OBJECTIVE In low-resource settings, complex decisions about the allocation of expensive cancer treatments, including radiotherapy (RT), are necessary to avoid implicit rationing based on ability to pay. Perspectives from the frontlines of this process in low-resource settings are nearly absent in the literature. This study aims to understand the experiences and views of stakeholders engaged in RT allocation at Butaro Hospital in Rwanda.
METHODS We conducted semi-structured interviews with a purposive sample of oncology physicians, nurses, program leaders and advisors who have been directly engaged in RT allocation at Butaro (n=22). Interviews were recorded and transcribed. Transcripts were coded using a data management software and analyzed using the Framework Method.
RESULTS Participants described improvement over time in the RT micro-allocation process, which now includes meetings to select patients from a waitlist using prioritization guidelines but identified numerous remaining procedural challenges. There was consensus that curability, related clinical factors (e.g. disease type, stage), and age should drive prioritization. Opinions about non-clinical factors varied widely, especially regarding the role of nationality, contribution to society, and health-related behaviours. Clinicians expressed moral distress associated with these decisions and emphasized the complexity in communicating about them with patients. Program leaders discussed challenges of macro-allocation for RT given competing needs in budget. Participants shared many recommendations: specific revisions to prioritization guidelines, expanded stakeholder engagement in deliberations, education about RT and support for on-the-ground decision-makers, real-time involvement of radiation oncologists, and improved post-RT outcome data collection. They also strongly advocated for increased access to RT.
CONCLUSIONS Efforts to increase access to RT in low-resource settings are ongoing; however, until RT resources are adequate to meet population demands, structured and deliberative approaches to RT priority setting are needed. Qualitative data from stakeholders involved in this process should be used to improve deliberative procedures and support for oncology clinicians and stakeholders.

BACKGROUND World Aid Exchange (WaidX) is an innovative intercontinental telemedicine platform oriented to oncology specialties. This platform, devoted to reducing the digital divide on health practice, provides telecommunication services between health care facilities in developed and developing countries. It conveys the ability to safely share radiologic images and patient medical records for diagnostic and care purposes. It has been implemented in varied settings such as Tanzania, Ethiopia, Djibouti and Brazil. We recognized the need for teleconferencing with the Radiation Department of National Center of Oncology, Yerevan, Armenia, to share expertise in general patient management and contouring and planning for radiotherapy.
OBJECTIVE To develop a TeleRadiotherapy platform that enables:
1.Conference calling for tumour boards to review radiotherapy plans, discuss disease management and conduct remote quality control
2.Real-time sharing of diagnostic images to guide clinical decision making
3.E-contouring activity performed by parties in Yerevan and Weill Cornell Medicine in NY on radiographic images, with minimization of time lag in contouring
4.Generation of a database for clinical data (i.e. radiation dose, toxicity, disease stage) that serves as a departmental registry and a tool for future research use
5.Access to lectures delivered by physicians, nurses, therapists and physicists both in Yerevan and New York on varied aspects of radiotherapy
METHODS The TeleRadiotherapy system is comprised of 2 WaidX physical units, equipped to support networking and telephony integration. An application was used to establish a simplified direct connection between mobile phones in New York and fixed phone extensions in Yerevan. A customized version of Veyon was used for remote connection to a contouring station. Zoom was used to establish the teleconference. Remote operators in Weill Cornell Medicine were trained for using the system.
RESULTS The first TeleRadiotherapy interaction with demonstration of contouring on the Oncentra treatment planning system in Yerevan revealed ease of use. The brush tool displayed less drag time than the point-by-point contouring tools. Diagnostic images were easily shared without compromise of the image resolution. Conference call quality was high. This conference has opened a series of biweekly chart rounds, between the two institutions.
CONCLUSIONS Teleradiotherapy is feasible with excellent voice quality, image sharing capability and real-time contouring. The database is under construction. We are developing a new model for learning, training and collaboration in radiotherapy using WaidX, to enable rapid knowledge and technology transfer for a more equitable access to high-quality cancer care worldwide.

