Hello and welcome to today's webinar, Global Access to Radiotherapy for Lung Cancer. My name is Corinne Faber-Finn, I'm a professor of thoracic radiation oncology at the Christie in Manchester, UK, and the chair of the ISLC art committee. I'm also the moderator for today's program. Next slide, please. So let's begin by running through the housekeeping notes. If you'd like to download today's slide, you can access them by clicking on the link to the webinar page in the chat. You will also be able to find a video recording of the webinar at that link within the next week. An email will be sent at the webinar instructions on how to claim your CME credits. We'll be using polling questions throughout the presentation. So when a question is asked, you will see a pop-up box on your screen, please select your answer so that the speaker can see the results and discuss the answers in relation to the cases. We please ask you that your camera and microphones remain off during this webinar. And then please enter any questions you may have the Q&A discussion in the Q&A section that you can find at the bottom of the screen. You may use the chat function for other discussions, but we will not be using the raise hand function for questions. So that's okay. We plan to have a 10 to 15 minutes panel discussion and Q&A after the presentation. So please enter the questions that you have in the Q&A section at any point during the talks. Next slide. I'm very excited to have three great speakers for this webinar, who I will introduce shortly. Next slide, please. Here are the speaker disclosures. Next slide. I'm now delighted to introduce our first speaker, who's Dr. Fabio Moraes. He's an assistant professor in the Department of Oncology at the Queen's University and executive member of both the Queen's University Global Oncology Program and the Kingston Health Service Centre Innovation Portfolio. He's a thoracic and CNS radiation oncologist whose practice focuses on SPRT and SRS. So we're looking forward to hear you talk, Fabio, to you. Thank you. Thank you. It's my pleasure to be here with you all today. So I'll be talking about global capacity of radiation and challenges for treating lung cancer with radiation in low and middle income country. As I said, I have no conflict of interest. So next, please. We know that cancer incidence is about 20 million new cases in the world in 2020. And also that that's account for about 2 million people. We are expecting that by 2040, there will be an increase in about 60%. So we'll have about 30 million new cases in over 70 million deaths related to cancer, an increase in death of about 70%. Globally, about 20% of people are being diagnosed with cancer. One out of eight men, one out of 11 women will die from cancer. And there's actually about 50 million people living within five years from cancer diagnosis. Lung cancer is the second in number of new cases just behind breast cancer, however, is the leader in cancerous death. So it's an important topic, and we are going to be discussing this today. We know that together with surgery and systemic therapy, radiotherapy has a major role to play in the manage of these patients. However, access to radiation or access to new technologies in radiation are not available for the most of the world. Next, please. We all know, and I want to highlight here that the need for radiation when you're treating cancer is clear. We know that one out of two cancer patients would benefit from radiation. About 40 to 50% of the cancers can be curable with radiation. Radiation is used to improve local control, quality of life, and also can impact on survival. Radiation has the potential to save about 1 million lives per year and has the potential to promote positive economical impact on the society. So we need to understand better ways to give access for radiation to everyone. And why I'm telling about access. Next, please. Because there's some data showing that about 70% of annual cases of cancer by 2040 will be from low and middle income country, and there's no adequate resources to tackle this challenge. There's also some data saying that about 80% of the cancer cases are from low and middle income country, and low and middle income country, they have less than 5% of the radiation machines. So we need to do a better job to get radiation available in all over the world, including Africa, South Asia, Latin America, and other regions. Next, please. And why is difficult to have access to radiation? There's many barriers to radiation in low and middle income country for delivering treatment. And one of the most important is lack of access to radiation. So there's no many Linux, there's no many centers available. There's also issues with quality control and safety when delivering radiation. There's lack of sustainable investments. And there's also a lack of training personnel. There's also a myth behind radiation that most of people believe that radiation is not cost effective or building a radiation department is way too expensive, is not going to return the investment for the country. However, there's some data showing that there's great benefits when you are scaling up radiation centers or access to treatment. Next slide, please. So this data was presented in 2015 on the Lancet Commission, where they were assessing spending global access to radiotherapy. So the authors developed two models, one efficiency model and a nominal model to report on how costs and benefits of investing on radiation would be in low and middle income country. And as you can see here, the benefits from radiation along the time, they are very impressive. So there is a return on the investment, and then you're going to see economical benefits for the society and also human capital benefits. So you're saving lives, you're keeping people active, and you're giving more potential for your economy to grow and for people to be together with their family. And that's not different in lung cancer. So that's why we need to provide access for radiation for lung cancer patients. Next slide, please. Radiotherapy is a standard of care on the treatment of lung cancer, and it goes from curative intent treatment of early stage to locally advanced lung cancer, as well as use on palliation. We know that infrastructure equipments and human resources may be limited in low and middle income country. So when we talk about radiation in low and middle income country, we should prioritize increase access to radiation equipment, and also train healthcare professionals to deliver safe and with quality radiation treatment. We also need to encourage innovation to increase the economic efficiency of radiation delivery on these settings. Next, please. When I talk about innovation, we have been seeing innovation in radiation technology in the last couple of years and decades. So before 1990s, radiation planning relied on two dimensions. So parallel poles will be a very simple way of delivering radiation. After mid 90s, there is a development of the use