Journal of Cancer Research and Therapeutics Medknow Publications on behalf of the Association of Radiation Oncologists of India (AROI) ISSN: 0973-1482 EISSN: 1998-4138 Vol. 1, Num. 1, 2005, pp. 9-11

Journal of Cancer Research and Therapeutics, Vol. 1, No. 1, January-March, 2005, pp. 9-11

Special Article

A view from far - Letter from Europe

Yarnold John

Professor pf Clinical Oncology, Royal Marsden Hospital, Sutton, Surrey

Correspondence Address:Professor pf Clinical Oncology, Royal Marsden Hospital, Sutton, Surrey

Code Number: cr05004

I enjoyed the enormous privilege and pleasure of a year′s sojourn in India back in 1977/78, courtesy of generous hospitality offered to me by colleagues at radiotherapy centres across India plus a grant from Middlesex Hospital, London and Caius and Gonville College, Cambridge. I am looking at a dusty volume written in 1978 entitled ′Radiotherapy and Cancer Control in India′. The contrast between 1977 and 2005 is so strong that extracts may be of interest to historians of such things. These are offered with apologies for errors in fact or interpretation.

Teletherapy facilities

One of the first isotope teletherapy units was a Theratron Junior installed in the Tata Memorial Hospital, Bombay, in 1958. By 1965, 19 institutions possessed either cobalt or caesium teletherapy units, and 10 years later this number had grown to 49 centres. By 1978, 57 departments had telegamma units and another 6 centres awaited their first cobalt machines representing a total of 63 departments in all. An inventory of teletherapy equipment in India at that time is shown below:

Of 44 stationary units, 10 used caesium sources and 34 used cobalt. Of the latter, 17 were Eldorado units (mainly gifted under the Colombo plan) and 17 were double-headed Janus units (manufactured in India) with fixed vertical beams. The majority of the 50 rotational units were Theratron 60′s or Gammatrons, although a new rotational cobalt unit was being manufactured by Elpro International at Pune. Most of the stationary units had been installed since 1970.

Brachytherapy Facilities

According to the Department of Radiological Protection, Bhabha Atomic Research Centre, Bombay, the brachytherapy facilities in India at the beginning of 1975 were as follows:

The total stock in curies (Ci) of brachytherapy sources in India at the beginning of 1975 was as follows: Radium 18 Ci, Cobalt 10 Ci + 20 Ci and Caesium 1.2 Ci. The 20 curies of cobalt listed apart relates to the Cathetron installed in Indore in 1973. A second Cathetron was commissioned at the Cancer Hospital and Radium Institute, Hyderabad, in 1978.

Population Coverage by Radiotherapy

Sixty-six radiotherapy departments with megavoltage equipment were located in 52 towns and cities. Ignoring the modest contribution of deep x-ray machines, a total of 96 teletherapy units served India′s needs, roughly one machine per six million population. It was noticeable that the south of India (Kerala and Tamil Nadu) and the northern states (Uttar Pradesh, Haryana including Delhi and Punjab) were served by 26 radiotherapy departments and a total of 38 machines. These five states covered a combined area of 558,000 square kilometres. Hence, 17% of India′s land surface was served by 40% of radiotherapy departments and 40% of the machines. Taking population density into account, the three northern and two southern states supported a combined population of around 200 million. So, 17% of India′s land surface supporting 33% of India′s population was served by 40% of the radiotherapy facilities. In the other regions, the four central states of the Deccan (Madhya Pradesh, Maharashtra, Orissa and Andhra Pradesh) had a combined population of 160 million. Twenty radiotherapy departments, with a total of 27 telegamma units, were situated in 15 towns and cities. In this region 26% of India′s population was served by 30% of the radiotherapy centres and 30% of the teletherapy resources. Eighty per cent of India′s population lived in rural areas at that time, whereas the radiotherapy facilities were located in towns and cities. Railway and air concessions for patients with an attendant were available in all regions, and free transport on the wide network of bus routes was offered by some states. Overall, the time taken to reach a radiotherapy department was up to 24 hours by bus or train.
(Table 1, 2)

Expertise

Despite recognition of radiotherapy as a separate clinical speciality by the Indian Medical Council as long ago as 1972, the emergence of independent radiotherapy departments was slow, partly because insufficient funds were available for creating new specialist posts. The Indian Radiological Association had 1500 members of which 150 were involved in radiotherapy either full-time or combined with diagnostic duties. To further the cause of radiotherapy, the Association of Radiation Oncologists of India (AROI) was established in 1977. With few exceptions radiotherapy departments or cancer institutes were part of, or affiliated to, a university medical college offering an M.D. degree in radiotherapy alone or a combined degree in therapy and radio-diagnosis. Most universities still offered a combined M.D. to their post-graduates although the move to separate the two courses was gathering momentum. Each year, 10-15 post-graduates qualified with an M.D. in radiotherapy and a much larger group qualified with a combined therapy/diagnosis M.D.

