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0 Special Feature: Developing Countries
NATIONAL TRAINING OF RADIOTHERAPISTS IN SRI LANKA AND ZIMBABWE: PRIORITIES AND STRATEGIES FOR CANCER CONTROL
IN DEVELOPING COUNTRIES
JAN STJERNSWARD, M.D.
Chief Cancer Unit, WHO, World Health Organization, CH 12 I 1 Geneva 27. Switzerland
The development of therapy resources should not be done in isolation of other cancer control activities. The right priorities and strategies must be determined in a systematic way, preferably through well-conceived national cancer control programs. If this is not done, it is unlikely that the therapy efforts will have any impact on cancer in the developing countries, as most cancers are incurable when seen for therapy. Therapy efforts must be linked with the search for earlier referral and diagnosis of cancer patients. However even limited resources may have an effect on controlling cancer, provided that the right priorities and strategies are followed. National and regional training facilities with a suitably adapted syllabus in radiotherapy and oncology must be a part of these priorities and strategies. The World Health Organization (WHO) has initiated, in close collaboration with the National Gov- ernments, national and regional training courses in radiotherapy and oncology in Sri Lanka and Zimbabwe.
Development of therapy resources, National cancer control programs, Sri Lanka, Zimbabwe.
Nothing would have a greater impact on cancer through- out the world today than being able to fully put into effect the enormous knowledge that has been gained in cancer control. This is the fundamental basis for WHOS Cancer Control Programme. One-third of all cancers are pre- ventable. At least one-third of all cancer patients can be cured provided that the diagnosis is made early enough and that adequate routine state-of-the-art therapies can be offered (5).
The great majority of the worlds cancer patients do not benefit from all the knowledge that has been gained in cancer control. Cancer is a third world problem too. More than half of all cancer patients are in developing countries and most of these patients are incurable at the time of diagnosis. From the aspect of purely clinical ther- apy, three points are important to consider in developing countries:
1. It is mandatory that therapy is linked with referral and diagnosis.
Palliative therapy and care, including symptom control and pain relief will be important for years to come, before point 1 above and point 3 below will have taken effect. The existing number of nurses and doctors are totally inadequate for dealing with the existing number of cancer patients, and the training of future cancer spe- cialists on the national level is a priority.
Size ofproblem There are about 7 million new cancer patients every
year, and about 5 million of them die of cancer. Half of these new patients are in developing countries. Two out of three cancer patients in developed countries die of their disease. In the developing countries this figure is much higher. Once an individual has survived the first 5 years. cancer is 1 of the 3 major killers, in both developed and developing countries. In spite of all the resources spent on therapy in the industrialized countries, age adjusted mortality for cancer increased between 1960 and 1980 (9). The mortality pattern of developing countries is ap- proaching that of industrialized countries. If existing trends continue, cancer mortality is expected to rise in the future in nearly all regions of the world. The major reasons for this are the increasing age of the population and the increasing use of tobacco. In other words, the
Presented at the 17th International Congress of Radiology, Paris, 1 July, 1989.
Accepted for publication 24 May 1990.
1276 1. J. Radiation Oncology 0 Biology 0 Physics
problem of cancer is already a major one in developing countries. It will become even worse in the near future if we do not act now.
Priorities and strategies Unless the right priorities and strategies are developed
in a systematic way to gain maximum benefit from avail- able resources (1 I), preferably through well-conceived national cancer control programs (1,2, 5) there is unlikely to be much impact on cancer, especially in the less de- veloped countries. Table 1 shows the priorities and strat- egies for the eight most common cancers worldwide. As can be seen, primary prevention should have much more emphasis than at present. Likewise, early diagnosis and palliative care should receive much greater emphasis. Therapy has no major curative effect in four of the most common cancers globally. However, 3 of the 8 most com- mon cancers, that is breast, cervix and mouth cancer, are eligible for curative therapy. In developing countries this does not occur. Why? Because most of these three com- mon cancers are first seen when incurable and in many developing countries less than 10% are seen at specialized centers, if at all. Thus, in Black Africa there are fewer than 75 full-time cancer specialists of any kind to serve over 285 million people. In Sri Lanka there are two ra- diotherapists for 15 million people. In Indonesia only about 33, cancer patients out of an estimated 170, new cancer patients every year are seen by a cancer doctor. Eighty-six percent of breast cancer patients seen at a lead- ing hospital in Djakarta are inoperable at time of diag- nosis. Three-fourths of the worlds cervical cancer patients are in developing countries. Early detection through screening has not decreased mortality in a single devel- oping country except China, as demonstrated in many developed countries. (10) All too often, the limited re-
Table 1. Priorities and strategies for the eight most common cancers worldwide
Pain relief and
Primary Early Curative palliative prevention diagnosis therapy+ care
Stomach + - _ ++ Lung ++ - _ ++ Breast - ++ ++ ++ Colon/rectum + + + ++ Cervix + ++ ++ ++ Mouth/pharynx ++ ++ ++ ++ Oesophagus - - _ ++ Liver ++ - _ ++
* Listed in order of the eight most common tumors globally. + Curative for majority of cases with a realistic opportunity
of finding them early. ++ = effective; + = partly effective; - = not effective.
