After the cobalt system at the public cancer hospital was rendered defunct, radiotherapy patients in the Brazilian state of Acre were forced to travel more than 500 kilometers (300 miles) away, where they faced long waiting periods of up to three months to begin potentially life-saving treatment.
Lack of capacity also triggered long waits to initiate treatment at Santa Casa de Misericórdia de Maceió, in Brazil’s state of Alagoas. Delivering more than half of the oncology services provided by the public health system for the region, the hospital had once been considered a healthcare pioneer, but with a linear accelerator more than 30 years old, it was limited in both the volume and complexity of treatments it could deliver.
Today, most patients in Acre can initiate treatment within a week. Wait times have been essentially eliminated at Santa Casa. The type of treatments available have also been expanded to include advanced technologies, such as intensity modulated radiotherapy (IMRT), and volumetric arc therapy (VMAT). Santa Casa also added 3D image-guided radiotherapy.
“The technology we were able to implement as part of this program enabled us to jump 50 years in five years in the treatment approaches we could offer patients,” said Melk Menezes Hadad, MD, Radiation Oncologist and Head of the Radiotherapy Service of the Acre State Cancer Hospital.
The expanded access has been made possible through an ambitious, ground-breaking contract Varian won in 2013 from Brazil’s Ministry of Health (MOH) to deliver radiotherapy systems to the country’s most under-resourced states. By the end of this year, Varian is expected to ship the 92nd C-series linac as part of its contract, which, along with nine high dose rate (HDR) afterloaders for brachytherapy, wraps up an initiative that represented the world’s largest public purchase of radiotherapy equipment when it began.
“At the end of the day, this was about the number of patients who were dying waiting for treatment, who were getting diagnosed but didn’t have a chance to fight,” said Humberto Izidoro, Varian Senior Managing Director for Latin America “Now, they have a chance to fight with technology that can really save them. For Varian, as part of Siemens Healthineers, this exemplifies our vision for a world without fear of cancer.”
Once the project is complete, the expansion of capacity is expected to have a significant impact, with an estimated 55,000 patients treated each year, a number that may be even 60% higher as centers adopt hypofractionation, Izidoro added.
“This now decade long collaboration with Brazil’s Ministry of Health demonstrates the impact that is possible in bridging the access to care gap when two like-minded organizations share a common vision of better healthcare for all,” said John Kowal, Varian’s President, Americas. “It’s amazing to see the dramatic differences available via advanced radiation treatments now observed in countless communities across Brazil, which should serve as a model for others across the world.”
“The technology we were able to implement as part of this program enabled us to jump 50 years in five years in the treatment approaches we could offer patients.”
- Melk Menezes Hadad, MD, Radiation Oncologist and Head of the Radiotherapy Service of the Acre State Cancer Hospital
Narrowing resource gaps
Varian won a public bid to run the more than $110 million “Plano de Expansão da Radioterapia no Sistema Unico de Saúde” or Radiotherapy Expansion Plan for the Brazilian Public Healthcare System (PER-SUS) in 2013, a project intended to narrow significant gaps and disparities in care across the country. The project included designing and managing the construction of 80 new bunkers for linacs, and nine for brachytherapy, in addition to providing training and the equipment to public hospitals in 24 of Brazil’s 26 states and also in the federal district.
Reports suggest the ambitious project couldn’t come soon enough. Research showed Brazil’s Unified Health System (Sistema Único de Saúde – SUS) had an estimated 62% of the linac capacity needed to treat the estimated cancer cases requiring radiotherapy expected by 2020. Not only were there too few linacs, patients had to travel an average of 73 kilometers – or nearly 45 miles – to access them.
But the project also highlights how challenging such programs are to complete and provides important lessons as Varian works to further expand access to care in Brazil and in other parts of the world.
A bumpy start
Expanding access is more complicated than simply delivering new equipment. Varian was also responsible for managing the design and project management of the construction of new bunkers, along with navigating all associated regulatory requirements. Varian also agreed to provide training and some transfer of technology through the establishment of a manufacturing center.
Varian’s contract initially included 80 of its C-series linacs, including 41 in centers that didn’t previously have radiotherapy equipment. The MOH later exercised an option to add another dozen to replace older radiotherapy systems.
Four years passed before the first of the C-series linacs was installed, as the company navigated complex regulatory organizations across local jurisdictions, as well as complications with site selection and construction plans. Political upheaval during the period also triggered delays.
“You really had to be connected to something bigger to have that kind of resilience,” Izidoro said. “Everyone felt connected to the mission because we were increasing capacity in the system by 40%.”
By 2021, nearly half of the sites had been delivered. The scale of the project, as well as the unique challenges of each site, added significant complexity.
At Santa Casa de Misericórdia de Maceió, installing the new C-series linac was complicated by the fact that the hospital was listed as a historic building, posing significant construction challenges. In Acre, one of Brazil’s most remote states, the project was delayed by a year by bureaucratic issues, difficulties finding qualified construction resources to build the bunker, and time resolving other issues that arose. Securing training for the radiotherapy team and finding a trained medical physicist in the remote region was also a challenge.
Working closely with the MOH and local officials, Varian teams worked to adapt their projects to each site.
“Now we are not only carrying out treatments with higher quality, which increases therapeutic success and reduces side effects, but it is also possible to offer shorter treatments, in different hypofractionation regimes and in advanced techniques such as IMRT, VMAT, SBRT and radiosurgery”
- Marcel Davi Melo, MD, a radiation oncologist at Santa Casa de Maceió
Expanding capacity, and quality of care
As the initiative nears completion, its impact on expanding care has been profound.
In Acre, the new system installed in 2018 enabled care teams to implement treatment planning techniques using a multi-leaf collimator (MLC), such as 3D and VMAT, rather than relying on 2D plans with manual shielding block protection, Dr. Hadad said. Following the installation of a new linac in 2017, Santa Casa exercised an option for an upgrade package from Varian enabling the system to significantly advance its radiotherapy treatment offerings.
“Now we are not only carrying out treatments with higher quality, which increases therapeutic success and reduces side effects, but it is also possible to offer shorter treatments, in different hypofractionation regimes and in advanced techniques such as IMRT, VMAT, SBRT and radiosurgery,” said Marcel Davi Melo, MD, a radiation oncologist at Santa Casa de Maceió.
Building capacity for future access initiatives
For Varian, the initiative was the basis for a long-term strategy to establish a significant footprint in Brazil and expand its expertise in project development. Throughout the various phases of the project, the company also built experience navigating complex networks of regulatory and health agencies, something it can leverage both in Brazil, but also in other regions where it is implementing similar projects. Varian’s true commitment to advancing cancer care in the country solidified relationships with the RT community at large leading to a stronger position in the private sector as well.
“When you look at the legacy that we’re leaving in the country—a transformation of radiation therapy—this is something that we’ll see the impact of for generations beyond this project,” Izidoro said. “We remain committed to working to expanding access to innovative treatments throughout Brazil.”
- Hanna SA, Gouveia AG, Moraes FY, Rosa AA, Viani GA, Massuda A. Lessons from the Brazilian radiotherapy expansion plan: A project database study. Lancet Reg Health Am. 2022 Jul 19;14:100333. doi: 10.1016/j.lana.2022.100333. PMID: 36777394; PMCID: PMC9903577.
- Hanna SA, Gouveia AG, Moraes FY, Rosa AA, Viani GA, Massuda A. Lessons from the Brazilian radiotherapy expansion plan: A project database study. Lancet Reg Health Am. 2022 Jul 19;14:100333. doi: 10.1016/j.lana.2022.100333. PMID: 36777394; PMCID: PMC9903577.