Global Task Force on Radiotherapy for Cancer Control

Comment Global Task Force on Radiotherapy for Cancer Control See The Lancet Oncology Commission page 1153 For the full list of members see www.gtfrcc.org For more on the Lancet/Lancet Oncology Cancer Campaign, please see http://www.thelancet. com/campaigns/cancer 1144 Cancer is an immense, fast-growing challenge to health and health systems worldwide. Previously thought to be restricted to high-income populations, it is now also recognised as an emerging and critical issue for low-income and middle-income countries. Although the challenge of cancer control in low-income and middle-income countries has been highlighted before,1 a comprehensive, integrated and global health system response was first forged with the work of the Global Task Force on Expanded Access to Cancer Care and Control, which began in 2009.2 This effort inspired the creation of the Global Task Force on Radiotherapy for Cancer Control (GTFRCC),3 chaired by David A Jaffray, which consisted of more than 100 members, including radiotherapy professionals, oncology experts, industry representatives, and economists. The Union for International Cancer Control (UICC), a global initiative dating to the 1930s that works to promote greater equity in cancer control, mandated the GTFRCC,4 which was launched under the President’s portfolio with essential support from key leaders in the European Society for Radiotherapy and Oncology (ESTRO), the International Atomic Energy Agency (IAEA), and the radiotherapy industry. Cancer control necessitates comprehensive and coordinated actions that span prevention, access to accurate and timely diagnosis, treatment, and palliation. Radiotherapy is a key curative and palliative treatment modality for cancer. However, the dearth of radiotherapy treatment capacity globally has led to gross inequities in access. The GTFRCC took on the task of quantifying the investment needed to close the global radiotherapy access gap. Through the inspiring leadership of the UICC board members—especially Felicia M Knaul, board member and leader of the GFTRCC—the GTFRCC recruited the foremost global experts in the field to form the Secretariat to coordinate and direct the task force’s efforts. It was recognised that developing the economic case for radiotherapy would be at the core of the GTFRCC’s efforts, and Rifat Atun, who has extensive experience in global health and innovative financing for health care,5–8 joined the Secretariat. The GTFRCC was fortunate to have the President of Uruguay, Tabaré Vásquez, who is a radiation oncologist, as its Honorary Chair. The GTFRCC assumed as its mandate the documentation of the challenge and quantification of the investment needed to achieve global equity in access to radiotherapy by 2035. The task force was determined to show not only the health benefit of this transformative investment in cancer control, but also the economic benefit of radiotherapy using an investment framework. The GTFRCC aims to connect the details of the need for radiotherapy to the global health agenda and machinery to advance comprehensive cancer services worldwide. We engaged The Lancet Oncology early in our deliberations9 and eventually became part of the Lancet Cancer Campaign as The Lancet Oncology Commission on Global Radiotherapy.10 Over the past 2 years, the GTFRCC investigated the role and global need for radiotherapy through the activities of two working groups. The first, under the leadership of Michael B Barton and with input from Freddie Bray of the International Agency for Research on Cancer, estimated the 20-year future burden of cancer requiring radiotherapy and determined the projected benefit in terms of lives saved of making radiotherapy available globally according to evidencebased practice guidelines.11,12 The second working group was led by Jacob Van Dyk and reviewed the requirements in terms of facilities, equipment, and human resources to generate sufficient capacity to deliver the scale of treatment necessary to deal with the projected burden. It also calculated the capital and operating costs of creating and delivering this capacity. In parallel, Rifat Atun led the development of the investment model to evaluate the economic case for investment in radiotherapy. The deliberations and progress of the working groups were presented and discussed throughout 2014 at GTFRCC-hosted sessions at the annual ESTRO, American Society of Clinical Oncology, American Society for Radiation Oncology, and UICC World Cancer Congress. Additionally, the GTFRCC Secretariat held a workshop in Toronto in February, 2015, to reach a consensus on the assumptions required to calculate the economic benefit. The full membership of GTFRCC was engaged in the work through participation in meetings, surveys, and a series of webinars held throughout spring of 2015 to canvass opinions and ideas for the final report before publication. www.lancet.com/oncology Vol 16 September 2015 The GTFRCC concentrated specifically on investment in radiotherapy as a neglected and necessary facet of global cancer control.13 Our work has attracted considerable interest and great expectations in the global cancer and radiotherapy communities. At the same time, it is clearly evident that to realise the full benefit from radiotherapy