A Look At Radiotherapy In Small Countries

About half of all cancer patients will need radiotherapy at least once in the course of their illness for a cure, prevention of tumor recurrence, or palliation of cancer symptoms (1). We estimated that in 2012 globally there were 7 million new cases of cancer each year who would benefit from radiotherapy.

The safe and effective delivery of radiotherapy requires facilities including high energy (megavoltage) X-ray sources such as Cobalt machines or linear accelerators, and highly trained doctors, physicists, and technicians. Each megavoltage machine can treat between 400 and 500 courses per year.


The World Bank categorizes countries by Gross National Income (GNI) per person (2). Low and Middle-Income Countries (LMIC) have annual incomes of <US$12,475 per person and for Low-Income Countries, the GNI/person is <US$1,025.

Access to radiotherapy is unacceptably low especially in LMIC (3). There is a clear investment case for increased access to radiotherapy. We have estimated that by 2035, 21,600 megavoltage machines will be needed globally to treat over 12 million new cases of cancer each year who would benefit from radiotherapy. If they all had access to radiotherapy it would save about 1 million lives per year and the investment in staff and equipment would return $365 billion in Low and Middle-Income Countries alone (3).

The International Agency for Research on Cancer collates data from national cancer registries (4). Data from High-Income Countries (HIC) is usually of high quality and coverage. Cancer registration is limited or non-existent in many LMIC so that the estimates of cancer incidence in LMIC are at best a lower limit of the disease burden. We have developed a model which identifies every indication for radiotherapy and how common each indication is in a population to calculate the proportion of cancer cases who would benefit from radiotherapy (1). Combining cancer incidence data with our model of demand for radiotherapy we have estimated the number of new radiotherapy cases per year for each country (5).

We examined access to radiotherapy in small countries with populations of less than one million that face additional difficulties in establishing and maintaining radiotherapy services (6) using the International Atomic Energy Agency’s DIRAC database of installed equipment (7).


Radiotherapy for patients in small countries could be accessed by travel overseas, an independent national service or a small satellite service linked to a larger fully capable service. Overseas travel is costly and dislocating. Only a small fraction of cases are able to travel and there are often considerable delays that may result in progression of cancer. An independent national service has traditionally comprised a minimum of two radiotherapy machines (in case of breakdown) and a small number of staff. Isolated departments struggle to retain staff and to maintain equipment. New technology (8) may reduce the size and staffing in small countries by providing remote quality assurance and peer review.

There are forty-one countries with populations under one million (6). Nearly two-thirds are LMIC and 28 are islands. We estimated that there were 11,000 new cases of cancer in small countries in 2012 that had an indication for radiotherapy. Only 11 countries had their own radiotherapy service. About 4000 cases annually had no access to radiotherapy.

Access to radiotherapy depended on caseload, income, and geography. 53% of HIC had radiotherapy services. All HIC islands with more than 80 cases per year had radiotherapy services. Mainland HIC had fewer radiotherapy services because of their ability to access radiotherapy in adjacent countries.

Only 12% of LMIC had radiotherapy services. No LMIC island had a radiotherapy service. Fiji is the only island with a population large enough to completely fill a megavoltage machine. A recent study (9) has shown investment in radiotherapy in Fiji is likely to be cost-effective and a radiotherapy department will open in the near future with assistance from the International Atomic Energy Agency.

These findings are described in the article entitled Radiotherapy in small countries, recently published in the journal Cancer EpidemiologyThis work was conducted by Michael B. Barton from Liverpool Hospital, UNSW, and Eduardo H. Zubizarreta and J. Alfredo Polo Rubio from the International Atomic Energy Agency.



  1. Barton MB, Jacob S, Shafiq J, Wong K, Thompson SR, Hanna TP, et al. Estimating the demand for radiotherapy from the evidence: A review of changes from 2003 to 2012. Radiotherapy and Oncology. 2014.
  2. Bank TW. World Bank Country and Lending Groups 2017 [Available from:
  3. Atun R, Jaffray DA, Barton MB, Bray F, Baumann M, Vikram B, et al. Expanding global access to radiotherapy. The Lancet Oncology. 2015;16(10):1153-86.
  4. Ferlay J, Bray F, Pisani P, Parkin DM. GLOBOCAN 2002: Cancer Incidence, Mortality and Prevalence Worldwide. 2.0 ed: IARCPress; 2004.
  5. Yap ML, Zubizarreta E, Bray F, Ferlay J, Barton M. Global Access to Radiotherapy Services: Have We Made Progress During the Past Decade? Journal of Global Oncology. 2016:JGO001545.
  6. Barton MB, Zubizarreta EH, Polo Rubio JA. Radiotherapy in small countries. Cancer Epidemiol. 2017;50(Pt B):257-9.
  7. Application HHNSa. Directory of Radiotherapy Centres (DIRAC) Vienna: International Atomic Energy Agency; 2017 [A register of radiotherapy hospitals and clinical institutions having radionuclide and high-energy teletherapy machines.]. Available from:
  8. Feain I, Court L, Palta J, Beddar S, Keall P. Innovations in Radiotherapy Technology. Clinical Oncology. 2017;29(2):120-8.
  9. Kim E, Cho Y-m, Kwon S, Park K. Cost-benefit analysis of establishing and operating radiation oncology services in Fiji. Cancer epidemiology. 2017;50:247-56.



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