Radiotherapy in India

History, current scenario and proposed solutions

Abstract

The history and current status of a biomedical discipline in a country or region provide important health system indicators. During the last one hundred years, radiotherapy has established its position as a vital specialty in cancer management. It has proved to be one of the most cost effective ways of treating cancer providing both radical and palliative treatments depending on patient stage and performance status. However, access to radiotherapy for cancer patients in India is limited by several factors including physical proximity of centre, cost and availability of required technology. This article gives an outline of the history, existing radiotherapy facilities and future trends related to radiotherapy practice in India.

Introduction

Radiotherapy is an essential component in the management of cancer patients and is used either alone or in combination with surgery or chemotherapy. It is used both for curative as well as palliative goals. Modern day cancer care increasingly needs a joint multimodality approach.[¹] Of those cancer patients who are cured, it is estimated that approximately 50% are cured by surgery, about 40% by radiotherapy alone (or combined with other surgery/chemotherapy), and 10% by chemotherapy alone or combined with (radiotherapy/surgery).[²] In developed countries, the radiotherapy utilisation rate (RTU, the proportion of cancer patients requiring at least one treatment course of radiotherapy during the evolution of their disease) is approximately 50%. However, in developing countries such as India, it is widely believed that the optimal RTU rate is higher (i.e., >55%) and that it may reach 70%–80% in some situations.[³] However, paradoxically, the actual figures for middle and low income countries (LMICs) are low (nearly 25%), primarily because of unavailability and inaccessibility of radiotherapy machines.[⁴] Availability of quality and affordable radiotherapy services is therefore a critical requirement for the fight against cancer in countries such as India.[⁵⁶]

Population Profile of India and Cancer Statistics

As per Census 2011 (the latest census in India), the total population of India at 00.00 hours of 1 March 2011 was 1.2 billion.[⁷] Of this, rural population was 0.8 billion, whereas the urban population stood at 0.37 billion. The state of Uttar Pradesh had the largest rural population of 155.3 million (18.6% of the country's rural population), whereas Maharashtra had the highest urban population of 50.8 million (13.5% of country's urban population) in the country. As per current information available online, the current population is 1.34 billion. More than 50% of that population is below the age of 25 years. About 65% is below the age of 35 years. The rural population is 72.2% (0.97 billion) while the urban population is 27.8% (0.37 billion).[⁷]

India has a relatively young cancer population. It witnesses approximately 1,200,000 new cases every year, 2,500,000 prevalent cases, with 550,000 cancer deaths/year. Nearly two-third of cancer patients need radiotherapy (RT) translating into 8,00,000 patients per year in India. In age-adjusted terms, the recorded incidence of cancer in India is at 94 per 100,000 people.[⁸] The most common sites of cancer in men are the oral cavity, lung, oesophagus, and stomach. In women, the most frequent cancers are cervical, breast, and oral cavity cancers. In urban registries (with the exception of Chennai), breast cancer is the most common type of cancer among women.[⁹] By 2020, annual cancer cases in LMICs are expected to rise by 30% to 10.3 million, [Advisory Group on increasing access to Radiotherapy (AGART)]. Radiotherapy programmes, including training courses offered by the International Atomic Energy Agency (IAEA), are therefore essential for capacity building in cancer treatment.[⁴]

Radiotherapy in India – Historical aspects

The first Department of Radiotherapy in India was opened on January 25, 1910 by the Countess of Minto at the Calcutta Medical College Hospital.[¹⁰] The earliest cases were treated with deep X-ray and radium. The use of X-rays in the treatment of various diseases including cancer started in the 1920s. The exact history of radium in India is not well known, but there are publications confirming that patients were treated in Kolkata with deep X-ray and radium brachytherapy by 1926.[¹¹] There was establishment of at least four radium institutes in the four corners of the country as early as the beginning of the 1940s. These included the Radium Institute in Patna, Radium Institute in Agra, Barnard Institute of Radiology in Madras and the Medical College of Lahore (now in Pakistan). The bulk stock of radium arrived at Ranchi (Bihar) and was then transported to the Radium Institute, Patna for clinical use in 1930. Over the years, 65 Indian hospitals had about 20 gof radium in total, contained in the form of a fine powder in hundreds of thin platinum-iridium tubes and needles.[¹²] By the year 1941, Dr Ramaiah Naidu, a former associate of Madame Curie, had established the first radon plant of India at the Tata Memorial Hospital (TMH).[¹³]

