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Cancer Control in Africa 4 Status of radiotherapy resources in Africa: an International Atomic Energy Agency analysis

May Abdel-Wahab*, Jean-Marc Bourque*, Yaroslav Pynda, Joanna Iżewska, Debbie Van der Merwe, Eduardo Zubizarreta, Eduardo Rosenblatt

Radiation therapy is an important component of cancer control programmes. The scarcity of radiation oncology Lancet Oncol 2013; 14: e168–75 resources in Africa is becoming more severe as cancer incidence increases in the continent. We did a longitudinal This is the fourth in a Series of assessment of the status of radiation oncology resources in Africa to measure the extent of the problem and the seven papers about cancer eff ects of programmes designed to enhance radiation services in the continent. Radiation oncology departments in control in Africa Africa were surveyed through the Directory of Radiotherapy Centres, and this information was supplemented by that See Comment page 277 available from International Atomic Energy Agency Regional African and Interregional project reports for 2010. Of *Joint fi rst authors 52 African countries included, only 23 are known to have teletherapy. These facilities are concentrated in the southern International Atomic Energy and northern states of the continent. Brachytherapy resources (high-dose rate or low-dose rate) were only available in Agency, Vienna, Austria (Prof M Abdel-Wahab MD, 20 of the 52 African countries. Although progress has been made in the establishment of radiation oncology services J-M Bourque MD, Y Pynda MS, in some countries, a large need still exists for basic radiation services, and much resource mobilisation is needed for J Iżewska PhD, Prof services to keep pace with the burgeoning populations of many countries. D Van der Merwe PhD, E Zubizarreta MD, E Rosenblatt MD); Department Introduction Data sources and collection of Radiation Oncology, Taussig Morbidity and mortality from communicable diseases The Directory of Radiotherapy Centres (DIRAC) is a Comprehensive Cancer Center, have been reduced substantially in the past century. computerised international registry of radiotherapy Cleveland Clinic, Cleveland, OH, USA (M Abdel-Wahab); and Although these remain a major affl iction for many centres that was created in 1995 and is the only London Regional Cancer countries in Africa, increases in chronic, non- centralised, comprehensive database of its type. It is Program, Western University, communicable diseases are characteristic of an estimated to include 90% of existing radiotherapy London, ON, Canada epidemiologic transition.1 Worldwide, non-communicable facilities worldwide, and contains information about (J-M Bourque) diseases are expected to cause more deaths than external beam radiotherapy, brachytherapy, dosimetry, Correspondence to: communicable diseases by 2015.2 Cancer currently causes ancillary equipment, and personnel. This information is Prof May Abdel-Wahab, Cleveland Clinic Main Campus, more deaths around the world than HIV, tuberculosis, essential for assessment of the availability and 9500 Euclid Avenue (T-28), and malaria combined.3 accessibility of radiotherapy in specifi c geographical Cleveland, OH 44195, USA Radiation therapy is an important component of contexts. The DIRAC database is maintained by [email protected] cancer control programmes (fi gure 1). The scarcity of personnel at the International Atomic Energy Agency radiation oncology resources in Africa is becoming more (IAEA). The directory is updated daily with information For the DIRAC database see severe with the increase in cancer incidence in the provided to IAEA by radiotherapy centres or national http://www-naweb.iaea.org/ nahu/dirac continent. In 2008, the total population of low-income organisations. To keep the database as accurate as and middle-income countries worldwide was 5·625 billion, among whom there were 7·82 million new cancer cases. This population is expected to reach 6·656 billion in the year 2020, with 9·28 million new cases of cancer in that year. This number will constitute almost two-thirds of the total new cases of cancer in the world, which is expected to reach more than 15 million.4 Moreover, from 1990 to 2020, the International Agency for Research on Cancer has predicted that cancer incidence will increase from 1·0 to 1·5 new cases per 1000 people in low-income and middle-income countries as life expectancies increase.4 Increases in life expectancy in all economic groups and low fertility rates in high- income countries5 are among the reasons that account for why 70% of all cancer deaths already occur in low- income and middle-income countries. Assessment of the status of radiotherapy services in Africa is essential so that interventions can be planned to

improve the situation and minimise the eff ect of scarce Reuters cancer resources on the population. Figure 1: A radiotherapist working at the Korle Bu Teaching Hospital, Accra, Ghana www.thelancet.com/oncology Vol 14 April 2013 e168 Series

