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Current status and future prospects of radiation oncology in Sri Lanka

      Highlights

      • Radiotherapy is used as a primary treatment for most of the cancer cases.
      • Using modern radiotherapy equipment is a challenging task for developing countries.
      • Currently available RT facilities is 0.93 megavoltage machines per million people.
      • Multidisciplinary staffing has been identified as inadequate.

      Abstract

      Purpose: To investigate the current status of radiation treatment facilities in Sri Lanka and to explore future possibilities required to adequately address increasing cancer care.
      Methods: Hospitals with radiation therapy facilities from across the country were identified. Data pertaining to the types of radiotherapy equipment, radiation oncology staffing, and radiotherapy education were collected by onsite visit, conversation over the phone, and from other available cancer resources in Sri Lanka.
      Results: Seven government hospitals and two private sectors were identified with radiation therapy facilities over nine provinces in Sri Lanka for 21.4 million people. At present, there are twenty megavoltage machines (MVMs) operating. This is 0.93 MVMs per one million people. After completion of proposed radiotherapy facilities, it will be able to provide 1.21 MVMs per million people. In addition, multidisciplinary staffing has also been identified as inadequate.
      Conclusions: There is a significant shortfall in radiotherapy facilities and workforce in Sri Lanka. The current and future scope of radiation facilities is sub-optimal compared to internationally recognized guidelines.

      Keywords

      1. Introduction

      Sri Lanka, officially named the “Democratic Socialist Republic of Sri Lanka”, formally Ceylon, is an island country in the Indian Ocean. Sri Lanka is a lower middle income country with a Gross Domestic Product (GDP) per capita of $4,020 (USD) and a total population of 21.4 million in 2020 [

      Central Bank of Sri Lanka. Gross Domestic Product (GDP),https://www.cbsl.gov.lk/en/statistics/statistical-tables/real-sector/national-accounts; 2022 [accessed 10 May 2022].

      ]. Generally, economic growth is associated with health. Globally, all countries face the burden of communicable diseases such as Covid-19, HIV/AIDS, malaria, tuberculosis, diarrheal disease, etc., and noncommunicable diseases such as cardiovascular disease, cancer, diabetes, etc. In particular, developing countries are at increased risk for communicable diseases due to various demographic, geographic and socio-economic factors. These diseases create major obstacles to economic and human development [
      • Preedy V.R.
      • Watson R.K.
      Handbook of disease burdens and quality of life measures.
      ].
      Cancer is one of the leading causes of death worldwide among men and women. According to GLOBOCAN 2020, about 10 million deaths and 19.3 million new cases were reported in 2020 globally [
      • Sung H.
      • Ferlay J.
      • Siegel R.L.
      • Laversanne M.
      • Soerjomataram I.
      • Jemal A.
      • Bray F.
      Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
      ]. In addition, it has been predicted that new cases and death due to cancer will be doubled by 2040 [

      Geneva: World Health Organization. WHO report on cancer: setting priorities, investing wisely and providing care for all. Licence: CC BY-NC-SA 3.0 IGO; 2020.

      ]. In Sri Lanka, there were 29604 new cases diagnosed and 16691 deaths in 2020 [

      Globocan 2020. Global Health Observatory. Geneva: World Health Organization,https://gco.iarc.fr/today/data/factsheets/populations/144-sri-lanka-fact-sheets.pdf; 2021 [accessed 02 March 2021].

      ]. Total crude incidence rate, crude incidence rate of males and females are shown in Fig. 1. The national hospital based-cancer registry was initiated in 1985 in Sri Lanka [

      Palatiyana VSCV, Dompeyalage SAFD, Hadagiripathira MIH, Shreeni A, Irosha N, Suraj P. Sri Lankan patterns of female cancers: Incidence and mortality over 1995-2010. Asian Pac J Cancer Care 2021; 6(1):27-33.https://doi.org/10.31557/APJCC.2021.6.1.27-33.

