Leveling Up the Access to Radiation Therapy in Latin America: Economic Analysis of Investment, Equity, and Inclusion Opportunities Up to 2030.

PURPOSE: Latin America faces a shortage in radiation therapy (RT) units and qualified personnel for timely and high-quality treatment of patients with cancer. Investing in equitable and inclusive access to RT over the next decade would prevent thousands of deaths. Measuring the investment gap and payoff is necessary for stakeholder discussions and capacity planning efforts. METHODS AND MATERIALS: Data were collected from the International Atomic Energy Agency's Directory of Radiotherapy Centers, industry stakeholders, and individual surveys sent to national scientific societies. Nationwide data on available devices and personnel were compiled. The 10 most common cancers in 2020 with RT indication and their respective incidence rates were considered for gap calculations. The gross 2-year financial return on investment was calculated based on an average monthly salary across Latin America. A 10-year cost projection was calculated according to the estimated population dynamics for the period until 2030. RESULTS: Eleven countries were included in the study, accounting for 557,213,447 people in 2020 and 561 RT facilities. Approximately 1,065,684 new cancer cases were diagnosed, and a mean density of 768,469 (standard deviation ±392,778) people per available unit was found. By projecting the currently available treatment fractions to determine those required in 2030, it was found that 62.3% and 130.8% increases in external beam RT and brachytherapy units are needed from the baseline, respectively. An overall regional investment of approximately United States (US) $349,650,480 in 2020 would have covered the existing demand. An investment of US $872,889,949 will be necessary by 2030, with the expectation of a 2-year posttreatment gross return on investment of more than US $2.1 billion from patients treated in 2030 only. CONCLUSIONS: Investment in RT services is lagging in Latin America in terms of the population's needs. An accelerated outlay could save additional lives during the next decade, create a self-sustaining system, and reduce region-wide inequities in cancer care access. Cash flow analyses are warranted to tailor precise national-level intervention strategies.

Longitudinal Remote SBRT/SRS Training in Latin America: A Prospective Cohort Study.

Background: Continuing medical education in stereotactic technology are scarcely accessible in developing countries. We report the results of upscaling a longitudinal telehealth training course on stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS), after successfully developing a pilot course in Latin America. Methods: Longitudinal training on SBRT and SRS was provided to radiation oncology practitioners in Peru and Colombia at no cost. The program included sixteen weekly 1-hour live conferencing sessions with interactive didactics and a cloud-based platform for case-based learning. Participant-reported confidence was measured in 16 SBRT/SRS practical domains, based on a 1-to-5 Likert scale. Pre- and post-curriculum exams were required for participation credit. Knowledge-baseline, pre- and post-curriculum surveys, overall and single professional-group confidence changes, and exam results were assessed. Results: One hundred and seventy-three radiotherapy professionals participated. An average of 56 (SD ±18) attendees per session were registered. Fifty (29.7%) participants completed the pre- and post-curriculum surveys, of which 30% were radiation oncologists (RO), 26% radiation therapists (RTT), 20% residents, 18% medical physicists and 6% neurosurgeons. Significant improvements were found across all 16 domains with overall mean +0.55 (SD ±0.17, p<0.001) Likert-scale points. Significant improvements in individual competences were most common among medical physicists, RTT and residents. Pre- and post-curriculum exams yielded a mean 16.15/30 (53.8 ± 20.3%) and 23.6/30 (78.7 ± 19.3%) correct answers (p<0.001). Conclusion: Longitudinal telehealth training is an effective method for improving confidence and knowledge on SBRT/SRS amongst professionals. Remote continuing medical education should be widely adopted in lower-middle income countries.

Long-Term Outcomes of an International Cooperative Study of Intraoperative Radiotherapy Upfront Boost With Low Energy X-Rays in Breast Cancer.

