Global Cancer

by Adam Olson

Dr. Zafar’s excellent presentation on cancer at the global level stimulated a vigorous and appropriate
conversation about the impact of cancer care delivery on the public health infrastructure of resource-limited settings. As Devon mentioned, there are facilities in Kenya that are considering installation of a radiation therapy center when basic medical supplies – IV tubing, intubation materials, etc. – are only intermittently available. I agree that this does not make sense, but I respectfully challenge the unspoken assumption that radiotherapy does not have a role in a cancer control program in a resource-limited setting.

The assumption that radiation therapy is not a cost effective treatment in a resource-limited setting is quite understandable. Radiation therapy in the US is expensive, technologically advanced particularly over the past 10-20 years), and it requires a combination of technical, human, and capacity resources that rivals any other medical specialty. Indeed, you can ask anyone in my department how many times our machines require maintenance to appreciate how hard it is to keep a linear accelerator functioning!

To attempt to replicate a radiotherapy department like Duke’s in a resource-limited setting would be folly for practical and financial purposes. Radiotherapy requires a significant upfront investment, which covers the construction of the treatment vault, the treatment machine, and the costs of installation, commissioning, and quality assurance. Unlike other medical treatments, the cost of “consumables” (such as the IV tubing that Devon frequently lacks) for radiotherapy is actually quite low. Thus, if a radiotherapy machine is installed and can treat patients for several years with minimal downtime (not a trivial matter), then a radiotherapy center is likely a cost effective treatment. There are older models of radiotherapy units that are reasonably priced and available with partial subsidies from the International Atomic Energy Agency. If you factor in the potential benefits of treating childhood malignancies (e.g., Wilms tumors, neuroblastoma, lymphoma) and malignancies affecting young women (e.g., breast and cervix), then you can begin to appreciate how radiotherapy access can translate into a public health benefit using DALYs as we learned about in class.

Investigators from the Union for International Cancer Control have performed a cost-effectiveness analysis of radiotherapy installation in low- and middle-income countries. Their analysis is eagerly anticipated and should be published this fall (I heard in the Lancet Oncology). In the interim, there have been a number of publications describing the potential role of radiation therapy expansion in resource-limited settings. See Pubmed IDs 24929155, 24929154, 24751411, to name a few.