Radiotherapy in the Caribbean: a spotlight on the human resource and equipment challenges among CARICOM nations.

BACKGROUND: There is limited data on access to radiotherapy services for CARICOM nations. METHODS: This was a descriptive mixed-methods observational study which used data collected via survey from staff working in Radiation Oncology in 14 CARICOM countries. Benchmark recommendations from the International Atomic Energy Agency were compared to existing numbers. The Directory of Radiotherapy Centers, World Bank, and Global Cancer Observatory databases were all accessed to provide information on radiotherapy machines in the region, population statistics, and cancer incidence data respectively. Both population and cancer incidence-based analyses were undertaken to facilitate an exhaustive review. RESULTS: Radiotherapy machines were present in only 50% of the countries. Brachytherapy services were performed in only six countries (42.9%). There were a total of 15 external beam machines, 22 radiation oncologists, 22 medical physicists, and 60 radiation therapists across all nations. Utilizing patient-based data, the requirement for machines, radiation oncologists, medical physicists, and radiation therapists was 40, 66, 44, and 106, respectively. Only four (28.6%) countries had sufficient radiation oncologists. Five (35.7%) countries had enough medical physicists and radiation therapists. Utilizing population-based data, the necessary number of machines, radiation oncologists, and medical physicists was 105, 186, and 96 respectively. Only one county (7.1%) had an adequate number of radiation oncologists. The number of medical physicists was sufficient in just three countries (21.4%). There were no International Atomic Energy Agency population guidelines for assessing radiation therapists. A lower economic index was associated with a larger patient/population to machine ratio. Consequentially, Haiti had the most significant challenge with staffing and equipment requirements, when compared to all other countries, regardless of the evaluative criteria. Depending on the mode of assessment, Haiti's individual needs accounted for 37.5% (patient-based) to 59.0% (population-based) of required machines, 40.1% (patient-based) to 59.7% (population-based) of needed radiation oncologists, 38.6% (patient-based) to 58.3% (population-based) of medical physicists, and 42.5% (patient-based) of radiation therapists. CONCLUSION: There are severe deficiencies in radiotherapy services among CARICOM nations. Regardless of the method of comparative analysis, the current allocation of equipment and staffing scarcely meets 50% of regional requirements.

Radiation Therapy Physics Quality Assurance and Management Practices in Low- and Middle-Income Countries: An Initial Pilot Survey in Six Countries and Validation Through a Site Visit.

Purpose: Our purpose was to assess physics quality assurance (QA) practices in less resourced radiation therapy (RT) centers to improve quality of care. Methods and Materials: A preliminary study was conducted in 2020 of 13 select RT centers in 6 countries, and in 2021, our team conducted onsite visits to all the RT centers in Ghana, one of the countries from the initial survey. The RT centers included 1 private and 2 public institutions (denoted as Public-1 and Public-2). Follow-up surveys were sent to 17 medical physicists from the site visit. Questions centered on the topics of equipment, institutional practice, physics quality assurance, management, and safety practices. Qualitative and descriptive methods were used for data analysis. Questions regarding operational challenges (machine downtime, patient-related issues, power outages, and staffing) were asked on a 5-point Likert scale. Results: The preliminary survey from 2020 had a 92% response rate. One key result showed that for RT centers in lower gross national income per capita countries there was a direct correlation between QA needs and the gross national income per capita of the country. The needs identified included film/array detectors, independent dose calculation software, calibration of ion chambers, diodes, thermoluminiscence diodes (TLDs), phantoms for verification, Treatment Planning System (TPS) test phantoms, imaging test phantoms and film dosimeters, education, and training. For the post survey after the site visit in 2021, we received a 100% response rate. The private and the Public-1 institutions each have computed tomography simulators located in their RT center. The average daily patient external beam workload for each clinic on a linear accelerator was: private = 25, Public-1 = 55, Public-2 = 40. The Co-60 workload was: Public-1 = 45, Public-2 = 25 (there was no Co-60 at the private hospital). Public-1 and -2 lacked the equipment necessary to conform to best practices in Task Group reports (TG) 142 and 198. Public-2 reported significant operational challenges. Notably, Public-1 and -2 have peer review chart rounds, which are attended by clinical oncologists, medical physicists, physicians, and physics trainees. All 17 physicists who responded to the post site visit survey indicated they had a system of documenting, tracking, and trending patient-related safety incidents, but only 1 physicist reported using International Atomic Energy Agency Safety in Radiation Oncology. Conclusions: The preliminary study showed a direct correlation between QA needs and the development index of a country, and the follow-up survey examines operational and physics QA practices in the RT clinics in Ghana, one of the initial countries surveyed. This will form the basis of a planned continent-wide survey in Africa intended to spotlight QA practices in low- and middle-income countries, the challenges faced, and lessons learned to help understand the gaps and needs to support local physics QA and management programs. Audits during the site visit show education and training remain the most important needs in operating successful QA programs.

A retrospective review of patients with stage IB2 cervical cancer treated with radical radiation versus radical surgery as a primary modality.

