[en] The radiotherapist (RTT) is a member of the multidisciplinary team responsible for the preparation and delivery of a course of radiotherapy to cancer patients. The roles and responsibilities of the RTT vary significantly among countries and, in some instances, within countries. They are a reflection of both the local or broader national factors and the available resources, but must always incorporate accurate and safe practice. Irrespective of the scope of practice, roles and responsibilities, any educational programme developed for this professional group must not only prepare the RTTs for current practice, but enable them to adapt to future developments and challenges. Quality and equality of care for all patients receiving radiotherapy are the ultimate goals. To achieve these goals, educational programmes must include the subjects underpinning accurate and safe practice and must integrate academic and clinical components. Health care is undergoing reform in many countries, with a much stronger emphasis on patient centred care. However, reform of the delivery and quality of health care cannot be achieved without the parallel reform in health professional education. This need for reform is emphasized in the report on health professions education issued by the Institute of Medicine of the National Academies, wherein it is stated that “all health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics” [17.1]. This chapter deals with health care education in the United States of America, but the sentiment is equally applicable to the delivery of high quality health care for cancer patients throughout the world.

[en] Cancer treatment is complex and calls for a diverse set of services. Radiotherapy is recognized as an essential tool in the cure and palliation of cancer. Currently, access to radiation treatment is limited in many countries and non-existent in some. This lack of radiotherapy resources exacerbates the burden of disease and underscores the continuing health care disparity among States. Closing this gap represents an essential measure in addressing this global health equity problem. This publication presents a comprehensive overview of the major topics and issues to be taken into consideration when planning a strategy to address this problem, in particular in low and middle income countries. With contributions from leaders in the field, it provides an introduction to the achievements and issues of radiation therapy as a cancer treatment modality around the world. Dedicated chapters focus on proton therapy, carbon ion radiotherapy, intraoperative radiotherapy, radiotherapy for children, HIV/AIDS related malignancies, and costing and quality management issues.

[en] Unforeseen developments and discoveries notwithstanding, a prediction regarding the future of radiotherapy must be based on a careful observation and analysis of current trends. In general terms, future developments in radiation oncology relate to two broad categories: developments in technology that will improve the accuracy of physical dose delivery, and developments in biology that will enhance the selectivity of cell kill by radiation, thus improving the therapeutic index. For health planners, international organizations or non-governmental organizations (NGOs) engaged in technical cooperation to strengthen radiotherapy services across the world, it is important to scan the scientific horizon and identify developments and trends that may impact radiation oncology in the future and be ready for them.

[en] This chapter provides a justification for more research in radiation oncology, identifies essential aspects of good research, and promotes a strategy for more rapidly improving research capacity and evidence based practice.

[en] The availability of trained staff in adequate numbers is one of the main obstacles to the development of modern radiotherapy in developing countries. While radiation oncologists practising in affluent environments may not be aware of this reality, limited number of positions, low wages, limited access to sources of evidence and ‘brain drain’ are common in countries with limited resources. Epidemiological predictions of an increase in the crude incidence of cancer that will affect predominantly developing countries represent an alarming situation in which the countries that will face the steepest increase are those most poorly prepared to cope with it. Modern cancer radiotherapy is characterized by team work in which different professionals have different roles and responsibilities. The radiation oncologist is the physician who has been trained to participate in diagnosis, staging, prescription of the radiotherapy dose and patient follow-up.

[en] The supply of radiotherapy infrastructure and staff does not meet the estimated needs in all of the North African countries even if there is a discernible trend towards better coverage when compared with the situation reported in 1999 by Levin et al., or that reported by Barton et al. in 2006. To improve radiotherapy availability and to facilitate access to one of the most cost effective forms of cancer treatment, it is mandatory to plan ahead for the development of radiotherapy services, and to invest in equipment, education, and awareness of the public and decision makers about the role of radiotherapy in cancer treatment.