of tomography, and then we were able to do three dimensional conformal radiation, and also intensity modality. So now we are able to deliver the treatment to the tumor and trying to spare the organs at risk. So that allowed us to decrease toxicity and potentially to target the volumes better. In recent, we have improvements on how to assess patient's positioning and also how to assess tumor positioning by having imaging on the Linux with either KV imagings or cone beam CT, a kind of tomography during treatment time, and also better imaging quality with PET CTs, MRIs, and other kinds of imagings to help us delineate tumor. Next slide, please. However, even with all the technology development, some people would say that there is a discussion if we need technology for everyone. So there's some data, new data reporting that for early stage that we can use radiation for curative intent, that treating with better technology with stereotactic ablative radiotherapy can improve survival compared to conventional. But with that said, we also know that conventional radiation gives better survival compared with no treatment. So having access to conventional radiation is already an important thing. If you have access to technology, it's even better. Next slide, please. Currently, the scenario for radiation capacity is very diverse among the world. We know that in Africa, for instance, 20% of the population has no access to any machines. We know that in Latin America, less than 5% of the centers will be able to generate plans with IMRT, with intensity modality. And there's little know about like number of centers and how available they are for the full population. There are some countries such as Brazil that you have a mixed system with public and private. So then you don't actually know how many of the patients that will need the public system will have access to treatment. In Asia, we also see that most of the centers are located in Japan, China, and India, leaving other countries with like maybe not ideal access to machines, to radiation oncologists, to therapists, to physicists, to personnel involved on the care. So we need to improve that to deliver better treatment to our lung patients. Next slide, please. So in that scenario, there are some indications in how we should be delivering radiation for lung patients in a resource-limited scenario. So for instance, when we are treating patients for palliative treatment of locally advanced and metastatic lung, it will be acceptable to treat them with the 2D, as I said, the parallel opposed, most simple way of treating lung tumors. For radical treatment and chemoradiation patients, stage three, most of the times, it's going to be acceptable to treat with 3D conformal radiation. For more complex case, we'll be suggesting intensity modulate with image guidance. And also, if there is any availability, specialized techniques should be considered for potentially early stage, stage one or two for a curative intent treatment. Next slide, please. So in summary, we know that cancer is a global problem and that lung cancer is the leading cause of that and the second in incidence. Expansion of radiation capacity is needed now so we can close the gap. If we don't act now, we'll face more issues in the future. Additional funding for radiation should be provided and we need to finish this myth that radiation is not cost effective for the system. Radiation is shown to provide both human and economical benefit. And on the lung cancer scenario, we need to invest in both human capacity and treatment resources, ensure quality of care, provide guidance on priority settings with limited resources, and foster innovation to increase the economic efficiency of radiation delivery. Next slide, please. So our first question for today is, if no acute intervention is performed in the next 10 years, the gap in access to radiotherapy will decrease, true or false? Should I give some time for people to answer and then comment the question? Okay, we have a split here. So 50% say it's true, 50% say it's false. So in fact, this is a false assumption. So if we don't do anything in the next 10 years, the number of cases will increase and the number of cases are gonna be majorly in low and middle income country. So it's gonna only make the problem worse because low and middle income country, they have less than 5% of the Linux of the world and then they are gonna be handling 60 to 80% of all cases. So it's false. We need to do acute intervention, increase access to radiotherapy so we can treat our patients better. Next slide, please. Question number two, when treating lung cancer with radiation, cutting edge technology is the most important variable to promote better outcomes. Is that true or false? Okay, I got answers here. So once again we have kind of a split, but true is winning so 58% of the, of our participants thinks that cutting edge technology is the most important variable to promote better outcomes and 42% think is false. And again, this false. So the most important variable to promote better outcomes is access to care. So it's access to radiation is access to screening early stage access to good pathology in imaging staging. So cutting edge technology, they can add a little, or maybe not many difference on outcomes. What is going to add and improve outcomes and survival for patients in low and middle income countries is access to treatment so we need to remember, access to treatment is more important than having better technology. So as I said, it's better to treat with conventional radiation, then not to treat the patients. Thank you. That's great. Thanks so much, Fabio. So, we can keep the questions to the end. So please do post your questions in the Q&A, rather than the chat, and I'm now delighted to introduce Meredith Giugnani, she's an associate professor in the Department of Radiation Oncology at the University of Toronto and the Director of Education at Princess Margaret Cancer Centre. She's a thoracic radiation oncologist and she focuses on SBRT, she has a special interest in globalization and the influence of educational health systems. So, to you Meredith. Thank you. Thank you very much and we can go to the next slide. We'll start with a polling question for everyone. So to meet the demand for cancer care by 2035, the workforce needs to, and the options are triple, grow at the current rate, double or reduce by 15%. Interesting, are we all split? So most of the modeling across the different professions including radiation, surgical, medical oncology seems to suggest that we're looking at a doubling of the workforce if we keep all of the factors the same in terms of work distribution, professional scopes of practice, etc. So I'll spend the next few slides, picking up on Dr. Murray's points about access and the health human resource aspects of that, and we'll look at maybe some ways that mean we don't need to double the workforce so we can go to the next slide. So this map has some very disturbing data, which