a parallel investment has to be made in diagnostic services (pathology and imaging), surgery, chemotherapy, and broader health-care strengthening platforms. The results of the task force complement and contribute to the ongoing efforts of the IAEA, the global cancer community, and WHO to promote greater equity in access to cancer care now and the future. Closing the gap in equitable access to radiotherapy is a complex undertaking. The effort to provide radiotherapy around the world will continue for decades. In recognition of the magnitude and the need for sustained advocacy and champions, the GTFRCC enlisted several young leaders who enthusiastically engaged in the work and created a new effort, GlobalRT, under the leadership of Danielle L Rodin.14 This social movement aims to connect young people interested in busting the myths and working together to ensure that evidence-based radiotherapy practice is included in the toolbox of cancer therapies available worldwide. Our findings, together with recommendations for concrete steps to close the divide in access to radiotherapy are presented in full in this issue of The Lancet Oncology. David A Jaffray, Felicia M Knaul, Rifat Atun, Cary Adams, Michael B Barton, Michael Baumann, Yolande Lievens, Tracey Y M Lui, Danielle L Rodin, Eduardo Rosenblatt, Julie Torode, Jacob Van Dyk, Bhadrasain Vikram, *Mary Gospodarowicz Princess Margaret Cancer Centre, 610 University Avenue, M5G 2M9, Toronto, ON, Canada (DAJ, MG); Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada (DAJ, DLR, MG); TECHNA Institute, University Health Network, Toronto, ON, Canada (DAJ, TYML); Harvard Global Equity Initiative (FMK), Harvard Medical School (FMK), and Harvard TH Chan School of Public Health (RA), Harvard University, Cambridge, MA, USA; Union for International Cancer Control, Geneva, Switzerland (CA, JT); Ingham Institute for Applied Medical Research, University of New South Wales, Liverpool, NSW, Australia (MBB); Department of Radiation Oncology, Medical Faculty and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany (MB); Ghent University Hospital, Ghent, Belgium (YL); Ghent University, Ghent, Belgium (YL); International Atomic Energy Agency, Vienna, Austria (ER); Department of Medical www.lancet.com/oncology Vol 16 September 2015 Isaac Lane Koval/Corbis Comment Biophysics, Western University, London, ON, Canada (JVD); and National Cancer Institute, US National Institutes of Health, Bethesda, MD, USA (BV) [email protected] DAJ reports grants or sponsored research agreements from Raysearch Laboratories, Philips Medical Systems, Eletka, Varian Medical Systems, Siemens Medical, and IMRIS; presenter fees from the American Society for Radiation Oncology; and royalties from Modus Medical and Precision X-ray related to non-patentable inventions, outside the submitted work and holds pending patents (US 2013/026137 A1, US61/178 319, US61/157 738, and US2013/0113802 A1) and issued patients (7399977, US11/867998, and PCT/ US2007/067847), as well as issued patents licensed to Elekta (8 039 790 [with royalties received], 20040234115, 20040096038, 20040218719, 7472765 [with royalties received], and 7 147 373 [with royalties received]) and iRT (US60/806842, PCT/CA2007/001209, and EP20070763872). FMK has received grants from GlaxoSmithKline, Pfizer, NADRO, Chinoin, Sanofi SA, Roche, Susan G Komen for the Cure, Fogarty International Center, the Pan-American Health Organization, WHO, and the International Development Research Center; and support from the National Institute of Public Health Mexico, Centro de Investigacion y Docencias Economicas Mexico, PISA, Celgene, and Grunenthal. She is director of the Secretariat of the Global Task Force on Expanded Access to Cancer Care and Control, a board member of the Union for International Cancer Control, and the founding President of Tómatelo a Pecho. YL is President-elect of the European Society for Radiotherapy and Oncology, an unpaid position. JVD received travel support from the Canadian Organization of Medical Physicists to attend meetings related to the Commission. TYML’s institution received funds from the Union for International Cancer Control to support her salary for time spent working on The Lancet Oncology Commission on Global Radiotherapy. MG is a member of the board of directors of IBA, which manufactures proton therapy equipment. RA, MB, ER, MBB, BV, CA, JT, and DLR declare no competing interests. 1 2 3 4 5 For more on GlobalRT see http://www.globalrt.org Sloan FA, Gellband H. Cancer control opportunities in low- and middleincome countries. Washington, DC: National Academy of Sciences, 2007. Knaul FM, Frenk J, Shulman Lawrence, for the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. Closing the cancer divide: a blueprint to expand access in low and middle income countries. Boston: Harvard Global Equity Initiative, 2011. Farmer P, Frenk J, Knaul FM, et al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet 2010; 376: 1186–93. Global Task Force on Radiotherapy for Cancer Control. A world cancer declaration, target 7 commitment. http://www.uicc.org/sites/main/files/ private/GTFRCC%20Introduction.pdf (accessed Aug 25, 2015). Vujicic M, Weber SE, Nikolic IA, Atun R, Kumar R. An analysis of GAVI, the Global Fund and World Bank support for human resources for health in developing countries. Health Pol Plan 2012; 27: 649–57. 