The development of medical physics in India began in the late 1950′s, following the launching of the atomic energy programme when it became clear that the implementation of the countrywide radiation safety programme was impossible without properly trained staff in hospitals using ionising radiations. In 1962 the Division of Radiological Protections, Bhabha Atomic Research Centre (B.A.R.C), Bombay, with the support of the World Health Organisation, established a one-year post-graduate diploma course in radiological physics recognised by the university of Bombay. Fifteen candidates were accepted each year and up to the beginning of 1976, 212 trainees had completed this course under W.H.O., I.A.E.A. or Colombo plan aided schemes. The number of hospitals having medical physicists at the beginning of 1975 was 42 according to the Department of Radiological Protection, B.A.R.C., Bombay. The total number of medical physicists working in radiotherapy departments was 64, a likely under-estimate. The Association of Medical Physicists in India formed in 1976 had a membership of 194, including 68 working at B.A.R.C. and 20 working abroad. The remaining 106 members were mostly hospital physicists and members of the newly-founded Indian Academy of Medical Physicists. The difficulty of providing suitable training for medical physicists that enabled them to discuss clinical problems was evident at that time, made difficult by lack of formal recognition by hospital authorities.

The scarcity of trained radiographers was an obvious weakness of Indian radiotherapy at that time. There were training schemes offered at around 10 centres in India, comprising a blend of academic course work and practical apprenticeship. There were no authentic figures for the number of full-time therapeutic radiographers at the time, but an estimate based on one radiographer and one X-ray assistant for each machine gives a total of approximately 200 individuals.

Comment

In the late seventies the Indian radiotherapists faced a daunting task in delivering optimal cancer care due to inadequate number and quality of radiotherapy equipment as well as suboptimal staffing. The gap between the optimal requirement and the availability of radiotherapy machines and manpower has narrowed somewhat in a quarter of century, although scope for considerable improvement still exists. The radiotherapy facilities have improved at a rate faster than the 65% increase in the Indian population during the same period. The current estimates of radiotherapy facilities in India in the year 2004 (personal communication with Rajiv Sarin) show that the number of radiotherapy facilities has almost quadrupled to 210. The quality of teletherapy equipment has also improved. Of 323 teletherapy machines, 70 are linear accelerators and most of the recent installations are capable of delivering state-of-the-art techniques like intensity modulated or stereotactic radiotherapy. The situation for Brachytherapy has also improved with 71 manual LDR units, 30 remote LDR units and 46 HDR units. There has also been a proportionate increase in the number of medical physicists, radiation oncologists and radiation therapists, though it still falls short of the demand, particularly for resource-intensive modern radiotherapy practice.

The contemporary situation in the UK was certainly different in 1977, but the UK still has substantial problems in delivering a satisfactory service nationwide. As an illustration of this, delay to treatment for radiotherapy for women with early breast cancer is lengthening rather than shortening in some parts of the country, extending to many weeks in some department. The issue of optimal fractionation for women with early breast cancer remains contentious, albeit one that is currently being addressed in a series of prospective randomised trials (perhaps the subject of a future letter). Meanwhile, three schedules are in common use; 50 Gy in 25 fractions, 45 Gy in 20 fractions and 40 Gy in 15 fractions, each delivering 5 fractions per week. In an era of written treatment guidelines, this variation sticks out as evidence that the clinical oncology community still has to put its house in order.

I was in India in 1977, the same year as the establishment of the Association of Radiation Oncologists of India. It is heartening to see that AROI has over 700 active members and has been able to achieve many of its objectives. Resource constraints in the delivery of optimal cancer care are not unique to India and radiotherapy. This official journal of AROI would serve as the much needed platform for sharing research and practical issues in improving cancer care in India and other regions of the world.

Copyright 2005 - Journal of Cancer Research and Therapeutics

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