really shows the gap in the access to care, related to the number of new cases that individual oncologists are attempting to manage in different parts of the world and you can see there's a fair number of places where no data is currently available, but in others you can see individual oncologists are managing over 1000 patients, which is a very heavy workload. And for those of us that are involved in training and accreditation of training programs, and the capacity for bringing on new trainees, the opportunities to double the workforce in the next 15 years is really unlikely. When you look at implementation data for training programs and curriculum, one of the main barriers to expanding capacity outside of funding and other logistical issues is actually the time for teachers to train people. And when you reflect on the workload that's represented in this slide, the demands of clinical work are often one of the things that make your capacity for training very challenging so we can go on to the next slide. And this really picks up with the conclusions from the last talk that says there really is no care if we do not have a workforce. And I'm going to introduce some concepts in this talk that might have us reimagine what we think of the traditional workforce to be so we can go to the next slide. So this is some great work by Sir Nigel Crisp and some presentations to the WHO over a decade ago. And these are really looking at options to increase our health human resources. And you can see in the medium term, people talk a lot about curriculum reform, and as being sort of a medium term option to addressing these issues. And you can see in the longer term we're talking about partnerships and other things. And I'm going to spend a little bit of time talking about curriculum because it gets talked about a lot as the panacea. We're going to find this great curriculum or this perfect solution. And we're going to train people and it's going to fix our health human resource issues and that's probably not a solution on its own and is fraught with a number of issues, including who's voice is really represented in the generation of the curriculum, what health context is sort of underlying the assumptions that go into the curriculum. And if you implement it in diverse local settings. Is that actually a fit for your local contacts and is that actually closing your care gaps or could it actually make things potentially worse. And if we think back to the Lancet Commission on Health Professions for the New Century, which is again over a decade ago, and their calls for reform. You know they really said that we need to reimagine what patients and families need from their system and underlying the sort of quality agenda and reform agenda. You know, is that is that driven by certain stakeholders does it really represent to the global problem, and from our perspective cancer. And so we can go to the next slide. So the Lancet Commission on Health Professions is a global curricula, and they speak to the issue of universalism in medical education which I'll come back to but global curricula are there conceptualized as a text, and they're intended to be used a common vocabulary and a shared philosophy, describing an outcome, including competency items that are intended to be applicable across nations. So if you think of the complexity of that, and how challenging it is in a global setting to actually obtain a common vocabulary for medicine and medical care, and for our health systems. And to have something that can be truly applicable across nations. So we can go to the next slide. So to present this really just, you know, I can see the the audience here and I'm sure people from many different countries are here today. People will watch it later and reflect on their own training as they went into their different professions. This is this maps of medical training. And I only put three routes up here there are many, but you can just see the diverse paths that people can go from their secondary school, through to the actual certification to become an independent practitioner in medicine and if we open it up to our colleagues and other professions there's even more complexity there. But when you when you reflect on this global complexity and differences in the path. You know how do people move between different regions. Are their credentials recognized as their previous training recognized. Do things need to be repeated is that necessary or unnecessary and what does that mean for, you know, addressing global shortages in health professionals. And if we are attempting to create some kind of universal or global curriculum you know how do you operationalize that within this complexity of the setup for for training throughout the world. And we can come to the next slide. And this next slide is really a great quote, again from the Lansing Commission that says the healthcare crisis is really fueled by a mismatch between curricula, and the needs of patients families in the healthcare system and this really speaks to the issue that very rarely do we completely re examine our curricula so some of you may have been involved in curriculum renewal efforts or other things in your local context and it's very rare that you sit down There's usually some document, it's either your own or something that's been brought from another location, and people start trying to modify it. And over time, things are very rarely removed but new things are attempted to be added it. And you know, so over time, do you get this this creep between what is being taught and what is being prioritized in our training, and what do we actually need. And without the health workforce and without the health system there really is no care. And so as we diverge in training from what is needed. We're only exacerbating the problems that we talked about in the earlier slide so we can go to the next slide. And this is just the issue of universalism and I think it's just good for people to have a sense of this is something in the discourse of health professions training and it really talks that there are international standards that can be defined. And so I think if it's as a group we need to question, is that really true. And is it really a good direction to be to be focusing in to try to create universal standards and should we be doing them in everywhere. In every aspect or are there certain areas that that lend themselves to universalism and other other areas that really need a high degree of local contextualization. So we can go to the next slide. This is the last quote from the Lancet Commission but I really encourage you to read it. This is an area of interest. But this is another issue with curricula that they're closely linked to historical legacy, and they codify traditions priorities and values of the faculty in that profession, and this issue of it's rarely reexamined over time so so whose history of these documents and whose priorities is something that people need to be asking themselves, especially