possible, a link is sent to the registered centres to ask recorded in the continent; overall, these house them to update their institutional data online every 277 radiotherapy machines (88 cobalt-60 units and 2 years. The institutional contact checks, corrects, and 189 linear accelerators). However, distribution of completes the data in DIRAC. New records for new radiotherapy resources is far from uniform. Machines installations are also inputted. If a piece of equipment is were concentrated in South Africa (92) and Egypt (76), no longer operational (decommissioned, etc) it is not which together accounted for 60% of the radiotherapy deleted, but recorded as non-operational from a pull- equipment resources in Africa. The regions of north down menu in the database. Africa and southern Africa together contained 90% of the One of the limitations of DIRAC is that institutions total number of machines and more than 70% of all self-report, which is subject to compliance issues. This brachytherapy services. An estimated 198 million people situation would limit the usefulness of the database if (or about 20% of the population of the continent) live in updates were not done regularly. However, the IAEA one of the 29 African countries that do not have any contacts centres that fall behind and proactive eff orts are teletherapy facilities. made on a regular basis to ensure that the database is Furthermore, Africa on the whole was the least kept up-to-date. developed world region with respect to radiotherapy We did a longitudinal assessment of the status of services, with an average capacity of fewer than one radiation oncology resources in Africa during the past teletherapy machine per million people. The countries 12 years to assess the eff ect of IAEA programmes with the highest capacities in Africa were Mauritius designed to enhance radiation services in the region. (2·36 teletherapy machines per million people), South Radiation oncology departments in Africa were Africa (1·89), Tunisia (1·55), and Egypt (0·93). Among surveyed through DIRAC and this data was the poorest countries, capacities ranged from supplemented by information from IAEA Regional 0·02 teletherapy machines per million people (ie, two African and Interregional project reports for 2010. machines for the whole population of more than Countries were grouped according to the regions 80 million people) in to 0·89 teletherapy defi ned by the US Centers for Disease Control and machines per million people (or roughly one teletherapy See Online for appendix Prevention (appendix).6 machine for every 1·1 million people) in Morocco. By Radiotherapy machines are the basic equipment contrast, the North American and western European necessary to provide radiation treatment. The number of regions have capacities of 14·89 and 6·12 teletherapy teletherapy machines per million people is often used as machines per million people, respectively. Investigators an indicator for access to radiation therapy for a given of a study in 25 European Union countries estimated the region. Because cobalt-60 units are also regarded as number of linear accelerators needed in each country on teletherapy machines and are widely used, we have the basis of cancer incidence, and reported that necessary included these alongside linear accelerators in our capacities were between 4·0 and 8·1 teletherapy machines analysis. We have recorded numbers of radiotherapy per million people.9 machines and brachytherapy services for 52 African countries and compared these with the numbers Changes from 1991 and 1998 recorded in 1991 and 1998. Countries with populations of Radiotherapy machines in Africa have increased in fewer than 100 000 people7 were excluded. number in the past two decades, from 63 recorded in 1991 to 155 in 1998 and 277 in 2010, according to data from Availability of radiotherapy machines DIRAC and from regional and inter-regional project The DIRAC database in 2010 listed 13 250 registered reports. The number of machines more than doubled radiotherapy machines, which served a world between 1991 and 1998;10 although the number increased population of about 6·68 billion people. A direct by 75% between 1998 and 2010, this rate of increase was association exists between the number of teletherapy lower than in the previous decade. The number of machines per million people and the gross national operational teletherapy machines increased in 17 African income per head: the average number of teletherapy countries between 1998 and 2010, with substantial machines per million people was 1·99 for the whole increases seen in South Africa (from 40 to 92), Egypt world, 8·6 for high-income countries, 1·6 for upper- (from 53 to 76), Morocco (from six to 28), Algeria (from middle-income countries, 0·71 for lower-middle- 11 to 20), and Tunisia (from eight to 16). Angola, Botswana, income countries, and 0·21 for low-income countries Mauritania, Senegal, and Zambia developed new (according to World Bank defi nitions for 2008).8 These radiation therapy capabilities where none existed in 1998. statistics suggest that many African countries are at a Congo, Gabon, and Zimbabwe had a decrease in the disadvantage with respect to availability of radiotherapy number of machines, whereas four countries (Liberia, resources. Mozambique, Uganda, and the Democratic Republic of Of the 52 African countries included in our analysis, Congo) lost some of their radiotherapy capabilities when only 23 off ered external beam radiotherapy in 2010 their previously functioning cobalt-60 units’ sources were (fi gure 2, appendix). 160 radiotherapy centres were not replaced. 60% of radiotherapy machines in Africa e169 www.thelancet.com/oncology Vol 14 April 2013 Series

