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PURPOSE: There is widespread accord among economists that the corona virus disease 2019 (COVID-19) pandemic will have a severe negative effect on the global economy. Establishing new radiation therapy (RT) infrastructure may be significantly compromised in the post-COVID-19 era. Alternative strategies are needed to improve the existing RT accessibility without significant cost escalation. The outcomes of these approaches on RT availability have been examined for Asia. METHODS AND MATERIALS: The details of RT infrastructures in 2020 for 51 countries in Asia were obtained from the Directory of Radiotherapy Centers of the International Atomic Energy Agency. Using the International Atomic Energy Agency guidelines, the percent of RT accessibility and the additional requirements of teletherapy (TRT) units were computed for these countries. To maximize the utilization of the existing RT facilities, 5 options were evaluated, namely, hypofractionation RT (HFRT) alone, with/without 25% or 50% additional working hours. The effect of these strategies on the percent of RT access and additional TRT unit requirements to achieve 100% RT access were estimated. RESULTS: In 46 countries, 4617 TRT units are available. The mean percent of RT accessibility is 62.4% in 43 countries (TRT units = 4491) where the information on cancer incidence was also available, and these would need an additional 6474 TRT units for achieving 100% RT accessibility. By adopting HFRT alone, increasing the working hours by 25% alone, 25% with HFRT, 50% alone, and 50% with HFRT, the percent of RT access could improve to 74.9%, 78%, 90.5%, 93.7%, and 106.1%, respectively. Correspondingly, the need for additional TRT units would progressively decrease to 4646, 4284, 3073, 2820, and 1958 units. CONCLUSIONS: The economic slowdown in the post-COVID-19 period could severely impend establishment of new RT facilities. Thus, maximal utilization of the available RT infrastructure with minimum additional costs could be possible by adopting HFRT with or without increased working hours to improve the RT coverage.

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PURPOSE: The economic viability of establishing a state-funded radiation therapy (RT) infrastructure in low- and middle-income countries (LMICs) in accordance with the World Bank definition has been assessed through computation of a return on investment (ROI). METHODS AND MATERIALS: Of the 139 LMICs, 100 were evaluated according to their RT facilities, gross national income (GNI) per capita, and employment/population ratio. The assumption was an investment of US$5 million for a basic RT center able to treat 1000 patients annually. The national breakeven points and percentage of ROI (%ROI) were calculated according to the GNI per capita and patient survival rates of 10% to 50% at 2 years. It was assumed that 50% of these patients would be of working age and that, if employed and able to work after treatment, they would contribute to the country's GNI for at least 2 years. The cumulative GNI after attaining the breakeven point until the end of the 15-year lifespan of the teletherapy unit was calculated to estimate the %ROI. The recurring and overhead costs were assumed to vary from 5.5% to 15% of the capital investment. RESULTS: The %ROI was dependent on the GNI per capita, employment/population ratio and 2-year patient survival (all P<.001). Accordingly, none of the low-income countries would attain an ROI. If 50% of the patients survived for 2 years, the %ROI in the lower-middle and upper-middle income countries could range from 0% to 159.9% and 11.2% to 844.7%, respectively. Patient user fees to offset recurring and overhead costs could vary from "nil" to US$750, depending on state subsidies. CONCLUSIONS: Countries with a greater GNI per capita, higher employment/population ratio, and better survival could achieve a faster breakeven point, resulting in a higher %ROI. Additional factors such as user fees have also been considered. These can be tailored to the patient's ability to pay to cover the recurring costs. Certain pragmatic steps that could be undertaken to address these issues are discussed in the present study.

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Globally, new cancer cases will rise by 57% within the next two decades, with the majority in the low- and middle-income countries (LMICs). Consequently, a steep increase of about 40% in cancer deaths is expected there, mainly because of lack of treatment facilities, especially radiotherapy. Radiotherapy is required for more than 50% of patients, but the capital cost for equipment often deters establishment of such facilities in LMICs. Presently, of the 139 LMICs, 55 do not even have a radiotherapy facility, whereas the remaining 84 have a deficit of 61.4% of their required radiotherapy units. Networking between centers could enhance the effectiveness and reach of existing radiotherapy in LMICs. A teleradiotherapy network could enable centers to share and optimally utilize their resources, both infrastructure and staffing. This could be in the form of a three-tier radiotherapy service consisting of primary, secondary, and tertiary radiotherapy centers interlinked through a network. The concept has been adopted in some LMICs and could also be used as a "service provider model," thereby reducing the investments to set up such a network. Teleradiotherapy networks could be a part of the multipronged approach to address the enormous gap in radiotherapy services in a cost-effective manner and to support better accessibility to radiotherapy facilities, especially for LMICs.

