Technologies and skilled personnel across disciplines go hand in hand with medicines

– the radiotherapy experience May Abdel-Wahab, MD, PhD, FACR, FASTRO

Director of the Division of Human Health Department of Nuclear Sciences and Applications

World Cancer Congress 31 October – 3 November 2016

Paris, France

Essential services for cancer

• Diagnostic – Pathology – Labs – Imaging

• Surgery • Radiotherapy • Chemotherapy • Palliative care

IAEA

Radiotherapy Comprehensive approach

• Radiotherapy is an essential component of

effective cancer care and provides sound motivation for investment.

• Multidisciplinary approach required. Use of

technologies and skilled personnel across disciplines using radiotherapy.

IAEA

Current Radiotherapy Coverage

Current coverage of radiotherapy services according to country as determined by global equipment databases, an activity-based operations model, cancer incidence, and evidenced-

based estimates of radiotherapy need. Lancet commission Report

2012: 14.2 million new cancer cases 8 million cancer deaths

* Projected :Ferlay J et al Sources, methods and major patterns in GLOBOCAN 2012. 2015; 136(5):E359-E386.

2030 : 24.6 million new cancer cases 13 million cancer deaths*

Atun et al., Lancet Oncology 2015

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Radiotherapy Coverage World-wide

Atun et al., Lancet Oncology 2015

Health benefits of radiotherapy Global expansion-life yrs saved

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DIRAC: RT equipment

7877

Radiotherapy Centers

140 Countries 13534

Teletherapy units

2453 Brachytherapy units

6411 TPSs 3740 Simulators 3444 CTs 66,726 Staff

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Global Radiotherapy Demand

Atun et al., Lancet Oncology 2015

expenditure on health per person, 2013 (US$)

radi

othe

rapy

util

isat

ion

(%)

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Needs in 2035

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RT is an essential part of effective cancer control in 2035

Atun et al., Lancet Oncology 2015

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Cost of Global expansion of radiotherapy 2015-2035

Atun et al, Lancet Oncology 2015

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CT - Transmission Imaging

Structural Information:

Size

Shape

Location

NM - Emission Imaging

Uptake Information

Activity

Function

Localization

Diagnosis and Staging

Images Courtesy D. Paez

Diagnosis Staging

Restaging Therapy planning Therapy response

IAEA

Radiation Therapy Treatments

• Radiotherapy has been used for curative or palliative treatment of cancer, alone or combined with chemotherapy or surgery.

Robotic Body Radiosurgery

External Beam 3-D/IMRT

Gamma-knife Radiosurgery

Brachytherapy

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Intensity Modulated Radiation Therapy Non-IMRT versus IMRT Port Films

IAEA

Comparison of Techniques

Radonc.ucla.edu

Courtesy Sua Yu, MD

IAEA

Radiation Therapy Process

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Weakest Link

Some of the steps in radiotherapy that can be represented by links in a chain; treatment accuracy will be limited by the weakest link in the chain

Njeh CF:J Med Phys. 2008 Oct-Dec; 33(4): 136–140. doi: 10.4103/0971-6203.44472

IAEA

Effect of Inaccurate Tumor Delineation and Smaller Margins

Njeh CF:J Med Phys. 2008 Oct-Dec; 33(4): 136–140. doi: 10.4103/0971-6203.44472

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Local Control and Survival Benefit from Radiation

Top 10 cancers globally by incidence: Radiotherapy utilization rate, average RT fractions and outcome benefits

(absolute proportional)**

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The world population benefit : 10% for local control 4% for overall survival.

Cancer imposes large economic burden on countries, estimated worldwide at US$2 trillion in 2010*

*Bloom DE et al Geneva: World Economic Forum, 2011 ** personal communication Lancet Commission Report

2012: 1.5 million people local control benefit > 580,000 people survival benefit

2035: 2.5 million people local control benefit 950,000 people survival benefit

IAEA International Atomic Energy Agency

IAEA

Radiation Therapy-what do we need?

People eg RO, RTT, MP, RS, Engineers Support services/technologies Maintenance Infrastructure eg electricity Quality and safety Other Disciplines eg pathology, medical

oncology infrastructure, surgery

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IAEA

Example of comprehensive planning and support : IAEA experience

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IAEA

Education & Training Development of interactive eLearning modules for Health Professionals: • Introduce new interactive E-learning

modules that enhance self-directed learning.

• Improve efficiency in education • Expand educational opportunities in

remote areas.

http://humanhealth.iaea.org

IAEA

IAEA COLLABORATION IN EDUCATIONAL ACTIVITIES

AFRONET

13%

11% 76%

Breast

Cervix

Others

•AFRONET network was established in June 2012 with the purpose of strengthening the process of clinical decision making in radiotherapy centers in Anglophone Africa.

•AFRONET was conceived to facilitate interactions among cancer specialists, and engage them in evidence-based cancer interventions

•Educational Virtual Tumor Boards and Lectures in relevant topics

IAEA

• Radiation oncologists from LMIC: hands-on IAEA training in 3-D radiotherapy tools • Facilitate 2D to 3D and also transition to IMRT • Plans: expand contouring training through e-Learning platform worldwide

IAEA GLOBAL COLLABORATION IN EDUCATION

TRAINING IN CONTOURING

• Research project to measure the impact of training in contouring

• Increase homogeneity among countries in contouring • Long term benefit and build new research on top

Human Health Campus

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• Page hits from 205 countries/territories

• One million pages viewed since 2010

• An average of 4.348 users visit the HHC

regularly per month • 175,000 users • 14,775 pages viewed in

March • An estimated additional 215,000 health professionals will be needed by

2035 to meet the need for radiotherapy services. • Novel competency based curricula • New models of training, and credentialing

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IAEA support in Radiotherapy & Medical Physics

• Setting up new centres/Upgrade/QA

• National education programmes

• Fellowships for education and training

• Experts (equip. commissioning, on-site training, etc.)