were cobalt-60 units in 1998, compared with 32% now. Decreases in radiotherapy machines per million people Tunisia were due to an increase in population (with no change in Morocco the number of machines) in Ghana, , Madagascar, The Gambia Algeria and Namibia. Libya Egypt Assessment of optimum radiotherapy use for each country, derived from evidence for disease-specifi c Mali indications of radiation therapy, shows that the biggest Mauritania Niger Chad gap between radiotherapy machine availability and need Senegal Burkina Sudan is in Nigeria, where there are currently seven teletherapy Faso Guinea radiotherapy machines, compared with an estimated Guinea- Nigeria CÔte Ghana Central African need of 145 (diff erence 138; table). The next biggest gap is Bissau D’Ivoire Ethiopia Cameroon Republic in Ethiopia (72), followed by the Democratic Republic of Sierra Leone Benin Liberia Togo Rwanda Uganda Congo (48), Kenya and Uganda (both 38), (27), Congo Kenya Gabon Democratic Mozambique (25), and Sudan (24). Equatorial Repubic of Most radiotherapy centres in Africa are fairly basic, Guinea the Congo Tanzania delivering mostly palliative services and simple, Angola Burundi curative treatments that are based on two-dimensional Angola imaging and treatment planning. About 80% of centres Zambia are small, with one to two radiotherapy machines (56% Mozambique Zimbabwe of centres operate with only one machine) and basic Namibia Malawi Botswana imaging and treatment-planning equipment. About Madagascar Mauritius 18% of centres are equipped with three to four teletherapy machines. Some advanced centres in Egypt Swaziland No machines and South Africa are equipped with fi ve or more South Africa Fewer than 1 per million people Lesotho radiotherapy machines, together with modern imaging Between 1 and 3 per million people equipment and treatment planning systems. These centres constitute, however, only about 2% of the Figure 2: External beam radiotherapy machines in Africa in 2010 radiotherapy centres in Africa. Compared with small Dots represents radiotherapy centres. Comoros, São Tomé and Príncipe, and Cape Verde (all of which have no machines) are not shown. centres, better equipped, larger centres do a higher proportion of more complex radiotherapy procedures such as three-dimensional conformal radiotherapy, Brtx-cap/year = (Number of manual load brachytherapy with some able to do intensity-modulated radiotherapy kits × 50) + (number of LDR machines × 80) + (number of and image-guided procedures. HDR machines × 500)

Availability of brachytherapy When this formula was applied to data for Brachytherapy resources (high-dose rate [HDR] or low- brachytherapy resources in Africa, we calculated a dose rate [LDR]) were only available in 20 of the 52 African potentially treatable capacity of 24 300 patients per year. countries (appendix). Of the 99 brachytherapy services in Since the incidence of cervical cancer in Africa was 72 017 the entire continent, the countries with the greatest in 2008,11 a clear disparity exists between available numbers were South Africa (21), Morocco (15), Algeria (15), services and need in the continent. By plotting potentially Egypt (nine), Tunisia (eight), and Nigeria (seven). treatable capacity for individual countries with those Compared with western countries, in Africa more countries’ gross national incomes per head, we can see cancer cases occur in young patients, and a relative that brachytherapy capacity is associated with economic female preponderance in cancer incidence is seen. The development (fi gure 3). large numbers of women aff ected by cancer in Africa is mainly due to the high incidence of cervical cancer, a Discussion highly preventable and potentially curable disease Radiation therapy is generally indicated for more than 50% where adequate radiation therapy is available. Tatsuzaki of cancer cases.13 Thus, the accessibility of radiotherapy and colleagues12 proposed a new quantitative indicator services is important in assessment of the quality of cancer to better assess the potential capacity of brachytherapy control programmes. Barton and colleagues13 did a detailed in diff erent countries or regions. Potential treatable analysis of the gap between the existing radiotherapy capacity is defi ned as the total number of patients with capacities of low-income and middle-income countries cervical cancer that could be treated with full use of and the needs of their populations for radiation treatment. brachytherapy resources. The potentially treatable The investigators reported that, in 2002, Africa had only capacity (number of patients) of patients with cervical 18% of the radiotherapy equipment needed for full cancer in a year (brtx-cap) is calculated as follows: coverage of the population. www.thelancet.com/oncology Vol 14 April 2013 e170 Series