OBJECTIVE Achieving universal radiotherapy access is desirable. However, the factors contributing to the establishment of safe and efficient radiotherapy services in low- and middle-income countries (LMICs) are poorly understood. Therefore, the aim of this study was to identify and describe the perceived barriers and facilitators to establishing and sustaining high-quality and accessible radiotherapy services in LMICs.
METHOD AND ANALYSIS An exploratory-descriptive qualitative study using semi-structured telephone interviews was undertaken. Purposive and snowball sampling techniques were used to recruit participants with experience of establishing radiotherapy in LMICs. The WHO Innovative Care for Chronic Conditions Framework informed the interview guide and the inductive data analysis. A constant comparative data analysis approach was adopted which allowed for an inductive and deductive to be completed.
RESULTS Seventeen participants were interviewed, 10 were working permanently in 9 LMICs and seven were permanently employed in four high-income countries. The majority were radiation/clinical oncologists (n=11) with a smaller number of medical physicists (n=3), radiation therapists (n=2) and one administrator. Three themes were developed, which included: 1) committing to a vison of improving cancer care; 2) making it happen and sustaining a safe service; and 3) leveraging off radiotherapy to strengthen integrated cancer care. Each of these main themes had several sub-themes, which were illustrated in a thematic map. Participants described the need for national radiotherapy development plan, project management plan, investment in workforce and comprehensive care and support.
CONCLUSION International efforts are underway to support LMICs in committing to the vision of universal access to radiotherapy and to establish innovative service models that focus on integrating cancer care across the disease trajectory. Promoting more integrated models of cancer care are required to optimise LMICs investment in radiotherapy and to improve patient outcomes.

OBJECTIVE The burden of cervical cancer is high in low- and middle-income countries (LMIC) where access to curative radiation treatment is limited. A non-profit organization donated a high dose rate (HDR) brachytherapy after loading unit to the sole cancer centre in Senegal in 2013. We describe the initial experience of a novel treatment approach using pre-planned brachytherapy as a component of curative chemo-radiation in Senegal.
METHODS A prospectively maintained institutional tumour registry was reviewed to identify all patients treated with radiotherapy for cervical cancer between January 1, 2013, and December 31, 2014. Charts were reviewed for treatment details, disease control, and toxicity. Telephone interviews were also conducted using a questionnaire similar to the cervix cancer-specific patient-reported quality of life EORTC QLQ-CX24 instrument.
RESULTS 285 patients were identified as receiving radiotherapy for cervical cancer during the timeframe analysed. Of these, 58 received curative intent chemoradiotherapy including HDR brachytherapy. Brachytherapy dose was modified according to WPRT dose and tolerance such that up to 3 fractions of 7.5 Gy or 8 Gy each were delivered. Median EQD2 dose to point A, bladder point, and rectum point were 77 Gy, 72 Gy, and 72 Gy, respectively. One patient suffered uterine perforation during brachytherapy. Late toxicity information was available for 26 (45%) patients. Two patients developed late grade 3 toxicity. Two additional patients developed rectovaginal fistulae, one occurring after salvage hysterectomy. At a median follow-up of 17 months, 6 (26%) patients with ≥90 days follow-up developed local progression including three who were treated for recurrent disease.
CONCLUSIONS HDR brachytherapy using pre-planned templates is feasible and safe in the curative treatment of cervical cancer in LMIC. Our strategy for brachytherapy implementation in cervical cancer could be used as a model in other LMIC.

OBJECTIVO Os serviços de radioterapia nos PALOP devem obedecer a critérios epidemiológicos, a padrões de qualidade e garantir a continuidade de cuidados ao doente oncológico. Os hospitais que tratam doentes do foro oncológico e que não possuam radioterapia devem estar articulados, por protocolo, com uma unidade de radioterapia instalada no sector público ou privado, no sentido de garantir equidade. Estas unidades devem cumprir os critérios mínimos de equipamento e especialistas garantindo boas práticas. A Formação das equipas é crucial, como é fundamental a criação de um acervo documental, em português, que apoie todos os países. A AORTIC tem um grupo de interesse dedicado à radioterapia que identifica as prioridades clínicas, educacionais e de investigação, promove a troca de informações e práticas no tratamento, pretendendo compilar um directório de recursos de radioterapia em África e organiza oportunidades de treinamento em centros de excelência. Angola e Moçambique já têm serviços de radioterapia, Cabo Verde pretende desenvolver um serviço. Assim, é fundamental criar o grupo de radioterapia dos PALOP-AORTIC.
MÉTODO No 3º Congresso PALOP-AORTIC na Praia, decidiu-se realizar o Manual de Boas Práticas de Radioterapia dos PALOP. Este será aprovado durante o Congresso em Maputo (2019), e definido o programa para a constituição do grupo, em Luanda em 2020.
RESULTADOS O manual inclui: Aspectos epidemiológicos, nomenclatura, conceitos, objectivos, rácio em equipamentos específicos, obrigações e responsabilidades, meios de registo, controlo de qualidade, procedimentos operativos, equipamentos de reanimação, armazenamento e segurança dos consumíveis, assumindo que cada unidade de tratamento poderá tratar 400 novos casos/ano.
CONCLUSÃO O Grupo PALOP de radioterapia dará particular atenção à formação de quadros de radio-oncologia, tendo em conta as normas internacionais e será um apoio às unidades para que o funcionamento seja seguro e de qualidade.