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Radiotherapy (RT) is required for nearly half of the newly diagnosed cancer patients. To optimise the quality and availability of RT, guidelines have been proposed by European Society for Radiotherapy and Oncology-QUAntification of Radiation Therapy Infrastructure And Staffing Needs (ESTRO-QUARTS) and the International Atomic Energy Agency (IAEA). This study evaluates the present status of RT capacity in Europe and the projected needs by 2020 as per these recommendations. Thirty-nine of the 53 countries, listed in Europe by the UN Statistical Division, whose cancer incidences, teletherapy and human resources were available in the Global Cancer Incidence, Mortality and Prevalence (GLOBOCAN), International Agency for Research on Cancer (IARC) and DIrectory of RAdiotherapy Centres (DIRAC) (IAEA) databases were evaluated. A total of 3550 teletherapy units (TRT), 7017 radiation oncologists (RO), 3685 medical physicists (MP) and 12,788 radiotherapy technologists (RTT) are presently available for the 3.44 million new cancer cases reported annually in these countries. The present infrastructure and human resources in RT are estimated to provide RT access to 74.3% of the patients requiring RT. The current capacity in TRT, RO, MP and RTT when compared with recommended guidelines has a deficit of 25.6%, 18.3%, 22.7% and 10.6%, respectively. Thus, to respond to requirements by 2020, the existing capacity needs to be augmented by an additional 1698 TRTs, 2429 ROs, 1563 MPs and 2956 RTTs. With an imminent rise in cancer incidence, multifaceted strategic planning at national and international levels within a coordinated comprehensive cancer control programme is highly desirable to give adequate access to all patients who require radiotherapy across Europe. Specific steps to address this issue at national and continental levels involving all major stakeholders are proposed.

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PURPOSE: Radiation therapy, a key component of cancer management, is required in more than half of new cancer patients, particularly in low- and middle-income countries (LMICs). The projected rise in cancer incidence over the next decades in LMICs will result in an increasing demand for radiation therapy services. Considering the present cancer incidence and that projected for 2020 (as listed in GLOBOCAN), we evaluated the current and anticipated needs for radiation therapy infrastructure and staffing by 2020 for each of the LMICs. METHODS AND MATERIALS: Based on World Bank classification, 139 countries fall in the category of LMICs. Details of teletherapy, radiation oncologists, medical physicists, and radiation therapy technologists were available for 84 LMICs from the International Atomic Energy Agency-Directory of Radiotherapy Centres (IAEA-DIRAC) database. Present requirements and those for 2020 were estimated according to recommendations from the IAEA and European Society for Radiotherapy & Oncology (ESTRO-QUARTS). RESULTS: Only 4 of the 139 LMICs have the requisite number of teletherapy units, and 55 (39.5%) have no radiation therapy facilities at present. Patient access to radiation therapy in the remaining 80 LMICs ranges from 2.3% to 98.8% (median: 36.7%). By 2020, these 84 LMICs would additionally need 9169 teletherapy units, 12,149 radiation oncologists, 9915 medical physicists, and 29,140 radiation therapy technologists. Moreover, de novo radiation therapy facilities would have to be considered for those with no services. CONCLUSIONS: Twelve pragmatic steps are proposed for consideration at national and international levels to narrow the gap in radiation therapy access. Multipronged and coordinated action from all national and international stakeholders is required to develop realistic strategies to curb this impending global crisis.

