RadiatingHope – A decade in global radiation oncology

RH realized that its mission of equipment donation was possible when RT machines were donated to Madagascar (cobalt) and Peru (linac) through the Luther Brady Research Institute. With the project in Dakar, Senegal, RH took its first step into the unknown.

The RH projects in Senegal, Ghana, Honduras, Guatemala and Nepal include equipment donations and training programs to create self-sustainability as well as methods for training others. These endeavors are described in detail in the sidebar to the right; many other projects are listed in Figure 2.

RH is working to help build a partnership with Kenyatta Hospital and Stanford University to create a paradigm for sustainable distance-based clinical learning and an HDR distance training program similar to the one in Ghana; in parts of Central and South America, RH is collaborating with Rayos Contra Cancer and Project ECHO to implement a similar program. Uniting with industry and an international builder, RH is working with Hospital Municipal La Portada in La Paz, Bolivia, to build and equip a start-up oncology center.

Starting in March 2014, RH hosted its first international meeting – the Greater Horn Oncology Symposium (GHOS), in Moshi, Tanzania, at the Kilimanjaro Christian Medical Centre (KCMC). GHOS serves as a multidisciplinary oncology forum for improving access to cancer care in the Greater Horn of Africa and to create a platform for exchanging ideas among oncology medical professionals around the globe. The second GHOS was held in June 2016 in Mwanza, Tanzania, in collaboration with Bugando Medical Center, and the third in June 2018 in Zanzibar. At the Zanzibar conference, 15 nations were present (Africa - 8, North America - 2, Europe - 4, South Asia -1). Of the 56 attendees, 29 were from Africa, 1 was from Nepal and the remainder were from North America and Europe (Figure 3). Ten participants were radiation oncology residents from Ocean Road Cancer Institute in Dar es Salaam, Tanzania, who had the opportunity to speak directly with international experts in radiation oncology. By bringing together this group of radiation oncologists (ROs), medical physicists (MPs), radiation therapists (RTTs), and members of industry for 3 days, GHOS has sparked collaborations among institutions in North America or Europe and LMICs present at the meeting, and among African nations to help create self-sustaining collaborations in developing local cancer care. Examples include partnerships between physicians in Tanzania and Turkey, as well as ties between institutions in Switzerland and Senegal to advance from 2D to 3D planning. The next GHOS is in June 2020.

A similar meeting – the Cuban Radiation Oncology Symposium (CROS) – was planned for October 2017 in Havana, Cuba. Due to US state department travel recommendations at the time, few US participants attended the meeting; however, more than 20 Cuban ROs were present.

These symposia are largely funded with assistance from industry members, such as Varian (Palo Alto, California) and Elekta (Stockholm, Sweden), covering the travel and lodging expenses of local conference participants; all North American and European participants have managed their own expenses.

While undertaking global radiation oncology work, the list of challenges quickly outpaces the list of successes. As is clear from the few projects discussed above, equipment alone is not the only piece of the puzzle missing in advancing global oncology care. The current projected need of these medical personnel in LMICs by 2035 is greater than 10 000 ROs, 9000 MPs and 25 000 RTTs.⁸ Training sites for these highly specialized individuals are difficult to access, as evidenced by Ghanaian physicists receiving training in China.

Regarding equipment, several nations will not accept used or refurbished RT equipment (including machines and physics equipment). For countries that do, not all donations have been or can be utilized. An institution may have a bunker to hold the machines, but may not have the infrastructure or resources to deploy the equipment. Prior to donating equipment (including machines, treatment applicators, software, etc.), RH undertakes thorough, in-person research of the receiving site in regard to space/bunker availability and appropriateness for equipment, medical personnel availability, medical personnel knowledge, financial stability, energy source stability, local government support, and maintenance for optimal use of equipment. Additionally, contracts are signed for agreement and sustained communication. However, despite these painstaking efforts, not all projects are completed. The 2 orthovoltage units donated to Central America are in storage due to costs of making the units functional, as is the case of the MLCs waiting to be installed in Guatemala. The linac donated to the Bugando Medical Center in Tanzania still sits in crates due to assembly costs required by the manufacturer and the Ministry of Health’s challenges in meeting these demands. Furthermore, governments here are often slower to respond and leadership can change frequently, setting back progress. The donation at the Kharkiv Institute in Ukraine could not be reassembled; however, it was used for parts to update linacs throughout the country.

In Dakar, where the HDR afterloader was successfully installed, used and maintained, several challenges remained with continued operation of the unit, including the cost and logistical difficulty with source changes, limited RO and treatment room time availability for procedures, and equipment downtime, which can be significant. Sustained communication with some sites after donation can also become difficult.

Last, but by no means least, shipping linacs and HDR afterloaders is no small feat. Disassembling a linac, transporting it to storage, shipping it overseas, and transporting it to a facility, can take months, sometimes longer, to reassemble and make functional. These steps depend on the availability of manufacturers in the region, and their ability to put into motion refurbished/used equipment with local government support.

RH’s vision remains clear, and its devotion to increasing access to global radiation oncology care runs deep, strengthened by the incredible individuals engaged in the work and their dedication to help provide cancer care to their family and friends. Since its inception in 2009, RH has learned much along its journey of advancing global cancer care and has encountered seemingly insurmountable difficulties. The importance of collaboration worldwide is obvious during the times of these impossible-appearing summits. As RH climbers have adopted a “climb on” mantra when facing obstacles on a trek, so too has the global oncology world.