Dr. Mora Mel, Radiation Oncology Resident at National Cancer Center (currently placement in the Philippines under IAEA fellowship)
Based on IARC’s Globocan 2012 project1, the estimated annual cancer incidence in Cambodia is approximately 14,000 cases. The incidence is predicted to rise rapidly in the future, due to the population and economic growth in the country. Due to the lack of access to comprehensive cancer care, the number of cancer deaths is projected at around 11,000.
In Cambodia, radiation therapy facilities first existed in 1960s, but they were completely destroyed during the Khmer Rouge regime from 1975 to 1979. It was not until 2003 that the Cambodian population had access to radiotherapy again through a collaboration between the Cambodian government, French government and French non-governmental organizations. A cobalt 60 machine, an X-Ray simulator, 2D dosimetry systems and a low dose cesium brachytherapy machine were installed in the Khmer-Soviet Friendship Hospital. However, the facilities broke down in the early 2010s and radiotherapy was absent for a few years again until a single linac was installed. Although hugely important, the capability of the facility is unable to meet the needs of cancer patients in the whole country.
Prof Sokha Eav, a pioneer in oncology after the tragedy in Cambodia, has been actively leading the effort to improve access to cancer care and to radiotherapy. In the early 2000s he initiated and planned a National Cancer Center (NCC) project to provide comprehensive cancer care to the public, including radiation oncology, nuclear medicine, medical oncology, onco-hematology and palliative care. NCC aims to function as a center of excellence in cancer care, education and research in the country.
On January 13, 2014 the groundbreaking ceremony for the construction of the NCC, presided by the International Atomic Energy Agency (IAEA) Director General, the Cambodian Minister of Health and the Director General of Calmette Hospital, marked the realization of the project in the compound of Calmette Hospital in the center of Phnom Penh. Two more regional cancer centers, one in the northwest and the other in the northeast of the country, are also part of the nationwide cancer care plan. One of the main key components in the project is to establish and maintain safe, accurate, and modern radiation facilities in the center. Three linear accelerators with capabilities of IMRT, IGRT, and SRS/SBRT, one CT-simulator and one HDR after-loading brachytherapy machine will be installed in the NCC. As of September 2017, one linac, a CT simulator and a HDR brachytherapy machine has been installed and awaiting commissioning. We aim to commence treating patients at the National Cancer Centre in Phnom Penh in 2018.
To assure and maintain the standard of radiotherapy, the NCC has been actively collaborating with the international community such as IAEA, Australia, Belgium, France, New Zealand and the United States. These partners have been involved in building up human resources, advice regarding building construction and machine selection, and technical assistance in machine installation and commissioning.
In 2015, a partnership between the NCC and the Asia Pacific Radiation Oncology Special Interest Group of the Royal Australian and New Zealand College of Radiologists (APROSIG) was established. The following year, a team from APROSIG including radiation oncologists, a medical physicist and radiation therapy technologist visited the NCC site in Phnom Penh alongside a team from the University of California San Francisco (UCSF), in order to understand the current needs of NCC and provide support in ensuring a safe and sustainable commencement of radiotherapy services. More importantly, the teams were able to assess the future roles they will play to assist the NCC in achieving the goal of safe and precise radiotherapy.
APROSIG were successful in obtaining Australian government funding through the Australian Volunteers International Development (AVID) program to send volunteer Australian radiation staff to Phnom Penh for periods of 12 months. The project was also recently awarded an Australia Awards fellowship to fund 3-week fellowships for 8 Cambodian oncology staff within Australian hospitals in 2018. A radiation therapist trainer, Ms Kate Rogl, is currently in country in Phnom Penh. 2 Australian medical physicist volunteers, Ms Soo Min Heng and Mr Garry Grogan have already travelled to Phnom Penh to help train the local medical physicist, with a third volunteer, Mrs. Nikki Shelton, to arrive later in 2017. The volunteers will be involved in training the local staff to provide safe and precise radiotherapy, deliver a sustainable service and ultimately, become the future trainers. The long-term goals of the collaboration between the NCC and APROSIG include the establishment of local training programs for radiation oncology, medical physics and radiation therapy technology, as well as establish a cancer research unit. The other international partners will also play crucial roles in assisting to achieve the ultimate aim: the Cambodian ‘triangle of cancer centers’ to provide the nationwide optimal care to cancer patients.
