Radiotherapy capacity in European countries: an analysis of the Directory of Radiotherapy Centres (DIRAC) database

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1 Radiotherapy capacity in European countries: an analysis of the Directory of Radiotherapy Centres (DIRAC) database Eduardo Rosenblatt, Joanna Izewska, Yavuz Anacak, Yaroslav Pynda, Pierre Scalliet, Mathieu Boniol, Philippe Autier Radiotherapy is used for cure or palliation in around half of patients with cancer. We analysed data on radiotherapy equipment in 33 European countries registered in the Directory of Radiotherapy Centres (DIRAC) database, managed by the International Atomic Energy Agency. As of July, 2012, Europe had 1286 active radiotherapy centres. The average number of teletherapy machines per radiotherapy centre ranged from 1 2 to 7 0 in different countries. Nordic countries, the UK, the Netherlands, and Slovenia all have large centres with four to ten teletherapy machines. Most western and southern European countries have several small centres with one or two machines, with few larger centres. The fragmentation in radiotherapy services that prevails in many European countries might affect the economic burden of radiotherapy and its quality. Eastern and southeastern European countries need to expand and modernise their radiotherapy equipment. Introduction Cancer is a major public health problem in Europe. Every year, 3 2 million Europeans are diagnosed with the disease; 1 this number is expected to increase, mainly because of population ageing and, particularly for some cancers (eg, breast and colorectal cancer), because of the increasing prevalence of obesity. 2 Radiotherapy is an effective and widespread method for treating cancer with curative intent. It is also an effective method of palliation in patients with advanced disease. A steady rise in the number of patients with cancer is boosting demand for radiotherapy services in Europe. Roughly 45 55% of patients with cancer require radiotherapy at some point, and about 20 25% will have more than one course of treatment. 3,4 An assessment of radiotherapy in cancer care in Sweden estimated that, of patients with cancer who are cured, 49% are cured by surgery, 40% by radiotherapy alone or in combination with other treatment methods, and 11% by chemotherapy alone or in combination with other methods. 5,6 In view of the importance and cost of radiotherapy and the infrastructure required, the European Society for Radiotherapy and Oncology (ESTRO) organised the QUAntification Of Radiation Therapy Infrastructure And Staffing Needs (QUARTS) project in 2003, which aimed to establish objective and quantifiable criteria for long-term capacity planning of radiotherapy services in Europe. 7 QUARTS gave an overview of national guidelines and proposed new evidence-based recommendations for planning radiotherapy infra structure and staff require ments. The project showed that the availability and need for radiotherapy services varies greatly from one European country to another; however, the data assembled for comparing existing and required equipment included only 13 countries and were of inconsistent quality, many being out-of-date or incomplete. The project s final report underlined the need for a prospective and continuously updated inventory of radiotherapy facilities and cost in Europe, in parallel with a continuous assessment of how treatment needs are being fulfilled. This Health-care Development article provides an inventory of radiotherapy capacity in Europe, based on an analysis of the European section of the Directory of Radiotherapy Centres (DIRAC). 8 The European Network for Information on Cancer (EUNICE) project, which analysed the DIRAC database, was done from by the International Atomic Energy Agency (IAEA), the International Agency for Research on Cancer (IARC), and the International Prevention Research Institute (ipri). This report summarises the radiotherapy component of the EUNICE project, and aims to provide basic indicators for planning radiotherapy infrastructure and manpower at national and regional levels. Data source and collection For the EUNICE project, Europe encompassed 33 countries: the 27 members of the European Union, three candidate countries for membership (Croatia, Macedonia, and Turkey), and three countries that are part of the European Free Trade Association (Iceland, Norway, and Switzerland). To categorise these countries into broader regions, we used the geographical subregions proposed by the UN Statistics Division, namely western, northern, and eastern Europe. 