The view of the AFRA
designated centre on how to
respond to the challenges in
PRO in the region
Mahmoud M. ElGantiry
Professor of Radiation Oncology
National Cancer Institute
Cairo University
[email protected]
1
Outlines
• The AFRA designated centre:
• The challenges in PRO:
– Challenges in management of PRO.
– Challenges in PRO in the African region.
• The AFRA designated centre response
to the challenges:
2
Outlines
• The AFRA designated centre:
• The challenges in PRO:
– Challenges in management of PRO.
– Challenges in PRO in the African region.
• The AFRA designated centre response
to the challenges:
3
• Nuclear Energy:
– Reactors, disposal of radioactive waste etc.
• Industry.
• Agriculture.
• Health:
– Radiation Oncology.
– Radiation Physics.
– Nuclear medicine.
– Other projects.
RDC
• The concept of Regional Designated Centre
(RDC): Radiation Oncology and Medical Physics:
–
–
–
–
Training Centre.
Experts.
Research.
Treatment guidelines.
• Recognition of RDC:
– English speaking countries:
• South Africa:
2000.
• NCI – Cairo University: 2006.
– French speaking countries:
• Morocco:
2003
5
Outlines
• The AFRA designated centre:
• The challenges in PRO:
– Challenges in management of PRO.
– Challenges in PRO in the African region.
• The AFRA designated centre response
to the challenges:
6
Challenges in management of PRO
• The survival:
• The late radiation effects:
7
Challenges in management of PRO
• The survival:
• The late radiation effects:
8
Challenges in management of PRO:
The survival.
• It has improved in the last decades:
– The expected cure rate is ~ 80%.
• Main causes of these results:
– The multidisciplinary approach.
– Use of effective systemic treatment.
– Proper use of the local treatments; surgery
and radiotherapy (RT).
– The majority of patients were treated in
controlled randomized studies.
9
Challenges in management of PRO:
The late radiation effects
• RT may produce late effects which are
generally more severe compared with
adult patients:
– Growth retardation.
– Endocrinal disorders.
– Neurocognitive deficits.
10
Challenges in management of PRO:
The late radiation effects
Factors contributing to late radiation effects:
• Age at receiving the radiation.
• Treatment volume:
– The volume of normal tissue irradiated.
• The total tumor dose.
• Dose per fraction.
• The sequence of treatment used e.g. CTh
during RT may cause severe effects.
11
Challenges in management of PRO:
How to limit the late radiation effects:
• Modification of RT techniques:
– Tailoring the dose according to age.
– Reducing the tumor dose.
– Reducing the irradiated volume.
– Excluding some normal tissues.
– Improvement of planning procedures.
– Use of new RT techniques.
• Postponing RT until patient is older.
• Use of combined chemo-radiotherapy.
12
How to limit the late radiation effects:
• Tailoring the dose according to age:
– Different international groups have tested
the tailoring of the radiation tumor dose to
the age of the patient.
– These studies have shown high survival
rate with less late toxicity as in Wilms’
tumors and neuroblastoma.
13
How to limit the late radiation effects:
• Reducing the tumor dose:
– Combined chemo-radiotherapy may be
given instead of RT alone.
– The RT is lower in dose and smaller in
volume which causes less morbidity e.g.
early stages of HD.
14
How to limit the late radiation effects:
• Improvement of planning procedures:
– Better fixation with use of anesthesia if needed.
– Better delineation of target volume and OAR.
• The use of new imaging modalities such as CT scan,
MRI and PET.
– More sophisticated TPS.
– Better treatment delivery methods e.g. MLC.
– Accurate treatment verification methods.
15
How to limit the late radiation effects:
The use of modern RT techniques: e.g.
• Conformal RT,
• Stereotactic radiosurgery,
• Intense modular RT (IMRT),
• Image guided RT (IGRT)
• Tomotherapy.
16
How to limit the late radiation effects:
• Postponing RT until patient is older:
– In view of the severe late radiation effects
to children below 3 years:
• Postpone RT and may use CTh till patients are
older e.g. brain tumors.
17
Outlines
• The AFRA designated centre:
• The challenges in PRO:
– Challenges in management of PRO.
– Challenges in PRO in the African region.
• The AFRA designated centre response
to the challenges:
18
The challenges in PRO:
Challenges in PRO in the African region.
•
•
•
•
Lack of statistics.
Lack of the equipment.
Lack of trained personnel.
Lack of the specialized pediatric oncology
centers:
– It is generally managed by same personnel.
• Lack of the specialized pediatric oncology
programs (Academic and training).
19
AFRICA
- 2nd largest continent.
- Countries: 56.
- Population: ~ 800 m.
- The least developed.
Current RT Services in Africa: 2006 (V. Levin)
Western standard
250,000/machine
< 2 million/machine
2 - 10 million/machine
> 10 million/machine
No known machines
Inoperable machines
New Projects underway
Zambia
Assessment of present status:
I- Equipment: Megavoltage machines (LA&Cobalt-60)
• Number of countries:
– Population:
56 countries.
~ 800 m.
• > 50% of African countries have NO RT.