if you're importing educational documents into a new context. So let's move away from curriculum, I will go to the next slide and we can just talk about a couple other potential ways where we might be able to address these health human resource issues so task shifting might be something that people here are familiar with I'll give you the definition though it's it's where you delegate tasks to different healthcare members. So it could be a physician, you know delegating contouring of normal structures or it from a radiation example or, you know, delegating prescribing or managing certain effects to another another group and task shifting potentially has its place in terms of human resource shortages when you have a real lack of certain professions and maybe more access to others so can you shift tasks to deliver care, but more and more people are talking about staff mix, which is really and this is what the puzzle kind of represents you know, the patients and their families need a certain degree of care to be accomplished. So what is the mix of staff that are needed to accomplish this and it's really the grouping of categories of professionals employed in a field. But that staff mix has largely been replaced by the concept of skills mix. And so if we think of skills mix that's really breaking down you know let's say radiation. What are the skills that are necessary across all professions or any professions to accomplish the task of, let's say delivering lung SBRT, and you can you can think about that in your own context but, you know, do you need a radiation oncologist, do you need an oncology nurse you need a physician assistant radiation therapist medical physicists who else, and what skills with those individuals potentially need. So when we're talking about the skills within that is who's making a decision for treatment, who is deciding the number of fractions who's going to contour the case, who's going to approve the combing CT who's going to set the patient up on the bed every day who's going to look after their side effects when they happen. Who's going to look at their imaging to say whether or not their disease has been controlled so those are the skills and the tasks that are necessary to treat somebody, potentially with it with an early stage lung cancer so if we go to the next slide. So this is really moving away from the concept of staff mix to skills mix so if you think of the different skills so ABCD to accomplish this tax, and the black bars are really the professional boundaries so you can have different professions that can accomplish the same tasks so depending on the setting that you're in. You could make decisions around, you know, these are the tasks, these are the people best suited to do it and who's available, and who are most proximal to the patients and make those decisions so you know those are linked to things like regulatory bodies and training schools, but it's something that can be explored, both on a global level and also, you know, contextualize locally around what does your workforce look like. One other area we can go to the next slide that people may or may not be familiar with this concept but it's not particularly new. But it's, and I think those of us in clinical practice, you know, would really recognize this and it's certainly been very much in the forefront of the, of the literature and the public discourse in the last year and a half with COVID is that, you know, they're called unpaid cares here I prefer essential care partners but caregivers of our patients are really the foundation of who is supporting the care for patients. And when we look at the cost that unpaid caregivers in the Canadian context save the healthcare systems billions of dollars in the equivalent of care that they provide in terms of, you know, looking after patients at home, providing transportation. You know doing wound care administering medications. It's a massive amount of care that's really the foundation of what is happening within our healthcare infrastructure, and they are really the foundation of, of what is happening in terms of operationalizing care. There was a very interesting study done in the United States and they asked family caregivers are essential care partners. You know, how did you learn to do the skills that you need to do to perform your caregiving duties and most of them said I learned on my own. And we know that caregiver burnout and caregiver burden is a really very significant issue and so if we recognize that they are the foundation of this, this pyramid that supplies healthcare, you know, I think we can do better and we can certainly do more to support our essential care partners and caregivers in delivering in assisting us and in supporting their family members and we can go to the next slide. So this is just one example of this is something that we've started at Princess Margaret. We're building a caregiver education support and skills program to really move away from that issue of I taught myself to try to distill what are some of the essential supports and education that family caregivers and essential care partners need, and we can better support it to try to make it safer for patients reduce burnout amongst caregivers and help them navigate the system so there's certainly more that can be done in that space and we don't have time to go into all of it today but I just wanted people to be thinking about that as they're thinking about these health human resource issues, and we can come to the next slide. This is one final innovation opportunity that people talk about and the traditional slide rule at the top is what we're all familiar with and if you think back to my slide with those three different pathways you know it's really some kind of schooling foundation undergraduate training post business medicine but the other professions would have something similar postgraduate and then you're out in practice and you're doing some professional development or skills upgrading but you know in the future people talk about something called micro credentialing. So what's the minimum amount of skills and certification that you need to actually go out and contribute to the workforce so if you think back to my first graph around, you know, thousands of patients being cared for by individual psychologists, and how that leads to a lack of teachers to be able to build the workforce because they're so busy delivering care if we can micro credential people and actually have them contributing to care and assisting it may increase the capacity in terms of being able to train more health professionals so just something for people to think about and we can go to my last slide, which is a quote from a good friends and mentor, Dr. who says medical education must become both a vehicle and the object for reform so I hope I've given you some things to think about today, potentially some innovations in the space. Thank you for an interesting talk, and we'll now move on to the final talk by Pablo Munoz, who