An analysis suggests large disparity in the availability and organisation of radiotherapy services between European countries

A recognised public health issue as the access to radiotherapy is an essential component of cancer care

Analysis of the radiotherapy facilities in 33 European countries has shown considerable disparity across the continent, with countries in Eastern and South-eastern Europe being largely underequipped compared with northern and western countries. It is a major public health issue as the access to radiotherapy is an essential component of cancer care and timely investment in the radiotherapy infrastructure is required to address the growing burden of cancer care.

Radiotherapy is an essential and very effective component of cancer care. Indeed, an estimated 45–55% of patients with cancer will require radiotherapy at some point during their course of disease, and up to 20% of these patients will require more than one course of treatment. In patients with cancer who are cured, about 40% of cures are achieved using radiotherapy, either alone or in combination with other treatment methods.

Although radiotherapy is a cost-effective treatment, it requires significant investments in infrastructure and personnel. Health-care costs have increased rapidly in many European countries in the past decade, while the average health spending per capita across Europe has stabilised or even fallen following the onset of the global financial crisis, especially in countries hardest hit.

Advanced regional or national planning based on expected needs is warranted to avoid overcapacity or shortages in the provision of radiotherapy services. In this context, a new report from Rosenblatt and colleagues, published recently in the Lancet Oncology, is of considerable interest. The researchers analysed the radiotherapy capacity of 33 European countries based on updated information from the Directory of Radiotherapy Centres (DIRAC) database. In the News and Views section of the April 2013 issue of Nature Reviews Clinical Oncology, Prof. Suresh Senan and Prof. Ben Slotman of the Department of Radiation Oncology, VU University Medical Centre, Amsterdam, The Netherlands discuss the findings from the DIRAC database analysis. 

A substantial disparity in the availability and organisation of radiotherapy services between European countries

The DIRAC project is managed by the International Atomic Energy Agency, and the authors used data updated between 2008 and 2012 to provide a more-extensive coverage than previous studies. The researchers used population data for 2012 from the European Commission (Eurostat), calculated the number of patients receiving external-beam radiotherapy per treatment machine, and correlated World Bank data on country-specific gross national income per head. This value was then compared with the country-specific number of patients with cancer who received radiotherapy in 2008. The benchmark defined in the European Society for Radiotherapy and Oncology (ESTRO) QUARTS project of 450 patients per machine per year was used to estimate whether the equipment would meet the demand for radiotherapy in each country.

The DIRAC analysis found that Nordic countries, Belgium, The Netherlands, and Switzerland were well-equipped with modern units, whereas most countries in Eastern and Southeastern Europe, including Bulgaria, Romania and Macedonia were largely underequipped and had a major shortfall in the provision of modern radiotherapy. In these countries, facilities were clearly inadequate; technically inferior cobalt-60 machines still represented a sizeable part of radiotherapy facilities and available teletherapy machines were often outdated.

In countries with a gross national income per head of ≥25,000 USD, between 400–450 patients were treated per machine per year, which met the ESTRO benchmark. In lower income countries, the number was much higher; in these countries between 800–1,200 patients were treated per machine per year. Important differences were also noted in the number of teletherapy machines per radiotherapy centre; in the Nordic countries, UK, The Netherlands, and Slovenia, all of whom had an infrastructure typified by a centralised mechanism for operating radiotherapy centres, the mean number of machines per centre was between 4 and 10, while the mean for all 33 analysed European countries was 2.5.

The DIRAC analysis does not address the quality of the infrastructure, quality assurance programmes, and the training and certification of personnel. Some limitations of the DIRAC analysis, such as the use of relatively crude benchmarks that do not take into account the differences in cancer epidemiology between countries, and the fact that the analysis is quantitative and not qualitative, have been highlighted in the original paper, but other assumptions that the authors make also might not hold true, commented Professors Senan and Slotman in their news article. The statement that a 2-Linac unit is suboptimal for ensuring delivery of high-level care is not justified, especially if the centre is a small centre embedded in a larger 'mother' institute and has the same quality assurance programmes in place and a sufficient number of radiation oncologists on site to cover all expertise areas. In addition, professors Senan and Slotman wrote that a review of the DIRAC website suggests some discrepancies in information contained about centres in The Netherlands and suggested that independent validation by national associations or regulatory bodies is necessary to confirm the conclusions from this report.

Data from the DIRAC database and QUARTS project only represent 'snapshot' views of radiotherapy practice in Europe—a complete picture of radiotherapy practice in different European countries is still needed. The use of population studies to assess how the introduction of new radiotherapy techniques affects patient care is reflected in the growing awareness by the radiation oncology community for the need to generate objective efficacy data in an era of expanding health-care costs. A key development has been the ESTRO–HERO (Health Economics in Radiation Oncology) project, which aims to develop a knowledge base and model for health-economic evaluation of radiation treatments at the European level.

The authors of the news declared that have received travel support and speakers honoraria from Varian Medical Systems. Their department has received research support from Varian Medical Systems and BrainLab AG.

The full news you can read in the ESMO Scientific Journal Access programme