Purpose: The purpose of this study was to assess the effectivity of upfront kilovoltage intraoperative radiotherapy (IORT) as a boost in high-risk early-stage breast cancer patients from an international pooled cohort. Materials/Methods: Patients from four centers in three different countries were retrospectively screened. Those with a minimum 1-year follow-up were included. Cumulative local (LR), regional (RR), and distant metastasis rates (DM) were analyzed. Additionally, the estimated overall survival (OS) was assessed. The Cox regression analysis was performed to identify failure predicting factors. Results: A total of 653 patients from centers in Peru, Spain, and Germany were included. The median follow-up was 55 (12-180) months, and age was 58 (27-86) years. Clinical tumor (T) staging was T1 65.85%, T2 30.17%, and T3 3.98%. Positive margins were found in 7.9% and in-situ component in 20.06%. The median IORT dose was 20 (6-20). The median time from IORT to EBRT was 74.5 (13-364) days. An overall 3.4% (n = 22) of patients developed local recurrence at some point during follow-up. The 12-, 60-, and 120-month cumulative LR were 0.3%, 2.3%, and 7.9%, respectively. After multivariate analysis, only age <50 remained to be a significant prognostic factor for local recurrence (HR 0.19, 95% CI 0.08-0.47; p < 0.05). The 10-year estimated OS was 81.2%. Conclusion: Upfront boost with IORT yields similar local control outcomes to those EBRT-based reports. Results from prospective trials, regarding toxicity, cosmesis, and effectivity are awaited to confirm these findings.

Single-Fraction Adjuvant Electronic Brachytherapy after Resection of Conjunctival Carcinoma.

A retrospective study was performed to assess the outcomes of a single-fraction adjuvant electronic brachytherapy (e-BT) approach for patients with squamous cell conjunctival carcinoma (SCCC). Forty-seven patients with T1-T3 SCCC were included. All patients underwent surgery followed by a single-fraction adjuvant e-BT with a porTable 50-kV device. Depending on margins, e-BT doses ranged between 18 to 22 Gy prescribed at 2 mm depth, resembling equivalent doses in 2 Gy (EQD2) per fraction of 46-66 Gy (α/ß ratio of 8-10 Gy and a relative biological effect (RBE) of 1.3). The median age was 69 (29-87) years. Most tumors were T1 (40.4%) or T2 (57.5%) with a median size of 7 mm (1.5-20). Margins were positive in 40.4% of cases. The median time from surgery to e-BT was nine weeks (0-37). After a median follow-up of 24 (17-40) months, recurrence occurred in only two patients (6 and 7 months after e-BT), yielding a median disease-free survival (DFS) of 24 (6-40) months and DFS at two years of 95.7%. Acute grade 2 conjunctivitis occurred in 25.5%. E-BT is a safe and effective for SCCC treatment, with clinical and logistic advantages compared to classical methods. Longer follow-up and prospective assessment are warranted.

COVID's Impact on Radiation Oncology: A Latin American Survey Study.

PURPOSE: The impact of the COVID-19 pandemic on Latin American radiation therapy services has not yet been widely assessed. In comparison to centers in Europe or the United States, the scarcity of data on these terms might impair design of adequate measures to ameliorate the pandemic's potential damage. The first survey-based analysis revealing regional information is herein presented. METHODS AND MATERIALS: From May 6 to May 30, 2020, the American Society for Radiation Oncology's COVID-19 Survey was distributed across Latin America with support of the local national radiation therapy societies. Twenty-six items, including facility demographic and financial characteristics, personnel and patient features, current and expected impact of the pandemic, and research perspectives, were included in the questionnaire. RESULTS: Complete responses were obtained from 115 (50%) of 229 practices across 15 countries. Only 2.6% of centers closed during the pandemic. A median of 4 radiation oncologists (1-27) and 9 (1-100) radiation therapists were reported per center. The median number of new patients treated in 2019 was 600 (24-6200). A median 8% (1%-90%) decrease in patient volume was reported, with a median of 53 patients (1-490) remaining under treatment. Estimated revenue reduction was 20% or more in 53% of cases. Shortage of personal protective equipment was reported in 51.3% of centers, and 27% reported personnel shortage due to COVID-19. Reported delays in treatment for low-risk entities included early stage breast cancer (42.6%), low-risk status prostate cancer (67%), and nonmalignant conditions (42.6%). Treatment of COVID-19 patients at designated treatment times and differentiated bunkers were reported in 22.6% and 10.4% of centers, respectively. Telehealth initiatives have been started in 64.3% of facilities to date for on-treatment (29.6%) and posttreatment (34.8%) patients. CONCLUSIONS: Regional information regarding COVID-19 pandemic in Latin America may help elucidate suitable intervention strategies for personnel and patients. Follow-up surveys will be performed to provide dynamic monitoring the pandemic's impact on radiation therapy services and adoption of ameliorating measures.