If you are interested in contributing towards the Cambodian-APROSIG project, please contact email@example.com (Cambodia) or firstname.lastname@example.org (Australia). You can also donate to the project at :
- Ferlay J, Soerjomataram I, Dikshit R, et al: Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 136:E359-E386, 2015
Rising above a community of butcher shops and fruit vendors in old Cairo, flanked by the historic Aqueduct of the Nile, the Children’s Cancer Hospital Egypt 57357 (CCHE) is quite the sight to see. With two enormous mesh structures billowing like sails in the wind, and its blue-green windows that defy the dusty layer of sand to glimmer in the sun, the hospital is designed to resemble a ship–sailing towards a healthy, cancer-free world for its children. CCHE has an international reputation as the largest pediatric cancer hospital in the world, with a capacity of 320 hospital beds and immediate plans to add 300 more within the next five years. Inspired by St. Jude Research Hospital, CCHE runs on an innovative finance model in which charitable giving supports 100% of the hospital’s services, allowing it to treat its patients at no charge. Patients from any background are accepted on a first-come, first-serve basis, as long as they are 1) between the ages of 0 and 18, 2) free of any previous treatment, and 3) referred to CCHE as a potential cancer case. The institution sees an approximate 2000-2500 new patients a year, an astounding amount that reflects the high demand of services within the nation as well as the broader Middle East region.
The Radiation Oncology service has been operating since the hospital’s opening in 2007. Dr. Mohamed Zaghloul, the head of the Radiation Oncology department, estimates that the unit treats about 100-120 patients a month on its two linear accelerators. As part of a practicum project for my Master of Public Health degree at Harvard, I traveled to CCHE to explore the strategic plan for its expansion. This ambitious plan includes the process of expanding its radiotherapy services to include a proton therapy center. After intense business planning, the hospital has signed its final agreement and is starting installation. The goal? To treat its first patient with proton therapy in July of 2019.
The hospital’s current expansion includes a shift from innumerable small donations to larger corporate donors, as well as units within the hospital that will be used for profit. Interestingly, the new proton facility will double as both a new treatment modality and a revenue-generating unit to contribute to the hospital’s budget. While it will continue to prioritize the pediatric population at no cost to the patient, it will also start treating adults in the region on a for-profit basis. These plans are in their preliminary stages, and it will be interesting to see how the hospital will balance the long pediatric waitlist with the inevitably high demand of adult patients. This has been an exciting period for the hospital, and during my time there, there was already much buzz floating among its staff in anticipation of this new machine. I was fortunate enough to attend a lecture series completely dedicated to proton therapy and the hospital’s vision (luckily in English). I was impressed by the transparency of the plans for the new center. Everybody in the hospital was invited to attend the lectures, including one given by Dr. Zaghloul detailing the basic science of radiation therapy, and another from a representative of the vendor installing the new machine.
The culture within CCHE was fascinating. I was especially struck by the complete focus on CCHE’s vision. Everyone, even my assigned driver, who became my good friend throughout my trip, knows the mission of the hospital by heart. The CEO is a dynamic, larger-than-life leader, intensely focused on his vision and immensely involved in all hospital activities. While running the analysis on our qualitative data, my partner and I both cited the mission-driven culture as one of CCHE’s biggest strengths. As the hospital continues its expansion and further advances the services it provides its patients, I look forward to it fulfilling its reputation as a beacon of hope for pediatric cancer patients in the region.
I had the pleasure of working as a radiation therapy technologist (RTT)/dosimetrist mentor in the Radiation Oncology Department at Yangon General Hospital (YGH), from July to December 2016. The role was organised through Australian Volunteers International. I normally work as an RTT/dosimetrist clinical educator at the Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia. My time at YGH was a challenging experience, but I felt it was beneficial to the staff at that clinic and in turn, the patients treated over that time, and hopefully into the future.
This was my second mentoring visit to Myanmar. I was previously at the Radiation Oncology Department at Mandalay General Hospital in July and August of 2015. The experiences I had at that time, and the relationships formed, provided me with an up-close view of under-resourced radiation therapy services in Myanmar. There’s certainly a huge need for attention and effort, but there is cause for optimism too.
Myanmar’s history is one that shares many common features with other low income nations. It’s a resource rich country, that was subject to centuries of Western colonialism, and has recently emerged from several decades of a repressive military junta. The establishment of democracy, and end of strict economic sanctions by the EU in 2013 and the USA in 2016 mean that Myanmar is now experiencing an economic and cultural boom. Many people have seen a rapid rise in their standard of living, personal freedoms and have a positive outlook as a result. These societal in advances Myanmar have been uneven, and health service provision has been an area of slower growth.
For decades Myanmar had a total of about 12,000 medical doctors for a country of close to 50 million people, and radiation therapy services were limited to six Cobalt 60 units nationwide. From 2013 to 2016, there were eight medical linear accelerator units and four brachytherapy units installed. The existing staff had no formal education or practical experience with these items of equipment. Their training needs were nominally met with a few days of vendor training, and short study trips to radiation therapy centres in other neighbouring developing nations like Thailand and India.
