Radiation Oncology Quality and Safety Considerations in Low-Resource Settings: A Medical Physics Perspective

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The past few years have seen a significant growth of interest in the global radiation therapy (RT) crisis. Various organizations have quantified the need and are providing aid in support of addressing the shortfalls existing in many low-to-middle income countries. With the tremendous demand for new facilities, equipment, and personnel, it is very important to recognize the quality and safety challenges and to address them directly. An examination of publications on quality and safety in RT indicates a consistency in a number of the recommendations; however, these authoritative reports were generally based on input from high-resourced contexts. Here, we review these recommendations with a special emphasis on issues that are significant in low-to-middle income countries. Although multidimensional, training, and staffing are top priorities, any support provided to lower-resourced settings must address the numerous facets associated with quality and safety indicators. Strong partnerships between high income and other countries will enhance the development of safe and resource-appropriate strategies for advancing the radiation treatment process. The real challenge is the engagement of a strong spirit of cooperation, collaboration, and communication among the multiple organizations in support of reducing the cancer divide and improving the provision of safe and effective RT.

Introduction

Recently, there has been an increased recognition of the growing cancer crisis, especially in low-to-middle income countries (LMICs). This is clearly demonstrated in Fig. 1A that shows a significant increase in the number of publications dealing with the global cancer problem, of which nearly 30% were published in 2014 and 2015. What is noteworthy, however, is that a similar publications search on the global radiotherapy problem yielded approximately 3% of the global cancer articles and of those approximately 80% were published in 2014 and 2015 (Fig. 1B). The most significant recent report is the Lancet Oncology Commission on global access to radiotherapy.1 This report indicates that radiation therapy (RT) is essential for effective cancer treatment, but the availability of RT in LMICs is unacceptably low. It quantifies the shortfall in access to RT by country and globally for 2015-2035 based on current and projected need, and it shows the substantial health and economic benefits to investing in RT in spite of the high up-front costs. The projections to 2035 indicate the need for very significant growth in RT facilities and personnel so that 22,000 additional medical physicists will be required in LMICs to meet the overall demand and recommends an action in human resource capacity building of at least 6000 newly trained medical physicists by 2025. With this tremendous demand for new facilities, equipment and personnel, it is important to recognize the quality and safety considerations in the lower-resourced settings and to address them directly as a means of maximizing treatment quality and minimizing potential patient misadministrations.

As pointed out in a report by the International Atomic Energy Agency (IAEA) on inequity in cancer care,2 “quality” in health care is a multidimensional concept3 with components of “inequality”(or disparity) encompassing all the other elements of “quality”. A program to improve quality must, therefore, include activities to address the inequality problem. Although this article does not address the problems of solving basic inequalities, it does address quality issues related to societal contexts where RT infrastructure is just being developed.

Section snippets

The Radiation Treatment Process and Elements of Quality and Safety

The radiation treatment process is complex with multiple steps and involves various professional personnel. Elements of quality and safety occur at both the programmatic and individual patient level as shown in Figure 2.

Effect of Quality on Patient Outcome

There is growing quantitative evidence that the quality of radiation treatment has a direct effect on clinical outcomes. A recent review4 that specifically addressed the question “Does quality of radiotherapy predict outcomes of multicenter cooperative group trials?” found, through a thorough literature review, that in nearly half the trials, clinical failure rates were significantly higher after inadequate vs adequate RT and that significantly worse overall and progression-free survival

Overview of Quality and Safety Considerations

In 1988, the World Health Organization (WHO) defined quality assurance (QA) as “all those procedures that ensure consistency of the medical prescription and the safe fulfillment of that prescription in connection with the target volume, together with minimal dose to normal tissue, minimal exposure of personnel, and adequate patient monitoring aimed at determining the end result of treatment”.16 Thus, the components of QA include:

  • (1)

    dose delivered to the target according to the prescription,

  • (2)

    safe

Planning and Integration of Radiotherapy in National Health Programs

The Lancet Oncology Commission1 on expanding global access to RT had 5 “Calls for Action” with the first being a target that 80% of countries should have national cancer plans that include RT by the year 2020. Clearly, if national plans are not in place, the likelihood of any RT occurring in the country is low. The access to RT problem is most acute in sub-Saharan Africa, where most countries almost completely lack RT facilities. The IAEA is working together with pre-eminent cancer-related

Considerations for New Facilities or Upgrade of Existing Facilities

In planning for new departments or additional machines in existing departments, the IAEA has developed some excellent resources.2, 34, 35, 36 Crucial to describing the operation of a new radiation oncology facility are 5 principal components: (1) facility design and development, (2) equipment, (3) consumable materials, (4) human resources, and (5) procedures. A clear chain of authority and communication needs to be established early. One of the general concerns in developing a new cancer

Lessons Learned From Past Experience

The 7 authoritative reports referred to in the Dunscombe article20 provide guidance on delivering safe RT, based on lessons learned from past experience— experience which is primarily based on high-income contexts. The question is, what the corresponding risks are in lower income settings. Table 1 lists the topics of the 12 top most cited recommendations made in these articles. Based on our national and international experience, our interactions with medical physicists in both low- and

Broad Quality and Safety Matters for Low-Resourced Settings

The specific issues for low-resourced settings are not all that different from issues that existed within high-resourced settings a number of years ago, with high-resourced settings having moved forward in the meantime. Hopefully, the high-resourced contexts can provide guidance and a higher rate of implementation for lower-resourced circumstances. The broad issues of significant concern include (1) support from upper level management and encouragement for quality and safety considerations

Summary and Conclusions

The radiation treatment process is complex involving sophisticated high-technology equipment and multiple professionals including radiation oncologists, medical physicists, and radiation therapists. The complexity, sophistication, high up-front costs, and a lack of trained professional staff have been a deterrent for implementation of RT in many LMICs. However, with appropriate political and organizational will, these barriers can be overcome and indeed are beneficial to both the health care of

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    Disclosure: Jacob Van Dyk has a license agreement with Modus Medical Devices Inc., London, Ontario, Canada associated with radiation therapy quality assurance equipment.

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