PErspective and current status of Radiotherapy Service in IRan (PERSIR)-1 study: assessment of current external beam radiotherapy facilities, staff and techniques compared to the international guidelines

The number of new cancer cases was 19.3 million people worldwide in 2020, which is expected to reach 24.6 million in 2030, suggesting an increase of 27.5% [1]. Developing countries account for around 60% of all new cancer cases and 70% of all cancer-related deaths globally [2]. In Iran, cancer is the third most common cause of disease-related mortality [3]. In 2020, the crude cancer incidence rate was 156.2 cases per 100,000 people in Iran. The numbers are projected to rise from around 131,000 to 184,000 between 2020 and 2030. This growth rate of 39% is higher than that expected in Asia (29%) and the world (25%) [1]. Besides the expected population aging, increased exposure to air pollution and other environmental carcinogens, a sedentary lifestyle, Western pattern diets, and smoking have led to a higher expected cancer rate [4].

Appropriate cancer care services must be readily available to accommodate the expected increase in cancer cases to provide adequate and acceptable patient care. Radiation therapy is an essential treatment that will be used, at some point, in over half of all cancer patients. Nevertheless, cancer treatment is a complicated and costly process, given the psychological, social, and economic pressure on patients and their families [5]. Radiation therapy (RT), which is recognized as a complex treatment, is also an effective and standard modality, regardless of the socioeconomic and cultural contexts of a country [6, 7].

Iran last time reported data on its RT resources in 2015 [8]. In order to ensure that patients have the appropriate access to therapeutic irradiation, it is crucial to identify and understand the current resources and gaps in radiotherapy. Therefore, the present study, which was conducted by the Radiation Oncology Research Center (RORC) of the Iran Cancer Institute, the leading organization for cancer treatment, education, and research in Iran and also the oldest in the Middle East since 1949 [9], aimed to overview Iran's RT current status and its challenges of achieving health equity.

This study aimed to provide an overview of Iran's current status of radiotherapy human and equipment resources and its challenges in achieving health equity all over the country. In addition, we tried to evaluate the trend of service in comparison to data from 2010 and 2015.

Our results revealed that Tehran, as the capital of Iran, with 10% of the national population, had the highest number of RT governmental centers, which accounts for 16% of all the country's governmental centers. In contrast, five provinces, with 15% of the country's total population, had no governmental centers. According to the 2016 census, 10.3% of Iran's population is entirely uninsured [20], and only 10% have supplementary health insurance [21], while one-third of RT resources are private. This issue could increase patient congestion in public centers, increasing the average wait time for RT services. Also, the load of patients has led to the non-adherence of physicians to hyper-fractionated regimens when indicated. Moreover, waiting lists for definitive therapy and palliative care can compromise clinical outcomes and quality of life [8]. It seems that the lack of universal health coverage and policies of reimbursement systems in the country are among the contributing factors to inequity in healthcare delivery.

Our findings implied that the unequal geographic distribution of RT centers (and LINACs) across the country might lead to disparities in providing care. Provinces with higher economic status, which could cover the cost of the private RT centers, had better availability of RT services, as most had more than 2.3 RT machines per one million province population. On the other hand, areas with economically weaker conditions had the poorest delivery of RT services, as some had below 0.7 RT machines per one million population, and even four had no RT facilities at all. In some centers, mainly located in the Eastern and Southern regions, there may be difficulties when the only LINAC machine is out of order.

Previous research emphasized that difficult access and long travel distances cause a financial burden, forcing some patients to withdraw from treatment or visit physicians in later stages, yielding poorer outcomes [22, 23]. Based on the present study, it was supposed that Iranian residents, particularly those residing in the eastern, southern, and southeastern regions, have a lower likelihood of receiving RT services as they live more than 50 miles (80 km) away from the centers.

According to the findings, 84 RT centers, consisting of 123 LINACs, were identified in the country. Besides, 344, 252, and 419 active radiation oncologists, medical physicists, and radiation therapy technologists (RTT) were identified in 2022, respectively. Establishing appropriate guidelines for radiation therapy can be challenging due to variations in cancer incidence and trends across different countries, as well as differences in workload, such as the amount of time machines and staff are available per shift. Additionally, treatment duration may differ between centers within a country and between low- and high-resource countries [15]. Besides, since diverse staff roles and responsibilities exist between countries, defining the required number of radiation specialists is complex [15]. Most high-income countries have provided precise data on RT staffing, and there needs to be more data in low- and middle-income countries [6, 15]. The guidelines for the required number of RT human and equipment resources are mainly based on the situation in European countries [18]. That is why QUARTZ has issued a range with no definitive recommendations [18]. Although Iran's current status regarding human and equipment resources is relatively acceptable based on the QUARTZ recommendations, the countries in the neighborhood have limited infrastructures per one million as it is 0.28 in Pakistan and indeterminate for Afghanistan [24] and Iraq [25]. Iran is hosted for some patients in border areas whose definite number is unknown. It should be borne in mind that radiation oncologists in Iran are involved in prescribing both chemotherapy and radiation therapy.