is an assistant professor in the Department of Radiation Oncology at the Catholic University in Santiago, Chile, and his interests are in thoracic and GI and particularly in high precision radiation therapy for oligometastasis. Thank you. And during the next few minutes we'll pick up from some of Dr. Moraes and Dr. Giuliani's points and focus more on innovation and research to increase access to radiation treatment. But first, we'll start with the question. Next slide. So, to address the challenge of improving access to radiation therapy for lung cancer, which is the most critical aspect in which research initiatives should focus in the short term. So I'll give you a few minutes, a few seconds to answer. So, different to the other polling questions, we can see that a majority of our assistants have answered that all of the above should be approached simultaneously, and I hope that by the end of this talk, I can further convince you that that's correct. So next slide. Thank you. So even though lung cancer incidence has been increasing worldwide over the last 40 years, critical global variations need to be considered when analyzing data. For example, as you can see in the slide, showing age-related adjusted rates separated by gender, lung cancer incidence has considerably increased in regions such as Western Europe and Eastern Asia, but on the other hand, in high-income regions such as North America and Australia, lung cancer incidence has decreased. Next slide. These differences are particularly relevant. In this dataset from GlobalCAN, showing the expected incidence of lung cancer by 2040 in several regions separated by human development index and gender, we can see that the global increase of lung cancer incidence is mainly driven by low- and middle-income countries, where there are multiple challenges related to cancer treatment funding, lacking cancer registries, different healthcare systems, infrastructure, and access to radiation therapy. Can we move on to the next slide? As we've discussed during this webinar, radiation therapy is an effective, evidence-based, and guideline-recommended treatment for patients with lung cancer, both for improving outcomes and palliating symptoms. In the last decade, several studies have aimed at determining the optimal radiotherapy utilization rate for lung cancer, or the percentage of patients that should receive radiation therapy at least once as part of their treatment, according to evidence-based and guideline-based recommendations. This figure has been proposed to be between 62 to 82 percent. However, the actual utilization rate, or the percentage of patients who actually received radiation therapy during a time period, remains lower. In a recent systematic review analyzing 21 studies, most of them coming from countries with a high human development index, show that the actual utilization rates do not go higher than 52 percent. And unfortunately, this number is expected to be lower in low- and middle-income countries, given the challenges that we've mentioned in the previous slide. Can we move on to the next slide, please? Thank you. So, at the moment, several organizations and initiatives are working to improve access to radiotherapy for cancer treatment. The International Atomic Energy Agency, or IAEA, is at the forefront of this effort through many initiatives, notably the Program of Action for Cancer Therapy, or PACT, a multi-partner initiative led by the IAEA and the World Health Organization, highlighting the need for and stimulating investment in radiotherapy, recognizing that encouraging radiation therapy availability and capacity should also boost broader cancer control planning and services efforts in low- and middle-income countries. In addition, the Union for International Cancer Control, or UICC, mandated the Global Task Force on Radiotherapy for Cancer Control that documented the challenge and quantified the investment needed to achieve global equity in access to radiotherapy by 2035, and as mentioned, showing not only the health benefits in cancer control, but also the economic benefit using an investment framework. Also, there are several partnerships between academic and private institutions based in high-income countries, such as the Bena-Farber Cancer Institute, in collaboration with the Rwandan Ministry of Health, the AMPATH Consortium with the Moi Teaching and Referral Hospital in Kenya, and many other consortium-based and industry-initiated training programs in many countries, such as Vietnam, South Africa, and India. Next slide. The IAEA's main objective is to improve access to safe and efficient radiotherapy, diagnostic imaging, and nuclear medicine. It carries this objective through multiple initiatives directly related to research and innovation. For example, through its coordinated research programs, it introduces radiation oncology professionals in low- and middle-income countries to new clinical research activities, evidence-based medicine, and international multi-institutional global clinical trials, facilitating collaboration with high-income countries and reducing bias in clinical trials. Furthermore, other initiatives based at the IAEA, such as the IRIS platform, the Directory of Radiotherapy Centers, and the Human Health Campus, are directly contributing to developing research and innovation in education, global curricula, and implementation science. Next slide. Research and innovation efforts aiming at improving global access to radiotherapy for lung cancer should focus on three main aspects. First, on the implementation challenges and how to address the knowledge gap between evidence-based interventions, such as access to radiotherapy for lung cancer and delivery, focusing particularly on aspects like why patients are not referred for radiation, having the necessary knowledge and equipment to implement a new treatment technique, adapting clinical guidelines to the local context, or the presence of radiation oncologists and tumor wards, among so many others. Second, educational innovation aiming to develop interprofessional initiatives adapted to guidelines from local governing bodies and new learning methods, such as distance and blended learning. And finally, efforts should also focus on multi-institutional global clinical trials, as was mentioned in the previous slide. Next slide. Nowadays, there are several tools to seize opportunities for innovation and collaboration to expand access to radiation therapy worldwide. Especially since the COVID-19 pandemic, we are now more comfortable and empowered with tools such as telecommunication, automation, remote support, virtual collaborative spaces, and blended learning that reduce the distance that separates knowledge from high-income countries and provides ground to develop collaboration and innovation hubs that can serve as mentoring sites. Next slide. Particularly, implementation science, or the scientific study of methods and strategies that facilitate the uptake of evidence-based practice and research