The first cobalt-60 teletherapy unit (Eldorado A) was commissioned at the Cancer Institute, Madras in 1956. One of the first isotope teletherapy units was a Theratron Junior installed in the TMH, Bombay, in 1958. By 1965, 19 institutions possessed either cobalt or caesium teletherapy units. The ever increasing workload forced the TMH to acquire their third cobalt unit that had two heads. The unit called Janus (named after a Roman mythological God) was installed in two adjacent treatment rooms each equipped with one head. The source can be remotely moved from one head to other head. While one patient was being treated in one treatment room, in the other room one could set up the next patient thus saving valuable time and increasing throughput. By 1978, 57 departments had telegamma units and another 6 centres awaited their first cobalt machines representing a total of 63 departments in all.[¹²] Cancer Institute, Madras had the country's first telecaesium unit in collaboration with Atomic Energy Establishment, Trombay (AEET) in 1962. The first linear accelerator in the country, a Clinac-4 machine with 80 cm source-to-axis distance, was installed at the Cancer Institute, Madras in 1976. Soon after, India had its only Betatron in the year 1978 when the Christian Medical College, Vellore, installed the high-energy particle accelerator. The first indigenously developed linear accelerator, called Jeevan-Jyoti, was installed at Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh (developed jointly by Society for Applied Microwave Electronics Engineering and Research, Bombay and Council of Scientific and Industrial Research – Central Scientific Instruments Organisation [CSIR-CSIO]) in March 1990.[¹⁴] Six machines were originally planned to be commissioned in six cancer hospitals in the country. Two machines, namely, SIDDHARTH I and SIDDHARTH II, were developed and deployed at MGIMS, Sevagram, Wardha (Maharashtra) and at Cancer Institute Chennai. Four more machines, namely SIDDHARTH IIIVI, are under way and are likely to be commissioned in four national cancer institutes in next 1-2 years.[¹⁴]

Supervoltage radiotherapy was started in India with the installation of ^6oCo units in various centres. The input was mainly from the establishment of cobalt units under the Colombo Plan, when almost 15 units were especially donated for the development of supervoltage radiotherapy.[¹⁵] Recently, the development of indigenous cobalt machine (Bhabhatron I and II) and linear accelerator (Siddharth) have given a boost to emergence of low cost alternatives for radiation therapy. The third Siddharth was installed at ILHNO Cancer centre, Indore. Bhabhatron, the indigenous telecobalt machine, is one of the successful products developed by Bhabha Atomic Research Centre, Mumbai for cancer treatment.[¹⁵¹⁶¹⁷]

India's brachytherapy history stretches back nearly nine decades when radium brachytherapy started in mid-1920s. The use of radium continued for more than six decades when the Bhabha Atomic Research Centre (BARC), Bombay, called back all the radium sources. Much before that, several hospitals acquired Cs-137 sources for manual afterloading brachytherapy. BARC also developed its own manual after-loading Cs-137 kit for gynecological cancers. The 1980s saw the emergence of remote afterloading brachytherapy units in India. India had installation base of almost all models like Selectron (LDR) using Cs-137 pellets, Selectron (HDR) using Co-60 pellets, Curietron (LDR and HDR) using Cs-137 sources, Buchler unit with an oscillating Cs-137 source, micro-Selectron (LDR, PDR and HDR) using Ir-192 miniature source, Ralston (HDR) using Co-60 source, GammaMed and GammaMed Plus models (HDR, Ir-192), Vari Source models (HDR, Ir-192) and Flexitron (LDR, Ir-192) models. In 1990s manual afterloading with Ir-192 wire sources was also prevalent in several centres. During the same period, remote afterloading intravascular brachytherapy systems were also available albeit for a very brief period in very few institutions.

Present radiotherapy infrastructure in India

The radiotherapy centres in India have either teletherapy facilities alone or both teletherapy and brachytherapy facilities [Table 1]. The Directory of Radiotherapy Centers (DIRAC) 2012 of IAEA has included India along with the poorest sub-Saharan African countries with less than one radiotherapy machine per million people.[¹⁸¹⁹] Globally, India has the largest number of people living below the World Bank's poverty line of US$ 1.25 per day.[²⁰] Currently India has approximately 545 teletherapy machines (180 telecobalt units and 365 medical accelerators), 22 advanced therapy machines (7 Gamma knife units, 8 Tomotherapy machines, 7 Cyber-knife machines and 2 intra-operative radiotherapy machines). The number of remote afterloading brachytherapy units is estimated at around 250 [Table 2].

Table 1: Distribution of radiotherapy machines across geographical regions

Table 2: Brachytherapy facilities

Across the world, according to the PTCOG data (Particle Therapy Co-Operative Group), 57 proton accelerators are being used for the treatment of diseases across the world. Most of them work in the USA (19), Japan (12) and Germany (6). Another 37 centers with a period of commissioning in 2017-2021 are under construction. The latest addition to radiotherapy advancement is the installation of proton therapy unit at Apollo Chennai. Other upcoming proton installations include TMH and National Cancer Institute in Delhi NCR.

