Human Resources Needed for Cancer Control
in Low & Middle Income Countries
Human resources are the key to diagnosing cancers early and treating them appropriately. One of the important first steps in addressing the growing problem of cancer in low and middle income countries (LMIC) is cancer control planning with regard to human resources needed in a country, province, city, or community. However, for the stakeholders few guidelines are available in that regard. The scarcity of cancer registries in LMICs only compounds the difficulties.
Here we propose a method for estimating the human and other resources needed for treating the most common cancers in some LMICs and/or their major urban centers. We hope that the methodology described here can guide decision-makers and form a framework for discussion among the various stakeholders. This methodology is readily adaptable to local practices and data.
Population and Cancer Incidence
Information about the population of countries and various cities was obtained from http://citypopulation.de(accessed on October 15, 2014). The number of new cancer cases annually and the major types of cancers was obtained from GLOBOCAN 2012 (http://globocan.iarc.fr/ accessed on October 15, 2014). GLOBOCAN does not report the data for specific cities. In the absence of any published cancer registry data we assumed that the proportion of the various kinds of cancers in each city was the same as the whole country. Thus, based on the population and the number of new cancer cases for a country, the number of new cancer cases for a city, region, province, governorate or district was estimated. Those estimates can be readily revised if and when more accurate data become available.
Estimating the Human and Other Resources Needed
for Treating Common Cancers
For estimating the human and other resources needed for treating the various kinds of cancers several specialty societies and organizations were consulted but most of them, with the notable exception of the International Atomic Energy Agency (IAEA) of the United Nations (http://www-pub.iaea.org/MTCD/publications/PDF/pub1296_web.pdf) could offer no official guidelines (see, for instance, the position of the Oncology Nursing Society at https://www.ons.org/practice-resources/clinical-practice/more-research-focuses-staffing-ratios-patient-outcomes-oncology). Therefore, colleagues active in those fields were consulted informally and the following assumptions were thereby made and used for our calculations:
Newly diagnosed cancer patients need pathology for diagnosis and for treatment surgery, chemotherapy, and/or radiation therapy. The percentage of patients requiring each of those therapeutic modalities and the average length of stay as in-patients were estimated for the most common cancers and are detailed in each spreadsheet. Those estimates can be readily revised if and when more accurate data become available or to conform better to local practices.
The number of specialists needed was estimated based upon the numbers of patients requiring surgery, chemotherapy, and/or radiation therapy as well as pathology. For developing countries, instead of separate medical and radiation oncology tracks, the IAEA recommends training radiation/clinical oncologists who can prescribe both radiation and chemotherapy for the common solid cancers (hematological malignancies are treated primarily by hematologist-oncologists). The number of radiation/clinical oncologists needed is estimated at five per 1000 cancer patients annually. The number of pathologists needed is estimated at two per 1000 cancer patients annually, recognizing that most of them do not concentrate solely on cancer. The number of surgical oncologists needed is based on the number of cancer patients requiring surgery annually, assuming that each surgical oncologist performs two surgeries per day, five days per week for 48 weeks per year. The number of gynecological oncologists, urological oncologists, neurological oncologists, and hematologist-oncologists needed is two per 1000 patients with gynecological, urological, neurological, and hematological malignancies, respectively. In addition, two palliative care specialists will be needed for each 1000 new cancer patients. Those assumptions can be readily revised if and when more accurate data become available or to conform better to local practices.
Many cancer patients require hospitalization for diagnosis and/or the treatment of the cancer and its complications, therefore an adequate number of oncology beds is needed. The number of oncology beds needed per day is the sum of the number of beds needed for surgery, chemotherapy and radiation therapy for patients with the most common cancers. An oncology ward is a 24-bed in-patient unit for only oncology patients. For each such ward there should be a nursing staff of 15 oncology nurses, working eight-hour shifts five days per week, four onco-pharmacists and six pharmacy technicians. Those estimates can be readily revised if and when more accurate data become available or to conform better to local practices.
Many cancer patients require radiotherapy; therefore, appropriately equipped facilities are needed along with well-trained radiation oncology staff. The radiation oncology staff needed for every 1000 patients requiring radiation therapy annually includes radiation/clinical oncologists along with a support staff of twelve radiation therapy technicians, four medical physicists, one linear accelerator (linac) engineer, and four radiation therapy nurses. The minimum radiation therapy equipment requirements for every 1000 patients requiring radiation therapy annually are at least one each of the following: megavoltage teletherapy unit (linac or cobalt), brachytherapy unit, CT simulator, treatment planning computer system, and dosimetry/quality assurance package. If there is only one megavoltage teletherapy unit per 1000 radiation therapy patients it should be operated nearly around the clock, albeit with regularly scheduled downtime for preventive maintenance and quality assurance. If around the clock operations are not feasible then a minimum of two such units are necessary per 1000 radiation therapy patients. Those estimates can be readily revised if and when more accurate data become available or to conform better to local practices.
Interventions for detecting cancers early and treating them appropriately are crucial components of cancer control planning. Human resources are the key but, unfortunately, are often neglected in LMIC. In planning new radiotherapy facilities, for instance, the major focus may be on the buildings and equipment while only a token number of staff are trained and/or hired. The result often is that the facilities are chronically understaffed and poorly maintained. That can lead to poor patient outcomes and low staff morale. Furthermore, the cost of treating each patient escalates because after making the substantial investment in buildings and equipment fewer patients are treated than could have been in an adequately staffed facility.
One of the reasons human resources are neglected may simply be the lack of guidance available to decision makers. We hope that the methodology described here can provide a framework for discussion among the stakeholders interested in cancer control in a country, region, city, or community. These projections are intended to provide a general scope of need and not to define specific needs or plans for any country.
Members of RRP and NCI are working with the Center for Global Health (http://www.cancer.gov/aboutnci/globalhealth) and with a non-governmental program, the International Cancer Expert Corps (ICEC) (www.iceccancer.org) to develop novel approaches toward filling the gap in experts in LMICs.