Australia serves as an example of adequate radiotherapy advanced-stage disease and treatment with a palliative coverage. The overall estimate of radiotherapy use for all intent is far more common than curative treatment. reported cancer cases in Australia is 52·3%. With 23% of Diff erent screening and awareness programmes do, patients retreated, an estimated 643 courses of radiation however, have an eff ect on the stage of disease that therapy would be needed for every 1000 patients patients present with, and so on the number of machines diagnosed with cancer (64%).14 This estimate might not needed in specifi c countries. The number of machines be applicable for all countries in Africa because of needed will also depend on cancer incidence, the types of variation in presenting stages of disease, indications for incident cancers, accepted indications for radiation treatment, and availability of equipment and trained therapy, patient preference, whether or not other personnel. However, we can assume that the optimum treatment modalities are available and off ered, and the radiotherapy use would be higher in low-income and workload of each machine.15 middle-income countries than a high-income country Dependent on the centre, the number of patients like Australia, because patients generally present with treated per year with one machine can vary from roughly

Population GNI per New cancer Patients who need Machines Existing Teletherapy Additional (thousands) head* (US$) cases in 2008† radiotherapy‡ needed§ machines per million machines (×103) (×103) people needed North Africa Algeria 34 373 4260 28·736 18·391 41 20 0·58 21 Egypt 81 527 1800 68·805 44·035 98 76 0·93 22 Libya 6294 12 380 5·045 3·229 75 0·79 2 Morocco 31 606 2520 27·597 17·662 39 28 0·89 11 Tunisia 10 328 3540 11·938 7·640 17 16 1·55 1 West Africa Benin 8662 700 5·285 3·382 80 0 8 Burkina Faso 15 234 480 7·814 5·001 11 0 0 11 Cape Verde 499 2830 0·336 0·215 00 0 0 Côte D’Ivoire 20 591 980 11·485 7·350 16 0 0 16 The Gambia 1660 400 1·004 0·643 10 0 1 Ghana 23 351 680 16·580 10·611 24 2 0·09 22 Guinea 9833 350 6·467 4·139 90 0 9 Guinea-Bissau 1575 250 1·052 0·673 10 0 1 Liberia 3793 170 2·148 1·375 30 0 3 Mali 12 706 610 8·146 5·213 12 0 0 12 Mauritania 3215 980 1·978 1·266 31 0·31 2 Niger 14 704 330 6·571 4·205 90 0 9 Nigeria 151 212 1170 101·797 65·150 145 7 0·05 138 Senegal 12211 980 6·646 4·253 91 0·08 8 Sierra Leone 5560 320 2·781 1·780 40 0 4 Togo 6459 410 3·980 2·547 60 0 6 Central African Angola 18 021 3340 9·198 5·887 13 1 0·06 12 Cameroon 19 088 1120 11·688 7·480 17 3 0·16 14 Central African Republic 4339 410 2·650 1·696 40 0 4 Chad 10 914 540 5·884 3·766 80 0 8 Congo 3615 1810 2·196 1·405 30 0 3 Democratic Republic of 64 257 150 33·746 21·597 48 0 0 48 the Congo Equatorial Guinea 659 14 980 0·428 0·274 10 0 1 Gabon 1448 7320 1·012 0·648 10 0 1 São Tomé and 165 1250 ·· ·· ·· 0 0 ·· Príncipe¶ Sudan 41 348 1120 21·860 13·990 31 7 0·17 24 Zambia 12 620 960 10·119 6·476 14 2 0·16 12 (Continues on next page)

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Population GNI per New cancer Patients who need Machine Existing Teletherapy Additional (thousands) head* (US$) cases in 2008† radiotherapy‡ needed§ machines per million machines (×103) (×103) people needed (Continued from previous page) East Africa Burundi 8074 140 5·860 3·750 80 0 8 Djibouti 849 1210 0·548 0·351 10 0 1 Eritrea 4927 300 2·489 1·593 40 0 4 Ethiopia 80 713 280 51·707 33·092 74 2 0·02 72 Kenya 38 765 730 27·897 17·854 40 2 0·05 38 Malawi 14 846 260 14·304 9·155 20 0 0 20 Mozambique 22 383 380 17·254 11·043 25 0 0 25 Rwanda 9721 410 6·598 4·223 90 0 9 Somalia|| 8926 ·· 5·809 3·718 80 0 8 Tanzania 42 484 460 21·180 13·555 30 3 0·07 27 Uganda 31 657 420 27·116 17·354 39 1 0·03 38 Indian Ocean Islands Comoros 735 750 0·414 0·265 1 0 0 1 Madagascar 19 111 420 14·487 9·272 21 1 0·05 20 Mauritius 1269 6720 1·522 0·974 23 2·36 –1 Southern Africa Botswana 1921 6760 1·201 0·769 21 0·52 1 Lesotho 2049 1060 1·474 0·943 20 0 2 Namibia 2130 4210 1·061 0·679 21 0·47 1 South Africa 48 793 5870 74·688 47·800 106 92 1·89 14 Swaziland 1168 2560 0·755 0·483 10 0 1 Zimbabwe|| 12 463 ·· 11·915 7·626 17 2 0·16 15

