Establishing and Delivering Quality Radiation Therapy in Resource-Constrained Settings: The Story of Botswana

Abstract

There is a global cancer crisis, and it is disproportionately affecting resource-constrained settings, especially in low- and middle-income countries (LMICs). Radiotherapy is a critical and cost-effective component of a comprehensive cancer control plan that offers the potential for cure, control, and palliation of disease in greater than 50% of patients with cancer. Globally, LMICs do not have adequate access to quality radiation therapy and this gap is particularly pronounced in sub-Saharan Africa. Although there are numerous challenges in implementing a radiation therapy program in a low-resource setting, providing more equitable global access to radiotherapy is a responsibility and investment worth prioritizing. We outline a systems approach and a series of key questions to direct strategy toward establishing quality radiation services in LMICs, and highlight the story of private-public investment in Botswana from the late 1990s to the present. After assessing the need and defining the value of radiation, we explore core investments required, barriers that need to be overcome, and assets that can be leveraged to establish a radiation program. Considerations addressed include infrastructure; machine choice; quality assurance and patient safety; acquisition, development, and retention of human capital; governmental engagement; public-private partnerships; international collaborations; and the need to critically evaluate the program to foster further growth and sustainability.

Fig 1.

(A) External beam radiation therapy (EBRT): world map of the number of EBRT units (linear accelerator and cobalt-60 units) per million population. (B) High-dose rate (HDR) brachytherapy: world map of annual cervical cancer cases per HDR unit (600 to 800 patients with cervical cancer per HDR unit per year is considered high use, assuming eight to nine procedures per day).^,

Fig 2.

Gap in demand and supply for radiation therapy in Botswana. Data are available from the Botswana National Cancer Registry between 2003 and 2009; the dotted line is a projection beyond data frame (projected from the inverse probability weighted Poisson model with bootstrap CI). For this chart, cancer requiring radiation included cervical, breast, head and neck, lung, esophageal, anal, brain, lymphoma, vulvar, vaginal, penile, conjunctival, and sarcoma.

Fig 3.

Timeline of key milestones in the development of radiation therapy in Botswana. 3D, three dimensional; BOTSOGO, Botswana Oncology Global Outreach program; CT, computed tomography; EMR, electronic medical record; HDR, high-dose rate; IAEA, International Atomic Energy Agency; IMRT, intensity-modulated radiation therapy; LINAC, linear accelerator; NGO, nongovernmental organization; UPenn, University of Pennsylvania.

Fig 4.

Memory Bvochora-Nsingo, MBChB, clinical oncologist at Gabarone Private Hospital, reviewing contours and radiation planning with Paul Busse, MD, PhD, visiting radiation oncologist from the Massachusetts General Hospital, in the Botswana Oncology Global Outreach partnership.