OBJECTIVE Errors in contouring and planning contribute to inferior treatment outcomes for patients both in terms of disease control and toxicities. In radiotherapy centres with limited resources, clinician-led quality assurance for radiotherapy planning is essential given the ongoing transition from 2D to 3D to IMRT treatment planning. Challenges exist, however, in instituting formal peer review programmes within current workflows, given high demand for treatment, and shortage of specialized manpower. Our collaborative project aims to tackle this problem by introducing novel cloud-based technology to facilitate remote peer review in radiotherapy. We aim to evaluate the feasibility and effectiveness of using cloud-based technology for quality improvement in up to five radiotherapy centres in sub-Saharan Africa (n=4) and the UK (n=1).
METHODS Cloud-based software can be downloaded to any Windows computer and used by any radiotherapy centre to upload DICOM images and radiotherapy treatment plans to a virtual cloud. At the time of upload, the software de-identifies the dataset, with no patient details visible. A nominated centre is subsequently able to download and review the planning scans, including contours and DVHs, on their secure network. This process facilitates remote review, critique and feedback on radiotherapy plans, as part of a formal peer review process between two centres. Study methods include:
1. Feasibility studies in each collaborating centre to understand the specific requirements and uses for cloud technology in the clinical setting in each country
2. Retrospective audit of radiotherapy plans (3D/IMRT) for cervix, prostate, and head and neck cancers to evaluate training needs for each centre
3. Production of peer review workflow for radiotherapy plans within each centre, and in collaboration with other radiotherapy centres (national and international)
4. Assessment of cloud-based peer review on quality improvement.
RESULTS The cloud software has been successfully downloaded at Ocean Road Cancer Institute and Guy’s Cancer Centre. There was a long lag time for software download at Komfo Anokye Hospital, Ghana and the Linear Accelerator remains inoperable currently. Further feasibility studies will be performed at Sweden Ghana Medical Centre, and potentially at Life Gaborone Private Hospital, Botswana. A retrospective audit of peer review is ongoing at Guy’s Cancer Centre and has identified contouring as the main cause for recommendation of plan revision. Retrospective audits are due to commence in other collaborating centres.
CONCLUSIONS Evaluation continues for the use of cloud-based technology to further understand its role in peer review, quality improvement and training in radiotherapy.

OBJECTIVE Radiation therapy (RT) is critical to cancer care, providing benefits of overall survival, local control and palliation, cost-effectively; however, over 15 African nations remain without RT. Radiating Hope (RH) is a nonprofit organization committed to advancing RT-related cancer care globally.
METHODS In Dakar, Senegal RH donated a high dose rate brachytherapy unit (HDRBU) to the Institut Jolio Curie (2012), followed by in-person training trips with US physicians and physicists. At the Sweden Ghana Medical Center (SGMC) in Accra, an RH physicist spent 2014-2015 training medical physicists on safe RT delivery. This center also received in-person brachytherapy (BT) training from US physicians and physicists (2018). Another center in Ghana received 2 HDRBUs (2018). RH donated a linear accelerator (linac) and an HDRBU (2014-2015) to the Bugando Medical Center in Mwanza, Tanzania.
RESULTS Dakar, Senegal: Cervical cancer was curable in Senegal once treatment with brachytherapy (BT) started in 2013. The training was designed to treat safely, with fewer fractions and to use a library of pre-designed RT plans minimizing need for complex treatment planning. This center is self-sustaining in treatment delivery with BT, now with new HDRBUs and linacs. Source changes, limited physician and room availability, and equipment downtime can be significant and impede treatment delivery. Accra, Ghana: Physicists at SGMC have trained others within Ghana, Nigeria and Senegal. The SGMC team benefitted from training and is using BT with continued remote assistance. The other site in Ghana that received HDRBUs is lost to communication. Mwanza, Tanzania: The donated linac and HDRBU remain in shipping crates due to assembly cost, obtaining maintenance contracts and governmental challenges in meeting these needs.
CONCLUSIONS RH has successfully worked with institutions in Africa providing RT equipment, training and building partnerships to form self-sustainable models of training and care. Challenges remain in making RT equipment donations functional.