into regular use by practitioners and policymakers, is fundamental in radiation oncology to address the knowledge gap between evidence-based interventions and their delivery to community practice. By focusing on the identification of barriers and facilitators, developing and testing implementation strategies, building expertise in scale-up and spread, as well as adapting and improving interventions over time and across space, it can identify complexities in health systems and cost evaluation of interventions, defining sustainability strategies for the future. Next slide. One of the main challenges in improving access to cancer radiation therapy around the world, and particularly in low- and middle-income countries, is having sufficient radiation therapy capacity, especially considering that in low- and middle-income countries, there are only one-third of the global radiation treatment units, but around 60 percent of the world's patients with cancer, as described in the first presentation. In addition, the complexity of operation and maintenance of advanced radiotherapy delivery equipment has freed researchers and industry to investigate novel devices that can broaden access. On the one hand, modified COBALT-60 units have shown that the improved conformal delivery expected in modern radiation therapy is somewhat achievable in a COBALT-60-based IMRT setting. However, COBALT-60 treatments would be longer, radioactivity would be slower, and the radioactive sources pose an environmental and security hazard. There's this notion that a COBALT-60 unit would be not good enough for a high-income country, but good enough for a low- and middle-income country. On the other hand, Linux suppliers have been developing units that are easier to use in low- and middle-income countries. However, as much of this technology is proprietary and not yet described in the literature so far, one approach has been to develop simple, low-energy units with the intentional removal of components that require more careful maintenance or frequent repair. This approach aims at developing a simpler Linux with limitations similar to more advanced COBALT-60 units that are now available. Next slide. To reduce inequality, health care needs to be extended beyond physical geographic boundaries. We already have the example of teleradiology, in which the radiologist interpreting medical images is not present in the location where their images are generated. And in the same line, several frameworks have been described to provide teleradiotherapy services. Given the rapid expansion of information and communication technologies, there's a potential for improving accessibility and capacity-building through remote services. Information transfer, nowadays being done through DICOM-RT interfaces, can be used to exchange data between different radiotherapy centers on a wider geographical scale. And this has already been applied in many developed countries and found to be cost-effective. For example, this framework describes radiotherapy capacity-building using tele-education, networking with 10 countries in Africa that do not have radiotherapy services, with other global institutions acting as mentoring sites. Then, through the integration of primary and secondary radiotherapy centers, by incorporating remote planning and automated quality assurance, part of the treatment planning and QA process can be centralized while delivering radiation therapy at each primary center. Next slide. This slide further describes this framework in which a secondary radiotherapy center acts as the hub where treatment planning is being done and then radiation therapy can be delivered closer to home. Next slide. The global health landscape also stands to benefit from artificial intelligence-based interventions. So far, AI applications promise to alleviate some of these shortages by providing specialized expert knowledge across disease sites and treatment modalities. And as such, many parts of the radiotherapy workflow, such as treatment decision, simulation, treatment planning, planning approval, and QA can be optimized using artificial intelligence. However, whether AI can address hardware equipment shortages or other issues that we've raised during this meeting remains unclear. Ultimately, the availability of AI tools will undoubtedly teach the composition and skillset of the radiation oncology workforce and ideally provide a positive impact on low- and middle- income countries. So, in summary… Next slide. In summary, first, remember that low- and middle-income countries are driving the increase in the incidence of lung cancer worldwide and face multiple challenges. Second, global access to radiation therapy for lung cancer must be tackled at many levels. We already mentioned healthcare systems, hardware shortages, and human resources. And finally, research and innovation to increase access to radiotherapy for lung cancer must focus on implementation science and addressing the gap between evidence-based interventions and their delivery, particularly focusing on challenges and guideline adaptation. Second, multi-institutional global clinical trials that expose radiation oncology professionals in the developing world to high-quality research and equipment. And finally, embrace research in new educational methods such as telementoring and blended learning. And with that, I'll close this presentation. Thanks a lot, Pablo. Very good talk. And I'd like to thank all three speakers for keeping to time. And I'm really, really impressed that you did all your talk exactly on time. Thanks a lot. So, we do have a few questions in the Q&A, but please, you know, if you're in the audience, do not hesitate to post any questions or comments that you may have. And we're partly interested to hear about whether you are experiencing problems with access to radiotherapy in your country, and, you know, learning from your experience would be fantastic. So, just wanted to start with a comment from a colleague, Dr. Tip DeWaal at Tata Memorial, who's saying that there is also a huge imbalance of radiotherapy centres between rural and urban areas, and we need to address this gap to improve the accessibility of radiotherapy to all. So, that's very true that in many low and middle income countries, you'll have a situation of some people living in urban areas who may have much better access, and actually have seen very little literature on that. I don't know whether any of the three speakers have, and whether they want to comment. I can comment on that a little bit from the Canadian perspective, because we also have, you know, a vast geography in Canada with very, with the similar issues with respect to rural and urban. And, you know, just picking up on Dr. Murnau's comments around, you know, the pandemic and virtual care and some changes that COVID-19 has brought in. You know, I think embracing virtual care when appropriate is helpful, reducing the amount of travel that's unnecessary. Our colleagues that led our virtual