key: cord-295138-xud3y0ko
authors: Datta, Niloy R.; Datta, Sneha; Samiei, Massoud
title: Strategies to maximize available resources with minimum cost escalation for improving radiotherapy accessibility in the post COVID-19 era : An analysis for Asia
date: 2020-09-24
journal: Adv Radiat Oncol
DOI: 10.1016/j.adro.2020.09.005
sha: 
doc_id: 295138
cord_uid: xud3y0ko

PURPOSE: There is widespread accord among economists that the COVID-19 pandemic will have a severe negative impact on the global economy. Establishing new radiotherapy (RT) infrastructure may be significantly compromised in the post COVID-19 era. Alternative strategies are needed to improve the existing RT accessibility without significant cost escalation. The outcomes of these approaches on the RT availability has been examined for Asia. METHODS AND MATERIALS: The details of RT infrastructures in 2020 for 51 countries in Asia were obtained from the Directory of Radiotherapy Centers of the International Atomic Energy Agency (IAEA). Using the IAEA guidelines, the %RT accessibility and the additional requirements of teletherapy (TRT) units were computed for these countries. To maximize the utilization of the existing RT facilities, five options were evaluated, namely, hypofractionation RT (HFRT) alone, with/without 25% or 50% additional working hours. The impact of these strategies on the %RT access and additional TRT unit requirements to achieve 100% RT access were estimated. RESULTS: 4617 TRT units are available in 46 countries. The mean %RT accessibility is 62.4% in 43 countries (TRT units =4491) where the information on cancer incidence was also available and these would need an additional 6474 TRT units for achieving 100% RT accessibility. By adopting HFRT alone, increasing the working hours by 25% alone, 25% with HFRT, 50% alone and 50% with HFRT; the %RT access could improve to 74.9%, 78%, 90.5%, 93.7% and 106.1% respectively. Correspondingly, the need for additional TRT units would progressively decrease to 4646, 4284, 3073, 2820 and 1958 units. CONCLUSION: The economic slowdown in the post Covid-19 period could severely impend establishment of new RT facilities. Thus, maximal utilization of the available RT infrastructure with minimum additional costs could be possible by adopting HFRT with or without increased working hours to improve the RT coverage.

The coronavirus disease 2019 (COVID-19) pandemic is expected to result in severe contraction of the global economy. 1, 2 According to the World Bank, the pandemic is likely to plunge the economy of most countries into recession with per capita income shrinking in majority of countries to magnitudes not seen since 1870. 3 In 2020 itself, the global economy is projected to contract by 4.93%. 4 Thus, the COVID-19 pandemic would also have an adverse impact on the targets of the United Nations (UN) "Sustainable Developmental Goals (SDG)" proposed to be achieved by 2030. 5, 6 This would certainly have widespread ramification in nearly all sectors, including health care; in particular for the diagnosis and treatment of non-communicable diseases such as cancer which require large investments. For cancer, expected to have a rising trend of incidence globally from 18.98 million in 2020 to 24.11 million in 2030, the allocation of funds towards cancer care in the near future could be severely curtailed. 7 Radiotherapy (RT), one of the essential components of multimodality cancer management, is capital intensive. [8] [9] [10] Even today, the available RT infrastructure and complementary human resources is insufficient to meet the growing RT demands, especially in the low-and middle-income economies. [11] [12] [13] [14] [15] [16] 17 The situation is likely to worsen as most countries may find it difficult to designate adequate finances for establishing new RT infrastructure in the post COVID-19 era.