Iran has recently fallen from a high-middle-income country to a low-middle-income country (LMIC), owing to a 40.9% decline in the gross national index (GNI) per capita from 2015 to 2022 [26]. Despite the remarkable drop in GNI per capita and the increase in population, a rising trend can be seen from 2010 to 2022 regarding RT facilities and staff. Although, after omitting the palliative and re-irradiation that roughly comprise 10% of treatment courses in our domestic reports [27], about 91.5% of patients who needed RT has received it in our survey. However, these estimates only reflect the quantity of treatment courses and not the quality of the techniques of planning and delivery of RT to the patients. Thus, considering the age and capability of available equipment, there are concerns regarding the need for more quality RT services in the near future, especially advanced techniques including IMRT/VMAT and SBRT. In Iran, modern RT treatments are limited due to a shortage of trained radiation oncologists, personnel, and equipment maintenance. Aside from developing RT machines and techniques, proper planning is necessary to increase the expertise of professionals in complex and advanced RT delivery and planning techniques.

Iran’s need for RT based on optimal RUR is close to other countries like Netherlands, Columbia and Argentina, Nigeria and Egypt [1]. Considering the number of LINACs in these countries our situation is more like Egypt that is better than Columbia and Nigeria but worse than Argentina and Netherlands [28]. It should be noted that these estimates only reflect the number of RT machines and not the quality of services and techniques.

Estimation for BT services, orthovoltage, and IORT has not been addressed in specific guidelines and was not available in ESTRO-QUARTZ, IAEA, or the Lancet Commission recommendations. Brachytherapy is one of the necessary modalities in delivering radiation to patients, particularly for cervix and prostate, head and neck, and skin cancer. Application of BT accounts for up to 10% of total radiotherapy treatment courses in the USA and 25% in European countries [29]. It’s worth noting that, despite high demands for BT services due to the high incidence of cervical cancer in Iran [4], the lack of specialized staff and dedicated wards has caused the infrastructure to be insufficient in this regard.

This study has some limitations. Firstly, in the current study, to calculate the optimal RUR based on the Lancet Commission and Australian publications, the epidemiological cancer incidence rates and indications for each tumor site method were used [6, 13]. However, variable patterns of cancer presentation make it challenging to estimate the proportion of cancer cases requiring RT. The RUR can be derived from epidemiological/evidence-based or criterion-based guidelines [6, 30]. Epidemiological/evidence-based guidelines have estimated higher rates of maximum demand as they consider the type and stage of cancer. Also, in developing countries, empirical approaches are difficult to define due to a lack of comprehensive patient data resources and long-term follow-up [31]. Secondly, since the accuracy of cancer incidence rates obtained from the GLOBOCAN varies depending on the country's health system, registry, and income status, the accuracy of the calculations might have been affected. However, according to GLOBOCAN, Iran has been classified as one of the 19 countries with high-quality incidence data. Third, it is noteworthy that the GLOBOCAN estimates do not reflect the effect of the coronavirus disease 2019 (COVID-19) pandemic [1, 32]. The complete scope of the impact of COVID-19 is still unknown. However, delays in diagnosis, treatment, and follow-up because of public concerns, screening program closures, and limited access to healthcare systems are expected to increase cancer incidence [32‐34]. In addition, the available formulations and estimations of RUR do not identify the technique of RT delivery or guidance. As we know, many head and neck or central nervous system cancers or malignancies in the pediatric population require advanced and sophisticated techniques, including SBRT/SRS, IMRT/VMAT, MR-LINAC, and Proton therapy, that are either unavailable in Iran or severely scarce throughout the country. Another limitation would be our lack of information regarding altered fractionation schedules. We know that one appropriate way to shorten the waiting list is hypofractionation when evidence supports such a fashion.

Although there has been notable growth in RT facilities in recent years, and Iran's current situation is acceptable as an LMIC country, it still needs more work to reach an acceptable level. To improve the country's RT status, qualitative goals such as the appropriate distribution of active facilities considering the regional cancer incidence rate, increasing the expertise of related professionals, and quantitative goals of providing more modern radiation delivery in the future, seem necessary.