      ].
      Figure thumbnail gr1
      Fig. 1Crude cancer incidence rates of Sri Lanka, 1985–2020. During the period of 1985 to 2000, the data was collected only from National Cancer Institute. Then, the data was collected from 6 cancer treatment centres during the period of 2005 to 2008. From 2010 onwards, the data has been accumulated from all 7 main government cancer hospitals. Source:[

      Globocan 2020. Global Health Observatory. Geneva: World Health Organization,https://gco.iarc.fr/today/data/factsheets/populations/144-sri-lanka-fact-sheets.pdf; 2021 [accessed 02 March 2021].

      ,

      National Cancer Control programme, Ministry of Health, Nutrition & Indigenous Medicine. Cancer incidence & mortality data, Sri Lanka. 17th Publication, Sri Lankan Cancer Registry; 2015.

      ].
      The most common cancer in Sri Lanka is lip/oral cavity cancer in men and breast cancer in women. It has been reported that the usage of tobacco in both ways of smoked such as cigarettes, beedi and cigar, and smokeless tobacco (chewing and snuffing) are the main causes for oral cancer in Sri Lanka [

      National Cancer Control programme. National guidelines for management of oral cancer-Sri Lanka. Oral Cancer Prevention and Control Unit, Ministry of Health, Sri Lanka; 2020.

      ]. The short summary of cancer incidence in 2020 is given in Table 1.
      Table 1Summary of cancer incidence in Sri Lanka in 2020. Source: Global Health Observatory Geneva

      Globocan 2020. Global Health Observatory. Geneva: World Health Organization,https://gco.iarc.fr/today/data/factsheets/populations/144-sri-lanka-fact-sheets.pdf; 2021 [accessed 02 March 2021].

      .
      MalesFemalesBoth sexes
      Population10 267 35111 145 89921 413 250
      New cancer cases14 13615 46829 604
      Cancer deaths8 7467 94516 691
      5 year prevalent cases32 51243 39775 909
      The 5-most frequent cancersLip-oral cavity, Lung, Oesophagus, Colorectum and ProstateBreast, Cervix uteri, Thyroid, Colorectum and OvaryBreast, Lip-oral cavity, Colorectum, Lung and Oesophagus
      About 50% of cancer patients receive radiotherapy during the course of their treatment due to the low cost compared with other treatment options [
      • Byron B.
      • Ralph R.W.
      Radiation as an immune modulator.
      ,

      Baskar R, Itahana K. Radiation therapy and cancer control in developing countries: Can we save more lives?. Int J Med Sci. 2017;14(1):13-17. https://doi:10.7150/ijms.17288.

      ]. Modern radiotherapy requires precise application. Qualified medical professionals in the field of radiotherapy are required. Modern radiotherapy equipment, maintenance of the equipment, and training health professionals are expensive processes for developing countries [
      • Ramanathan V.
      The current role of Cobalt-60 teletherapy in cancer care.
      ]. As new cancer cases are dramatically increasing globally it is useful to analyze the radiation therapy facilities in each countries. This paper presents the current status and future perspectives of radiotherapy facilities, education systems and staffing in Radiation Oncology in Sri Lanka.

      2. Materials and methods

      The Sri Lankan health policy started in 1951 and covers all Sri Lankans. The health system is publicly funded and its facilities are freely accessible to all citizens. The system covers approximately 50% of outpatient services and 90% of hospital services. Prevention services are free [

      The Borgen Project. Facts about healthcare in SriLanka,https://borgenproject.org/healthcare-in-sri-lanka; 2022 [accessed 28 February 2022].

      ]. The first cancer institute in the western province of Sri Lanka, National Cancer Institute of Sri Lanka, currently known as Apeksha Hospital was established in 1958 at Maharagama, Colombo. There are altogether 24 government cancer treatment centers, 7 provide radiotherapy, which are shown in Fig. 2. Also included two private hospitals, Ceylinco Healthcare center [

      Ceylinco healthcare center. Radiation treatment unit,https://www.ceylincohealth.lk/cancer; 2021 [accessed 01 March 2021].

      ] and Asiri Surgical Hospital [

      Asiri AOI Cancer Centre. World-class Cancer Center – Asiri AOI – to transform cancer care in Sri Lanka,https://www.asirihealth.com/asiri-group/news-and-events/asiri-in-the-news?nid=45; 2021 [accessed 01 March 2021].