As per the Global Cancer Observatory, in 2020, a cancer incidence of 9.22 million and mortality of 5.79 million in Asia would account for nearly 48.5% and 57.6% of the global cancer incidence and mortality respectively. 7 This is the highest amongst all five continents. It therefore becomes imperative and timely to judiciously explore alternative strategies in the post COVID-19 era J o u r n a l P r e -p r o o f 4 TRT units for 100% RT access in 2020 for each country was computed. The details of the available human resources regarding RT (radiation oncologists, medical physicists, and RT technologists) in these countries could not be assessed as information on various personnel were not available in the present DIRAC database. 19 Strategies for maximal utilization of radiotherapy infrastructure with minimal cost escalation It is assumed that RT centers presently functioning have adequate RT personnel to run their existing facilities for an eight-hour normal working hours of a department. Thus, the various approaches that were considered for increasing patient throughput from 500 patients/TRT unit/year with minimal cost escalation are:

(a) Hypofractionated radiotherapy (HFRT) within eight working hours of a department: It is assumed that in a routine department, patients undergoing radical, postoperative, preoperative RT are usually treated with standard fractionation RT (SFRT) schedules of 70 Gy/35 fractions/7 weeks, 60 Gy/30 fractions/6 weeks and 50 Gy/25 fractions/5 weeks and annually these constitute around 30%, 30% and 20% of patients respectively. Remaining 20% of the patients are treated with palliative RT to doses of 30 Gy/10 fractions/2 weeks (10%) and <20Gy/5 fractions/1 week (10%) (Supplementary Table 1 ). Most patients considered for palliative treatment with <20 Gy present with bone metastasis. They are likely to be treated by single fraction as this has been shown to be equally effective as multiple fraction RT. 20 The above assumptions are based on first author's experience of working at several centers in an Asian country. However, individual centers in different countries could review their own patient data and distribution of patients subjected to different RT treatment fractionation plans based on the current practices prevalent in a particular center. Accordingly they could J o u r n a l P r e -p r o o f alter these values to conform to their patient population and RT time-dose-fractionation schedules.

A mild to moderate HFRT could be adopted whereby the treatment duration for radical, postoperative, preoperative and the two-week palliative RT schedule are reduced by one week each keeping the respective total RT doses the same. Correspondingly, this would result in a dose/fraction of 2.33 Gy, 2.40 Gy, 2.5 Gy and 3 Gy for these treatments. The biologically effective doses (BED) for early effects with time factor for both SFRT and HFRT schedules could be computed using the linear-quadratic model assuming, α/β = 10 Gy, α = 0.3 Gy -1 , potential doubling time, T pot = 5 days and kick off time (Tk) = 21 days. 21 The BED for late effects for all regimens were computed assuming α/β = 3 Gy. 

The 51 countries included in Asia presently has a population of 4.64 billion. This constitutes around 59.5% of the global population. 17 The cancer incidence data in 2020 was available for 47 countries while the RT infrastructure was listed in the DIARC database for 46 countries (Supplementary Table   2 

The COVID-19 pandemic is expected to result in the deepest global recession in eight decades with significant contraction of global economy. 3 In the post COVID-19 era, allocation of an amount of this magnitude or even a fraction of it to set up new RT infrastructure appears to be extremely unlikely.

The RT dose fractionation schedules are quite variable and are often dictated by the local treatment policies adopted by a particular center, unless the patients are being treated under a specific study protocol. [25] [26] [27] However, in contrast to the usual clinical practice of using a higher dose per fraction in Western countries, the usual practice in Asian continent is to treat patients using standard dose fractionation of 1.8 to Gy/ fraction in most cases for radical and pre-or postoperative RT. This is because most patients present in locally advanced stages thereby requiring larger planning target volumes. This contributes to a higher risk of treatment related morbidity, poor nutritional status and adverse hot and humid climate (especially in summer and rainy seasons Privately owned centers charging RT services based on the number of fractions may be initially apprehensive that advocating HFRT might reduce their revenue. The RT charges could therefore be tailored based on the treatment package for a specific RT indication rather than on the number of fractions. However, in the longer run, additional patients that would be treated due to HFRT, might even over compensate the revenue and could be financially rewarding. In state-owned centers, HFRT should not cause a problem as these are usually overburdened with long waiting lists.

HFRT could in fact help to reduce their patient waiting period and increase through put.

