms/mL), another protein synthesis inhibitor (at the transcriptional level), had no effect of basal receptor concentration, but counteracted by about one-half the antiserum-induced maintenance. This effect of actinomycin D is much clearer here than the effect previously observed on prolactin-induced receptor levels in rat liver cells in culture. The effect of dinitrophenol (1 mM) on basal levels was of limited amplitude but maintenance was again partly reversed by this drug. In accordance with previous results obtained with prolactin, chloroquine (100 microM) and colchicine (1 microM) failed to alter prolactin binding either in the absence or presence of 5% antireceptor serum. The effect of the antiserum indicates that prolactin itself is not required beyond the membrane for its effect on receptor regulation to be attained. These results also confirm our previous results with prolactin maintenance of prolactin receptor levels in rat liver cells in culture, that the mechanism of receptor maintenance appears to be due in part to a stimulation of receptor synthesis but to be independent of the internalization or of lysosomal degradation.

Hypotension during acetate and bicarbonate dialysis in patients with acute renal failure

Bicarbonate dialysate is claimed to be superior to acetate for both chronic and acute hemodialysis. We compared acetate and bicarbonate dialysates in 30 acute renal failure patients during 120 dialyses. 4 patients were diabetic and 2 had liver failure. Patients were dialyzed alternating acetate and bicarbonate dialysate in a double-blind cross-over manner; each patient was his own control. BUN, creatinine, Na+, K+, osmolality, delta osmolality, % ultrafiltration, arterial blood gases, pre, post and lowest dialysis mean arterial blood pressure, dialysis with hypotensive episodes and symptoms of hypotension were recorded. The measurements obtained for each patient during dialyses with acetate and bicarbonate were compared. There was no difference in predialysis chemistries, osmolality or osmolality fall, no change in mean arterial blood pressure or hypotensive episodes and symptoms and ultrafiltration. PCO2 and pH were slightly lower for the acetate group at the 2nd h but not at the end of dialysis. 4 patients had serum acetate determinations, all metabolized acetate normally. These findings contradict recent suggestions that severely ill patients should not be dialyzed against acetate. Since acetate is technically much easier to use and has no clinical drawbacks, it does not need to be replaced with bicarbonate in acute patients. Other factors must be more important than acetate in generating hypotension during acute dialysis.

The importance of osmolality fall and ultrafiltration rate on hemodialysis side effects. Influence of intravenous mannitol

The decreases in serum osmolality as well as the rate of ultrafiltration during hemodialysis and the influence of each upon the side effects of this treatment were studied in 13 chronic stable dialysis patients. Mannitol (9 mosm/kg water) was infused in two out of four dialyses, in a double blind fashion. A solution of 5% glucose in water was used as control. 1 week after the treatment, there was no residual mannitol in the patients' serum (p less than 0.0005). The decrease in osmolality during dialysis was lower when the patients received treatment with mannitol than with placebo: 14.7 versus 25.0 mosm/kg water (p less than 0.001). The symptoms during dialysis were much less severe when the patients received mannitol (p less than 0.05). Analyzed separately, ultrafiltration rate had no effect on severity of symptoms during dialysis (p greater than 0.1). Decrease in serum osmolality during dialysis seems to be the most important factor in the genesis of dialysis symptoms in chronic stable dialysis patients and are counteracted by the infusion of an osmotically active substance such as mannitol, 1 g/kg/dialysis; this results in a slight increase in body weight between dialyses, and cannot be used routinely because of slow accumulation.

Dialysis symptoms and stabilization in long-term dialysis. Practical application of the CUSUM plot

Six symptoms that occur during hemodialysis were investigated to determine their frequency and to define when a patient's condition becomes "stable." Three symptoms--nausea, hypotension, and muscle cramps--stabilized after 13 dialysis treatments (approximately one month). Two symptoms, hypertension and vomiting, stabilized after 17 and 20 dialyses, respectively. Headache showed little variation per dialysis. The changes in the frequency of these symptoms were detected through the use of the cumulative sum technique (CUSUM). This technique was found to be much more discriminating than the original data. Hemodialysis patients should not be considered "stable" for investigation of changes in techniques or therapy until after 1 1/2 months of dialysis. Even then, symptoms will be found during each dialysis.