The Landscape of Pediatric Radiation Oncology in Nigeria

Abstract

Radiation therapy (RT) is an essential part of the multidisciplinary treatment of pediatric cancer. Over the past five decades, significant advances have been made in the delivery of RT, with better dose delivery to disease targets while minimizing exposure to nearby organs at risk. These advances have led to improved treatment outcomes, increased survival, and reduced treatment-related toxicities. Advanced treatment techniques, however, require significant investment in infrastructural and personnel resources. This review documents what is currently available regarding expertise and infrastructure for pediatric radiation oncology practice in Nigeria. It was performed to serve as a foundation for the creation and design of tailored solutions (initiatives and policies) to increase pediatric radiation availability, accessibility, and equity in Nigeria and ultimately improve pediatric cancer treatment outcomes in the region.

Pediatric Radiation Oncology in Nigeria: Current Landscape, Challenges and Progress

BACKGROUND

Over the past 50 years, cancer has emerged as a leading cause of morbidity and mortality in the pediatric population, recording a 20% increase in incidence between the years 2001 and 2010.¹ In 2017, Steliarova-Foucher et al¹ reported that an estimated 300,000 children and adolescents and young adults age 0-19 years are diagnosed with cancer every year. Force et al, in 2017, reported that a greater proportion of children who are at risk of developing cancer are in low- and middle-income countries (LMICs), with significantly lower chances of survival than children living in high-income countries.²

In contrast to the most common cancers in adults, the pediatric cancer continuum does not have significant prevention and screening components. As such, early detection, accurate diagnosis, and effective treatment are critical to ensure and improve survival.³ Many pediatric cancers can be successfully treated and cured through different combinations of conventional therapies, such as surgery, chemotherapy, and radiation therapy (RT). In high-income countries, up to 80% of children diagnosed with cancer survive 5 years after diagnosis, a stark contrast to LMICs with average survival rates of around 30%.⁴ Deficient community and health care professional awareness, inadequate health-seeking behavior, diagnostic delays and errors leading to delayed specialist intervention, disparities in access to therapy, frail health care systems, high rates of treatment abandonment because of financial or geographic constraints, and lack of adequate (pediatric) oncology infrastructure are some of the documented reasons for the lower survival rates seen in LMICs.^4-6

RT as a treatment modality for cancer has been in practice for more than 100 years.^7-9 The first documented use of radiation as a therapeutic agent was in 1896 when Emile Grubbe treated a malignant breast tumor with high-dose X-rays at the pioneering RT facility in Chicago.¹⁰ Since then, more sophisticated RT techniques, such as intensity-modulated radiation therapy and tomotherapy, image-guided radiation therapy, stereotactic radiosurgery, and charged particle therapy, have been developed, leading to improved clinical outcomes.⁵

RT is one of the core treatment modalities in oncology, with as many as 50% of all patients with cancer requiring radiation at some point in their cancer treatment, either as monotherapy or in sequence or combination with surgery and chemotherapy.¹¹ RT is a highly specialized treatment, requiring specialized equipment operated and used by a multidisciplinary team of purpose-trained health care professionals, including radiation oncologists, medical physicists, dosimetrists, and therapy radiographers or radiation therapy technologists (RTTs).¹² These niche-skilled professionals often require further expert training for effective and safe delivery of RT for cancer treatment in pediatric patients.

According to the International Atomic Energy Agency (IAEA), all African countries fall below the globally estimated treatment needs in terms of RT equipment. Nigeria, with its 200 million population making up 20% of sub-Saharan Africa (SSA), has seen an increase in RT capacity in recent years.¹³ The pace of this increase is, however, outmatched by the rising cancer incidence rate and treatment need.^14,15 Elmore et al¹⁵ reported that the widest gap between treatment need and RT capacity in West Africa occurs in Nigeria.