      ] which provide radiotherapy treatment facilities in the western province (Table 2).
      Figure thumbnail gr2
      Fig. 2Cancer treatment centers in Sri Lanka. The red circles represent radiation oncology facilities in government hospitals, the green circles represent private radiation oncology departments and the blue open circle indicates cancer centres without radiation oncology departments. Source:
      [

      National Cancer Control Programme, Ministry of Health and Indigenous Medical Services. Cancer treatment centers of Sri Lanka,https://www.nccp.health.gov.lk/nccp/public/index.php/es/treatmentCenter; 2020 [accessed 2 May 2020].

      ]
      .
      Table 2The hospital names which are indicated in Fig. 2. Source:

      Vijitha Ramanathan, The current status of Medical Physics in Sri Lanka. 20th AOCMP, 18th SEACOMP, 120th JSMP, 12th TMPS Proceedings, Phuket, Thailand; 2020.

      ,

      Democratic Socialist Republic of Sri Lanka. Population statistics for countries, administrative divisions, cities, urban areas and agglomerations-interactive maps and charts,https://www.citypopulation.de/en/srilanka/cities/; 2022 [accessed 08 May 2022].

      .
      ProvincePopulationHospital
      Western6,219,0001. Apeksha Hospital Maharagama

      2. Base Hospital Avissavella

      3. University Hospital Kotelawala Defence University

      4. Asiri Surgical Hospital

      5. Ceylinco Healthcare center

      6. Colombo North Teaching Hospital Ragama

      7. District General Hospital Gampaha

      8. District General Hospital Kalutara
      Southern2,696,0009. Teaching Hospital Karapitiya

      10. District General Hospital Hambantota

      11. District General Hospital Matara
      Eastern1,783,00012. Teaching Hospital-Batticaloa

      13. District General Hospital Trincomalee

      14. District General Hospital Ampara
      Northern1,061,31515. Base Hospital-Tellippalai

      16. District General Hospital Vavuniya
      North Central1,402,00017.Teaching Hospital-Anuradhapura

      18. District General Hospital Polonnaruwa
      North Western2,592,00019. Provincial General Hospital Kurunegala

      20. District General Hospital Chilaw
      Centra2,811,00021. Teaching Hospital-Kandy

      22. District General Hospital Nuwaraeliya
      Sabaragamuwa2,088,00023.Teaching Hospital Ratnapura

      24. District General Hospital Kegalle
      Uva1,400,00025. Provincial General Hospital-Badulla

      26. District General Hospital Monaragala
      From the 9 identified radiotherapy centers data was collected by onsite visit, conversation over the phone, online resources from Sri Lanka Atomic Energy Regulatory Council [

      Sri Lanka Atomic Energy Regulatory Council. Registered institutes,https://www.aerc.gov.lk/Home/index.php?option=com_content&view=article&id=15&Itemid=117&lang=en; 2021 [accessed 4 January 2021].

      ] and DIrectory of RAdiotherapy Centres (DIRAC) [

      International Atomic Energy Agency. DIrectory of RAdiotherapy Centres (DIRAC),https://www.iaea.org/resources/databases/dirac; 2022 [accessed 12 May 2022].

      ]. Data included radiation oncology staff details and information about the education system. The future work details were gathered from within the official sources Auditor Generals Department [

      Auditor Generals Department, Performance and Environment Audit Division. Installation of high energy radiation equipment with high quality for cancer patients,http://www.auditorgeneral.gov.lk/web/images/audit-reports/upload/2017/performance_2017/cancerpatientsE.pdf; 2021 [accessed 14 January 2021].

      ] and Office of the Cabinet of Ministers – Sri Lanka [

      Office of the Cabinet of Ministers – Sri Lanka. The project for the supply of equipment of high quality radiotherapy with high energy radiation including the infrastructure for cancer patients in Sri Lanka,http://www.cabinetoffice.gov.lk/cab/index.php?option=com_content&view=article&id=16&Itemid=49&lang=en&dID=6046; 2021 [accessed 14 January 2021].

      ].

