Implementing hypofractionated radiotherapy for prostate cancer could enable treatment for an additional 0.8 million patients, easing radiotherapy demands. It will also help save resources, for example, a 50% shift from conventional radiotherapy to hypofractionated RT could yield potential cost savings of $1.28 billion for prostate cancer. Increasing the substitution to 80% would raise these savings to $2.04 billion.
To estimate hypofractionation’s impact on radiotherapy needs, prostate cancer incidence data from 2022 (GLOBOCAN) was adjusted to 2024 populations. The optimal radiotherapy utilization rate, set at 58% for prostate cancer by the Lancet Oncology Commission on expanding global radiotherapy access, provided the basis for estimating the total annual need for radiotherapy courses in each country. The number of fractions per radiotherapy course for conventional and hypofractionated treatments was based on published guidelines and validated by a 2022 IAEA survey of over 200 radiotherapy centers in 55 countries. For localized prostate cancer, hypofractionated radiotherapy involved 60 Gy in 20 fractions, while conventional radiotherapy followed the standard of 74 Gy in 37 fractions.
When treating moving targets, such as the prostate, radiotherapy accuracy can be enhanced with motion management techniques. These allow real-time tracking of the target’s position and adjustments during treatment or pausing if the target moves beyond a set range. However, these technologies require substantial investment in equipment and staff training. Figures from the Commission reveal a disparity in access, with HICs adopting these techniques more frequently than LMICs.
According to IAEA’s DIRAC, from 2013 to 2022, the number of radiotherapy machines globally grew by 18%, increasing from 13,103 to 15,460, with most regions seeing a rise in machines per million population. In Africa, access to teletherapy expanded from 23 out of 52 countries in 2010 to only 28 out of 54 countries by 2020, and significant disparities remain. Innovative solutions like hypofractionation are crucial for maximizing machine use and expanding access. Despite advances, the limited availability of trained professionals, particularly medical physicists, remains a challenge globally, especially in LMICs.
There is also a rising demand for theranostics, which combines diagnostic and therapeutic approaches using radiopharmaceutical therapies. The recent approval of [177Lu]PSMA therapy for prostate cancer has highlighted the potential for new theranostic treatments to impact patient care. However, the production of key radioisotopes (e.g., ⁹⁹Mo, ¹³¹I, ¹⁷⁷Lu, and ²²⁵Ac) is concentrated in a few countries, posing supply chain constraints. Coordination of production capacity and distribution is required to ensure there is equitable access to radioisotopes used both for imaging and therapeutic radiopharmaceuticals in all countries.
As part of the Commission, data from 166 countries was obtained by IAEA and examined issues impacting on access and availability of theranostics at a global level. The findings revealed critical shortages of nuclear medicine professionals, including nuclear medicine physicians, technologists, radiochemists, radiopharmacists, even in HICs, and medical physicists lacking in MICs and HICs. Programs to create a well-trained workforce are essential, and the development of theranostic training curricula for nuclear medicine professionals is being pursued as an urgent priority in many countries.
To provide equitable access to theranostics, including newly approved therapies such as [177Lu]DOTATATE for advanced neuroendocrine cancer and [177Lu]PSMA for advanced prostate cancer, issues relating to the availability of these treatments were explored. Currently, the availability of [1⁷⁷Lu]PSMA and [177Lu]DOTATATE treatment is predominantly limited to HICs, with workforce shortages, adequate facilities for treatment, and funding constraints emerging as significant obstacles to broader access and implementation.
To determine the global need for new theranostic treatments, the Commission explored the numbers of prostate cancer patients who would potentially require [177Lu]PSMA treatment based on FDA-approved indication at a global level. It was calculated that over 158,000 patients with metastatic castrate-resistant prostate cancer annually could benefit from [¹⁷⁷Lu]PSMA treatment, requiring more than 553,000 individual doses. Demand for [177Lu]PSMA therapy is expected to grow with increasing numbers of prostate cancer cases being diagnosed particularly in MICs and LICs, and evidence emerging for the benefits of [177Lu]PSMA therapy earlier in the treatment of metastatic prostate cancer. Costs of [177Lu]PSMA therapy vary widely, with treatment being disproportionately expensive in LMICs relative to GDP. Social and economic analyses in nine HICs and MICs revealed missed opportunities for improving productivity and quality-adjusted life years, with unrealized benefits totaling $725 million over seven years. These findings indicate the compelling case for improving access and availability of [177Lu]PSMA treatment in all countries.
Written by:
- May Abdel-Wahab, MD, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
- Andrew M. Scott, MD, Department of Molecular Imaging and Therapy, Austin Health, Melbourne, VIC, Australia; Olivia Newton-John Cancer Research Institute, Melbourne, VIC, Australia; School of Cancer Medicine, La Trobe University, Melbourne, VIC, Australia; Faculty of Medicine, University of Melbourne, Melbourne, VIC, Australia
- Ekaterina Harsdorf, MA, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
Read the Abstract