Access to RT services encompasses multiple dimensions, including the availability of service infrastructure, geographical accessibility, economic affordability, and awareness on the part of physicians and the population.¹⁴ According to the Global Task Force on Radiation Therapy for Cancer Control, there will be a 12,000-plus linear accelerator (LINAC) gap and a need for 30,000 radiation oncologists, 22,000 medical physicists, and 80,000 RTTs to meet the cancer treatment needs of LMICs by the year 2035.¹⁶ Although there is a worldwide shortage of RT services, this shortage is most pronounced in LMICs where over 50% of patients with cancer lack access to RT services.¹⁷ High-income countries have an estimated one RT machine available for every 120,000 people, compared with one machine to over one million people in middle-income countries and one machine to five million or more people in low-income countries.⁶

The radiation therapy utilization (RTU) rate measures the proportion of patients with cancer requiring at least one treatment course of RT during their disease process. In high-income countries, the RTU rate is approximately 50%, meaning that 50% of patients diagnosed with cancer will require RT treatment at least once at some stage in the disease process. In LMICs, it is estimated that the optimal RTU rate may reach 70%-80%. Despite this higher need, it is estimated that the actual RTU rate in low-income countries is between 25% and 40%.⁷ While factors such as patient or caregiver awareness and perceptions about RT may affect uptake, the main barrier to optimal RTU rates in LMICs is the lack of access to RT.¹⁸

A 2013 study in the United Kingdom revealed that only 10% of people were aware that RT can treat a large proportion of cancers and approximately 40% had negative perceptions about RT.¹⁹ A 2019 cross-sectional survey of people with cancer, health professionals, medical students, nursing students, and the general public in Dar es Salaam, Tanzania, found that only 34.5% of respondents had positive perceptions of RT. The study showed that respondents with higher awareness and a positive perception of RT were more likely to accept RT as a treatment modality.¹⁸

EVOLUTION OF RT IN PEDIATRIC CANCER

RT for pediatric cancer has undergone a significant evolution. The first pediatric patient to receive RT delivered by a LINAC was Gordon Isaacs, a 7-month-old boy in 1955, who was treated by Dr Henry Kaplan using the then relatively unknown but promising technique of radiation treatment delivered from a LINAC.²⁰ Harvey Cushing, often regarded as the doyen of neurosurgery, is less well-known for, but just as pivotal to, the improvement of pediatric outcomes using RT. Cushing's most recognized work documented the addition of postoperative RT as a modality to improve survival rates for medulloblastoma.^21,22 Over the rest of the mid-20th century, the work of these and other pioneers led to the emergence of RT as an integral part of the successful management of many pediatric cancers.⁵

Pediatric cancers pose a unique challenge for many oncology systems. They are less common than adult cancers, with significantly different biologic features and behavior.²³ As such, pediatric cancer treatment, including RT delivery to patients with pediatric cancer, requires expertise and specialization that is tailored to this patient population. RT is indicated in the management of some of the most common pediatric cancers, including leukemia and lymphomas, sarcomas of bone and soft tissue, tumors of the CNS, optic pathway cancers such as retinoblastoma, and other common pediatric cancers such as Wilms' tumor (nephroblastoma).^24,25 In the treatment of children with acute lymphoblastic leukemia, the implementation of selective prophylactic craniospinal irradiation and intrathecal methotrexate has significantly reduced the number of children who develop isolated CNS relapse to <10%.^26,27 The Children's Oncology Group A3973 trial demonstrated the effectiveness of RT as a part of multimodal treatment for high-risk neuroblastoma, establishing the present standard of care.^26,28

The importance of RT in the control of many pediatric cancers has been well-documented over the past century. As the understanding of tumor biology and behavior deepens and with modern techniques and carefully researched protocols, it has become more attainable to achieve good disease control or cure while preventing, limiting, or eliminating adverse treatment effects.⁵

RT IN SSA

There are three common treatment modalities for pediatric cancer: surgery, chemotherapy, and RT. Of the three, RT remains the least available and least used in SSA.²⁹ A review of 34 cancer treatment institutions in SSA showed that the majority of these centers offered surgical and chemotherapy services, whereas only 18 of them had RT facilities available for use.³⁰ In a 2020 evaluation of pediatric RT facilities by Anacak et al,³¹ it was observed that only 53% of children were treated with an intent to cure in low-income countries, as opposed to over 80% in high-income countries. Underutilization of RT in SSA can be attributed to various limitations, including limited specialized workforce and infrastructure, inaccessibility of health care centers, and lack of health insurance.²⁹ There is only one dedicated pediatric radiotherapy center in SSA, and its status as an LMIC resource could be disputed given its location in South Africa. Other RT centers in SSA treat their pediatric patients as a part of the general RT program designed for and centered around adults.³²