[en] Mauritania, a country of 3.4 million people, did not have any radiotherapy facility until 2009. As is usually the case in countries without radiotherapy services, cancer patients with a need for this treatment travelled to neighbouring countries (Morocco or Tunisia) or to Europe to receive it, or switched to alternative forms of care. Cancer is a rising cause of death in Mauritania. According to WHO estimates, about 2200 people died of cancer in 2011, of whom 1400 were aged below 70 years of age. The number of patients sent abroad for treatment by the National Health Insurance Fund rose to 500 patients in 2007, causing a significant drain on the State budget. Cancer was the main cause of health related travel abroad. The average cost of such travel was two million ouguiya per patient (US $8000). Through a technical cooperation project initiated in 2009 between the Mauritanian Government and the IAEA, the latter assisted the country with the establishment and operation of its first radiotherapy facility. The National Oncology Centre, including a radiotherapy department, was built in Nouakchott in 2010 and began operation in early 2011 with a limited staff, all hired from abroad. Its equipment includes a modern medical linac with a multileaf collimator and portal imaging, a CT simulator, a 3-D CRT TPS and a remote afterloading HDR brachytherapy system. The centre was planned with an additional bunker, where a second accelerator can be installed in the future. Except for the training of the Department Head, the entire professional team has been trained through the IAEA’s technical cooperation fellowship programme. The centre treated a total of 250 patients in 2012 and treated 176 in the first half of 2013. Most patients undergo simulation and computerized radiotherapy treatment planning. The centre ensures the sustainability of the equipment through full maintenance contracts for the major radiation equipment and source replacements for the HDR brachytherapy unit.

[en] El Salvador, like other Central American countries, has among the highest incidences of cervical cancer in the world, with 18.7 cases per 100 000 population in 2008 (age standardized rate: 37.2). The Cancer Institute of El Salvador ‘Dr. Narciso Díaz Bazán’ is a private centre for public service financed by the Liga Nacional Contra el Cáncer de El Salvador, a non-profit foundation. The mission of the Institute is to provide radiotherapy services to 80% of the population of El Salvador, while the other 20% should be covered by the social security system, which has another treatment centre. Since this project was finalized, two new private radiotherapy centres have opened their doors in the city of San Salvador, providing modern external beam radiotherapy but not brachytherapy.

[en] Each year, hundreds of cancer patients in Bulgaria receive bone marrow transplants as treatment for haematological malignancies such as leukaemia, lymphoma and multiple myeloma, or for solid tumours such as neuroblastoma, one of the more common cancers in infancy. To undergo a bone marrow transplant, patients must first go through a preparatory process that conditions the body for the transplant. This involves a special radiotherapy technique called total body irradiation (TBI). TBI helps to make space for the transplanted marrow, destroys any malignant cells that may be left in the bone marrow after chemotherapy and suppresses the immune system to help prevent rejection of the transplant. To avoid complications, patients must also receive irradiated cellular blood components during the preparatory process. The IAEA assisted medical professionals in Bulgaria in optimizing bone marrow transplants by providing the equipment and building the capabilities necessary to carry out TBI. The IAEA also offered very specialized radiotherapy training to the medical staff, including blood irradiation.

[en] Over the past 30 years, computed tomography and magnetic resonance imaging have made possible the three dimensional (3-D) visualization of gross tumour volume as well as organs at risk, enabling 3-D treatment planning and conformal therapy techniques. These techniques form the backbone of a large number of prospective, randomized clinical trials exploring radiation dose escalation, altered fractionation (in particular hypofractionation) and/or the addition of a variety of systemic agents. These trials constitute the basis of much of the contemporary practice of evidence based radiation oncology even today. Some illustrative examples are summarized below. More recently, for many kinds of cancers the use of FDG-PET (fluorine-18 fluorodeoxyglucose positron emission tomography) for staging has improved patient selection by identifying patients with distant metastases for whom ‘curative’ radiotherapy would be futile. During the past decade, intensity modulated radiation therapy (IMRT), stereotactic radiotherapy, proton radiotherapy and carbon ion radiotherapy have attracted a great deal of publicity and resources, but their evidence base remains weak at present. They have not been proven to prolong the survival of cancer patients over standard 3-D conformal techniques. Furthermore, implementing adequate quality assurance measures for these techniques has proven difficult not only in less developed countries, but even in some more developed countries such as the United States of America. This chapter describes selected radiation oncology studies that have had a significant impact in the routine treatment of common adult cancers with radiotherapy. The authors have selected studies which in their opinion have changed or have the potential to change the practice of radiation oncology and improve the outcomes for cancer patients, both for cure and for effective palliation.