'I can walk again': radiotherapy transforms a cancer patient's life.

THE PAIN IN HIS BACK was so sharp that Wisdom Nutakor, a 48-year-old agribusiness expert from Accra, Ghana, swung his car to the side of the road. He was not going to work today. He phoned his wife, a registered nurse, and quickly agreed it was time to get help. Once in the hospital's emergency room, however, this tall and proud African succumbed to partial paralysis-no feeling below his waist and unable to walk.

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Dr. Joel Yarney, a newly-trained oncologist, sized up the CT-scan. "You have a lung tumour that's protruding into your spine and causing pain and paralysis", he explained. "The best we can do is to relieve the pain." A one-month course of cobalt-beam radiotherapy began. "Dr. Yarney saw little hope for my recovery", explained Mr. Nutakor. "I thought I'd be bed-ridden for life." But miracles do happen. The daily dose of radiation was eating away the tumour, and by the end of the treatment Mr. Nutakor was recovering and had feeling again in his legs. With a follow-on course of chemotherapy, he would be walking in less than six months, and with further physical rehabilitation, he would be able to return to work and live a normal life with his wife and young daughter within a year. "My doctors and family were afraid to tell me that cancer was causing my problems", he said. "But my case proves that even in Africa cancer is no longer a death sentence."

With increases in life expectancy, developing countries are experiencing sharp increases in the incidence of cancer. "The most common forms of cancer in Ghanaian men are of the lungs and oesophagus, while in women are breast and cervical cancers", said Dr. K. Frimbong-Boateng, Executive Director of the Korle Bu Teaching Hospital, Ghana's biggest and most effective treatment centre, offering radiotherapy, surgery and chemotherapy services. As more cancer cases are being diagnosed, an increasing number of Africans are seeking modern treatment. However, the statistics for Ghana reveal a service shortage of crisis proportion; with a population of 20 million, it can expect up to 20,000 new cases of cancer each year.

Korle Bu Hospital, which was built with the help of the Technical Cooperation Programme of the International Atomic Energy Agency (IAEA), began treating patients in 1997, although its capacity hardly exceeds 1,000 patients per year, while a second IAEA-assisted facility at Komfo Anokye Hospital in Kumasi started in early 2004. However, even with the expansion of these two facilities and the completion in five years of a third treatment centre in the northern province, Ghana will have a capacity to treat about 6,000 cancer patients a year. This scarcity of facilities and trained personnel can likewise happen in other low- and middle-income countries. As IAEA Director General Mohamed ElBaradei  described it, "given the current lack of access to radiotherapy, as well as to nuclear medicine for diagnosis and treatment, we have no time to lose ... only the lives that will be lost, if we fail to act".

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Cancer is a global problem and its prevalence will increase dramatically over the next decade, especially in the developing world. Each year over 10 million persons, more than half in developing countries, are diagnosed with the disease (not counting skin cancer). According to the World Health Organization (WHO), 12.5 per cent of all deaths worldwide are due to cancer--a greater percentage than those caused by HIV/AIDS, tuberculosis and malaria combined. While cancer is often viewed as primarily affecting industrialized States, where it is already the second leading cause of death, it is among the three leading causes of adult deaths in developing countries. Nearly 16 million persons will likely be diagnosed with the disease in 2020. Poor developing countries remain seriously underserved with therapies designed to save lives or improve the quality of life. They make up 85 per cent of the global population, yet they only have about one third of the total radiotherapy facilities.

The most common cancer is of the lung, but among women it is breast cancer. In addition, some 200,000 women in developing countries die from cervical cancer each year. These are totally unnecessary deaths since it is curable if diagnosed early through screening, such as by pap smear, or mammograms for breast cancer. However, few people undergo screening due to lack of awareness or resources. But for other forms of the disease, such as lung, there are still no effective screening methods. All too often, cancer is suspected only when it has developed and produced symptoms like cough, lump or bleeding. To prove its presence, a biopsy-the removal and examination of tissue taken from the affected area--is almost always necessary. Full physical examination and other tests, including x-rays and scans, are usually required to determine the cause, "stage", extent and scope of cancer. The best treatment depends on many factors: the area affected; the histological type and stage of cancer; and the age of the patient. Prognosis also depends on whether adequate treatment facilities and trained health-care professionals are available.

Radiation therapy or radiotherapy is an effective treatment for over 50 per cent of all forms of cancer. The energy it deposits destroys or injures the genetic material of cells, making it impossible for them to reproduce. Although radiation damages both cancer and normal cells, if given in the right dosage and used appropriately in a timely manner, normal cells are able to repair themselves and function properly. Radiotherapy may be used in combination with chemotherapy drugs or surgery to treat localized solid tumours, such as of the skin, larynx, brain, breast and uterine cervix, as well as cancer of the blood-forming cells and lymphatic system like lymphoma. But like all cancer treatment, radiotherapy can cause some side effects, including loss of hair, skin irritation or discolouration and fatigue.

The harsh reality for developing nations is one of overburdened health systems, with little cancer screening, unnecessarily late diagnosis and non-curative treatment. The IAEA estimates that about 5,000 care centres and systems, including doctors and skilled health workers, are needed to help low- and middle-income countries fight cancer. It has stepped up to help patients survive through early diagnosis and better treatment. But equipment alone will not solve the problem, and establishing new treatment facilities is a long process requiring governmental support and an appropriate national cancer-control strategy and programme.