EVOLUTION OF RT IN NIGERIA

RT began in Nigeria with the acquisition and installation of a superficial kilovoltage RT machine in 1968, followed by a Cobalt-60 machine in 1973 at the Lagos University Teaching Hospital.³³ This was followed by a second Cobalt-60 machine at the University College Hospital in 1987. The first LINAC in Nigeria was commissioned at the National Hospital Abuja, in 2001.³⁴ The VAMED initiative, in collaboration with the IAEA, subsequently saw the establishment of seven RT centers across the country by 2005, equipping the centers with LINACs, treatment planning systems, and dosimetry equipment.³⁵ As of 2010, the total number of commissioned teletherapy machines in Nigeria, a country of 200 million people, was eight: three Cobalt-60 machines and five LINACs.³⁶ Over the next 6 years, more machines were purchased or installed, and by 2016, the Nigerian government had commissioned a total of nine functioning RT centers. These included seven government-owned, one public-private partnership (PPP) project, and one private center.³⁷

This growth rate was, however, still no match for the climbing demand; compounded by frequent and extended machine downtimes, RT services in the country remained below ideal. Irabor et al³⁴ in 2016 reported that the entire nation was served by five LINACs, two Cobalt-60 units, two superficial x-ray units, three low-dose rate Caesium-137 brachytherapy equipment, two high-dose rate (HDR) Cobalt-60 and Iridium-192 brachytherapy equipment, one conventional simulator, five 3-dimensional (3D) treatment planning systems, and seven mold rooms. As at the year 2020, there were 11 centers offering RT to Nigeria's population of 200 million. Among these centers, they had four Cobalt-60 machines, seven LINACs, and 11 brachytherapy afterloaders, with only one center having a 3D HDR brachytherapy afterloader.³⁸

The IAEA recommends two radiation oncologists per machine and an additional radiation oncologist for every 200-250 patients with new cancer treated annually. In addition, to curtail the risk of radiation accidents and to ensure high-quality cancer treatment, it is recommended that no more than 25-30 patients should be managed by a radiation oncologist at any one time. Other staffing requirements include medical physicists, therapy radiographers (or RTTs), and other treatment planning staff.³⁹

CURRENT STATE OF RT IN NIGERIA

Several factors have been reported as responsible for the paucity of access to RT in Nigeria, including a low national health care budget, inadequate health insurance coverage for cancer leading to almost exclusive out-of-pocket payments by patients, infrastructural barriers such as machine breakdowns and power outages, health care worker strikes, shortages of personnel and expertise, geographic barriers such as distance and travel time to RT centers, and lack of awareness of available services.^7,35 Nigeria has limited oncology-dedicated facilities and RT treatment centers relative to its population size. On the basis of IAEA recommendations in 2016, Nigeria, with a national population of approximately 180 million at that time, should have had 720 units; however, the country had seven units, <1% of the recommended number at the time.¹¹ Since then, Nigeria's population has grown to 220 million with little increase in the number of units, further widening the gap.

The Nigerian government have commissioned nine new RT centers since 1973: seven government-owned, one PPP project, and one private center.³⁸ As of year 2020, there were 11 centers offering RT to Nigeria's population of 200 million.³⁹ More recently, privately owned or partnered RT centers have been commissioned increasing the number of RT centers to 14 (four private, eight public, and two PPPs). Presently, as of June 2023, there are a total of 14 LINACs, four Cobalt-60 machines, and eight HDR brachytherapy afterloaders available in the country (Table 1).

TABLE 1.

Distribution of Radiation Therapy Centers Across Geopolitical Zones

Geopolitical Zone	Radiation Therapy Center	Cobalt-60, No.	LINAC, No.	HDR Brachytherapy, No.
South West	NSIA-LUTH Cancer Centre	NA	3	1
	Eko Hospital	1	NA	NA
	University College Hospital, Ibadan	1a	NA	1
	Marcelle Ruth Cancer Centre	NA	1	NA
South East	University of Nigeria Teaching Hospital, Enugu	NA	2	1
	American Cancer Hospital, Owerri	1	NA	NA
South South	Asi Ukpo Comprehensive Cancer Centre	NA	1	NA
	University of Benin Teaching Hospital (UBTH)	NA	NA	1
North Central	National Hospital Abuja	NA	2	1
North East	University of Maiduguri Teaching Hospital (UMTH)	NA	2	NA
	Federal Teaching Hospital Gombe	NA	NA	1
North West	Ahmadu Bello University Teaching Hospital, Zaria	1a	NA	1
	Usmanu Danfodiyo University Teaching Hospital, Sokoto	NA	1	1
	Kano Cancer Treatment Centre, Kano	NA	2a	NA
Total		4	14	8

Abbreviations: HDR, high dose rate; LINAC, linear accelerator; NA, not available.