      3. Results

      3.1 Radiotherapy equipment: current and future perspectives

      Currently, there are 8-linear accelerators (linacs), 9-cobalt teletherapy machines, and 2-high dose rate (HDR) brachytherapy units operating at government hospitals (see Table 3). In addition, there are two private sector facilities - One hospital with Tomotherapy, a conventional linac, and a remote afterloader (RAL) for delivery of HDR brachytherapy and a second facility equipped with a single linac [

      Vijitha Ramanathan, The current status of Medical Physics in Sri Lanka. 20th AOCMP, 18th SEACOMP, 120th JSMP, 12th TMPS Proceedings, Phuket, Thailand; 2020.

      ].
      Table 3Radiotherapy facilities in Sri Lanka. * indicates installation has occurred, but treatment has not started yet. ** indicates private radiation oncology departments.
      ProvinceHospitalRadiotherapy facilities
      WesternApeksha Hospital-MaharagamaLinac-5

      Cobalt - 3

      HDR-RAL - 1
      **Ceylinco Healthcare centerTomotherapy- 1

      Linac- 1

      HDR-RAL - 1
      **Asiri Surgical HospitalLinac- 1
      SouthernTeaching Hospital-KarapitiyaLinac - 1

      Cobalt - 1
      EasternTeaching Hospital-BatticaloaLinac - 1
      NorthernBase Hospital-TellippalaiLinac - 1

      Cobalt - 1
      North CentralTeaching Hospital-AnuradhapuraCobalt - 1
      North Western-
      CentralTeaching Hospital-Kandy*Linac - 2

      Cobalt - 2

      HDR-RAL - 1
      Sabaragamuwa-
      UvaProvincial General Hospital-BadullaCobalt - 1
      About ten years ago, the government of Sri Lanka has given the Cabinet approval to upgrade the radiotherapy treatment facilities in two phases [

      Auditor Generals Department, Performance and Environment Audit Division. Installation of high energy radiation equipment with high quality for cancer patients,http://www.auditorgeneral.gov.lk/web/images/audit-reports/upload/2017/performance_2017/cancerpatientsE.pdf; 2021 [accessed 14 January 2021].

      ,

      Office of the Cabinet of Ministers – Sri Lanka. The project for the supply of equipment of high quality radiotherapy with high energy radiation including the infrastructure for cancer patients in Sri Lanka,http://www.cabinetoffice.gov.lk/cab/index.php?option=com_content&view=article&id=16&Itemid=49&lang=en&dID=6046; 2021 [accessed 14 January 2021].

      ]. In phase I as shown in Table 4, the Sri Lankan government agreed to purchase 9 linacs. Out of 9 linacs, the first linac was installed and started treatment in 2014 at Apeksha Hospital, followed by Karapitiya, Batticaloa, and Tellippalai Hospitals each receiving a single linac. Due to economic and bureaucratic problems, these linacs were not installed at that time even though those linacs were purchased in 2015. After a long struggle, a linac was installed in Base Hospital-Tellippalai and treatment started in 2019. Citizens from both the northern and eastern province benefited from this linac installation. Teaching Hospital-Karapittiya and Teaching Hospital- Batticaloa also installed a dual energy linac and started treatment recently. Teaching Hospital- Kandy has installed two linacs but the treatment has not started yet. Apeksha Hospital has installed recently 3 single energy linacs and treatment started from 2022.
      Table 4Sri Lankan government project – Phase I.
      HospitalAllocated number of LinacsPresent status
      Apeksha Hospital Maharagama4Installed and functioning
      Teaching Hospital-Kandy2Installed but treatment has not started yet
      Teaching Hospital Karapitiya1Installed and functioning
      Teaching Hospital-Batticaloa1Installed and functioning
      Base Hospital-Tellippalai1Installed and functioning
      In Phase II as shown in Table 5, it has been decided to provide 4 single energy linacs to Annuradhapura, Rathnapura, Kurunagala, and Hambantota cancer treatment centers [

      Auditor Generals Department, Performance and Environment Audit Division. Installation of high energy radiation equipment with high quality for cancer patients,http://www.auditorgeneral.gov.lk/web/images/audit-reports/upload/2017/performance_2017/cancerpatientsE.pdf; 2021 [accessed 14 January 2021].