As described by other authors on the topic of radiation therapy services in the developing world, there is a rapidly rising need for cancer services in Myanmar. YGH treated approximately 2000 patients with radiation therapy in 2012, and this grew to about 7400 in 2016. The Myanmar Ministry of Health’s efforts to ensure satisfactory radiation therapy service coverage to their population have been partially helped by the upgrading of major equipment in their government hospitals. This is also complicated by parallel private radiation therapy centres, military radiation therapy centres, and health service companies which send wealthy patients to developed nations for treatment. Nevertheless, these factors combine to mean that there is a huge need to treat an ever-growing majority of patients with more sophisticated radiation therapy treatments, by a group of professionals in the public sphere, who still have large technical and organizational knowledge deficits.
My aim was to address these knowledge deficits. I was fortunate enough to work with a wonderful group of staff at YGH who were very hard working and welcoming, open to change, and were fast learners. As a result, we achieved some large and lasting technical practice gains in a relatively short amount of time. Some of the bigger achievements that were regularly taking place by the time I left YGH included:
- Tattoos for isocentre placement
- Shielded / shaped electron beams for clinical use,
- 3DCRT mono-isocentric breast and supraclavicular fossa treatment,
- Multiphase 3D conformal mono-isocentric head and neck technique, including junctional electron beams for post cervical chain node irradiation
- Computerized patient and resource scheduling
There were also a large range of other reforms that were launched, to contribute to the development of a quality assurance culture. Other positive professional cultural changes have started. There is now a six month RTT workplace training scheme, which is part of the way through producing its first cohort of new RTTs who will work at various government radiation therapy centres in late 2017. There will also be a select number of medical physicists who will move to Thailand to study and gain a Masters Of Medical Physics, and there will be a Myanmar National Cancer Institute established in the Nay Pyi Daw.
However, resource and knowledge gaps still exist. Individual radiation oncologists, radiation therapy technologists and medical physicists from around the globe can help make a difference, through efforts to address the knowledge deficits described above. It is a lot to ask for any of us to travel to another country and to be a mentor to colleagues there, but there are also other ways to assist without leaving home. Any help would always be welcome and will make a difference.
If you are interested in helping, or have questions, please contact:
Craig Opie [Craig.Opie@health.nsw.gov.au]
Dr. Biniyam Tefera Deressa
University of Gondar, Ethiopia
Two years ago, in January 2015, Dr Daniel Rauch, a Swiss oncologist, and ! were in Gondar, Northwest Ethiopia to evaluate the first cancer patients. Until that day there was no dedicated cancer treatment in the University of Gondar Hospital. Our first patient, Abeba*, came into the office and started to tell us her story. She taught in a primary school in a small village 15km from Gondar. After an operation for breast cancer, her surgeon told her she needed to go to the capital, Addis Ababa for adjuvant chemotherapy and radiation therapy. Over there she encountered many unexpected issues. There were thousands of patients waiting for treatment. After one week of struggles, she finally received a card that would grant her an appointment for oncology evaluation. The waiting list was very long, and she was only able to obtain an appointment after 4 months. They also informed her that the chemotherapy would be administered every 3 weeks for 6 cycles. This was bad news for her since she would need to travel 750km every 3 weeks. This was unaffordable not only financially, but also psychologically. When she heard that a cancer center had been established in Gondar she was very pleased and thankful to be able to get treatment closer to her village.
The story of Abeba is the story of most cancer patients in Ethiopia. Since the country up till now, has had only one center dedicated for cancer treatment, with four qualified clinical oncologists and two radiotherapy machines, all cancer patients were forced to go to Addis Ababa. This certainly exposed them to different financial, social, psychological and even medical harms.
Here it is important to thank four Ethiopian senior clinical oncologists (Dr Mathewos, Dr Wondemagegnehu, Dr Aynalem and Dr Bogale) who worked hard in order to increase cancer awareness in the country, whilst treating patients under difficult circumstances. It became increasingly obvious to them that Ethiopia needed more oncology centers and professionals.
It was in 2014 when Dr Daniel Rauch and I proposed to establish a cancer treatment center in Gondar. Our proposal was mainly based on using small applicable steps to carry out a big dream. We planned to use the available resources and create new solutions for an oncology service. With extraordinary support from the University of Gondar, in January 2015 the Gondar oncology center was ready to accept its first patient, Abeba.
The main steps in our journey to establish the cancer center were:
- Renovating the already existing building but now exclusively repurposed for cancer patients;
- Training of nurses and doctors in Addis Ababa in basic oncology practice;
- Preparing protocols for chemotherapy, premedication and management of oncologic emergencies.
- Organizing short training programs for other disciplines such as pathology (e.g. immunohistochemistry) and radiology (e.g. contrast-enhanced ultrasound) in Switzerland which were previously unavailable in Gondar.
- Establishing tumor board meetings which recommend treatments based on available resources and establish the practice of multidisciplinary discussions.