implementation, at least in the initial implementation, described like the millions of miles and traveling that were saved by switching to virtual visits for patients. So, and as well as the out-of-pocket costs related to parking, gas, people taking time off work. So, you know, where appropriate, you know, reducing the visits to the Cancer Centre. And from a radiation perspective, my practice is largely SBRT, and we have participated in the RTOG study of single fraction, but outside of that had not really routinely used it. We used three and four fractions and eight for central more commonly, but now we've really moved to single fraction as long as it's appropriate. And it's great in terms of it cuts down four visits to one and the outcomes are good. Our experience is growing. Our colleagues and other centers who had moved there before us were great about answering our questions. But I think there's things like that that can be done, embracing hypofractionation where it's appropriate, virtual care where it's appropriate, but then also gathering data. Sometimes having the data on the amount of traveled out-of-pocket costs can be helpful. In persuading government, all three presentations talked about implementation science and the links to the health system, but in my province, Ontario, there was a lot of work over the last two decades to actually build additional radiotherapy centers in places that had more limited access. Yes, and that will be facilitated by the use of telemedicine, of course, because patients could be potentially assessed by people who work at the hub in Toronto, for example, and then treated locally. Yeah, absolutely. Thanks a lot. There is a question. Would you mind if I comment on that one as well? Yeah. Yeah, I would just like to highlight the importance of getting data that Dr. Giuliani brought, because if we want to see this change, we know there's imbalance on outcomes when you compare patients from rural and urban area, and also there's some correlation between distance to oncology center and outcomes. And I just finished some studies in Brazil, and we also found that distance to the center actually correlate with outcomes, or worse outcomes for patients who lives far away. And now we actually, we have data to show to the governors that we need to change the way that we deliver treatment. We need to have new policies to provide access to people and to provide access closer to home. So without data, they don't listen to you. When you start to gathering data, when you have the data together, they will at least listen to you, and they will start planning some actions from the future. So data is the most important thing when you want to do like a big change like that. Yeah, absolutely. But I suspect that in many countries, it is actually difficult to gather data on a population basis as to whether some people who live far away from cancer centers have any access to care at all. I guess there may not be any national audits that exist, which is a barrier in itself. Can I make a quick comment on that? Although I totally second what Dr. Giuliani and Dr. Morais have mentioned, we need to tackle the problem of rurality actually as a multifactorial problem. Are these patients presented in actual tumor wards? Is there a radiation oncologist involved in the decision-making of these patients' treatment? And although we tend to only focus on the accessibility side or whether we are far or closer to the radiation treatment center, it's most likely related to things that come even before that. So I absolutely second what we were discussing, that data is fundamental, but approaching it not only from the accessibility side, but also from the implementation research perspective. And actually, there was a question I was going to ask you about the talk that Fabio gave. I mean, he focused obviously on the data that we have, which is access to technology, but there's all of the aspects of access to care that are up front of that. Simply are they patients having access to cancer care? Are there multidisciplinary team meetings? Is there sufficient access to imaging, to pathology, and so on? And I guess we know a lot less about that from the literature in the context of radiation oncology, do we, Fabio? Yes. So in addition to access to treatments, there's also like this big need, as you highlighted, like needs to access for good pathologies, for good surgery, for biopsies, or for removal of early curable cancers, and also access for imaging. And there's like a Lancet commission in imaging while highlighting the issues for early diagnosis, and then picking like cancers in early stage that you can cure and decrease the odds that that is going to short patient's lives or decrease quality of life. And then like there's many issues that we still need to face. It's not only access to radiation, but there's like a lot of steps before that. And also including palliative care. So access to palliative care in low and middle income countries is low, and then that's unacceptable. So patients, they need to have access to palliative care so they'll have an end of life in the best way possible. Yeah, thank you. So there's a question from Maria Werner-Vasek, who's asking why should caregiver contribution be unpaid? Are there any initiatives to reimburse caregivers, at least partially? So Meredith, what do you know about that? Yeah, that's a great discussion. Just in the essence of time, I didn't go to sort of too deep into that whole space, but it's a very gendered space. So the majority of these caregivers are women. And when you look on a global scale, it does contribute to wage gaps and other issues with respect to gender. It's actually almost even worse than being unpaid. There's actually financial toxicity associated with these caregiver roles in terms of reduced or being unable to work, the cost of, let's say, if you're taking elderly parents, and then you need to engage childcare for your own children, travel, parking, all of those expenses. So it's a really, really complicated area. And then I touched briefly on the training program, but many of these caregivers are doing very significant medical care at home, like looking after tracheostomy tubes, feeding tubes, lines. In some cases, they're assisting with lifting people, just because there's not somebody around 24-7 to do that, and they can be injured. So burnout's an issue, physical injury is an issue, the psychological strain of these types of things when you're ill-prepared and not properly supported. So financially reimbursing them, I don't know if any health system could actually absorb that cost. Because if you look at the data just from the Canadian context, I mentioned it's billions of dollars. If you were actually paying these people a wage to do the care that they do, I don't think any system can support it. So it's a really, really important area. Financial toxicity, physical repercussions are very real. And so something that we can all be doing more about. Yeah, that's