      ]. This project has not been started yet. Moreover, the Ministry of Health has taken the decision to replace all Cobalt units with linacs in 2016 due to the age of the machines, cost and overall performance.
      Table 5Sri Lankan government project – Phase II.
      HospitalAllocated number of LinacsPresent status
      Teaching Hospital-Anuradhapura1Not installed
      Teaching Hospital Ratnapura1Not installed
      Provincial General Hospital Kurunegala1Not installed
      District General Hospital Hambantota1Not installed

      3.2 Radiotherapy staff

      3.2.1 Radiation oncologist

      In Sri Lanka, consultant clinical oncologists practice in radiotherapy and there is no specified profession as radiation oncologist. The clinical oncologists are educated and trained to provide the services of medical oncology and radiation oncology. According to the IAEA recommendations on staff requirements for clinical radiotherapy, there should be one chief radiation oncologist per program. In addition, a radiation oncologist should be appointed per addition of 200–250 patients treated annually. No more than 25 to 30 patients should be simultaneously treated by one physician, but a higher number, of mainly palliative patients, could be handled [

      International Atomic Energy Agency. Planning National Radiotherapy Services: A Practical Tool, IAEA Human health series, No. 14, IAEA in Vienna, 2010.

      ]. 2018 and 2019 staffing and patient census data are given in Table 6. The number of radiotherapy patients were not included from teaching hospital Batticaloa since the radiotherapy was initiated in 2021. As Asiri Surgical Hospital started radiotherapy in 2019, there is no radiotherapy patients data in 2018. The number of patients treated in 2020 was not considered due to disruptions from the pandemic. Each hospital has appointed a chief radiation oncologist according to the recommendations of IAEA.
      Table 6Radiotherapy patient statistics and staffing at government and private hospitals in Sri Lanka. The notations are indicated as follows: CO – Consultant Oncologist, MP – Medical Physicist, RT – Radiation Therapy Technologist. Most oncologists who work in government hospitals in the western province also work as a visiting oncologist in the private sector.
      Number of radiotherapy patientsStaff
      Hospital20182019COMPRT
      Apeksha Hospital Maharagama1365114314171432
      Teaching Hospital Karapitiya25682635358
      Teaching Hospital Batticaloa225
      Base Hospital Tellippalai10701186338
      Teaching Hospital Anuradhapura13281453224
      Teaching Hospital Kandy402341533411
      Provincial General Hospital Badulla14011248225
      Ceylinco Healthcare center4965451- permanent + about 20 visiting oncologists24
      Asiri Surgical Hospital3891- permanent + about 20 visiting oncologists23

      3.2.2 Medical physicist

      According to the IAEA recommendations, up to 400 patients can be treated annually per physicist and the staff of radiotherapy treatment planning (either dosimetrist or physics assistant) can manage 300 patients yearly [

      International Atomic Energy Agency. Planning National Radiotherapy Services: A Practical Tool, IAEA Human health series, No. 14, IAEA in Vienna, 2010.

      ]. In Sri Lanka, there is no staff appointments either for dosimetrist or physics assistants. Medical physicists perform all radiotherapy treatment planning except some 2D planning for palliative cases which is performed by radiation therapy technologists. Calibration, commissioning, and all machine and patient specific quality assurance procedures are carried out by medical physicists. Staff details of medical physicists in radiotherapy centres are given in Table 6.

      3.2.3 Radiation therapy technologist

      Radiation therapy technologist (RTT) staffing levels are recommended at one per 600 patients annually. It is further recommended there should be one lead-RTT per center and two RTT’s treating 25 patients per day per MVM [

      International Atomic Energy Agency. Planning National Radiotherapy Services: A Practical Tool, IAEA Human health series, No. 14, IAEA in Vienna, 2010.

      ]. Due to the limited number of MVMs, it is hard to implement these guildlines in Sri Lanka. At present, 60–90 patients are treated per day at each radiotherapy center. Staff details of radiation therapists in radiotherapy centres are given in Table 6.

      3.3 Education and training

      3.3.1 Consultant clinical oncologist

      There are fundamentally two different models of postgraduate education and training in the world. In the first model, the specialist title is “radiation oncologist” or “radiotherapist” depending on the country. This model focuses almost entirely on radiation oncology and relevant subjects excluding medical oncology. Canada, USA and Australia follow this model. In these countries radiation oncology and medical oncology training are separate postgraduate courses. In the second model, the specialist name is ”consultant clinical oncologist”. The education and training in this model consists of both radiation oncology and medical oncology and related subjects. This specialist training in clinical oncology takes place in countries such as United Kingdom, Sri Lanka etc. [

      International Atomic Energy Agency. Radiotherapy in Cancer Care: Facing the Global Challenge, IAEA in Vienna, STI/PUB/638, 2017.