9 We grouped together Croatia, Macedonia, Greece, Cyprus, and Turkey as a fourth region southeastern Europe. Radiotherapy data were collected using DIRAC, 8 a registry of worldwide radiotherapy facilities maintained by the Division of Human Health of the IAEA since The current electronic version of DIRAC contains data collected since 1995 pertaining to radiotherapy machines, sources and devices used in brachytherapy, equipment for dosimetry, staffing, dose calculation, and quality assurance instruments. Worldwide data stored in DIRAC are collected from 137 countries, representing 7620 radiotherapy centres and teletherapy machines. DIRAC is continuously updated by direct online access by centres, and with data from the IAEA and WHO thermoluminescence dosimetry postal audit programme, the National Secondary Standards Dosimetry Laboratories, Lancet Oncol 2013; 14: e79 86 Published Online January 24, S (12) See Health-care Research Lancet Oncol 2006; 7: International Atomic Energy Agency, Vienna, Austria (E Rosenblatt MD, J Izewska PhD, Y Anacak MD, Y Pynda MSc); Department of Radiotherapy, Catholic University of Louvain, Brussels, Belgium (P Scalliet MD); and International Prevention Research Institute, Lyon, France (M Boniol PhD, P Autier MD) Correspondence to: Dr Eduardo Rosenblatt, Applied Radiation Biology and Radiotherapy Section, International Atomic Energy Agency, Wagramer Strasse 5, Vienna A-1400, Austria e.rosenblatt@iaea.org For more on the QUARTS project see org/projects/pages/quarts. aspx Vol 14 February 2013 e79

2 Total population 10 radiotherapy centres megavoltage teletherapy machines Mean number of megavoltage teletherapy machines per centre Megavoltage teletherapy machines per million people linear accelerators Austria Belgium Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Iceland Ireland Italy Latvia Lithuania Luxembourg Macedonia Malta Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Switzerland Netherlands Turkey United Kingdom Total Table 1: Teletherapy centres and equipment in 33 European countries (July, 2012) cobalt-60 megavoltage teletherapy machines and data gathered during expert visits and planned update efforts focused on specific countries or regions. From 2008 to 2012, the European component of the DIRAC database underwent a systematic update and analysis. The results presented here reflect the situation as of July, Definition of a radiotherapy centre DIRAC considers a radiotherapy centre to be a health facility with radiotherapy equipment (radionuclide teletherapy unit, clinical accelerator, radiosurgery unit, heavy particle accelerator, or brachytherapy afterloader) used for treating patients with cancer. Facilities are not registered if they meet any of the following criteria: those set up to treat non-malignant diseases only, those operating an orthovoltage x-ray machine only, radiation research centres where no active treatment is given to patients, veterinary care centres, or urology and gynaecology centres that provide manual brachytherapy alone. When a hospital, centre, institute, or a health-care group has more than one facility in separate postal addresses, each is registered as an individual radiotherapy centre. Centres recorded in DIRAC as inactive due to discontinuation of radiotherapy services were excluded from our analysis. Equipment In DIRAC, radiotherapy equipment is recorded in separate sections for external-beam therapy (teletherapy) machines, brachytherapy equipment, imaging devices, computerised planning systems, and dosimetry e80 Vol 14 February 2013

3 instruments. Teletherapy and brachytherapy machines were the focus of this study. Teletherapy machines are classified by DIRAC as radionuclide units (cobalt-60 or caesium-137 machines), clinical accelerators and linear accelerators that generate high energy x-rays or electron beams, or both, and heavyparticle accelerators that generate proton and heavy-ion beams. New generation machines such as helical tomotherapy, robotic radiotherapy, high-energy stereo tactic x-ray radiosurgery machines, and mobile electron accelerators for intraoperative radiotherapy are counted as clinical accelerators. Heavy-particle accelerators are counted only if routinely used for patient care. Radionuclide stereotactic machines are counted as radionuclide therapy units. Kilovoltage x-ray generators (superficial and orthovoltage) are