RCC's in India

Under the National Cancer Control Programme, launched in 1975-1976, Regional Cancer Centres (RCC) are cancer hospitals established for cancer care and research under the joint control of union and state governments. These RCCs are designated to manage the cancer patients within a defined region of India, develop education, training and research activities, and provide palliative care as a continuum of treatment to the relief of patients and family caregivers. Currently, 27 RCCs are recognised under this scheme, which receive funding and grants from the governments. The oldest cancer hospitals which have pioneered the cancer care in India, namely the TMH, Mumbai; Cancer Institute, Chennai; Gujarat Cancer Research Institute, Ahmedabad; Chittaranjan National Cancer Institute, Kolkata; Regional Cancer Centre, Thiruvananthapuram; Kidwai Memorial Institute of Oncology, Bengaluru; Institute Rotary Cancer Hospital, AIIMS, Delhi were established between 1940s and 1980s. A new initiative under the Tata Trusts is the National Cancer Grid. It has been created to form a union of cancer centres, with research and advocacy groups to formulate uniformity across the spectrum of cancer prevention, diagnosis, and treatment.

Per capita Radiotherapy statistics in India

Most high income countries have at least one radiotherapy unit available for every 250,000 people.[⁴] This, on an average, would mean four radiotherapy machines per million population. Applying this factor to India would translate into a total requirement of 5000 radiation therapy units in India, as of now [Table 3]. Based on the number of existing installed units in India, this still would mean a shortfall of >4500 machines. The World Health Organization (WHO) recommends at least 1 teletherapy unit per million populations. Even with this recommendation, the minimum required number of teletherapy units is around 1250 as against the presently available 545 units making a huge shortfall of nearly 700 units.

Table 3: Required, available and shortfall of resources in India

Every year about 40 units are added and 15 units decommissioned which makes the number of new units effectively added at 25. These 25 new units are insufficient to take care of India's annual population growth which is pegged at 25 million per year. Table 3 gives information about the shortfall of other radiotherapy equipment such as simulators, treatment planning systems and brachytherapy units in India.

Proposed solutions

1. Waiving of customs duty for linear accelerators and remote afterloading brachytherapy systems
Installation of radiotherapy equipment can be expensive with equipment cost ranging from US $4-10 million, and building costs for a radiotherapy treatment room ranging from US $400,000 to US $1 million.[²¹] In addition to these costs there are recurrent costs, related auxiliary costs for source replacement (for (60) Co units or brachytherapy afterloaders) and QA procedures. Yet, despite these expenses, the administration of radiotherapy, when evaluated per fraction throughout the lifetime of a machine, is actually a relatively cost-effective procedure. The customs duty for linear accelerators in India is currently around 20% which is a major deterrent for investors to setup new radiotherapy centres and add machines in existing ones. Reducing this duty shall reduce the gap between the minimum required units and the available units. One of the reasons cited for the high customs duty is the support for the indigenous manufacturing of linacs. While it is true that indigenous technology needs to be encouraged, one has to make a balanced comparison between the indigenous technology and the global technology that modern radiation oncology thrives on. The local manufacturing industry is in the budding state offering only low-energy linacs with very limited features. It lacks important requirements like intensity modulated radiotherapy (IMRT), image guidance, multiple electron energies, stereotactic treatment capability and many more. Hence, the parallel drawn between the indigenous technology and the globally available technology becomes untenable and has to be done away with. Cancer treatment in India is already unaffordable to a large section of the society and the high customs duty on such lifesaving equipment affects not only patient's affordability but also results in widening the gap between required and available resources. The revenue impact to the Government would be minimal since the number of linacs installed per year in the country is only around 25-40.