1145 Comment 6 7 8 9 10 Resch S, Korenromp E, Stover J, et al. Economic returns to investment in AIDS treatment in low and middle income countries. PLoS One 2011; 6: e25310. Cavalli F, Atun R. Towards a global cancer fund. Lancet Oncol 2015; 16: 133–34. Schwartlander B, Stover J, Hallett T, et al. Towards an improved investment approach for an effective response to HIV/AIDS. Lancet 2011; 377: 2031–41. Rodin DL, Jaffray DA, Atun R, et al. The need to expand global access to radiotherapy. Lancet Oncol 2014; 15: 378–80. Atun R, Jaffray DA, Barton MB, et al. Expanding global access to radiotherapy. Lancet Oncol 2015; 16: 1153–86. 11 12 13 14 Barton MB, Jacob S, Shafiq J, et al. Estimating the demand for radiotherapy from the evidence: a review of changes from 2003 to 2012. Radiother Oncol 2014; 112: 140–44. Shafiq J, Delaney G, Barton MB. An evidence-based estimation of local control and survival benefit of radiotherapy for breast cancer. Radiother Oncol 2007; 84: 11–17. Barton MB, Frommer M, Shafiq J. Role of radiotherapy in cancer control in low-income and middle-income countries. Lancet Oncol 2006; 7: 584–95. Rodin DL, Yap ML, Hanna TP. GlobalRT: building a new radiotherapy community. Lancet Oncol 2014; 15: 926. The verdict is in: the time for effective solutions to the global cancer burden is now See The Lancet Oncology Commission page 1153 For more on the Global Taskforce on Radiotherapy for Cancer Control see http://gtfrcc.org/ For more on the Union for International Cancer Control see http://www.uicc.org For more on the International Caner Expert Corps see http://www.iceccancer.org 1146 That the growing global burden of non-communicable diseases is a human catastrophe requiring action was brought to the world’s attention over the past decade by WHO,1 culminating in a UN declaration in 2011.2 Non-communicable diseases—respiratory diseases, obesity, cardiovascular disease, and cancer— have common causes, including nutrition, personal habits, environment, and ageing.3 The importance of non-communicable diseases does not diminish that of communicable diseases, and there are clear links between human papillomavirus and cervical cancer, and the hepatitis viruses and liver cancer. Effective cancer control necessitates a multidimensional, multisectoral, multidisciplinary, and international approach. In debates, the issue of affordability is invariably raised, particularly for radiotherapy, in view of the cost of establishing and maintaining facilities. In this issue of The Lancet Oncology, the comprehensive need assessment and economic analysis by Rifat Atun and colleagues4 rejects the argument that radiotherapy is unaffordable, and shows that investment in radiation oncology both saves lives and is associated with positive economic returns. Radiotherapy is a key component of curative and palliative treatment. Substantial benefit is achievable from combined treatment with radiation and standard drugs to cure some locally advanced cancers and from shortcourse radiation (hypofractionation) as part of palliative care. Investment in partnerships is needed to train, educate, mentor, and sustain programmes in settings with limited personnel, resources, and infrastructure. The Global Taskforce on Radiotherapy for Cancer Control set up by the Union for International Cancer Control (UICC) is a remarkable project. Its analyses and robust collection of contributors provide clear evidence that there could be an effective way forward.4 If addressing global cancer care results in both health and economic benefits,4 why are effective radiotherapy and cancer care programmes so difficult to establish in low-income and middle-income countries? There are several frequently articulated reasons for not addressing this problem, all of which are certainly resolvable. Some suggest a focus only on prevention. Prevention is crucial, but what happens to patients for whom it is not effective? Furthermore, prevention has not eliminated cancer in resource-rich countries. Others suggest that cancer care is too expensive, or the problems too complicated, but the results of the Commission show that non-treatment is more expensive4—and there are examples of high-quality cancer care in low-income and middle-income countries. Successful, affordable treatment regimens exist, and technology can link global experts to centres in low-income and middle-income countries, enabling access to new concepts and mentoring. Suboptimum health-care and physical infrastructures are other common reasons cited for not addressing the issue. However, systems are in need of repair for everything from maternal and child health, to communicable and non-communicable diseases.5,6 There is the opportunity for innovative technology to cope with challenging infrastructure. That low-income and middle-income countries do not have the expertise is another common concern, but the world has the expertise to train, mentor, and sustain people in these areas. Effective mentoring models are needed, such as the International Cancer Expert Corps.7 Policy makers in resource-rich countries appropriately suggest that they cannot be responsible for provision www.lancet.com/oncology Vol 16 September 2015 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.