Low-dose radiotherapy for COVID-19 pneumonia treatment: case report, procedure, and literature review.

BACKGROUND: The COVID-19 pandemic outbreak has set the emergency services in developing countries on major alert, as the installed response capacities are easily overwhelmed by the constantly increasing high demand. The deficit of intensive care unit beds and ventilators in countries like Peru is forcing practitioners to seek preventive or early interventional strategies to prevent saturating these chronically neglected facilities. CASE PRESENTATION: A 64-year-old patient is reported after presenting with COVID-19 pneumonia and rapidly progressing to deteriorated ventilatory function. Compassionate treatment with a single 1­Gy dose to the bilateral whole-lung volume was administered, with gradual daily improvement of ventilatory function and decrease in serum inflammatory markers and oxygen support needs, including intubation. No treatment-related toxicity developed. Procedures of transport, disinfection, and treatment planning and delivery are described. CONCLUSION: Whole-lung low-dose radiotherapy seems to be a promising approach for avoiding or delaying invasive respiratory support. Delivered low doses are far from meeting toxicity ranges. On-going prospective trials will elucidate the effectiveness of this approach.

Impact of a SBRT/SRS longitudinal telehealth training pilot course in Latin America.

PURPOSE: To assess the impact of longitudinal telehealth training in stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) for clinicians in Latin America. MATERIALS AND METHODS: Professionals from two Peruvian centers received an initial SBRT/SRS on-site training course and subsequently received follow-up telehealth training (interventional group) or not (negative control arm). Twelve live video conference sessions were scheduled. Surveys pre- and post-curriculum measured participants' confidence in seven practical domains of SBRT/SRS, based on Likert scales of 1-5, and post-curriculum surveys assessed educators' experiences. RESULTS: Sixty-one participants were registered, with an average of 24 attendees per session. Pre- and post- surveys were completed by 22 participants. For interventional and negative-control groups, mean changes in Likert scale were satisfactory for the former and remained unmodified for the latter. CONCLUSIONS: Conducting telehealth educational programs via virtual classroom sessions could be a reliable method to augment training for SBRT and SRS.

Single-fraction low-energy electronic brachytherapy for conjunctival lymphoma.

PURPOSE: Conjunctival lymphoma represents an uncommon tumor, accounting for 5-10% of total extranodal lymphomas. Although radiotherapy is a frequent treatment option, limited capacities and lack of specialized centers are common problems in Peru, forcing radiation oncologists to apply short courses of radiotherapy. Here, we report a case series of patients treated with a novel single-shot scheme. Additionally, we present a literature review of the current short-course irradiation strategies. CASES PRESENTATION: Three cases of conjunctival marginal zone (B-cell) lymphoma (marginal zone lymphoma [MZL]/mucosa-associated lymphoid tissue [MALT]) of the fornix are presented. Following biopsy and sonographic assessment of the lesion thickness, we applied a focused single dose of 14 Gy kilovoltage brachytherapy (prescribed to the maximum thickness of the lesion). Follow-up was scheduled in quarterly intervals. After 28, 31, and 40 months of follow-up, none of the three patients treated exhibited acute or chronic toxicities and remained local or distant disease-free. CONCLUSIONS: Single dose kilovoltage brachytherapy was effective and safe in this small cohort of patients. Based on the literature, there is an evidence that local treatment in short-course radiotherapy is effective and should be considered amongst therapeutic options for these patients; however, this novel approach should be evaluated prospectively in a larger cohort.