counted separately. Brachytherapy equipment is classified as using manual delivery (wires, needles, or seeds) or afterloaders (low dose rate [LDR], high dose rate [HDR], or pulsed dose rate [PDR]), and the type of isotope is recorded (eg, iridium-192, cobalt-60, caesium-137, or iodine-125). The DIRAC database does not have an accurate record of the number of LDR sources for manual loading; therefore, only data on LDR afterloaders are presented here. Devices for radiotherapy imaging are classified as conventional simulators and CT simulators. The data on CT simulators are less reliable than for conventional simulators, because CT machines in radiology departments are also used for general imaging and no information is available on time-sharing between radiotherapy planning and other activities. Furthermore, analysis of data related to radiotherapy planning systems proved difficult because of the rapid turnover of computer hardware and software, and is therefore not presented here. Computation of indicators We used population, epidemiological, and economic data to compute basic indicators that allowed comparisons of radiotherapy equipment between countries. The number of teletherapy machines, linear accelerators, and radionuclide units per radiotherapy centre is an indicator of the degree of fragmentation of radiotherapy services in a country. A high number represents low fragmentation, with most teletherapy machines located in a few centres. A low number represents a high level of fragmentation, with many centres operating only one or two teletherapy machines. The number of teletherapy machines, linear accelerators, and radionuclide units per million people is another key indicator. To calculate this number, we used 2012 population data extracted from the statistical office of the European Commission (Eurostat) database. 10 To interpret this indicator, we used two benchmarks from the QUARTS project; 6 we considered the European average of 5 9 machines per million inhabitants to be the desirable density for radiotherapy equipment, and a density of four Number Medical accelerators 3072 Linear accelerators 2912 Electron-beam units for intraoperative radiotherapy 46 X-ray radiosurgery units 40 Helical tomotherapy units 61 Charged-particle accelerators 13 Radionuclide units 277 Cobalt-60 units 245 Caesium-137 units 12 Radiosurgery units 20 Kilovoltage machines 399 Brachytherapy equipment 945 Afterloaders 712 Manual systems 233 Table 2: Radiotherapy equipment in the 33 European countries included in this study machines per million people to be the minimum requirement this being the estimated density of radiotherapy machines in Cyprus, the European country that QUARTS estimated as having the lowest requirements according to its cancer epi demi ological profile. A third indicator calculated was the number of patients who received cancer treatment per teletherapy machine, using cancer incidence in 2008 for each of the 33 European countries. 1 The incidence was probably underestimated for Turkey because of suboptimum quality of data on cancer cases and death; 11 we therefore estimated an incidence based on figures for neighbouring countries (Malta, Greece, Bulgaria, Macedonia, and Romania). We used as a benchmark the estimate that 50% of patients with cancer will need radiotherapy treatment, which we increased by a factor of 25% to account for retreatment. 7 Therefore, we multiplied the estimated number of new cancer cases in 2008 by a correction factor of 62 5% to obtain the country-specific number of patients with cancer who would have required radiotherapy in To estimate the number of machines needed, we used the QUARTS benchmark of 450 patients per year per machine (whether for cancer treatment or retreatment). 7 Finally, we used World Bank data on country-specific gross national income (GNI) per head 12 to correlate the wealth of nations against the country-specific number of patients with cancer who received radiotherapy in To explore the relationship between macroeconomic data and supply in radiotherapy machines, we fitted a loglinear regression between the number of patients with cancer per teletherapy machine and the GNI per head in US$. We then computed the corresponding Pearson correlation coefficient. Infrastructure In July, 2012, Europe had 1286 active radiotherapy centres registered in the DIRAC database (table 1). Germany had Vol 14 February 2013 e81