      ].
      In Sri Lanka, the postgraduate MD (Doctor of Medicine) program in clinical oncology is conducted by postgraduate institute of medicine (PGIM) at University of Colombo, Sri Lanka from 1986. Before 1986, specialist clinical oncologists completed their education and training overseas, mainly in the UK and obtained the FRCR (Fellow of the Royal College of Radiologists) qualification. The new recruitment rule was not retroactively applied and acquired rights were maintained for those who previously qualified with FRCR when the new MD program was introduced by PGIM. The MD specialist program is the mandatory requirement to practice as a clinical oncologist since 1986. It is difficult to consider separate postgraduate programs for radiation oncology and medical oncology in Sri Lanka for practical reasons. The current MD program in clinical oncology is a five years training program plus a year of rotating internship after completion of 5 years medical school. In addition, the oncology trainers must complete at least 1 year overseas training in the selected developed countries before being granted board certification. If they wanted to follow subspecialty training it will take additionally 2 years to complete their program [
      • Gunasekera S.
      • Seneviratne S.
      • Wijeratne T.
      • Christopher M.B.
      Delivery of cancer care in Sri Lanka.
      ]. The graduation rate for Oncologists per year is 5 to 10.

      3.3.2 Medical physicist

      The minimum requirement for a Medical Physicist in Sri Lanka is a special degree in physics (4 years program). Medical physicists are recruited by Sri Lanka Scientific Service (SLSS), which publish recruitment Gazette notifications, usually every five years. Following this, they conduct the selection examination and conduct interviews to confirm candidate qualifications. If they are selected in the interview they will be appointed as a medical physicist. As they don’t have either postgraduate degree in Medical Physics or any clinical experience as a Medical Physicist, after their appointment, they will get on-the-job-training under a senior medical physicist in any of the government cancer treatment centres. In addition, they need to complete a Master’s degree program in medical physics. This degree program is conducted by two Sri Lankan government Universities: University of Peradeniya (UOP) and University of Colombo (UOC). The first postgraduate degree program in Medical physics was started in 1996 at UOP, then UOC started MSc in Medical physics program in 2013 [

      Round WH, Jafari S, Kron T, Azhari HA, Chhom S, Hu Y, Mauldon GF, Cheung KY, Kuppusamy T, Pawiro SA, Lubis LE, Soejoko DS, Haryanto F, Endo M, Han Y, Suh TS, Ng KH, Luvsan-Ish A, Maung SO, Chaurasia PP, Jafri SM, Farrukh S, Peralta A, Toh HJ, Sarasanandarajah S, Shiau AC, Krisanachinda A, Suriyapee S, Vinijsorn S, Nguyen TC. Brief histories of medical physics in Asia-Oceania. Australas Phys Eng Sci Med. 2015 Sep; 38(3):381-98. https://doi:10.1007/s13246-015-0342-9.

      ]. A maximum of 20 students are recruited to each batch. The students for this postgraduate program are not recruited yearly but according to staffing needs. Biomedical engineers and other relevant professionals also do this degree program. The graduation rate for Medical Physicists is 2 to 3 per year.
      IAEA recommends clinical training for a period of not less than two years in radiation oncology medical physics in the form of a structured competency based clinical training supervised by a senior CQMP [
      • International Atomic Energy Agency
      ] to become a CQMP. The M.Sc program in medical physics at University of Peradeniya incorporates at least 6 months clinical training and assessment [

      Wong JHD, Ng KH, Sarasanandarajah S. Survey of postgraduate medical physics programmes in the Asia-Oceania region. Phys Med. 2019 Oct;66:21-28. http://doi.org/10.1016/j.ejmp.2019.09.079.

      ]. This short training is below the length of training recommended by IAEA to become a clinically qualified medical physicist (CQMP) in radiation oncology.