November 1990, Volume 19, Number 5
Table 2. Earlier referral, diagnosis, and therapy of cancer of the breast, cervix, and mouth has greater prognostic
importance than any therapy effort, however sophisticated, applied at a late stage of disease
In developed countries
In developing countries
Stage of disease at 5-year diagnosis % pts. survival % pts. What to do
I-II -8O%-+ 80% ~20% Move the 80% of Stage
III and IV patients to Stage I-11 by earlier referral and diagnosis
III-IV -20% \\ 20% >80%
sources of developing countries are spent on therapies only, which have a marginal effect when applied to an ocean of incurable patients. However, both cancers of the breast, cervix, and mouth can be cured, if found early, by basic standard therapies. Therefore it is vital that therapy efforts in developing countries are linked with the active search for earlier referral and diagnosis. For the three common cancers above, an early diagnosis leads to a much higher survival than any therapy, however sophisticated, applied in a late stage of disease, as done at present. The importance of earlier diagnosis and referral is noted in Table 2. The search for earlier referral should be the re- sponsibility of every radiotherapist and cancer surgeon in developing countries.
Early diagnosis of oral cancer by primary health care workers was shown to be effective in Sri Lanka (7, 8). However, the implementation of a nationwide early de- tection program had to be delayed due to a lack of radio- therapists able to treat found cases. Thus, before early detection programs can be activated there must be ade- quate therapy facilities to absorb found cases and if es- tablished therapy facilities in developing countries are to have any impact on mortality, they must be linked with the search for earlier referral and diagnosis of cancer pa- tients.
Training of cancer specialists in the countries. WHO eforts in Sri Lanka and Zimbabwe.
It is estimated that there is a lack of about 3000 to 4000 radiotherapists, 5000- 10,000 radiotherapy technicians, 2000-3000 medical physicists, and about 1400- 1800 teletherapy machines in the developing countries (3, 6).
There are many reasons for establishing regional or na- tional syllabi and degrees. The brain drain is one of these reasons. Many trained specialists are either not re- turning home or are leaving soon after their return. Such a situation is common, and it contributes to the contin- uous shortage of radiotherapists in many countries in Af-
Cancer control in developing countries 0 J. STJERNSWARD 1177
rica and South East Asia. Another reason is that the types of tumors and stages of disease the trainee studies during his training abroad are totally different from what he/she will have to treat upon return home. A third factor is the equipment-as well as the environment of the hospital- which in industrialized countries has practically no, or few, limitations compared to the situation our colleagues will face upon returning home. The above factors fully justify the argument that radiotherapists should be trained as closely as possible under the conditions in which their work will take place.
Many developing countries have Nationals qualified in radiotherapy but only a few remain to serve their own people. The majority remain abroad after training (e.g., this is the situation in Sri Lanka and Sudan). Zimbabwe, a country of 8 million people has an adequate number of available radiotherapy machines but not a single African radiotherapist. All future African radiotherapy specialists South of the Sahara must leave their countries for training abroad. This training is often not relevant to the cancer situation in their own countries.
WHO has initiated, in close collaboration with the na- tional governments and external donors, national and re- gional training courses in radiotherapy and oncology in Sri Lanka and Zimbabwe (4, 12). It is important to stress that the syllabus should be relevant to the individual countrys cancer control situation without compromise on quality; this is essential.
In 1984, the government of Sri Lanka decided to de- velop post-graduate training in radiotherapy and oncology in an effort to build up a cadre of specialists likely to remain in the country. WHO supported this training with WHO consultants in radiotherapy and oncology. A 3- year training program was developed, which leads to the degree of M.D. (Radiotherapy and Oncology) ofthe Post- graduate Institute of Medicine (PGIM), University of Co- lombo, and to board certification for the status of Con- sultant in Radiotherapy and Oncology.
The first stage of the course consists of 12 months in service at the Cancer Hospital with lectures, followed by written and oral exams. The second stage is 24 months in service leading to a M.D. degree. This is followed by 12 months of study abroad and 12 months as an Assistant in Radiotherapy and Oncology in Sri Lanka. After a dis- sertation, board certification for the status of Consultant in Radiotherapy and Oncology can be achieved. Of the first hve students, starting in 1986, three passed the first exam and two failed. At present seven doctors are un-
dergoing training and one has qualified as M.D. (Radio- therapy and Oncology). Three new students per year are expected and the government has earmarked at least nine future positions to Consultants in Radiotherapy and On- cology.
The course in Zimbabwe, financed by funds from the Swiss Government, will, in collaboration with the Ministry of Health and the University Postgraduate School, be run by three WHO consultants during 4 years. Four Zimbab- wian doctors and six doctors from other African English speaking countries will be trained in the first course. Be- sides radiotherapy and chemotherapy of solid tumors, primary prevention, early referral and diagnosis, cancer pain relief and other symptoms management will be cov- ered in the course. Adequate therapy facilities are available in the form of one linear Accelerator (6-Mev). two Co and two 250-Kw machines, Strontium, Cesium. Curie- therapy applicators and similators. A teacher in radi- ophysics to train the radiophysisists is promised from the International Atomic Energy Agency, Vienna. Twinning that will say support of teaching faculties and resources from a cancer centre in a developed countries is encour- aged and welcomed.
A sufficient number of doctors will be trained in the above two courses, so that Sri Lanka and Zimbabwe will be self-sufficient in numbers of radiotherapists during the 1990s.
The ultimate goal is to obtain a critical mass of excel- lence and knowledge locally, so that Zimbabwe can serve as a future center for the training of African doctors by African doctors in cancer control without need for exten- sive training abroad.
The development of therapy resources should not be done in isolation to other cancer control activities. The right priorities and strategies must be determined in a systematic way, preferably through well-conceived na- tional cancer control programs. If this is not done, it is unlikely to have any impact on cancer, especially in the developing countries. However, even limited resources may have an effect on controlling cancer, provided the right priorities and strategies are followed. National and regional training facilities with a suitably adapted syllabus in radiotherapy and oncology must be a part of those priorities and strategies.
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3. Racoveanu N. T. Radiotherapy in developing countries- constraints and possible solutions. In: Radiotherapy in de-
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