• Africa needs:
– International standards (1MVM / 250,000):
–
(1MVM / 1,000,000):
• Number of MVM in Africa:
• Egypt (~75 m):
• South Africa (~49 m):
3200 MVM
~ 800 MVM
~190 MVM.
~ 71 MVM
~ 58 MVM
~ 2/3
Assessment of present status: (Levin 2006)
II- Training requirements: Decade 2006 – 2016
• Self-sustaining countries:
– EGY, SA, MOR, NIG, ALG, TUN, ZIM.
• Other countries:
– 135 RO need to be trained.
– 65 Medical physicists need to be trained.
Assessment of present status: (Levin 2006)
III- Level of RT practice:
• Up to level 3:
– ALG, EGY, MOR, SA, TUN.
(Conventional 2DRT: The commonest tech)
• Level 1-2:
– Rest of the countries.
Three Levels of Absorbed Dose Computation Sophistication: (ICRU 50)
• Level 1: Basic Techniques:
(1D).
• Level 2: Advanced Techniques:
(2D).
• Level 3: Developmental Techniques: (e.g. 3DCRT)
(3D).
Challenges in RO in the African region.
• "A silent crisis in cancer treatment exists in
developing countries and is intensifying
every year“.
Mohamed ElBaradei, IAEA Director General.
• "We do not have sufficient RT facilities or
staff to treat the coming cancer crisis in
the developing world."
Bhadrasain Vikram, IAEA Radiation Oncologist.
(PR 2003/11 - 26 June 2003)
Outlines
• The AFRA designated centre:
• The challenges in PRO:
– Challenges in management of PRO.
– Challenges in PRO in the African region.
• The AFRA designated centre response
to the challenges:
26
The response to the challenges by AFRA
designated centre (NCI-Cairo University):
Challenges in management of PRO:
• Establishing PRO unit.
Challenges in PRO in the African region:
(Equipment acquisition)
• Relying on NGO,s and private sector.
27
NCI – Cairo University
• PRO unit:
– Experts.
– Trained staff.
– Multidisciplinary approach.
• PRO unit & IAEA offer:
– Awareness.
– Training (short and long term).
– Expert missions.
– Clinical research.
– Guidelines.
28
Bridging the Gap in Equipment
• Governments.
• IAEA:
– AFRA.
– Regional Designated Centers.
• ? Regional organizations: e.g. African Union.
• NGO’s.
• Private sector.
Service providers of RO in EGY
30
LA
Co-60
Total
Government
27
11
38
Private
16
5
21*
NGO,s
11
1
12*
Total
54
17
71
* Private + NGO,s ~ 50%
Lateral thinking ???
??? Alternatives
• The acquisition of RT equipment is very
slow in Africa.
• If we wait until the attitude changes; we
may have to wait for decades.
• The Egyptian experience:
– Private sector:
– NGO’s:
??? Lateral thinking:
I- Private sector:
• Establishing Oncology Centers initially RT and CTh:
– + Lab + Radiodiagnosis (CT scan and MRI).
• The design of the center is uniform and the
equipments are the same:
– Lower cost of design and price of equipments.
• Sound economical basis:
– For sustainability and continuity of the project.
– At some stage “giving back to community” e.g.
“not-for-profit” centers.
??? Lateral thinking:
I- Private sector:
• Involvement of local RO,MP and RTT and other staff.
• Good investment environment; preferably with
governmental guarantees is required.
• I suggest PACT as the body to study this idea.
??? Lateral thinking: II- NGO’s:
Children Cancer Hospital (www.57357.com)
• NGO project (League of Friends of NCI).
• Word of Gratitude:
– Hospital 57357 is a monumental medical, scientific, and cultural
project.
– It is the fruit of labor of all Egyptians.
– A unique and perfect example for charitable giving and for what
people(Egyptians, Arabs and friends from all over the world) can
achieve when they work together for a common cause.
– "Thank you" for all those who shared in its accomplishment.
– "Thank you" for all those who are keen to continuously support
and encourage us to achieve our mission of providing excellent
medical and psychological care for children with cancer, free of
charge.
34
Hospital Departments
• Anesthesia, Surgery, Pediatric Oncology,
Radiation Oncology, Nuclear Medicine,
ICU, Lab Multi Specialty, Psychosocial
Oncology, Physical Therapy, Bio-Medical,
Dental Unit, Pharmaceutical services.
• Day Treatment, In-patient, Out-patient.
• Human Resources, Engineering, IT.
• Patient Relations, Volunteer.
35
36
Conclusions
• PRO is challenging specialty; particularly
in Africa.
• RDC and IAEA play role in teaching and
training.
• NGO,s and private sectors should be
involved more in equipment acquisition.
• PACT may be involved in these activities.
Conclusions
.‫• ﻣﺎﺣﻚ ﻇﻬﺮك ﻣﺜﻞ ﻇﻔﺮك‬
• No one can scratch your back as good as
your nails.
.‫• ﻻ ﻳﻐﻴﺮ اﷲ ﻣﺎ ﺑﻘﻮم ﺣﺘﻰ ﻳﻐﻴﺮوا ﻣﺎ ﺑﺄﻧﻔﺴﻬﻢ‬
• God does not change your situation until
you change.