Expanding global access to radiotherapy

Summary

Radiotherapy is a critical and inseparable component of comprehensive cancer treatment and care. For many of the most common cancers in low-income and middle-income countries, radiotherapy is essential for effective treatment. In high-income countries, radiotherapy is used in more than half of all cases of cancer to cure localised disease, palliate symptoms, and control disease in incurable cancers. Yet, in planning and building treatment capacity for cancer, radiotherapy is frequently the last resource to be considered. Consequently, worldwide access to radiotherapy is unacceptably low. We present a new body of evidence that quantifies the worldwide coverage of radiotherapy services by country. We show the shortfall in access to radiotherapy by country and globally for 2015–35 based on current and projected need, and show substantial health and economic benefits to investing in radiotherapy. The cost of scaling up radiotherapy in the nominal model in 2015–35 is US$26·6 billion in low-income countries, $62·6 billion in lower-middle-income countries, and $94·8 billion in upper-middle-income countries, which amounts to $184·0 billion across all low-income and middle-income countries. In the efficiency model the costs were lower: $14·1 billion in low-income, $33·3 billion in lower-middle-income, and $49·4 billion in upper-middle-income countries—a total of $96·8 billion. Scale-up of radiotherapy capacity in 2015–35 from current levels could lead to saving of 26·9 million life-years in low-income and middle-income countries over the lifetime of the patients who received treatment. The economic benefits of investment in radiotherapy are very substantial. Using the nominal cost model could produce a net benefit of $278·1 billion in 2015–35 ($265·2 million in low-income countries, $38·5 billion in lower-middle-income countries, and $239·3 billion in upper-middle-income countries). Investment in the efficiency model would produce in the same period an even greater total benefit of $365·4 billion ($12·8 billion in low-income countries, $67·7 billion in lower-middle-income countries, and $284·7 billion in upper-middle-income countries). The returns, by the human-capital approach, are projected to be less with the nominal cost model, amounting to $16·9 billion in 2015–35 (–$14·9 billion in low-income countries; –$18·7 billion in lower-middle-income countries, and $50·5 billion in upper-middle-income countries). The returns with the efficiency model were projected to be greater, however, amounting to $104·2 billion (–$2·4 billion in low-income countries, $10·7 billion in lower-middle-income countries, and $95·9 billion in upper-middle-income countries). Our results provide compelling evidence that investment in radiotherapy not only enables treatment of large numbers of cancer cases to save lives, but also brings positive economic benefits.

Introduction

In 2012, 14·1 million new cases of cancer were reported worldwide (figure 1A), and this number is projected to reach 24·6 million by 2030.¹ 8·2 million cancer deaths were recorded in 2012, and this figure is projected to rise to 13·0 million by 2030, when most of the deaths will occur in low-income and middle-income countries,² (where, in 2012, cancer became a leading cause of death and disability).³ Beyond the human suffering, cancer imposes an enormous economic burden worldwide—US$2 trillion in 2010.⁴

Radiotherapy is a fundamental component of effective cancer treatment and control.⁵ It is estimated that about half of cancer patients would benefit from radiotherapy for treatment of localised disease, local control, and palliation.⁶ Yet this crucial component of the response to cancer has been largely absent from global health discourse, and has received limited domestic and international funding. Even in high-income countries, radiotherapy has frequently been used suboptimally despite facilities being available. As a result, there is a worldwide shortfall of radiotherapy services, with more than 90% of the population in low-income countries lacking access to radiotherapy.⁷ The growing burden of cancer will place increased demand on the already- scarce radiotherapy services worldwide.

Much has been written about the need for a comprehensive approach to population-based cancer control. In 2011, the UN General Assembly committed to prevention and control of non-communicable diseases (NCDs).⁸ In 2013, WHO member states agreed at the World Health Assembly to develop comprehensive NCD global monitoring framework targets to reduce by 2025 premature mortality from cardiovascular and chronic respiratory diseases, cancers, and diabetes by 25% relative to their 2010 levels.9, 10 At least 1·5 million deaths from cancer will need to be prevented each year to achieve the so-called 25 by 25 target,¹¹ but global efforts to control cancer are woefully inadequate so far,12, 13 especially in low-income and middle-income countries, which have only 5% of the resources but 80% of the global cancer burden.¹⁴ The 25 by 25 target cannot be achieved by prevention alone. Managing cancer requires both effective preventive measures to reduce future burden of disease, and health-care systems that provide accurate diagnosis and high-quality multimodality treatment. Such multimodality treatment should include radiotherapy, surgery, drugs, and access to palliative and supportive care. However, persistent underinvestment in radiotherapy resources with resulting unnecessary deaths shows that this clinical service is frequently forgotten when planning cancer control systems. Investment in radiotherapy is crucial and an imperative in low-income and middle-income countries¹⁵ if unnecessary cancer deaths and suffering are to be avoided. Thus, with WHO's focus on access to cancer drugs,¹⁶ global access to surgery,¹⁷ and access to palliative care,¹⁸ we thought it timely to be concerned about the gap in access to radiotherapy, and consider the economic case for investment in radiotherapy.

Radiotherapy is perceived as a complex treatment. A misleading assumption is that its deployment in poorer nations is not feasible, but nothing could be further from the truth. Radiotherapy can be effectively standardised and delivered irrespective of socioeconomic, political, and cultural context.19, 20, 21, 22 Here, we present new evidence to show that radiotherapy is affordable and feasible, and can be safely and consistently deployed in low-income and middle-income countries. Our report will show the health and economic benefits of investing in radiotherapy in these nations. Investment in radiotherapy is timely for many reasons, including evidence from The Lancet Commission on Investing in Health²³ showing the benefits of investing in health to achieve convergence in health outcomes between low-income countries and upper-middle-income countries, the momentum for investing in low-income and middle-income countries to expand surgery,²⁴ and the UN resolution on sustainable development, which recognises that “universal health coverage is a key instrument to enhancing health, social cohesion and sustainable human and economic development”.²⁵

This Commission presents new analyses that quantify coverage of radiotherapy services worldwide and by country. It also includes new estimates for the future burden of cancer to 2035 and the projected demand for radiotherapy services by country and globally from 2015 to 2035, to ascertain the scale-up of radiotherapy services needed. Provision of high-quality, safe, effective, timely, efficient, equitable, and patient-centred²⁶ radiotherapy services is particularly important because service quality critically affects cancer outcomes.27, 28, 29 Our analysis also includes health systems investments needed to create an enabling environment for delivery of high-quality radiotherapy services in low-income and middle-income countries.

Investment in radiotherapy necessitates an important set of skills and resources. We project the financial, human, and physical resources needed to address the worldwide shortfall in radiotherapy services. Here, we calculate the financial resources and investment needed to expand coverage of radiotherapy in low-income and middle-income countries between 2015 and 2035, and estimate health and economic benefits of investing in radiotherapy. Finally, we describe the opportunities that could be created by innovations in science, human resources, and financing, and discuss the importance of leadership that could help to develop an inclusive response. We conclude by identifying a series of actions that should underpin the global efforts to scale up coverage of radiotherapy in low-income and middle-income countries.