Currently, the center is treating more than 600 patients per year. It is also recognized as the second cancer treatment center in the country by the Federal Ministry of Health of Ethiopia. In addition to these achievements the Gondar cancer center has a collaboration with University Hospital Inselspital, Bern and Spital STAG, Thun in Switzerland which includes an exchange program of professionals. As wel, the Gondar cancer center has been visited by experts from the MD Anderson Cancer Center and ASCO.
To further improve cancer care for our patients, the University of Gondar is currently constructing a modern building which is designed to provide full oncology services such as medical oncology, radiation oncology and hemato-oncology. Varian Medical Systems has been selected to supply advanced linear accelerators to the hospital. The current cancer center in Gondar is the footsteps of the future modern center. All the nurses and doctors are working passionately to provide great care for our patients. We are all very much looking forward to our upcoming modern oncology and research center.
*Abeba is a fictitious name in order to preserve patient’s privacy.
By Jake Van Dyk
The recent Lancet Oncology Commission report on Expanding Global Access to Radiotherapy indicated that more than 22,000 Medical Physicists will be needed over the next 20 years to address the rising cancer crisis in low-to-middle income countries. Medical Physicists Without Borders (MPWB) (www.mpwb.org ) is a new volunteer organization with a primary mandate of providing intellectual support through training, mentoring and partnering. The overall purpose is to yield safe and effective use of physics and technologies in medicine, especially in low-to-middle income settings. MPWB is incorporated in Canada and is seeking the same in the US along with charitable status in both countries. It is in discussion with various organizations about involvement in master’s degree training programs including those in Zimbabwe and Ethiopia. Furthermore, it is receiving requests from Medical Physics graduate students to participate in electives in lower income settings. While MPWB is still in its early phase of development, it is clear that there is significant interest in support of this activity as it now has a mailing list exceeding 500 contacts.
The concept of MPWB came to me after working as a consultant at the International Atomic Energy Agency (IAEA), in its Human Health Division, for nearly two years between 2009 and 2011. The IAEA has major programs toward providing support and increasing capacity for radiation medicine, especially in low-to-middle income countries. During that time I came into contact with Physicien Médical Sans Frontières, a French-based organization with the goal of providing “missions of aid in support of cancer in developing countries.” When contacting them about setting up an English-speaking sister organization, the response was very positive. Thus, in 2011, as part of the Canadian Organization of Medical Physicists (COMP) Gold Medal award ceremony, I announced my interest in developing MPWB. The response to that announcement and to several informal meetings held at COMP and American Association of Physicists (AAPM) annual scientific meetings was more than enthusiastic. It was clear that there are many Medical Physicists who were eager to get involved, but were not sure how to.
A major emphasis of MPWB is to work in close partnerships with other organizations that support the enhancement of medical physics activities as well as working closely with medical physics colleagues in the lower income settings. To this end, MPWB has developed a joint memorandum of understanding with the American Association of Physicists in Medicine (AAPM) and is working on a similar relationship with the International Organization of Medical Physicists (IOMP). Furthermore, in reviewing potential projects, MPWB continues to seek the input of the IAEA in terms their activities in different countries. The goal of MPWB is to add value and not to overlap with other activities. In a similar vein, MPWB is in close communication with International Cancer Experts Corps (ICEC,)with two of the MPWB board members being on the advisory board for ICEC.
Looking to get involved?
MPWB is a membership-driven organization. Membership is available to individuals who:
- Are medical physicists; or
- Are graduate students or residents (registrars) in medical physics or closely aligned fields; or
- Are working in an environment that is closely aligned with medical physics and are able to partner in less advantaged medical physics contexts.
Membership is available by filling in the application form found on our website (www.mpwb.org) and paying a nominal membership fee. The application questionnaire is quite lengthy primarily because we need to develop a detailed database of information. As projects develop, individuals will be aligned with the needs in lower income settings and their availability. (Note that as I write this, the on-line membership process is not fully implemented but there is a place to register to be on the mailing list.)
“Only the wearer knows where the shoe pinches most,” so the idiom goes, but it’s a fair representation to thousands of cancer patients in Kenya. While radiotherapy services do not cost an arm and a leg as compared to charges abroad, the challenge here is unique; the availability of radiotherapy machines for the majority poor patients. And, therefore, many of the patients here must cling to hope. Hope that maybe tomorrow will bring with it better tidings. But as we all know, hope is never a strategy. Therefore, hopelessness begins to slowly take over as they wait, maybe for a year, for their turn to receive the elusive treatment.
According to the UICC, 29 of 52 countries in Africa have no radiotherapy available to patients . Kenya is fortunate to have radiotherapy services. However, Kenyatta National Hospital, the largest public referral hospital in the country, currently has only two radiotherapy machines. More than 1000 patients are scheduled for radiotherapy stretching from now all the way to 2016. The sad truth is this that many of them will not make it to their appointment date. While several private hospitals in Nairobi also offer radiotherapy, the costs are beyond the reach of the majority of the population who live on a dollar a day. With cancer as the number three cause of death in the country, there remains an urgent need for action to expand access to radiotherapy machines in Kenya and Africa as a whole.