4 megavoltage teletherapy machines patients with cancer 1 treatments and retreatments needed* treatments and retreatments per machine, per year Expected number of machines Expected observed number of machines Austria % Belgium % Bulgaria % Croatia % Cyprus % Czech Republic % Denmark % Estonia % Finland % France % Germany % Greece % Hungary % Iceland % Ireland % Italy % Latvia % Lithuania % Luxembourg % Macedonia % Malta % Norway % Poland % Portugal % Romania % Slovakia % Slovenia % Spain % Sweden % Switzerland % Netherlands % Turkey % United Kingdom % Total % % unmet needs *Based on an estimate that 62 5% of patients with cancer will need radiotherapy treatment or retreatment. Based on a maximum of 450 patients treated or retreated per machine per year. 5 (Expected observed number of machines) / expected number. patients with cancer estimated from numbers in Macedonia, Malta, Greece, Romania, and Bulgaria. Average number per country. Table 3: Existing and required megavoltage radiotherapy machines in European countries the highest number (n=289), followed by France (n=177), Italy (n=172), Spain (n=117), Turkey (n=95), and the UK (n=76); the remaining countries had between one and 36 centres each. These centres operated a total of 3157 high-energy linear accelators or cobalt-60 teletherapy machines. In addition, they operated electron-beam units for intraoperative radiotherapy, x-ray radiosurgery units, helical tomotherapy machines, proton or heavyparticle accelerators, and other radionuclide teletherapy units, such as caesium-137 machines and radiosurgery units using cobalt-60 sources (table 2). There were also 399 registered kilovoltage x-ray machines in the database. The mean number of teletherapy machines per radiotherapy centre was 2 5 (table 1). Slovenia had the highest average number of machines per centre (7 0), and Bulgaria had the lowest (1 2). Five countries had an average of four or more machines per centre, whereas six countries had an average of less than two, meaning that in these countries, many radiotherapy centres operate with only one teletherapy machine. In general, the Nordic countries, the UK, the Netherlands, and Slovenia had a more centralised radiotherapy infrastructure with a high number of machines per centre. e82 Vol 14 February 2013

5 There was an average of 5 3 teletherapy machines per million people in Europe, with large variations across countries (table 1). More than eight machines per million people were available in Belgium, the Nordic countries (except Iceland), and Switzerland, whereas Macedonia and Romania had fewer than two machines per million people. 17 countries had more than 5 1 machines per million people, and ten had fewer than four machines per million people. In the 33 countries studied, linear accelerators accounted for 92% of all teletherapy machines. Although radionuclide teletherapy units are rare or non-existent in most countries in northern and western Europe, they represent about 31% of all teletherapy machines in the group including Bulgaria, Hungary, Croatia, Czech Republic, Malta, Slovakia, Romania, Macedonia, and Turkey. However, in general, radionuclide-based teletherapy units are being replaced with linear accelerators. DIRAC registered nine teletherapy machines that use caesium-137: eight in the Czech Republic and one in Hungary. Of these machines, only four in the Czech Republic are operational and are mostly used for treatment of inflammatory musculoskeletal disorders. 12 centres were providing treatment to patients using proton or heavy-ion particle beams. These centres are located in Italy, France, UK, Germany, Poland, Russia, Sweden, and Switzerland. 14 particle-therapy facilities were in the planning stage or under construction in Austria, the Czech Republic, Germany, Italy, Switzerland, Sweden, and Slovakia. 13 Population, patients with cancer, and economic indicators In 2008, about million people living in the 33 countries that were part of this study were diagnosed with cancer, 1 about half of whom required radiotherapy. The actual and required availability of teletherapy machines in 2012, according to the estimated cancer incidence in 2008 and the QUARTS benchmark for supply of teletherapy machines, is shown in table 3. We estimated that the number of patients with cancer per radiotherapy machine per year ranged from 307 in Switzerland to 1583 in Romania, with an average of 556 patients per machine. Unmet needs were defined as the percentage of patients with cancer in each country who would not have access to