not directly translatable to other populations [3.19]. 45 TABLE 3.1. OPTIMAL RADIOTHERAPY UTILIZATION RATE BY CANCER OPTIMAL RADIOTHERAPY UTILIZATION RATE BY CANCER TYPE (cont.) Tumour type Proportion of all cancers in Australia in 2000 Optimal proportion of patients receiving radiotherapy (%) Patients receiving radiotherapy (% of all cancers) Bladder 0.03 58 1.7 Testis 0.01 49 0.5 Thyroid 0.01 10 0.1 Unknown primary 0.04 61 2.4 Other 0.02 50 1.0 Total 1.00 — 52.3 3.3. DISTRIBUTION OF TYPES OF CANCER AND THE NEED FOR RADIOTHERAPY The proportion of cancer patients in low and middle income countries (LMICs) with an indication for radiotherapy is likely to be higher than that in high income countries because of the types of cancers [3.5]. In addition, these cancers are often diagnosed at a more advanced stage, which limits surgical options. To demonstrate the effect of differences in types of cancers, the model by Delaney et al. [3.1] has been adapted to assess the needs for radiotherapy by substituting the distribution of cancer types estimated by the International Agency for Research on Cancer (IARC) in its Globocan project for the year 2008 [3.20] for IAEA regions, as reported in the Directory of Radiotherapy Centres (DIRAC) [3.21]. Because the types of cancer vary from region to region, the proportion with an indication for radiotherapy varies from 48% of new cases of cancer in Mexico and Central America, and the Middle East, to 55% in the Caribbean (Table 3.2). The numbers of new cancers by site and region are shown in Fig. 3.1, and the numbers with an indication for radiotherapy are shown in Fig. 3.2. This shows the larger number of cases of lung cancer and stomach cancer in East Asia. 47 FIG. 3.1. Number of new cases of cancer by tumour site for IAEA regions. 48 FIG. 3.2. Number of cases by tumour type with an indication for radiotherapy by IAEA regions. 49 It is likely that the estimates given in Table 3.2 significantly underestimate the demand for radiotherapy in LMICs because: — The distribution of stages at presentation will be skewed to more advanced stages where radiotherapy has a higher utilization rate (see below). — If surgery is not available, then radiotherapy will have a greater role to play in the treatment. This is often the case for cervical and lung cancers. TABLE 3.2. OPTIMAL RADIOTHERAPY UTILIZATION RATES FOR IAEA REGIONS (cont.) DIRAC region Radiotherapy utilization rate (%) Caribbean 55% Central Africa 53% East Africa 52% East Asia 52% Eastern Europe and Northern Asia 54% Indian Ocean Islands 52% Mexico and Central America 48% Middle East 48% North Africa 51% North America 53% South Asia 53% Southeast Asia 49% Southern Africa 54% Southern and Western Pacific 49% 50 TABLE 3.2. OPTIMAL RADIOTHERAPY UTILIZATION RATES FOR IAEA REGIONS (cont.) DIRAC region Radiotherapy utilization rate (%) Temperate South America 53% Tropical South America 53% West Africa 53% Western Europe 53% The estimates of the numbers of cases with an indication for radiotherapy should thus be viewed as minima. 3.4. THE EFFECT OF STAGE AT PRESENTATION ON THE NEED FOR RADIOTHERAPY In LMICs, patients present with more advanced stage cancers [3.5]. Between 50% and 80% of breast cancers are advanced at diagnosis [3.22], compared with 15% in high income countries [3.23]; 56% of cervical cancers in Bangalore, India, were stage III, compared with 15% in high income countries [3.24]. More advanced cancers are less likely to be amenable to surgery and therefore are more likely to be treated by radiotherapy. As an example of the effect of staging on the need for radiotherapy, the data for indigenous Australians, who have health outcomes very similar to those in many LMICs, were examined [3.25]. Limited staging data [3.26] have been used to calculate the optimal radiotherapy utilization rate for this population. It shows that there is a 59% need for radiotherapy for cancers in indigenous Australians compared with 52% for the general population. This is because indigenous Australians present with later stage cervical, breast and colorectal cancers. Advanced stage cervical cancer was seen in 39% of cases, compared with 12% of