Radiotherapy plays a significant role in cancer care.. In combination with other treatments such as chemotherapy and surgery, many cancer patients may survive. Further, many women in Africa are affected by cervical cancer which if detected early, can be cured where adequate radiation therapy is available. There must be affordable access to cancer treatment, most importantly, access to affordable radiotherapy treatment in Kenya. It’s quite encouraging to note that some African countries such as Egypt, Mauritius and South Africa have made tremendous progress with radiation therapy access in the public sector.Looking at the current cancer situation in my home country Kenya, I want to be counted as a person who walks the talk. I am embarking on a journey of raising awareness of cancer care and the importance of radiotherapy machines. This is not a one-woman journey, but I embark on it with full confidence that like-minded people, who see the need to expand radiotherapy in the public sector by getting more machines at Kenyatta National Hospital and other public facilities will join in this worthy cause and make a difference.
In March, I will be working on a short film that aims to highlight the current state of cancer care in Kenya and, in particular, access to radiotherapy service at Kenyatta National Hospital. My hope is that through this film, various stakeholders will be able to get first-hand experience of the current situation and understand the deep need for radiotherapy in Kenya as well as in many other African countries – some of which do not have a single radiation therapy machine.
 Picture From: http://www.businessdailyafrica.com/
I immediately recognized the simple blue-green door marked with the words “RADIATION AREA” in bold, red letters. Recognize is perhaps too strong a word: I had seen it in a New York Times photograph. It was shut, as it had been in the photo, meaning that the machine was working, as it nearly always was.
“That door was shown in a very famous paper in the United States,” I said to Dr. Daniel Kanyike, one of the clinical oncologists who delivers both radiation therapy and chemotherapy to patients at Mulago Hospital in Kampala, Uganda and our tour guide for the day. “They did a story on breast cancer in Uganda, and talked a great deal about Mulago. Were you here when they visited?”
Dr. Kanyike let out an exclamation of polite surprise mixed with disinterest. Throughout the short time we’d spent getting to know him, he was always more interested in talking about patient care, particularly radiotherapy, than anything else. So, it seemed quite in character that he wouldn’t care to have a lengthy discussion on what a paper in New York had said about Uganda, even if his work was the subject. After a quick silence, he let out a burst of his infectious, unique laughter. “I had heard about that,” he said with bemusement. “But I was not here that day.” We discussed the article no further, moving on to the particularities of the brachytherapy treatment room, which was right next door to “RADIATION AREA.”
I had come to Mulago’s radiotherapy department along with Roshan Sethi, a fellow medical student who would be matching into radiation oncology in mere days, as part of a series of unofficial site visits to radiation facilities in Uganda and Kenya to get a better sense of how radiation therapy is provided for cancer care in the region. While I had visited and worked in a number of hospitals in Eastern and Southern Africa, I had never been in a radiation center in the region. In fact, I’d only visited two in the United States, and rather recently as I shadowed radiation oncologists to see if I would eventually join their field. Because of the high prevalence of cancer, medical students often gain a good deal of general oncology exposure, whether it’s clinical or basic science. However, very little exposure to radiation oncology is offered to those who aren’t looking for it. Radiation is considered so technical, so specialized, so rarified that it barely merits mentioning.
And yet, more than 50% of all patients with cancer will require radiotherapy as a core part of their treatment. That is surely something worth mentioning, if even in one or two lectures. Further, in the fight for global access to comprehensive cancer care, which has been gaining steam year by year, radiotherapy has also been marginal. Even though radiation therapy is an essential part of both palliative and curative treatments for cancer, arguments against its wider implementation have mirrored those that were initially made against access to other life and quality-of-life saving interventions like antiretroviral therapy and surgical care. In short, critics argue that radiation is too expensive, too difficult to implement, and that more “cost-effective” (read: lower cost) strategies, like cancer prevention, should be implemented in its place. While prevention is essential, it can never be held up as a substitute for treatment. Radiation therapy, like surgery, chemotherapy, and social and economic support, are all essential aspects of cancer care the world over.
While I still cannot tell whether Dr. Kanyike had read the article on Mulago, I know that I found things to be quite different than the New York Times’ report. Certainly, many of the facts matched up: a door to a radiation machine, patients, mostly women, waiting along its side for their treatments to begin. However, the feeling transmitted by the photograph and the article was spare, dire, catastrophic. While cancer itself is all of these things, Mulago’s radiotherapy unit struck me as no more and no less individually existentially challenging than the Dana-Farber in Boston. The resources, of course, were orders of magnitude less. That in and of itself is unsettling if not surprising, and calls us with clarity to a moral duty to do more, collectively.