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Survival following a diagnosis of cancer is contingent upon an interplay of factors, some non-modifiable (e.g., age, sex, genetics) and some modifiable (e.g., volitional choices) but the majority determined by circumstance (personal, social, health system context and capacity, and health policy). Accordingly, mortality and survival rates vary considerably as a function of geography, opportunity, wealth and development. Quality of life is impacted similarly, such that aspects of care related to coordination and integration of care across primary, community and specialist environments; symptom control, palliative and end-of-life care for those who will die of cancer; and survivorship challenges for those who will survive cancer, differs greatly across low, middle and high-income resource settings. Session 3 of the 4th International Cancer Control Congress (ICCC-4) focused on cancer care and treatment through three plenary presentations and five interactive workshop discussions: 1) establishing, implementing, operating and sustaining the capacity for quality cancer care; 2) the role of primary, community, and specialist care in cancer care and treatment; 3) the economics of affordable and sustainable cancer care; 4) issues around symptom control, support, and palliative/end-of-life care; and 5) issues around survivorship. A number of recommendations were proposed relating to capacity-building (standards and guidelines, protocols, new technologies and training and deployment) for safe, appropriate evidence-informed care; mapping and analysis of variations in primary, community and specialist care across countries with identification of models for effective, integrated clinical practice; the importance of considering the introduction, or expansion, of evidence-supported clinical practices from the perspectives of health economic impact, the value for health resources expended, and sustainability; capacity-building for palliative, end-of-life care and symptom control and integration of these services into national cancer control plans; the need for public education to reduce the fear and stigma associated with cancer so that patients are better able to make informed decisions regarding follow-up care and treatment; and the need to recognize the challenges and needs of survivors, their increasing number, the necessity to integrate survivorship into cancer control plans and the economic and societal value of functional survival after cancer. Discussions highlighted that coordinated care and treatment for cancer patients is both a ' systems'challenge and solution, requiring the consideration of patient and family circumstances, societal values and priorities, the functioning of the health system (access, capacity, resources, etc.) and the importance assigned to health and illness management within public policy.

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The Breast Health Global Initiative (BHGI) brought together international breast cancer experts to discuss breast cancer in low resource countries (LRCs) and identify common concerns reviewed in this consensus statement. There continues to be a lack of public and health care professionals' awareness of the importance of early detection of breast cancer. Mastectomy continues to be the most common treatment for breast cancer; and a lack of surgeons and anesthesia services was identified as a contributing factor in delayed surgical therapy in LRCs. Where available, radiation therapy is still more likely to be used for palliation rather than for curative treatment. Tumor receptor status is often suboptimally performed due to lack of advanced pathology services and variable quality control of tissue handling and processing. Regional pathology services can be a cost-effective approach and can serve as reference, training and research centers. Limited availability of medical oncologists in LRCs often results in non-specialist providing chemotherapeutic services, which requires additional supervision and training. Palliative care is an emerging field in LRCs that requires investment in training and infrastructure development. A commitment and investment in the development of breast cancer care services by LRC governments and health authorities remains a critical need in LRCs.

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As cancer is to a large extent avoidable and treatable, a cancer control program should be able to reduce mortality and morbidity and improve the quality of life of cancer patients and their families. However, the extent to which the goals of a cancer control program can be achieved will depend on the resource constraints a country faces. Such population-based cancer control plans should prioritize effective interventions and programs that are beneficial to the largest part of the population, and should include activities devoted to prevention, screening and early detection, treatment, palliation and end-of-life care, and rehabilitation. In order to develop a successful cancer control program, leadership and the relevant stakeholders, including patient organizations, need to be identified early on in the process so that all partners can take ownership and responsibility for the program. Various tools have been developed to aid them in the planning and implementation process. However, countries developing a national cancer control program would benefit from a discussion of different models for planning and delivery of population-based cancer control in settings with differing levels of resource commitment, in order to determine how best to proceed given their current level of commitment, political engagement and resources. As the priority assigned to different components of cancer control will differ depending on available resources and the burden and pattern of cancer, it is important to consider the relative roles of prevention, early detection, diagnosis, treatment, rehabilitation and palliative care in a cancer control program, as well as how to align available resources to meet prioritized needs. Experiences from countries with differing levels of resources are presented and serve to illustrate the difficulties in developing and implementing cancer control programs, as well as the innovative strategies that are being used to maximize available resources and enhance the quality of care provided to cancer patients around the world.

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Developing and maintaining a comprehensive cancer control program are two distinct entities. Key issues related to building and sustaining cancer control programs include how to integrate initiatives and efforts across multiple constituencies addressing components of the implementation of cancer control and non-communicable disease programs, the processes used in different resource settings to achieve effective drug budgeting, health technology assessment and health economics, and how countries can support public and societal engagement. There are promising examples in both resource-rich and resource-challenged countries of constituencies that have developed programs which can contribute to comprehensive cancer control. Some take advantage of newer technology and information services, while others are more people and patient focused. Critical issues and factors for establishing and maintaining population-based comprehensive cancer control programs are identified and reviewed.

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