2. Public-Private Partnerships (PPP)
There has been a surge of corporate and private sector hospitals in India over the past decade. Such hospitals often have radiotherapy package costs which are out of reach for the lower middle and the poor. A financial model in which poorer sections of the society can be treated at lower cost after regular treatment hours of the radiotherapy machine in corporate hospitals can be a mutually beneficial PPP.
The following is an example to show how many extra patients can be treated if private centres allow extra 2 hours of use in each of their machines in India. Assuming about 300 machines are in the private sector and a time slot of 2 hours is made available for the treatment of economically weaker patients in each of these machines, 600,000 treatment sessions can be realised annually through such a collaboration (50 weeks/year × 5 days/week × 2 hours/day × 4 sessions/hr/machine × 300 machines = 600,000 treatment sessions). This would roughly translate to the treatment of 30,000 patients each requiring on an average 20 sessions. The figures are equivalent to the annual workload of 50 private centres treating 600 patients in a year. The example shows that there is a huge potential lying to be tapped. For palliative hypofractionated radiotherapy patients, this number can easily show a 100% increase. In private/corporate hospital, utilisation of the lean periods of patient load during weekends (Saturday and Sunday) can benefit both the corporate as well as the patients with poorer financial status
Although conceptually easy to envisage, such a scheme requires tremendous coordination between the parties concerned and a mechanism for speedy redressal of issues that are bound to occur. The PPP model is definitely encouraging but there is likely to be some conflict of interest with hospital management.

3. Correcting the skewed spread and density of radiotherapy installations
It is well known that having a treatment centre close to the patient's home improves treatment compliance.[²²] Such phenomena are likely to be amplified in developing countries such as India. This underlines the need to have an oncology centre at a reasonable distance from the patients residence, besides having an even spread of centres. In India, there had been a steady linear increase in installation of cobalt units in India till 2005. However, beyond 2005, there has been a doubling of installation of linear accelerators every 5 years for the past decade.[¹⁰] It is also noteworthy that more than 80% of these installations have been done by private centers or groups and have been guided by commercial gains. Corresponding growth or modernisation in existing government installations has lagged behind. This has led to an asymmetric and skewed distribution of teletherapy installations in India in terms of area and as well as in terms of population [Table 1]. The southern region covering less than 20% of the total area with a population share of 21% accounts for 28% of the telecobalt units and 41% of the linacs. On the other hand, the eastern region having only 11% and 6% of the telecobalt units and linacs respectively, together serves 22.3% of the total population. In comparison, the northern and the western regions have a balanced distribution of these teletherapy units
However, there are aberrations even within a region. As an example the National Capital Region (Delhi and adjoining suburbs) which accounts for only 4% of the northern region's area and 10% of its population has about one-third of the total teletherapy units available in the region. We need governmental policies to regulate the setting up of new private and corporate centres and to provid incentives for setting up such centres in non-metropolitan areas
A technique such as 3D conformal radiotherapy would be an appropriate technique for most lung cancer patients in LMIC. This technique is easily possible on a linear accelerator and can be reasonably well performed on a cobalt unit as well. The suggested simulation technique would be CT-based simulation wherever possible, even using the existing hospital diagnostic CT with some modifications for the purpose. Patients for specialized techniques such as stereotactic body radiotherapy (SBRT) and IMRT need to be referred to higher centers with appropriate facilities [Table 4].




Table 4: Guidelines for radiotherapy treatment in LMIC such as India

4. Teaching programs in radiation oncology, medical physics and radiotherapy technology
India needs well-structured teaching programs with common academic syllabi in radiation oncology, medical physics and radiotherapy technology
The first medical degree in radiation oncology was instituted at the Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh and the first radiotherapy resident graduated from the (PGIMER), Chandigarh, in 1972. This provided a great momentum for attracting many candidates to come forward and take up radiotherapy as their career. It was also an important milestone in that several practicing radiotherapists joined together and formed the Association of Radiation Oncologists of India, whose membership was limited to those who were 100% engaged in radiotherapy practice. As of now, a total of 59 colleges in India are offering MD Radiotherapy programs.[²³] More than 2000 post MD radiation oncologists are currently practicing in the country. The critical issue is that the teaching standards across the country are not uniform; both in terms of the existing faculty as well as the available equipment, with the occasional tale of a student passing MD examination without having seen a functioning teletherapy machine.
The first medical physics teaching course was started in the University of Bombay at Bhabha Atomic Research Centre, Bombay in 1962. Later Anna University in Madras started a post-graduate course in 1981. Since then several courses have come up and as of today there are more than 17 courses producing about 170 trained students in this discipline every year. Starting 2013, AERB has made it mandatory for every medical physics student to undergo 1 year of internship following the medical physics graduation. As of now, there are 1150 physicists and about 600 radiation safety officers in India. There are currently 57 courses for radiotherapy technologists which are recognized by AERB, Mumbai. As of date there are 2200 certified radiation technologists in practice in India.

Summary

This article summarizes the existing radiotherapy scenario in India and the future trends. In spite of a huge population burden, India can overcome the problem. The solution to the problem lies in pragmatic use of existing resources and judicious location of new installations. Support coming from the government in the form of incentives for setting up centers in the rural regions should not only help in reducing the gap between the required and available machines, but also in overcoming the skewed distribution of available machines.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.