radiotherapy, based on the QUARTS criteria of 450 patients per machine per year. A negative percentage for unmet needs means that more machines are available than the number defined by the QUARTS benchmark. Our results show that the Nordic countries, Belgium, the Netherlands, and Switzerland are well-equipped with teletherapy machines. There is an apparent shortage of machines in Germany, Italy, Austria, Portugal, and the UK, and most countries in eastern and southeastern Europe (in particular Bulgaria, Macedonia, and Romania) are largely underequipped. patients with cancer per teletherapy machine GNI per head Figure: Log-linear regression between the number of patients per teletherapy machine and gross national income (GNI) per head (r= 0 80; p<0 0001) We found a negative correlation between GNI per head and the number of the patients per radiotherapy machine per year (figure). High-income countries (GNI per head of US$ or more in 2011) have fewer patients per year served by each machine than countries whose GNI per head is lower. At the higher-end income of $ GNI per head or more, the number of patients treated achieves the level of patients per machine per year. Brachytherapy 945 brachytherapy systems were identified; these included 712 remote afterloading machines and 233 manual brachytherapy systems (table 2). 546 machines used HDR sources, 328 used LDR, 31 used medium dose rate, and 40 used PDR. Overall, 657 centres in Europe had brachytherapy facilities, representing about 52% of all radiotherapy centres. 562 centres had remote afterloading systems and the remaining 125 centres used manual delivery of brachytherapy. Thus, only 43 7% of all European centres had remote afterloading capability. For individual countries, the percentage of centres with brachytherapy systems varied from less than 40% of centres in France, Italy, and Spain, to 60% or more in northern, eastern, and southeastern European countries (data not shown). Countries with smaller populations typically used only remote afterloading systems (Croatia, Cyprus, Estonia, Macedonia, Iceland, Latvia, Luxembourg, Malta, Slovakia, and Slovenia); some countries with a strong tradition of LDR brachytherapy had a large proportion of manual brachytherapy systems (eg, France, Belgium, Bulgaria, and Spain). Iridium-192 was the most common radioactive source used for brachytherapy in Europe (table 4). This was followed by caesium-137, iodine-125, and cobalt Vol 14 February 2013 e83

6 High dose rate Low dose rate Medium dose rate Pulsed dose rate Total Iridium Caesium Iodine Cobalt No data Total Table 4: brachytherapy machines, according to isotope and operating mode, in the 33 European countries included in this study In three countries (Belgium, Czech Republic, and Spain), a few institutions kept a stock of radium-226 brachytherapy sources, but these were no longer used for patient care. There was not a marked east west difference for quality of brachytherapy equipment, possibly due to the relatively lower cost of this type of equipment. For 219 systems, entries in DIRAC did not provide details of the radionuclide source. Conclusions This first comprehensive analysis of DIRAC data for Europe shows a substantial disparity in the availability and organisation of radiotherapy services between countries. For countries with a well-developed radiotherapy infrastructure, we identified two main approaches to organisation of radiotherapy services. In Nordic countries, the UK, and the Netherlands, radiotherapy services are usually centralised in a few large cancer-care centres that provide all types of radiotherapy techniques, with four to ten machines per centre, and all necessary equipment and personnel. In most other European countries, radiotherapy facilities vary in size and capacity, with many small facilities fitted with one or two machines and treatment focused on specific cancer types. If we use a benchmark of four machines per radiotherapy centre as the threshold below which fragmentation of radiotherapy facilities occurs, then fragmentation exists in 28 of the 33 countries included in this analysis, and hyperfragmentation (ie, fewer than two machines per centre) exists in six countries. A study from Belgium calculated a lower threshold of 1000 patients per radiotherapy centre (ie, a minimum of two machines per centre) to optimise cost-effectiveness. 