Increasing the working hours of the department could also increase the throughput. Even presently, some of the RT centers might be forced to increase their working hours to accommodate the waiting list of patients for RT. This would have to also take into consideration the logistics and the available human resources in each RT center. Surveys carried out reveal that patients are willing to come for RT outside the normal working hours of the department if this could help to reduce their waiting time for initiating RT. [37] [38] [39] An additional 50% working hours would need additional personnel or additional financial incentives or compensatory offers to the staff. Further, in centers, which would like to run two-shifts with the same infrastructure, could help to generate additional employment for various groups of RT personnel. The cost involved may be a fraction of the investment needed to achieve a similar throughput by establishing additional RT infrastructure.

Moreover, in the post COVID-19 era, job losses are widely anticipated. Recently qualified RT personnel may therefore face difficulties to secure employment due to lack of demand as new RT infrastructure may be held in limbo during the post COVID-19 period. Thus, extended working hours could also help to gainfully employ additional skilled workforce if they are available. This could create an overall "win-win" situation for patients, personnel, establishment and the country.

The benchmark for computing RT accessibility was carried out using 500 patients that could be treated by conventional and relatively simple RT techniques. However, for complicated procedures, the number would be reduced depending on the proportion of such patients being treated in a RT center. By adopting the various options as discussed above, nearly half of the centers (20/43) would have more than 100% access (Fig. 3c) . This would allow these centers to also practice specialized RT techniques, like intensity modulated RT, image guided RT, respiratory gated procedures or stereotactic RT procedures. These would be taking more time for setting up, quality assurance and execution. Thus, by implementing HFRT and additional working hours, a department could allocate the RT procedures that they would like to practice depending on the type of patients and treatment policies practiced in a particular center. These have to be decided at individual departmental level taking into consideration their existing infrastructure, available time and personnel.

Another potentially beneficial approach, could be by pooling and sharing of the available resources within a country or sub-region. 6, 11, [40] [41] [42] The widespread availability of telecommunication technology provides an opportunity for building a 3-tier teleradiotherapy network by creating primary, secondary and tertiary RT centers (Fig. 4) . While the primary RT center could only execute TRT, the secondary centers could have BRT in addition to teletherapy. The tertiary centers could be having the state-of-the-art RT facilities and be responsible for coordinating teaching and training for all the subsidiary centers within the network. Patients if needed could be referred to higher center for specialized treatments. The tertiary centers would also be the focal point for framing national and regional guidelines to provide uniformity and quality in cancer care. This allows pooling and sharing of resources, gives access to the entire range of radiotherapy facilities and improves quality of radiotherapy. 6, 11, 41, 42 This approach is also cost-effective and could provide substantial positive returns on investment. 6, 9 The 3-tier teleradiotherapy network could be further integrated as a part of teleoncology network and include teleradiodiagnostics, telepathology, tele-education with capacity building, teleconsultation and telefollow-up. 43 The present pandemic certainly possess immense challenges to provide adequate RT access to patients, especially when the global economy is undergoing a deep and unprecedented plunge.

One -size-fits-all may not be applicable to all countries. Individual centers and countries needs to J o u r n a l P r e -p r o o f frame out pragmatic strategies to allow maximal resource utilization without cost escalation until such time that a steady economic recovery takes place and the situation normalizes. The challenges also opens up new opportunities for improvements to cancer care and treatment as discussed.

The strategies presented here could be applicable to any center and could enhance cancer care capability not only in Asia but also in any other region thereby providing a cost-effective solution with additional returns on investment. 6 However these opportunities need to be individualized based on the available RT infrastructure, human resources, prevalent type of cancers, treatment guidelines, practices and associated logistics. Collectively, even in the present adverse conditions of COVID-19 pandemic, these cost-effective measures could provide pragmatic solutions to help move towards meeting the targets of the UN 2030 Agenda as defined by the Sustainable Development Goals (SDGs) in particular SDG 3, related to good health and wellbeing. 47 One of the targets of SDG 3 is to reduce by one-third the premature mortality from non-communicable diseases 

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