Intraoperative radiotherapy for glioblastoma: an international pooled analysis.

PURPOSE: To report the results of the first international pooled analysis of patients with glioblastoma treated with intraoperative radiotherapy (IORT) in addition to standard of care therapy. METHODS: Data from 51 patients treated at five centers in Germany, China and Peru were analyzed. All patients underwent tumor resection followed by a single application of IORT (10-40 Gy, prescribed to the applicator surface) with low-energy X-rays. Thereafter, standard adjuvant radiochemotherapy and maintenance chemotherapy were applied. Factors of interest were overall survival (OS), progression-free survival (PFS), local PFS (L-PFS; defined as appearance of new lesions ≤1 cm to the cavity border) and distant PFS (D-PFS; lesions >1 cm). The same endpoints were estimated at 1-, 2- and 3-years using the Kaplan-Meier method. Additionally, rates and severity (as per Common Terminology Criteria for Adverse Events Version 5.0) of radionecrosis (RN) were analyzed. RESULTS: The median age was 55 years (range: 16-75) and the median Karnofsky Performance Status was 80 (20-100). At a median follow-up of 18.0 months (2-42.4), the median OS, PFS, L-PFS and D-PFS were 18.0 months (95% CI: 14.7-21.3), 11.4 months (95%CI: 7.58-15.22), 16 months (95%CI: 10.21-21.8) and 30.0 months (95%CI: 18.59 - 41.41), respectively. The estimated 1-, 2- and 3-year OS, PFS, L-PFS and D-PFS were 79.5%, 38.7% and 25.6%; 46.2%, 29.4%, and 5.9%; 60.9, 37.9%, and 12.6%; and 76.7%, 65.0%, and 39.0% respectively. First progression occurred locally in only 35.3% of cases. Grade 1 RN was detected in 7.8% and grade 3 in 17.6% of the patients. No grade 4 toxicity was reported and no treatment-related deaths occurred. CONCLUSION: Compared to historical data, this pooled analysis suggests improved efficacy and safety of IORT with low-energy X-rays for newly diagnosed glioblastoma. Prospective data is warranted to confirm these findings.

Phase I/II study on kilovoltage surface brachytherapy in conjunctival cancer: preliminary results.

INTRODUCTION: In ocular conjunctival carcinoma after surgery, adjuvant treatment has a role and kilovoltage surface brachytherapy opens a new door for the range of therapeutic options. MATERIALS AND METHODS: Between October 2014 and June 2017, at the National Institute of Neoplastic Diseases (INEN) from Peru, 39 patients with squamous cell carcinoma of ocular conjunctiva, T1-T3, resected, were selected to receive adjuvant treatment. The portable accelerator of 50-kV INTRABEAM (Carl Zeiss Meditec) was used, after local anaesthesia and blocking of ocular muscles movement. The doses used were 18 Gy for patients with free margins and 22 Gy for positive edges, according to calculation of equivalent dose of 2Gy per fraction of 46 and 66 Gy, respectively, assuming a tumoural α/ß ratio of 8 Gy. The prescription was done to 2 mm depth. RESULTS: The median age was 69 years, distributed evenly between both genders, with a median follow-up of 12 months. The surgical margins were 59% free and 41% committed, with no difference between the institutions where the surgery was performed (P = 0.069). The median tumour size was 7 mm with 2 mm of invasion, 61.5% was T2 and 35.9% T1. The mean time between surgery and irradiation was 1.5 months, 23.1% of patients developed grade I toxicity of spontaneous resolution, without evidence of greater degree in any case. The dose had no statistical relationship with toxicity (P = 0.533). One-year disease-free survival was 96.7%. CONCLUSIONS: Kilovoltage surface brachytherapy is an applicable and reproducible tool in the treatment of squamous cell carcinoma of ocular conjunctiva. The administered doses are well tolerated by patients with low levels of acute toxicity. Longer follow-up is needed to establish disease control rates and late toxicities.