14 Fragmentation of radiotherapy services might have an effect on the economic burden of radiotherapy and on its quality. Some European countries spend more on resources and have more equipment and personnel than others. However, because of frag mentation, greater resource allocation does not necessarily translate into benefits for patients; countries that devote fewer resources to radiotherapy might do so in a way that fulfils needs better than suggested by the statistics in table 3. The question of whether differences in equipment and organisation have an effect on cancer outcomes was beyond the scope of this study, but further research is needed into how to optimise the efficiency of radiotherapy services. The type of radiotherapy equipment used differs between regions of Europe. Apart from radionuclide units specific to radiosurgery, radionuclide teletherapy is almost non-existent in northern and western Europe. In eastern and southeastern Europe, cobalt-60 machines still represent a sizeable part of the radiotherapy armamentarium. In some eastern European countries, teletherapy machines are out-dated and need to be replaced by modern equipment; these countries have the greatest need to broaden the coverage of their radiotherapy services. Eastern and southeastern European countries need to expand and modernise their radiotherapy equipment. How these needs will be met is yet to be determined, since our study found that, in Europe, less wealthy countries allocate fewer resources to radiotherapy. Similar relationships between GNI per head and level of radiotherapy infrastructure have been reported, 15 in particular for African, 16 Asian, 17 and Latin American 18 countries. Half of all radiotherapy centres in Europe provide brachytherapy services, and around three-quarters of brachytherapy systems use afterloading delivery. DIRAC data probably underestimate the use of brachytherapy, because many gynaecology and urology centres provide only manual brachytherapy for cervical and prostate cancers, and these centres are not recorded in the database. HDR is the most common method of delivering brachytherapy, although LDR is still widely used. Many centres have capacity for both techniques, since their use depends on cancer site. A recent survey on brachytherapy in Europe (which did not include Germany, Turkey, Greece, Ireland, and Slovakia) 19 reported increased use of HDR and PDR techniques between 2002 and 2007, and a decline in LDR brachytherapy. Radium-226 sources have been almost completely replaced in Europe by newer iridium-192, caesium-137, coblalt-60, and iodine-125 brachytherapy sources. This study has several limitations. The benchmarks we used were crude, but proposing new benchmarks was beyond the scope of this report. The benchmarks we used do not take into account the epidemiological cancer profiles specific to each of the 33 countries, or the possible existence of new national guidelines for radiotherapy. In this respect, estimating radiotherapy equipment requirements on the basis of population (table 1) or on cancer cases (table 3) might not be consistent, since incidence rates are higher in older populations. Although the QUARTS project 7 was a start, there is still a need in most European countries for benchmarking on the basis of incidence and treatment methods specific to different types of cancer. Since many European countries do not have nationwide cancer registration, benchmarks based on cancer burden depend on estimates of incident cancer cases. e84 Vol 14 February 2013

7 The demand for radiotherapy depends heavily on the incidence of breast and prostate cancers, which is itself affected by the extent of screening programmes. Also, the proportion of patients with breast or prostate cancer who are receiving radiotherapy can vary from country to country. Another approach would be to set benchmarks based on the proportion of the population older than 50 years, since most cancers occur in older individuals. Although our report provides a quantitative overview of radiotherapy infrastructure in Europe, it does not address quality issues. How radiotherapy capacity is being used needs to be explored. The quality of the infrastructure (age and condition of equipment, radiotherapy techniques in routine use, and quality assurance programmes) and manpower (training and certification) should be assessed separately. Although DIRAC contains some equipment quality data (eg, on dosimetry and quality assurance equipment), information on quality assurance programmes falls outside the scope of the DIRAC datasets; therefore, it