Countries are grouped according to the regions defi ned by the US Centers for Disease Control and Prevention (appendix).6 *Gross national income (GNI) per head is based on the World Bank Atlas method.8 †New cancer cases in 2008 are based on data from GLOBOCAN.11 ‡Radiotherapy need is calculated as 64% of incident cases in 2008. §Number of machines needed is based on the assumption that one machine treats an average of 450 patients per year (machines needed is listed as 0 if fewer than 450 patients per year need radiotherapy). ¶No GLOBOCAN data were available for São Tomé and Príncipe. ||No World Bank data were available for Somalia and Zimbabwe.

Table: Number of radiotherapy machines needed in Africa, by country

300 to 1200. Despite this variability, one machine to cover African countries are probably under-reported. Factors a population of 10 million or more people, as noted here, such as very low numbers of physicians and a low is clearly highly inappropriate when compared with awareness of cancer among African populations suggest regions such as North America and western Europe, that our calculations probably underestimate the need where they have roughly one machine per 70 000 and for resources for cancer control. 160 000 people, respectively. Radiation therapy has been shown to be one of the The annual incidence of cancer in Africa in 2008 was most cost-eff ective ways to treat patients on a curative 713 206.11 Assuming a machine can treat 450 new cases and palliative basis.13 The cost of treating patients with per year,9 we can estimate that Africa needs more than cobalt-60 units is much lower than the cost of treat ment 700 additional machines. As discussed, this might be an with a linear accelerator in low-income or middle- underestimate because the need for radiotherapy might income settings.18 Cobalt-60 machines are reliable and be higher in low-income and middle-income countries the source only needs to be replaced every 5–7 years. than in high-income countries. Furthermore, worldwide Despite linear accelerators being more versatile, cancer incidence is projected to increase to 15·4 million cobalt-60 units normally need fewer resources with new cancers per year by 2020,16 with about two-thirds respect to infrastructure, maintenance, and quality occurring in developing countries. Thus, the number of control. Thus, the increase in purchase and use of linear machines needed in Africa will increase accordingly. accelerators as compared with cobalt-60 units could Additionally, the use of tobacco in low-income and potentially lead to an increased dependence on more middle-income countries peaked in the mid-1980s and complex maintenance contracts, with issues related to early 1990s; as a result, tobacco-related malignancies in the paucity of in-country technical support and parts. Africa are expected to increase within the next half Several installations of radiotherapy equipment have century.17 Furthermore, the incidences of cancer in most taken place in Africa in the past few years, particularly www.thelancet.com/oncology Vol 14 April 2013 e172 Series

100·000

10·000

1·000

0·100 Brachytherapy capacity per cancer case

0·010

0·001 200 2000 20 000 Gross national income per head (US$)

Figure 3: Gross national income per head and brachytherapy capacity per case of cervical cancer per year Each data point represents a country.