• Procurement of equipment

• Regional training courses

• Dosimetry services • Comprehensive audits

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Radiation oncologist Medical physicist RTT Safety specialist (local)

QUANUM, QUATRO, QUAADRIL missions

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IAEA/WHO TLD postal service for external beam radiotherapy

• About 500 beams per year • Includes Co-60 and High Energy

X-ray beams • Discrepancies are followed up, if

necessary by an expert visit

IAEA-WHO SSDL Network • 80 SSDL laboratories in 67 countries • 6 SSDL organizations • Five collaborating international

organizations

Calibration service for national dosimetry standards

QA Calibration & Audit services Support to end-users in dosimetry:

Verification of clinical beam calibration

IAEA

IAEA Technical cooperation Program

Developed and managed jointly by the Member States and the IAEA Secretariat. The IAEA Technical Departments are responsible for the technical integrity of the TC programme. IAEA TC Department responsible for the management of the TC programme Yearly budget of about €120 million About €32 million (~26%) are spent on Human Health

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General Solutions to Human resource shortfalls

• Avoid fragmented approaches –not sustainable.

• Innovative leadership and stewardship models are required to promote multi-national partnerships with those in need.

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Cervix Cancer

• Radiotherapy improves the absolute 5-year survival rate by 17% over the contribution of surgery and chemotherapy.

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IAEA

CERVICAL CANCER CONTROL

9 of 10 deaths of all cervical cancer cases occur in in less developed regions of the world Every 10th case of cancer in LMIC is cervical cancer Mortality varies 18-fold between the different regions of the world

Cancer of the uterine cervix, one of the most common female cancers

A major cause: Human papilloma virus (HPV) infection

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A JOINT GLOBAL PROGRAMME ON CERVICAL CANCER PREVENTION AND CONTROL

5 year Program supports sustainable national comprehensive cervical cancer control programme (NCCCP) equitable access: • Increased coverage of screening and treatment

for cervical pre-cancer. • Increased capacity of health systems to diagnose

and treat cervical cancer, including provision of palliative care;

• Monitoring and evaluation system developed and implemented.

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COLLABORATION IN THE UN JOINT GLOBAL PROGRAMME ON CERVICAL CANCER

IAEA

PARTICIPANTS • World Health Organisation (WHO) • International Atomic Energy Agency (IAEA) • International Agency for Research on Cancer

(IARC) • United Nations Population Fund (UNFPA) • UNAIDS • UNICEF • UNWOMEN • UNDP/UNFPA/UNICEF/WHO/World Bank Special

Programme of Research, Development and Research Training in Human Reproduction (HRP)

• *UNODC- currently as an observer

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Challenges and Solutions

• Uncertain energy supply • Lack of control of building temperatures • Weak health systems, limited laboratory/

diagnostic & medical support.

Atun et al., Lancet Oncology 2015

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Factors Affecting Resources needed

• Facility size & construction costs. • Equipment chosen • Personnel costs • Operations working hours time required to perform various activities by

staff • Economic standards

Atun et al., Lancet Oncology 2015

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Factors Affecting Resources needed

• Proportion of long versus short course treatments

• Level of complexity used. • Guidelines vs rapid evolution in radiotherapy

practice • Work regulations • Distance to facilities & patients’ travel needs

Atun et al., Lancet Oncology 2015

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Division of Human Health CRPs

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RESEARCH

Section No of CRPs ARBR 13 NMDI 10

NAHRES 8 DMRP 6

Background Axial image-based brachytherapy treatment planning is becoming the most accurate and reliable approach. However, it currently relies on MRI/open-MRI technology Scientific question (tentative) Can ultra-sound based treatment planning replace MRI in the brachytherapy planning of cervical cancer? Benefit to MS If US-based can be proven equivalent to MRI, then a much resource economic method can be developed and recommended to RT centres.

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Coordinated Research Projects (CRP)

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Impacting Policy Activities that influence policy • Develop novel

strategies/ be proactive

• Intergenerational learning and strategies

• Be informed outside own area of expertise

• Databanks, search tools, news feeds, aggregators, fellow citizens.

Cooperation/ inside track

Policy briefings Environmental petitioning

Company lobbying

Evidence/ science based

Direct action

Confrontation/ outside track

Interest/ values based

Advocacy Advising

Activism Lobbying

Start, D. and Hovland, I. (2004) Tools for policy impact: a handbook for researchers. London: ODI (www.odi.org.uk/resources/download/156.pdf).

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Thank you!

IAEA

Questions

• How is radiotherapy cost-effective given the significant upfront cost of radiotherapy equipment ?

• How can international organizations like the IAEA help increase technology transfer in radiotherapy to contribute to achieving target 3.4 of the SDG

• What are some of the challenges in the development and access to radiation therapy and radiodiagnostic technologies for cancer diagnosis and treatment to developing countries,?