great. Thanks, Meredith. Also wanted to ask you another question. You talked about, you questioned whether it's necessary to have international standards. I just wondered, and you focus on the curriculum, but I just also wondered about international guidelines. We obviously have many European, North American international guidelines with regards to lung cancer as to what is the role of radiotherapy, but are they actually appropriate for low and middle income countries? And should there be, in a way, an adaptation made of these guidelines to take into account what is actually possible? Or is it important to try to push for the best? What's your opinion on that? I think those are all the right questions. Curriculum, accreditation, treatment guidelines, all of those things. And I think they have a place in terms of the safety and quality agenda. They also have a place in terms of the advocacy agenda. And I'll give a short example from curriculum. When curricular standards state that there needs to be a minimum of three years or five years of training, that can be very useful to lobby and advocate at the government level to increase funding for training positions and increase the duration of training. So they have very, very important positive attributes, but then there can also be unintended effects because of a lack of fit. And so is it representation at the table, at the development? Is it local adaptation and resources to do that? There's sort of many ways that you could potentially address the fit issue. But I think an awareness of the issue and sort of being purposeful in attending to them is very important. And the European, so ESTRO, their curriculum, they've done very excellent work in terms of purposefully addressing, increasing the amount of input and the people involved in the generation of those, the ESTRO core curriculum. And if you look at the most recent edition and then the generation of the clinical oncology module, it was very purposeful in terms of very diverse stakeholder engagement, which is a really, really great example. Thank you. So Pablo, there's a question about whether artificial intelligence may really help in terms of solving global access to radiotherapy. And I was actually going to ask you on the sort of same note, you talked about various aspects where AI could help, including treatment decision. But actually, do you really believe that it's the case, especially in low and middle income countries where patients may have very specific issues that in many cases would be related to poverty? And can we actually use these AI algorithms that will be developed on often databases coming from affluent countries? So what's your view on that? That's a great question. And it goes back to what we were mentioning before about data. So unfortunately, as long as we don't have enough data to have responsible and inclusive AI, it will be difficult to embrace treatment decision or to implement treatment decision, AI-based treatment decision as a tool that can help us improve access to radiation therapy. So I do agree with the comment for sure. So what we would need that is to build inclusive AI that includes patients from low, data from low and middle income countries, not bringing just only algorithms and data from high income countries. So adapting, developing, and then validating AI-based tools, but developed in low and middle income countries for low and middle income countries. So it's kind of, yeah. I totally agree with that. Any other comments on AI? We're getting to the end of the webinar, but I think that's quite an important topic because on one hand, it could help a lot in terms of automating some tasks where there's a lack of staff, but on the other hand, it's all about being able to use the right data sets that are actually pertinent to the local population. So Fabio or Meredith, do you have any comments on that? Yeah, yeah, actually, like I agree with what has been discussed. And I see that like AI can either like increase or decrease the gap for low income countries. So we need to make like a ethical use of it and we need to have like representation from the globe. In addition to that, I see there's a good potential for AI on automation in low and middle income country because we can use chatbots based on artificial intelligency to help doing triage of patients with symptoms where we don't have like enough resources. We can also be using AI to help scheduling. So then you're doing scheduling more efficiently and then you're able to see more patients. And also with telepathology, teleradiology, even teleradiation oncology, you can use AI to help one with like diagnosis. So reading like pathology slides or reporting on imaging scans and also automated plan with AI based planning and AI based quality assurance. So the data does not need to be there, but can be like sent to a cloud. And then in the cloud, all the algorithms will run and then provide with a good and quality assured plan in places that you don't have enough human resources as Dr. Giuliani said, we need to double or maybe more the workforce so we can close the gap. So that's not gonna happen tomorrow. That's gonna take like at least five to 10 years to get like all these like human resources. So I see a lot of potentials. Yeah, the final question, I don't know whether any of you know about international programs that are actively engaging in sort of some of the top international institutions with other institutions in low and middle income country to try to help with the educational side and train the staff adequately. Anyone would like to answer that one? I guess I would just say, there's many sort of partnerships, many partnerships out there. And I maybe just, there was a question in the chat that I answered, but just in case people don't have the chat open, the global oncology space is a really rich growing profession and sort of subspecialty space. And there's a free course that's just started and you can catch up on all the talks. I posted the link and you can enroll for free. So there's presenters for many of the things that our different talks touched on around the PACT program, leadership and global oncology, all of that. So if you're interested in more partnerships, mentorship opportunities, I would encourage you to click that link and check it out because it's free to join, so. Yeah, that's great. Thanks for that, Meredith. So that's unfortunately all we have time for today. So it was a really, really good webinar. Thank you to the three speakers. Thank you for your questions. So keep an eye out for an email that will be sent to the program evaluation and CME information later today. And we've posted in the chat, the link so you can see the slides if you want to look at them at a later stage. Thank you very much all for your participation and I hope you all have a good day or a good evening wherever you are. Bye-bye.

webinar

global access

radiotherapy

lung cancer

research

innovation

collaboration

barriers

data

implementation science