of linear accelerators. About 40% of the 189 linear projects, educational workshops, and fellowship training accelerators in Africa registered in DIRAC were less for radiation oncology professionals.19 The programme than 5 years old in 2010. By contrast, about half of the also provides technical assistance for the design, 88 cobalt-60 units were older than 20 years and need to establishment, commissioning, implementation, and be replaced because of obsolescence. expansion of safe and eff ective national radiation therapy Brachytherapy equipment does not necessarily follow services, as well as the development of education and the same patterns of distribution as teletherapy training programmes. equipment, since these are two separate treatment The agency also encourages advanced planning at a modalities within the fi eld of radiotherapy. Although national level to prevent shortages of staff and to promote brachytherapy can be quite cost-eff ective, its treatment the procurement of equipment for radiation therapy indication is far narrower than that of teletherapy. centres (eg, relevant imaging, treatment planning, Moreover, brachytherapy generally needs additional dosimetry, and quality control items) within a training to administer and diff erent specifi cations in comprehensive technical cooperation programme. The terms of infrastructure for treatment delivery. The programme includes clinical, medical physics, and paucity of brachytherapy resources as compared with radiation safety components, review of local infrastructure teletherapy resources is a refl ection of the challenge of (room layout, shielding, utilities, and radiation safety) obtaining the additional specialised education, training, and review of the availability of qualifi ed staff members and administrative infrastructure. (radiation oncologists, medical physicists, and radiation technologists and therapists). This planning and Collaborative approaches execution process is an excellent model that provides Novel solutions to these issues have been made possible solutions to the scarcity of radiation therapy resources and continue through initiatives that allow collaboration while ensuring a safe and eff ective increase in radiation between international organisations, local governments, oncology facilities and resources. and regional organisations. Advanced planning by Regional coordination meetings are held where governments and professional associations is essential representatives from each member state identify needs to the success of these initiatives. The IAEA has been and develop a strategic plan; visits by invited experts collaborating with diff erent regions of Africa to help to enhance local capacities and skills; fellowships allow build capacity for cancer control through a professionals to enhance their competencies at other comprehensive programme that includes national, training institutions; regional training courses provide a regional, and inter-regional technical cooperation setting in which professionals of diff erent backgrounds e173 www.thelancet.com/oncology Vol 14 April 2013 Series

come together to learn about specifi c topics; and coordinated research projects focus on development of Search strategy and selection critera the research capabilities of members. We used MeSH (Medical Subject Headings) to search Medline Through these diff erent programmes, some countries (PubMed) for indexed abstracts related to cancer control in are in the process of setting up their fi rst radiation Africa. The strategy was intended to be broad so as to capture therapy centres, including Niger, Mali, Eritrea, Malawi, all relevant material. We used the search terms ”developing and Côte D’Ivoire. Furthermore, the IAEA has been countries”, “Africa”, “radiotherapy”, and “neoplasms”. Articles collaborating with national governments with assistance unrelated to Africa or population health were excluded. Our for the development of feasibility studies, the design and search covered articles published in English or French up to construction of facilities, and the procurement and Aug 26, 2011. commissioning of teletherapy, brachytherapy, imaging, treatment planning, and dosimetry systems. awareness and improvement of cancer registration. Challenges for radiation oncology in Africa These changes will directly aff ect the demand for Low awareness of cancer among African populations— radiotherapy services in Africa and reinforce the together with the dearth of facilities—contributes to increasing need for cancer prevention, early detection, people in need of care not seeking medical attention, treatment, and palliation. and therefore to late-stage presentation. Other Nevertheless, a large shortfall still exists for basic contributing factors include an absence of radiation services and much work is needed to keep pace comprehensive screening and prevention programmes with the burgeoning populations of many African and inadequate access to eff ective cancer treatments.20 countries. DIRAC exemplifi es a step in the right direction. Insuffi cient resources mean that all facets of health-care However, data registration could still be improved, and systems are underfi nanced, including equipment, other areas such as staffi ng, equipment, maintenance, staffi ng, and distribution, which results in an inability quality assurance, optimisation of resource use, and to manage chronic disease.21,22 Similarly, access to care is especially access to care continue to need special attention. hindered by poorly functioning referral systems, and Contributors either the complete absence of cancer registries or MA-W contributed to development, background research, data collection inadequate data in those that do exist. Additional factors and analysis, writing, and editing. J-MB contributed to background include competing priorities, social or political research, data collection and analysis, writing, and editing. YP contributed to data collection and analysis, was consulted for the report, and reviewed 22 instability, confl ict, and corruption. Barriers to access the draft version. JI was consulted on data collection and analysis, and to radiation treatment include a scarcity of trained reviewed the draft report. DVdM contributed to data collection and professionals, technical support, and proper equipment analysis, was consulted for the report, and reviewed the draft version. (and their appropriate geographical distribution), EZ and ER were consulted for the report, and reviewed the draft version. together with poor access to other multidisciplinary care Confl icts of interest We declare that we have no confl icts of interest. and diagnostic facilities (ie, radiology and pathology), and the inadequate fi nancial capacity of patients in References 1 Bulatao RA. Mortality by cause, 1970 to 2015. In: Gribble JN, countries where there is no universal health care. Preston SH, eds. 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