Surveying the Challenges to Improve Linear Accelerator-based Radiation Therapy in Africa: a Unique Collaborative Platform of All 28 African Countries Offering Such Treatment

Abstract

Radiation therapy is a critical component for curative and palliative treatment of cancer and is used in more than half of all patients with cancer. Yet there is a global shortage of access to this treatment, especially in Sub-Saharan Africa, where there is a shortage of technical staff as well as equipment. Linear accelerators (LINACs) offer state-of-the-art treatment, but this technology is expensive to acquire, operate and service, especially for low-and middle-income countries (LMICs), and often their harsh environment negatively affects the performance of LINACs, causing downtime. A global initiative was launched in 2016 to address the technology and system barriers to providing radiation therapy in LMICs through the development of a novel LINAC-based radiation therapy system designed for their challenging environments. As the LINAC prototype design phase progressed, it was recognised that additional information was needed from LMICs on the performance of LINAC components, on variables that may influence machine performance and their association, if any, with equipment downtime. Thus, a survey was developed to collect these data from all countries in Africa that have LINAC-based radiation therapy facilities. In order to understand the extent to which these performance factors are the same or different in high-income countries, facilities in Canada, Switzerland, the UK and the USA were invited to participate in the survey, as was Jordan, a middle-income country. Throughout this process, LMIC representatives have provided input on technology challenges in their respective countries. This report presents the method used to conduct this multilevel study of the macro-and microenvironments, the organisation of departments, the technology, the training and the service models that will provide input into the design of a LINAC prototype for a LINAC-based radiation therapy system that will improve access to radiation therapy and thus improve cancer treatment outcomes. It is important to note that new technology should be introduced in a contextual manner so as not to disrupt existing health systems inadvertently, especially with regards to existing staffing, infrastructure and socioeconomic issues. A detailed analysis of data is underway and will be presented in a follow-up report. Selected preliminary results of the study are the observation that LINAC-based facilities in LMICs experience downtime associated with failures in multileaf collimators and vacuum pumps, as well as power instability. Also, that there is a strong association of gross national product per capita with the number of LINACs per population.

Expanding radiotherapy access in Sub-Saharan Africa: an analysis of travel burdens and patient-related benefits of hypofractionation

“…Inadequate access to radiotherapy machines has been cited as a major contributing factor to the disproportionately highand increasingcancer mortality rates in SSA (22). While all three countries fall short of the recommendations set forth by the IAEA of one radiation therapy unit per 200,000 persons, patients in South Africa have significantly better access to RT compared to patients in Nigeria and Tanzania (23,24). South Africa has 1 RT machine per 608,000 persons, which is far more than Nigeria's 1 machine per 29.4 million persons and Tanzania's 1 machine per 11.9 million persons (24).…”

Targeting elimination of cervical cancer by 2030: a baseline assessment in six African countries—part II

“…According to these norms, Rwanda would need 52 radiation therapy units, Uganda 228 and Zambia 89. Such coverage has not yet been attained on the African continent, but the figures are supported by thorough studies, and constitute a clear target for planning, over a longer perspective [29].…”

Collaboration: The Force That Makes the Impossible Possible

“…Along the same lines, we are supporting the initiative of linear accelerators for other developing countries, including in Africa. 12 , 13 , 14 The project, 15 launched again at CERN, is called Smart Technologies to Extend Lives with Linear Accelerators and it aims at improving access to cancer treatment in those regions where there is either almost no care at all or where there is limited availability of Radiation therapy, which is often delivered using cobalt-60, a radioactive source that carries with it the potential problems of illicit use for terrorist threats as well as environmental and economic challenges related to source end-of-life disposal.…”