OBJECTIVE: To review the efficacy of treatment modalities in patients with stage IB2 cervical cancer treated at Groote Schuur Hospital, Cape Town, South Africa. MATERIALS AND METHODS: This was a retrospective observational study of patients with stage IB2 cervical cancer treated from 1993 to 2008 with either primary radiotherapy, (with or without follow-on hysterectomy) or primary surgery (with or without adjuvant radiotherapy). Weekly cisplatin given concurrently with radiotherapy was used since 2003. Patient outcomes and grade 3 to grade 4 treatment-related toxicities were recorded. RESULTS: The study included 78 eligible patients for whom the 5-year overall survival rate was 70.8%. Overall 5-year survival rate by treatment modality was 88% for the 25 patients in the surgery group and 62.5% for the 53 patients in the radiotherapy group. There was a marked difference in the proportion of patients in each group receiving additional therapy: 88% of patients in the primary surgery group had adjuvant radiotherapy, whereas only 5.7% of patients in the primary radiotherapy group went on to have a hysterectomy. Grade 3 to grade 4 toxicity was found in 13.2% of the radiotherapy group versus 4% of the surgery group (P = 0.4). CONCLUSION: The optimal primary treatment for stage IB2 cervical cancer remains unclear. Both types of primary treatments were found to be feasible therapeutic approaches. Primary surgery seems to have better survival outcomes at our institution. Selection bias including a larger median tumor size in the radiotherapy group and inadequate concurrent chemotherapy (≤3 cycles) in 58% of the patients receiving primary radiotherapy probably accounted for the difference in survival.Thus, primary concurrent chemoradiation is being increasingly used for these patients at our institution in an effort to decrease bimodal treatment and limit the potential for increased toxicity and treatment costs. Evidence from a randomized controlled study is needed to determine the optimal treatment for stage IB2 cervical cancer.

Heterogeneity in head and neck cancer incidence among black populations from Africa, the Caribbean and the USA: Analysis of cancer registry data by the AC3.

BACKGROUND: Africa and the Caribbean are projected to have greater increases in Head and neck cancer (HNC) burden in comparison to North America and Europe. The knowledge needed to reinforce prevention in these populations is limited. We compared for the first time, incidence rates of HNC in black populations from African, the Caribbean and USA. METHODS: Annual age-standardized incidence rates (IR) and 95% confidence intervals (95%CI) per 100,000 were calculated for 2013-2015 using population-based cancer registry data for 14,911 HNC cases from the Caribbean (Barbados, Guadeloupe, Trinidad & Tobago, N = 443), Africa (Kenya, Nigeria, N = 772) and the United States (SEER, Florida, N = 13,696). We compared rates by sub-sites and sex among countries using data from registries with high quality and completeness. RESULTS: In 2013-2015, compared to other countries, HNC incidence was highest among SEER states (IR: 18.2, 95%CI = 17.6-18.8) among men, and highest in Kenya (IR: 7.5, 95%CI = 6.3-8.7) among women. Nasopharyngeal cancer IR was higher in Kenya for men (IR: 3.1, 95%CI = 2.5-3.7) and women (IR: 1.5, 95%CI = 1.0-1.9). Female oral cavity cancer was also notably higher in Kenya (IR = 3.9, 95%CI = 3.0-4.9). Blacks from SEER states had higher incidence of laryngeal cancer (IR: 5.5, 95%CI = 5.2-5.8) compared to other countries and even Florida blacks (IR: 4.4, 95%CI = 3.9-5.0). CONCLUSION: We found heterogeneity in IRs for HNC among these diverse black populations; notably, Kenya which had distinctively higher incidence of nasopharyngeal and female oral cavity cancer. Targeted etiological investigations are warranted considering the low consumption of tobacco and alcohol among Kenyan women. Overall, our findings suggest that behavioral and environmental factors are more important determinants of HNC than race.

The Caribbean Community Clinical Oncology Workforce: Analyzing Where We Are Today and Projecting for Tomorrow.

PURPOSE: To analyze the current physician clinical oncological workforce within the CARICOM full member states with an aim to make recommendations for building capacity. METHODS: A questionnaire was prepared and emailed to professionals working in oncology in 14 CARICOM full member countries. It was designed to identify the number of specialists providing hematology, medical oncology, and radiotherapy services. RESULTS: Ten countries (71.4%) supplied information. Oncology services were insufficient in the majority of countries. Hematology proved to be the most adequately staffed with six countries (60%) having the recommended number of specialists. Medical oncology services were deficient in five countries (50%). Radiation oncology services were the most limited with nine countries (90%) unable to provide the required quota of specialists. The majority of the workforce consisted of nonnationals (55%). The remaining practitioners were nationals, and of these 50% were regionally trained. Oncological care was primarily offered within the public sector. CONCLUSION: Oncological staffing within the CARICOM full member states is insufficient to meet the demands of the current population. Encouraging training through locoregional or international programs is key to obtaining the numbers required. Cancer registries will help provide data to influence public policy and improve the oncological healthcare system.