is complemented by two additional sets of elements: supporting accessories and trained staff. Supporting accessories include: modern imaging equipment (e.g. a conventional or fluoroscopic simulator, a computed tomography simulator); a treatment planning system with appropriate software and commissioned beam data; a mould room for shielding and immobilization devices; and dosimetry and quality assurance (QA) equipment. Teletherapy machines have to be conceived of as one element of a package that includes all of the above. In addition, initial commissioning, a programme of preventive maintenance and servicing, scheduled QA procedures and eventual repairs have to be planned for and budgeted. Appropriately trained staff is essential too, and the lack of this component is a major obstacle for the modernization of radiotherapy services in some countries and regions of the world. Lack of training programmes, low wages, lack of 17 professional recognition and internal migration from the public to the private sector or migration to higher income countries are some of the issues involved. The IAEA has published a guide on how to establish and develop a modern radiotherapy facility, including specifications for linear accelerators and high dose rate brachytherapy units [1.4]. This is complemented by another publication aimed at assisting Member States at the time of planning radiotherapy services at the national level [1.5]. 1.4. MAKING RADIOTHERAPY MORE ACCESSIBLE Radiation medicine is one of the most important groups of disciplines for detecting, diagnosing and treating cancer, with more than half of cancer patients requiring some form of radiotherapy during the course of their treatment [1.6]. As low and middle income countries (LMICs) face an expected rise in annual cancer incidence rates of nearly 25% by 2020 (Table 1.1), the question of providing affordable means of treating the growing number of patients has acquired greater prominence [1.8]. The basis of this increasing concern lies in the fact that, despite being home to 85% of the world’s population, LMICs only maintain approximately 40% of the world’s radiotherapy facilities, leaving only around 25% of cancer patients in LMICs with access to radiotherapy treatment [1.8]. TABLE 1.1. CRUDE CANCER INCIDENCE DATA, IN DEVELOPED AND DEVELOPING REGIONS OF THE WORLD, 2012, AND PREDICTIONS FOR 2020 AND 2030 (GLOBOCAN 2012) [1.7] 2012 2020 2030 World 14 067 900 17 113 588 21 645 658 More developed regions 6 053 600 6 794 807 7 617 751 Less developed regions 8 014 300 10 009 819 13 091 083 This situation is even more inequitable when comparing the availability of radiotherapy services across regions. Europe maintains 17 times as many radiotherapy units as are available in Africa. Latin America and the Caribbean 18 combined have just one third the number of machines available in North America [1.9] (Fig. 1.1). The lack of availability of radiotherapy treatment does not stem from a lesser need in LMICs. In fact, due to the absence of effective prevention and screening services, a higher proportion of cancers in LMICs are detected at an advanced stage, leaving palliative radiotherapy as one of the few options for treatment, even for cancers that, when found at earlier stages, have other treatment options [1.5]. FIG. 1.1. Number of people served by one radiotherapy unit. But inequity of access to radiotherapy goes beyond availability; in order for radiotherapy to be accessible, it must be provided in a manner that takes into account the geographical distribution of the population and the direct and indirect costs of receiving treatment, as well as affordability and the distribution of treatment, among other factors. Accessibility can even be an issue in upper middle income countries, which maintain large numbers of cancer centres but have variable accessibility to treatment across the country, with most radiotherapy clinics and modern equipment confined to the private sector. Beyond the issues of availability and distribution of radiotherapy facilities, another factor influencing patient outcomes is affordability of treatment. The costs associated with treatment contribute to the overall inaccessibility of cancer