      3.3.3 Radiation therapy technologist

      Radiation therapy technologist are internal members of the interdisciplinary radiation oncology team. Sri Lanka school of Radiography has produced qualified Therapists since 1957 through a diploma course. It is preferred for radiation therapy technologist to have a degree in radiotherapy which will provide wider knowledge and skills. Currently, two universities; University of Peradeniya and General Sir John Kotelawala Defence University offer Bachelors (Honours) degree programs in Radiotherapy. A Radiation therapist with a Bachelor’s degree in Radiotherapy is entitled to registration with the Sri Lanka Medical Council (SLMC). Approximately 10 radiation therapists graduate from these programs per year. Radiation therapists are recruited by the Ministry of Health according to the cadre requirements.

      4. Discussion

      4.1 Megavoltage radiotherapy units according to the population

      Looking at currently functioning MVMs, there are 20 machines available for a population of 21.4 million. It provides 0.93 MVMs per one million people. International Atomic Energy Agency (IAEA) recommends an ideal ratio of 4–8 radiotherapy centers per 1 million people or 1 MVM per 250,000 people [

      International Atomic Energy Agency. Setting up a radiotherapy programme: Clinical, Medical Physics, Radiation Protection and Safety Aspects, IAEA in Vienna, Austria; 2015.

      ,

      Surbhi G, Melody J. Xu, Alyssa Y, Lori R, Reinou SG, Smita C, Danielle R, Margaret M, Sommer N, Annemarie F, Lilie LL, GillianT, AnaI T. A systematic review of radiotherapy capacity in low- and middle-income countries. Frontiers in Oncology, 2015; https://doi: 10.3389/fonc.2014.00380.

      ]. Compared to this international benchmark, Sri Lanka faces a significant shortfall.
      According to phase I of the project for the supply of equipment of high quality radiotherapy for cancer patients in Sri Lanka, 2 linacs have been installed at Teaching Hospital-Kandy but treatment has not started yet. When Phase I is completed, the total available linear accelerators will be 13 including private sector radiation oncology facilities. If including the currently available cobalt units, there would be 22 MVMs for 21.4 million people, nearly four times less than the recommended levels. If the Phase I and Phase II projects could be completed, Sri Lanka will have 26 MVMs for 21.4 million population. It will provide 1.21 MVMs per million people. If we follow the IAEA recommendations of the ideal ratio for radiotherapy treatment of 4 to 8 MVMs per million people, at least 60 MVMs need to be installed. Even if Sri Lanka completes their Phase I and Phase II projects, it will not be adequate for the treatment of cancer patients. If we don’t have enough radiotherapy machines it will lead to longer waiting lists and it will worsen the cancer patients’ condition. As the number of cancer diagnosis are increasing dramatically, the radiotherapy treatment facilities will have to be upgraded.
      Fig. 3 shows estimated cancer incidence and mortality rates in males and females from 2020 to 2030 in Sri Lanka. The population of Sri Lanka is projected to reach 22 million in 2030 [

      PopulationPyramid.net. Population Pyramids of the World from 1950 to 2100,https://www.populationpyramid.net/sri-lanka/2030/; 2021 [accessed 12 December 2021].

      ]. With steadily increasing cancer cases it is necessary to upgrade the radiotherapy facilities according to the population and cancer incidence rate.
      Figure thumbnail gr3
      Fig. 3Estimated numbers from 2020 to 2040, Males & Females, age (0–85+) All cancers Sri Lanka. Source:
      [

      International Agency for Research on Cancer (IARC). Cancer Tomorrow,https://gco.iarc.fr/tomorrow/en/dataviz/trends?populations=144&sexes=1_2; 2021 [accessed 12 December 2021].

      ]
      .

      4.2 Megavoltage radiotherapy units according to cancer incidence

      There is an alternative metric to estimate the number of megavoltage radiotherapy units in a country or region. The IAEA recommends a MVM for every 500 new treatment courses per year. These courses can include new cases, recurrences, metastasis and non-malignant tumor, etc. [

      International Atomic Energy Agency. Inequity in Cancer Care: A Global Perspective IAEA Human health reports, No. 3, IAEA in Vienna, Austria, 2011.