But the radiotherapy care delivered at Mulago, by Dr. Kanyike and the other clinical oncologists, by the medical physicists, dosimetrists, and radiation therapists that work as a team, was impressive. Yes, the machine runs most of the day and most of the night, because it is the best way to treat the most patients. Certainly, the machine’s source, a piece of radioactive cobalt that emits the radiation that treats patients’ tumors, is older than would be optimal, but all of the staff and leadership are quite aware of this and are fighting through the complex series of steps to get a new source. To get a new machine, even, in good time, one that delivers a more modern type of radiation therapy. The entire treatment team here is working to provide radiation therapy to more than one hundred patients each day, care the currently can’t be acquired anywhere else in Uganda. Further, Dr. Kanyike and the other clinical oncologists at Mulago provide radiation therapy for patients with virtually every type of tumor possible, from women with breast cancer to children with brain tumors to patients with rarer malignancies still. This is something that most, if not all, American-trained radiation oncologists would be unable to do, simply because most eventually sub-specialize to treat only certain types of cancer.
As Julie Livingston describes in her book Improvising Medicine, which details the workings of Botswana’s first official cancer hospital, there are real resource constraints at play when considering oncology care in low and middle income countries, but there is also a tireless, caring, innovative and successful struggle against these constraints. Success amidst challenge was the main thing that I took away from my visit to Mulago’s radiotherapy center.
Visiting Mulago Hospital inspired me with a glimpse of what is possible for radiotherapy as a part of cancer care in Uganda, East Africa, and across the globe. Our charge is to leverage resources and build movements of global health solidarity that support the amazing efforts that already exist. We are lucky as students to have such wonderful models for the delivery of equitable cancer care that include equitable access to radiotherapy.
Acknowledgements: Many thanks to Dr. Daniel Kanyike for his time, and, moreover for his tireless dedication to patient care and to radiotherapy.
In the last few decades, there has been a growing interest in global health electives – clinical or research experiences that are usually performed abroad –by medical students and residents. In 1978 only 6% of American medical students experienced a global health elective. Last year, this number was 30%. This trend has been similar in Canada, where a 2012 survey revealed that more than 20% of all residents planned to complete an international elective in global health. Historically international and global health projects have focused heavily on infectious and acute diseases and less on non-communicable and chronic diseases. Cancer, which spans both realms but is generally thought of as a non-communicable disease, has received little focus in global health. Further, as many low- and middle-income countries have no or limited radiotherapy services, radiation oncology has received even less attention. This begs the question: is there a role for global health electives in radiation oncology?
First, it is notable that more and more attention in the field of global health is being paid to the significant burden of non-communicable and chronic diseases, including cancer, diabetes, and cardiovascular disease. Cancer mortality is highest in low-income nations, where cancers are often diagnosed late and treatment infrastructure remains limited. Radiotherapy is required in about 50% of all cancer treatments. And, for large tumors where surgery or chemotherapy would be ineffective or impractical, radiotherapy often remains an option. Thus, sustained partnership between established radiotherapy centers and new or under-resourced radiotherapy efforts to build existing capacity is an essential component of global health efforts focusing on cancer care. The International Atomic Energy Agency and other academic and NGO partners are working to develop and strengthen such collaborations.
It is no surprise, then, that radiation oncology residents want to participate in this exchange of knowledge and skills. In a survey of Canadian radiation oncology training programs conducted in 2012, half of residents said there was interest in global health electives at their center. Surprisingly, only one Canadian resident in the last five years actually went on such an exchange.
Studies on barriers to global health electives tend to put finances at the top of the list. The ASTRO-AARO Global Health Scholars program has been financially supporting radiation oncology residents in pursuit of global health electives since 2011. In Canada, a workgroup of the Canadian Association of Radiation Oncology (CARO) has recently created a scholarship for the same purpose. The CARO International Communications (CIC) Global Health Scholarship will be rolled out later this year as a pilot program for one Canadian resident or fellow. As this program grows more trainees will be able to benefit from financial support from the CIC.
In radiation oncology, the complexity of the treatment makes partnerships and collaborations essential to achieve excellent care. As residents, we have the opportunity to build lasting relationships with the physicians, residents, physicists, therapists and other radiotherapy workers in countries we travel to. Our experiences will allow us broader perspective on barriers to health and healthcare. As the attending physicians of tomorrow, residents with global health experience will be better prepared to advocate for equitable access to radiotherapy for all.
Dr. Horia Vulpe is a resident in the department of Radiation Oncology at the University of Toronto.
In less than 2 minutes, we highlight a few of the social consequences of untreated cancer. We hope that after watching the clip, you’ll be able to share it among your friends, family and colleagues in order to raise awareness of this important cause.
Kevin Tan, a radiation oncology registrar working in Gippsland, Australia and creator of this short film, had this to say about the film:
“I’ve found that some some of the most meaningful work we can do is often also the most humble. Combating cancer on a global scale needn’t be pioneering stuff, nor is it particularly sexy. It begins simply by counting, by framing the challenge, and advocating for interdisciplinary solutions. I am optimistic that the global community will rise to this challenge. But first, let’s get the agenda on the table! Help us spread the word!