would not be appropriate to draw conclusions about the quality of radiotherapy services based on DIRAC data. Data from DIRAC on manpower were not at present considered sufficiently accurate for our purposes. The radiation oncology community in Europe includes about 6000 radiation oncologists, more than 3000 medical physicists, and radiotherapy technologists. Collecting and interpreting manpower data is difficult because the definitions of radiation oncologist, medical physicist, and radiation technicians differ between European countries, and sometimes also within countries. For example, in the UK and Macedonia, radiation oncologists are not differentiated from medical oncologists (also known as clinical oncologists). Furthermore, technologists often work part-time, mainly in small radiotherapy centres, which complicates manpower statistics. Tasks done by medical physicists differ from country to country and from centre to centre, with varying levels of specialisation. In some areas, medical physicists perform all tasks related to radiation medicine (eg, radiotherapy, nuclear medicine, and diagnostic radiology), whereas in other countries or centres, they are dedicated to one field of radiation medicine. Despite radiotherapy being more cost effective than surgery and chemotherapy for treating cancer, 5,6 the building and running of a radiotherapy centre requires substantial financial and technical investment. This includes construction of treatment rooms and purchase of treatment machines, conventional or CT simulators, computer hardware and software, dosimetry equipment, and patient positioning devices. Training for radiation oncologists, medical physicists, and radiotherapy technicians is necessary. The initial cost of a basic centre equipped with a single radiotherapy machine is at least 5 million, a figure which can climb to tens of millions depending on the size of the centre and the radiotherapy Search strategy and selection criteria We searched PubMed, ISI Web of Science, Scopus, and Google Scholar, with the terms radiotherapy or brachytherapy combined with economics or health care organization or staffing for papers published in English between January, 1995, and July, We searched references cited in reports and websites dedicated to projects on radiotherapy having a European agenda. We also searched documents and technical reports stored or produced by the IAEA. We compiled the literature and selected reports relevant to the objective and scope of the DIRAC project, with special attention to Europe. technology used. Running costs, maintenance contracts, replacement of radioactive sources, and upgrades of software and hardware are all recurring costs. Because of the capital investment required for radiotherapy equipment and its long depreciation period (a linear accelerator might work for 10 years or more), changes in radiotherapy needs must be predicted far in advance. In this respect, the DIRAC database is very useful for planning radiotherapy infrastructure and manpower. However, to take full advantage of its potential, the DIRAC database needs complementary data, such as epidemiological trends in number and types of cancers, including time projections for demographic and riskfactor changes. Other factors need to be taken into account, such as variation in cancer treatment and differences in treatment guidelines between and within nations. Finally, the service life of existing radiotherapy equipment is a crucial parameter, since the cost of replacement might divert resources for building new infrastructure. Some countries have developed standards for running radiotherapy services; 20,21 however, there is no common policy within Europe regarding installation and operation of radiotherapy centres. 3,7 The IAEA published guidelines and requirements for planning national radiotherapy services for its member states, 22,23 including European countries. Several reports and recommendations on the minimum requirements for radiotherapy infrastructure and staffing are available, but few guidelines exist on the optimum way to organise and run radiotherapy services. The IAEA has initiated a process for defining staffing requirements at radiation medicine centres based on the number of patients served, and on an activity-based model that takes into account the complexity of modern equipment and techniques. In conclusion, we have documented the current radiotherapy capacity in Europe and identified shortfalls in infrastructure and manpower, particularly in some European countries. We hope that governments, European Union bodies, and international organisations will take advantage of the DIRAC initiative and use it as a guideline for setting standards and planning investment into radiotherapy services. Vol 14 February 2013 e85