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Radiotherapy involves staff training, facility planning and construction, equipment specification and procurement, installation, commissioning, designing protocol and procedure manuals, and development of quality control programmes. The IAEA is helping countries address this enormous task and is currently involved in upgrading facilities, training staff and establishing quality assurance in approximately 100 countries worldwide. Only about 2,400 radiotherapy machines are currently operating. Some 15 nations in Africa and several in Asia still lack radiotherapy machines. Ethiopia, with over 70 million population, has only one machine, while many developing countries have far less treatment capacity. With IAEA support, however, modern radiotherapy facilities have been set up in Ethiopia, Ghana, Namibia, United Republic of Tanzania, Uganda and Mongolia. Nigeria has established its fourth centre, while other countries, including Angola, Eritrea, Haiti, Yemen and Zambia, have received IAEA support to initiate radiotherapy.

IAEA assistance also strengthens teaching in radiotherapy, which entails national educational and training programme for technicians and registers, including radiographers. Projects in southeastern Europe and the former Soviet Union are helping countries emerge from years of conflict and economic hardship. In most cases, these countries retained medical expertise, but had to rebuild or upgrade their facilities. IAEA activities have ranged from simply providing a treatment planning system to completely revamping a radiotherapy department. However, no global programme is addressing cancer across the broad spectrum of multidisciplinary care, training and resource needs.

The IAEA has a unique mandate to "accelerate and enlarge the contribution of atomic energy to peace, health and prosperity throughout the world". It has demonstrated technical expertise and experience in the diagnosis and treatment of cancer, particularly by responding to the need for safe, effective and sustained implementation of radiotherapy services. The Agency's experience in the past 25 years, with over $150 million of cancer assistance provided to developing countries, demonstrates that radiotherapy technology and skills can be transferred successfully to less developed countries. These investments have been more than matched by contributions from recipient countries, enabling many of them to establish for the first time safe and effective radiotherapy capabilities.

However, IAEA resources are inadequate to respond effectively to the looming cancer crisis. Meeting present needs would cost billions of additional dollars, far more than the Agency can provide, and are projected to increase by more than 50 per cent over the next 15 to 20 years.

To respond effectively to this challenge, as well as to a call for action by WHO and the International Union Against Cancer (UICC), the IAEA has launched the Programme of Action for Cancer Therapy (PACT), which would address the legal, regulatory, technical and human resources needed to establish, improve and expand radiotherapy treatment programmes in the context of national cancer-control strategies and in accordance with the priorities and needs of the countries and regions concerned.

PACT seeks to: build a global alliance committed to addressing the challenges of cancer in developing countries in all its aspects, with emphasis on therapy; ensure the effective and sustainable transfer of radiation and nuclear oncology capabilities to countries where unmet needs exist; and mobilize resources from charitable trusts, foundations and the public and private sectors for the benefit of patients. PACT also presents ambitious goals over the next 15 years, with the strategic focus required to tackle the cancer problem in the developing world. Through it, the IAEA will focus on its area of expertise, radiotherapy and nuclear medicine, while building a cancer-control alliance.

In cooperation with the WHO, UICC, the American Cancer Society, the International Agency for Research on Cancer, the United States National Cancer Institute and the International Network of Cancer Treatment and Research, PACT will focus on national needs assessment and model capacity-building projects in select developing nations and initiate a global programme and fund-raising.

The IAEA recognizes that planning and capacity-building for cancer therapy cannot be achieved in isolation. Treatment is most effective when set within a comprehensive cancer-control framework that includes prevention, screening and diagnosis, treatment, rehabilitation and palliation. Over the next decade, the IAEA estimates that several billion dollars will be needed to provide the developing world adequate treatment facilities and machines and train public health specialists and physicians to ensure comprehensive care. The Agency's ultimate goal is to fill this tremendous resource gap and bring relief to millions of cancer sufferers like Wisdom Nutakor.

Building on the IAEA and its core partners' experience, PACT and its cancer-control alliance will raise public awareness, build strategic partnerships to establish national cancer-control strategies and programmes, and support the establishment of radiotherapy centres with adequate safety and protection programmes, as well as the creation of centres of excellence in developing countries for training and research in radiotherapy.

For more information, visit the IAEA website at www.iaea.org

Massoud Samiei (left) has been Programme Manager for PACT ([e-mail]) since February 2005. He joined the IAEA Department of Technical Cooperation in 1989, with responsibilities for Eastern Europe and the Middle East, and became Head of Europe Region in 1993.

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David H. Kinley III is a writer and photographer with the IAEA Division of Public Information. He has worked with the UN Development Programme, the World Bank and several non-governmental organizations.

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A containment protocol will enable a coordinated approach to rapid detection, assessment and response to the emergence of a pandemic virus. While no efforts to stop the influenza pandemics have ever been attempted, the continued surveillance of the H5N1 strain allows the international community a unique opportunity to monitor the evolution of a possible pandemic strain. Even if there is just a small chance that the enormous health, economic and social damages caused by a pandemic might be averted, WHO has a responsibility to try.