I spent the month of July working at the Radiotherapy Department at Mulago Hospital, Uganda’s flagship public hospital located in the teeming, rambunctious capital city of Kampala. This is the only radiation oncology center in Uganda, a country of 36 million people. The clinic also draws patients from South Sudan, Eastern Congo, and parts of Kenya. The workhorse of the clinic is a singular Cobalt-60 machine, originally installed in 1994. The cobalt source has not been changed in 12 years. In order to accommodate the patient load, the machine treats patients 24 hours a day, Monday through Friday, reserving most Saturdays for larger palliative fractions.
The physicians, house officers, nurses, therapists, and staff embraced me from the moment I crossed the clinic threshold and quickly incorporated me into their busy practice. As I arrived early each morning for LDR brachytherapy insertions, dozens of patients would be lined up. Many of them had spent the previous night camped out on the hospital grounds. By the time the morning chart rounds and tumor boards were over and we were ready to start, new consultations, patients under treatment, and follow-ups filled every inch of the waiting area.
Clinic was ripe with both learning opportunities and challenges. I developed a level of comfort managing cervix, nasopharynx, and other cancers common in Uganda but less prevalent in the US. Seeing the radiation oncology zebras like endemic Kaposi’s sarcoma and penile cancer seared these sites in my mind. The neglected breast, rectal, or vulvar cancers called attention to the lack of screening and general cancer awareness in the country.
Soon after settling in, I was given my own cramped office and a stack of patient files to see each day. Although the physicians were available for help, they encouraged autonomy. I was forced to overcome language barriers (60 tribes in Uganda, each speaking their own language), work around limited medical records, and navigate a foreign healthcare system. There were frustrating and stressful moments. But there were many more moments of the privileged patient provider connection that drove me to pursue medicine in the first place.
Exposure to 2D planning was a highlight. The clinic lacks a CT sim, so the majority of cases were planned using fluoroscopy. Others were planned using tumor and bony anatomy alone. Field dimensions and separation were measured, recorded, and outlined with marker and torn pieces of plaster. There were many times I missed the seemingly limitless planning tools and image guidance available at home but I also came to appreciate the simplicity, efficiency, and efficacy of 2D planning. In between procedures, meetings, and clinics, I managed to deliver twelve radiation oncology -focused lectures. This teaching component enabled me to share educational resources and insights from the West. This peaked the curiosity of my Ugandan colleagues and generated robust discussions.
My experience in the Radiotherapy Department at Mulago Hospital was transforming professionally and personally. My commitment to working in resource-limited settings domestically and internationally has been solidified. I look forward to building upon the relationships I have made in Kampala and helping others in our field connect with cancer care providers around the world.
John Mac Longo is a fourth year resident in radiation Oncology at the Medical College of Wisconsin in Milwaukee, Wisconsin (USA).
What do you mean by that?
Margaret Chan, Director-General of the World Health Organization has said ‘What gets measured gets done’. One major challenge to cancer control is to understand what we’re up against. What needs to be improved, and by how much? How many cancers are there in each country and region? What are the survival and mortality trends? How is the cancer control system performing? Answering these questions requires counting and categorizing information about many individuals and situations. This information then needs to be interpreted to create useable knowledge. Once this sort of knowledge is created, it must get into the hands of the right people, at the right time.
Tell us about yourself
My name is Timothy Hanna, and I am a Canadian radiation oncologist involved in health services research. In my research, I investigate access to cancer care and quality of cancer care. The goal is to seek out ways to improve cancer control. These research themes are of global importance given the increasing incidence of cancer across the globe. Being a radiation oncologist, my work focuses on cancer treatment, particularly radiation therapy.
What are you working on right now?
There are a few things. As one example, I’m investigating the achievable benefit of radiation therapy in the general population. If we were able to get this cancer treatment to everyone that needed it, how many people would we help? The primary work focuses on Australia, but this will be adapted to other settings. I’m working on this with a team in New South Wales, Australia. This work will inform the investment framework under development by the Union for International Cancer Control’s (UICC) Global Task Force on Radiotherapy for Cancer Control (GTFRCC).
How did you get involved?
I have had a longstanding interest in global health. As a medical student, I spent some time in Niger. I was struck by the limited cancer treatment resources where we were, the late stage of presentation and social determinants impacting access to cancer care. That was an important exposure that helped me think about global disparities and inequities in cancer care and health care. In residency, I had the chance to work with an experienced radiation oncologist clinician scientist who showed me how health data could be used to shed light on inequities and other quality issues in cancer care. This led to my fellowship work at the Ingham Institute in Sydney, Australia, and ultimately to my work at Queen’s University in Kingston, Ontario where I work as a radiation oncologist and clinician scientist supported by the Ontario Institute for Cancer Research (OICR).
