1Consultant Radiation Oncologist
Jaslok Hospital, Mumbai
Email ID: nikhil.kalyani@yahoo.com
Head and neck cancers are one of the commonest cancers in Indian subcontinent. As per GLOBOCON 2020, head and neck cancers comprise of around 15% of total cancers in India. [1] About 60 to 70 percent of head and neck cancers present in locally advanced stage in India. They require multimodality treatment comprising of surgery, radiation and chemotherapy in combination. [2]
Radiotherapy is an integral part of multimodality management in head and neck cancers. Radiation can be used as either single modality or in combination with surgery or chemotherapy. Radiation can be used as definitive treatment or as adjuvant treatment post-surgical excision of tumor especially in oral cavity cancers. In addition, radiotherapy has significant role as palliative treatment for recurrent / metastatic cancers. Loco regional recurrence is the most common pattern of failure for head and neck cancers. Re-irradiation using Intensity modulated Radiotherapy (IMRT) or Volumetric Arc Radiotherapy (VAMT) is emerging as a viable option in management of recurrent cancers. The outcomes are encouraging in patients having long duration between two irradiation schedules and those who are operated for recurrent disease.
Traditionally radiotherapy for head neck cancer is given for 30 to 35 fractions over period of 6 to 7 weeks. Radiation treatment can be divided based on techniques in to conventional treatment, 3D conformal treatments (3DCRT), IMRT, Image guided Radiotherapy (IGRT) and VMAT. Conventional treatment can be delivered on older telecobalt machines as well as newer liner accelerators (LA). However, other treatment delivery needs computer tomography (CT scan) based planning.
Radiation to head and neck region is extremely challenging. It is associated with significant acute (mucositis, dermatitis etc.) and late (xerostomia, skin fibrosis, dysphagia etc.) toxicities. Conventional treatment comprises of treatment of large area without any differential doses to target volume and organ at risk (OAR). The newer techniques like IMRT and VAMT can deliver differential doses between target and OARs, hence they have ability to reduce normal tissue toxicities without compromising outcomes of treatment. This has been validated in prospective randomized trials. [3]
Head neck cancers are more common in poor economic strata. Cancer treatment is associated with significant financial burden for the patient and their family. Initially radiation facilities were available in few large cities only. Hence patients had to travel for long distance or had to make arrangements to stay away from their home for long duration. Now, more and more centers are being established in Tier 2 and Tier 3 cities, providing treatment close to patient’s native place. There is a huge difference in cost of radiation treatment depending on treatment technique and location of radiation center.
As mentioned earlier, head and neck cancers comprise of significant burden of cancer in India. More than 80 percent of head neck cancer patients need radiotherapy as part of treatment. Treatment used to be delivered with conventional techniques on Telecobalt machines for decades. Almost all centers had telecobalt machines. Over last three decades, radiation centers have started upgrading from telecobalt to modern linear accelerators (LA). All new centers are equipped with LAs capable of delivering highly precise treatments like IMRT, IGRT and VAMT.
India has low ratio of radiation machine per million populations currently being less than 1 machine per million population. As of 2019, there are around 545 radiotherapy machines in India comprising of 180 telecobalt and 365 linear accelerators. There is one particle radiation center (Proton Radiotherapy at Chennai) which is functional and other two centers are in process of installation.
Majority of developed countries have about 4 teletherapy machine per million population. WHO recommend at least one teletherapy machine per million population. [4] Applying this criteria India needs about 1300 functional teletherapy machines. Every year about 40 new units are installed and 15 get decommissioned. So, net addition is about 25 machines per year which is grossly inadequate for the present and future need for optimal cancer treatment. In addition, there is wide variation in geographic distribution of radiation facilities. This creates inequality in availability of radiation treatment for majority of our population.
It has been seen that availability of radiation facility near to native place increases treatment compliance and reduces dropout rate. This in turn improves oncological outcomes. We need to install radiation centers in different geographies across India to increase compliance rate. This can be achieved by introducing government scheme to provide incentive to set up new facilities, encouraging public-private partnership and reducing tax rate on imported machines. Treatment machines can also be set up at the government medical colleges across India.
Courtesy - Indian Journal of Medical and Paediatric Oncology (IJMPO)
Editor-in-Chief - Dr. Padmaj Kulkarni
Section Editor - Dr. Sneha Bothra
Editorial Assistant - Devika Joshi