8 Contributors ER and JI drafted the article. YA and YP managed the DIRAC database. MB did statistical analyses. PS provided clinical expertise. PA finalised the article. ER, JI, PS, and PA contributed to the interpretation of findings. Conflicts of interest PA and MB are former staff members of the International Agency for Research on Cancer. All other authors declared no conflicts of interest. References 1 Ferlay J, Parkin DM, Steliarova-Foucher E. Estimates of cancer incidence and mortality in Europe in Eur J Cancer 2010; 46: Wang YC, McPherson K, Marsh T, Gortmaker SL, Brown M. Health and economic burden of the projected obesity trends in the USA and the UK. Lancet 2011; 378: Slotman BJ, Cottier B, Bentzen SM, Heeren G, Lievens Y, van den Bogaert W. Overview of national guidelines for infrastructure and staffing of radiotherapy. ESTRO-QUARTS: work package 1. Radiother Oncol 2005; 75: Delaney G, Jacob S, Featherstone C, Barton M. The role of radiotherapy in cancer treatment: estimating optimal utilization from a review of evidence-based clinical guidelines. Cancer 2005; 104: Frödin JE, Jonsson E, Möller T, Werkö L. Radiotherapy in Sweden: a study of present use in relation to the literature and future trends. Acta Oncol 1996; 35: The Swedish Council on Technology Assessment in Health Care (SBU). Radiotherapy for cancer. Acta Oncol 1996; 35 (suppl 6): Bentzen SM, Heeren G, Cottier B, et al. Towards evidence-based guidelines for radiotherapy infrastructure and staffing needs in Europe: the ESTRO QUARTS project. Radiother Oncol 2005; 75: International Atomic Energy Agency. DIRAC (DIrectory of RAdiotherapy Centres). default.asp (accessed Sept 11, 2012). 9 United Nations Statistics Division. Composition of macro geographical (continental) regions, geographical sub-regions, and selected economic and other groupings. unsd/methods/m49/m49regin.htm (accessed Sept 11, 2012). 10 European Commission. EUROSTAT database. ec.europa.eu/portal/page/portal/eurostat/home (accessed Sept 11, 2012). 11 International Agency for Research on Cancer. Globocan (accessed Sept 11, 2012). 12 The World Bank. Gross national income per capita 2011, Atlas method and PPP. download/gnipc.pdf (accessed Sept 10, 2012). 13 Particle Therapy Cooperative Group. Particle therapy facilities in a planning stage or under construction. newptcentres.html (accessed Sept 11, 2012). 14 Lievens Y, van den Bogaert W, Kesteloot K. Activity-based costing: a practical model for cost calculation in radiotherapy. Int J Radiat Oncol Biol Phys 2003; 57: Levin V, Tatsuzaki H. Radiotherapy services in countries in transition: gross national income per capita as a significant factor. Radiother Oncol 2002; 63: Abdel-Wahab M, Rosenblatt E, van der Merwe D, Pynda Y, Meghzifene A. Changes in the availability of radiation oncology services in Africa; a report from the IAEA. rsna2011/program/event_display.cfm?em_id= (accessed Dec 18, 2012). 17 Tatsuzaki H, Levin CV. Quantitative status of resources for radiation therapy in Asia and Pacific region. Radiother Oncol 2001; 60: Zubizarreta EH, Poitevin A, Levin CV. Overview of radiotherapy resources in Latin America: a survey by the International Atomic Energy Agency (IAEA). Radiother Oncol 2004; 73: Guedea F, Venselaar J, Hoskin P, et al. Patterns of care for brachytherapy in Europe: updated results. Radiother Oncol 2010; 97: Esco R, Palacios A, Pardo J, et al. Infrastructure of radiotherapy in Spain: a minimal standard of radiotherapy resources. Int J Radiat Oncol Biol Phys 2003; 56: Ruggieri-Pignon S, Pignon T, Marty M, Rodde-Dunet MH, Destembert B, Fritsch B. Infrastructure of radiation oncology in France: a large survey of evolution of external beam radiotherapy practice. Int J Radiat Oncol Biol Phys 2005; 61: International Atomic Energy Agency. Setting-up a radiotherapy programme: clinical, medical physics, radiation protection and safety aspects. TecDoc_1040_Design_RT_proj.pdf.(accessed Dec 18, 2012). 23 International Atomic Energy Agency. Planning national radiotherapy services: a practical tool. books/iaeabooks/8419/planning-national-radiotherapy-services-a- Practical-Tool (accessed Dec 18, 2012). e86 Vol 14 February 2013