Why do you think radiation therapy is important?
Radiation therapy is an irreplaceable part of cancer control. Cancer is a global problem, affecting countries of all levels of economic development. Radiation therapy delivers outstanding value for money, and is especially important in contexts where there is a burden of advanced cancers requiring treatment. When radiation therapy reaches those who need it, lives can be saved, body function maintained, and quality of life improved. These are all exceedingly important to people diagnosed with cancer.
Mei is a radiation oncologist in Sydney, Australia and has written Global RT’s inaugural blog post. Learn about how she has combined a career in radiation oncology and global health.
Who are you and where do you work?
My name is Mei Ling Yap and I am a radiation oncologist from Sydney, Australia. My clinical practice is at Liverpool and Macarthur Cancer Therapy Centres, in the South-western region of Sydney. It is a unique part of Australia, very culturally diverse – so I see an interesting case mix of patients. My clinical sub-sites are lung, breast and gynecological cancers. As well as my clinical role, I keep busy through research, undergraduate and post-graduate teaching and my role as the director of registrar (resident) training.
Why radiation oncology?
I decided to specialize in oncology as I feel that it’s a very ‘human’ specialty. My patients and their families are so inspiring. Working in oncology, one has the potential to help people through what is an important and challenging time in their lives, and that truly is a privilege.
I chose radiation oncology in particular as I felt it was a field where we can make a difference for patients. Radiotherapy is often the primary treatment used to cure patients, in sub-sites such as head and neck, prostate and cervix cancer, to name a few. Achieving cure for cancer patients is a wonderful outcome. Equally as important, I feel, is the ability to palliate incurable patients from potentially distressing symptoms such as pain and bleeding – with radiotherapy able to achieve that in usually more than 2/3 of cases.
How did you become involved in global health, and in particular global access to radiotherapy?
Global health has been an interest of mine since my medical student years at the University of New South Wales, where I was involved in an Australian medical student-run aid organization (MSAP), and did a posting in Chennai, India. It was alarming to witness upfront, the lack of access to medical treatment, which exists in many parts of the world.
In 2008-9 I did part of my radiation oncology training at the National University Cancer Institute in Singapore. I found it interesting to manage a different case-mix of patients (e.g. High incidence of nasopharyngeal cancer), and learn the different cultural perceptions of cancer, which exist there.
It was while I spent a 2-year fellowship at Princess Margaret Cancer Centre (PMCC) in Toronto that I realized that my passions for radiation oncology and global health could be united. Dr Mary Gospordarowicz, at that time the head of PMCC and now UICC, was harnessing members of the radiation oncology community who were interested in tackling the issue of global access to RT. After returning back to Australia, I was fortunate enough to be given the opportunity to work alongside my GTFRCC mentor, Professor Michael Barton, who is an extremely prolific researcher in global cancer health research, as part of his team at CCORE.
What is your role in GTFRCC?
My role in the GTFRCC is as part of the burden and outcomes working group, which is working to define the scope of the need for radiotherapy in low and middle income countries, as well as estimating the benefit in outcomes that radiotherapy would add to these countries. The work that we are performing will be a significant part in the GTFRCC ‘white paper’ to be launched at the UICC meeting in Melbourne in December. I am also part of the GTFRCC Young Leader’s program.
What research are you doing in global health?
At present, I conduct cancer health services research as part of CCORE, Ingham Medical research, Liverpool. The CCORE team, under the direction of Professor Michael Barton, developed an evidence-based model, which estimates the optimal utilization of radiotherapy in a developed country. We are currently adopting this model to low and middle-income countries to measure the optimal utilization of radiotherapy in those countries, with projections up to 2035. We are also estimating the differences between what should be, and what is currently available, in terms of radiotherapy resources – and comparing the present deficit to that of a decade ago.
Why do you think advocacy for improved access to radiation is important?
Advocacy for improved access to radiation oncology will play a central role in achieving the goal of closing the gap in terms of radiotherapy resource provision. We have made huge gains in term of cancer outcomes in high-income countries, but unfortunately cancer in low and middle-income countries has gone largely ignored. This cannot continue! The statistics are harrowing – 70% of cancer deaths occur in low and middle income countries, and cancer causes more deaths worldwide than malaria, TB and HIV put together – yet majority of people are unaware of this. This is where I think globalRT will make a huge difference. We need to communicate these facts, particularly harnessing social media – twitter, facebook etc etc. So readers, go ahead and spread the word!
Where is the most interesting place that your global RT work has taken you?
There have been many interesting visits, but my most recent was to Imam Khomeini Hospital in Tehran, Iran. The radiation oncology department, headed by Professor Peiman Haddad, is currently in the process of some exciting developments. It was especially nice to meet the radiation oncology residents, currently 10 of the 13 are female.