Technologies and skilled personnel across Radiosurgery Brachytherapy IAEA Intensity Modulated Radiation…

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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

IAEA

Radiotherapy Coverage World-wide

Atun et al., Lancet Oncology 2015

Health benefits of radiotherapy Global expansion-life yrs saved

IAEA

DIRAC: RT equipment

7877

Radiotherapy Centers

140 Countries 13534

Teletherapy units

2453 Brachytherapy units

6411 TPSs 3740 Simulators 3444 CTs 66,726 Staff

IAEA

Global Radiotherapy Demand

Atun et al., Lancet Oncology 2015

expenditure on health per person, 2013 (US$)

radi

othe

rapy

util

isat

ion

(%)

IAEA

Needs in 2035

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RT is an essential part of effective cancer control in 2035

Atun et al., Lancet Oncology 2015

IAEA

Cost of Global expansion of radiotherapy 2015-2035

Atun et al, Lancet Oncology 2015

IAEA

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

IAEA

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

IAEA

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): 136140. 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): 136140. doi: 10.4103/0971-6203.44472

IAEA

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

20

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

24

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

IAEA

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

IAEA

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

IAEA

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.

IAEA

Cervix Cancer

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

29

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

IAEA

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.

IAEA

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