      ]. By considering the number of patients treated in 2019 as shown in Table 6 and available MVMs (Table 3), the required MVMs for each hospitals have been shown in Table 7. Overall, Apeksha Hospital Maharagama has a significant shortfall.
      Table 7Required megavoltage radiotherapy units according to cancer incidence.
      HospitalRT patients in 2019Required MVMsAvailable MVMs
      Apeksha Hospital Maharagama14314295
      Teaching Hospital Karapitiya263552
      Base Hospital Tellippalai118622
      Teaching Hospital Anuradhapura145331
      Teaching Hospital Kandy415382
      Provincial General Hospital Badulla124831
      Ceylinco Healthcare cente54512
      Asiri Surgical Hospital38911

      4.3 Staffing

      Considering the number of radiotherapy patients in government hospitals, the number allocated patients per oncologist is in the range of 395–1384. The workload of oncologists might vary from center to center. However, looking at overall staffing, workforce is not adequate according to the IAEA recommendations, which may lead to compromises in quality and suboptimal outcomes [

      Ntokozo Ndlovu. Radiotherapy treatment in cancer control and its important role in Africa. ecancer 2019; 13:942.https://doi.org/10.3332/ecancer.2019.942.

      ].
      If we look at the workload of medical physicists, we have to consider the number of MVMs and type of radiotherapy machines. Some centers only have cobalt teletherapy machines. Therefore, workload of medical physicists is going to vary according to the type of machines. Looking at staffing of medical physicist and number of radiotherapy patients treated in 2019, allocated number of patients per physicist is in the range of 195–1038. Overall, the staffing of medical physicists is not adequate according to the IAEA recommendations. Staffing of radiation therapists also is not adequate but it can be overcome in future since number of students intake into their degree program has been increased recently.

      4.4 Education and training

      Recent trends in professional and medical education demand the inclusion of disciplines and competencies that were not considered in the past. These include, but are not limited to, principles of management, professionalism, basics of medical research, interpersonal communication. These additional skills are important for effective team work in this multidisciplinary profession. There is a general mandatory registration system available for medical graduates with an MBBS degree with SLMC. However, there are no special registration or maintenance of board certification system with continuous professional development requirements available for specialist consultant doctors (including clinical oncologists) in Sri Lanka.
      In this context, for medical physicists competency based structured clinical training is recommended over traditional learning from on-the job training. Certification for CQMP is highly recommended by IAEA in the recent publication [
      • International Atomic Energy Agency
      ] in line with other medical specialist professions to recognize and ensure professional competency. IAEA recommends that when the process of certification is first introduced, the new rule of recruitment is not retroactively applied and acquired rights are maintained for the existing experienced CQMP according to the Sri Lankan national law. This is similar to medical consultant specialists who do not hold MD and board certification from PGIM but hold FRCS or FRCP before the MD system was introduced in 1986. IAEA guidelines also recommend having a regulatory state registration system for CQMP with a mandatory continuous professional development (CPD) requirement and recency of practice requirement to maintain the registration. This is important to satisfy the ”safe to practice” requirement and lifelong learning as technology is rapidly changing. Due to staff shortages, lack of research funding and incentives, clinical medical physicists are not involved in research activities in the hospital. The postgraduate Master’s degree in medical physics incorporates a six month research project, this should be improved according to the IAEA recommendations [

      International Atomic Energy Agency. Postgraduate medical physics academic programmes, Endorsed by the international organization for medical Physics (IOMP), Training course series No.56 (Rev. 1), IAEA in Vienna, Austria; 2021.

      ].
      Continuous professional development and recency of practice are also important to radiation therapy technologist. Conducting conferences, workshops and relevant training programs can help to improve their knowledge.

      5. Conclusion

      The purpose of this study was to analyze the radiotherapy facilities in Sri Lanka. The current status is far behind the IAEA recommendation and future plans are also not adequate to meet these established benchmarks. It is important to install additional radiotherapy MVMs, recruit more qualified staff, and implement continuous professional development programs for all medical professionals relevant to radiation oncology in order to tackle the increasing number of cancer patients and rapidly evolving radiotherapy technology. The results of this study could be used to outline a plan to improve the necessary radiation treatment facilities and resources as recommended by the IAEA to effectively address the needs of Sri Lanka.

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