OBJECTIVE We demonstrate a natural language processing (NLP) method to enable radiologists to accurately read more studies per day across all radiology modalities independent of patient population.
METHODS In radiology reports, the impression section is in many ways a summary of the key items from the more extensive findings section. We modified a long short-term memory and pointer generator artificial neural network with state-of-the-art performance in summarizing news articles into findings to impression NLP model for radiology reports. We gathered the necessary data to train the scaled up neural network through partnerships with radiology groups across the United States to collect millions of reports across all modalities and diagnoses. From this data we generated synthetic training datasets designed to follow radiology best practices and the most up-to-date published recommendations. We trained the NLP model on the synthetic data for each radiology modality, evaluated results in a double-blind fashion with a panel of radiologists, and are live beta-testing with radiology groups.
RESULTS We show that significant improvement in radiologist efficiency can be achieved with NLP. Radiologist time typically scales linearly with increasing findings lengths, but with the NLP model radiologist time scaled sub-linearly. For short reports radiologists saved on average 10%
When using the NLP model, radiologists saved on average 10% of time on short reports (radiographs) and 25% for longer reports (CTs). Across an average workday, a radiologist using the NLP model can read an additional 15 to 38 studies.
CONCLUSIONS This and methods like it could be highly scalable and cost-effective methods for reducing radiologist scarcity in resource-poor regions. As we integrate computer vision with our NLP models on increasingly large data sets we expect to see further improvements in efficiency. For the most common modalities we see these end-to-end radiology models doing the majority of the boring radiology work.

OBJECTIVE The Technical Cooperation Programme (TCP) is the principal mechanism by which the International Atomic Energy Agency (IAEA) transfers technology and training to Member States. We aim to evaluate the impact of radiotherapy (RT)-related, TCP projects on the professional and academic capacity of Ghana.
METHODS The TCP database was searched for projects conducted in Ghana. Fellows trained as radiation oncologists (ROs), medical physicists (MPs), radiotherapy technicians (RTTs), or oncology nurses (ONs) were identified, and a search for their current employers was performed. PubMed was searched for publications by TCP fellows, and stakeholders were consulted regarding the status of the educational infrastructure.
RESULTS RT services are offered at Korle Bu Hospital (KBH), Komfo Anyoke Hospital (KAH), and Sweden Ghana Medical Centre (SGMC). The TCP has trained 35 fellows (10 ROs, 8 MPs, 9 RTTs, 8 ONs). Eight are working as ROs (2 at KBH, 3 at KAH, 2 at SGMC, 1 in South Africa). Seven MPs are employed in Ghana including 3 at KBH, 2 at KAH, 1 at the Ghana Atomic Energy Commission, and 1 as a senior lecturer at a Ghanaian university. ROs and MPs have co-authored 72 journal articles, including 17 first author publications. Both KBH and KAH now offer clinical training in radiation oncology. With the support of the IAEA, masters and PhD-level studies in medical physics are offered at the University of Ghana. A 4-year degree in therapy radiography is also available. Since 2009, Ghana has hosted 22 TCP fellows from other African countries for academic training.
CONCLUSIONS The TCP has enhanced the professional and academic RT capacity of Ghana. Nearly all TCP-trained ROs and MPs are working in Ghana, and these fellows have made significant clinical and scholarly contributions. The Ghana experience highlights the ability of the TCP to assist in the development of sustainable, RT-related, human resource infrastructure.