^a Not operational.

The NSIA-LUTH cancer center, a PPP venture between the Nigeria Sovereign Investment Agency and the Lagos University Teaching Hospital, has commenced services with three LINACs capable of delivering modern techniques such as intensity-modulated RT and volumetric modulated arc therapy. Other examples of the use of PPP in the country include the maintenance of one LINAC acquired by the federal government at the University of Nigeria Teaching Hospital and one HDR brachytherapy afterloader acquired by a PPP at University College Hospital.^15,40-42

While the small increase in numbers signifies a miniscule step in the right direction, the functionality of a number of these machines remains unstable. The operational capacity of many RT centers in the country at any time has proved to be unpredictable. Many centers fail to reach their full functional capacity because of difficulty in accessing RT accessories or frequent breakdowns of essential machine components.¹² In their 2016 commentary on Nigeria, Irabor et al³⁴ described RT resource decay because of poor maintenance, funding, and inadequate or inconsistent health policies.

At the time of this review, Nigeria documents 72 clinical and radiation oncologists practicing in the country (Fig 1), 14 working LINACs, and 14 radiation treatment facilities spread across 12 states—six in the north, four in southwest, two in southeast, and two in the south south region (Table 1).

FIG 1.

Regional distribution of radiation oncologists in Nigeria.

PEDIATRIC RT IN NIGERIA

Specialized pediatric RT is a crucial part of the provision of comprehensive standard oncology care to children. Multiple clinical trials in high-income countries have led to recent technological advances in the delivery of RT to pediatric patients with significant tissue sparing.⁴³ Setting up a pediatric RT department requires a workforce that has undergone specialized training in the unique pediatric oncology protocols.

At the time of this review, there are no dedicated pediatric cancer center in Nigeria and no full-service center set up exclusively to offer cancer treatment, radiation, or otherwise to pediatric patients. The closest dedicated pediatric RT center to the Nigerian patient is thousands of miles away in South Africa.³² In addition, a majority of the treatment protocols followed in the RT of pediatric patients in Nigeria (and SSA) are inherited from clinical trials conducted in high-income countries. Local research in pediatric RT has been mostly limited to retrospective cross-sectional studies and audits of adapted treatment protocols from high-income countries.⁴⁶

An online survey was performed involving representatives of radiation oncology teams at the 14 existing radiation oncology centers in Nigeria. There was a 78.6% response rate (Fig 2). Of the participating centers, none had a LINAC dedicated to patients with pediatric cancer. Only one center located in Lagos State (the NSIA-LUTH Cancer Centre) had pediatric-size immobilization devices, and only one (16.7%) center had a dedicated pediatric oncology ward attached to their oncology service.

FIG 2.

Geographic distribution of radiation therapy centers in Nigeria and survey respondents.

Furthermore, of the 46 radiation oncologists at these centers, none was reported to have undergone a fellowship subspecialty training in pediatric radiation oncology. A total of two (4.3%) of 46 radiation oncologists were reported to have a specific interest in pediatric radiation oncology. These responding centers had a combined number of 39 medical physicists and 63 RT technicians, with none having any formal training in pediatric RT. Among members of the allied pediatric RT workforce, including oncology nurses and anesthesiologists, none had received any further training focused on pediatric RT. Only one center had an organized pediatric radiation oncology team comprising radiation oncologists, physicists, RT technicians, and oncology nurses.

This lack of pediatric radiation training in the majority of workforce could be attributed to the complete absence of pediatric radiation oncology fellowship programs, tailored fellowships, or training programs for radiation oncologists, physicists, or therapy technicians dedicated to pediatric radiation treatment in the country.³² Although there are general RT training programs in SSA and Nigeria, there are no dedicated fellowship programs specifically for pediatric radiation oncology. In addition to medical services, the survey showed that no center had a support group for children or their caregivers, psychoeducational interventions such as play and behavioral therapy programs, child life specialists, or play therapists on staff. There was no awareness of availability of any training programs for these specialty areas within Nigeria or West Africa among respondents.

In conclusion, this review documents the current status of pediatric radiation oncology in Nigeria, with clear infrastructural, workforce training and expertise deficiencies. Pediatric cancer is a leading cause of childhood death in Nigeria, and it is a matter of urgency to increase and improve access to care. The current findings highlight the urgent need to improve the availability and access to radiation oncology services for the pediatric population as a means to improve survival. Addressing this challenge could involve establishing specialized pediatric radiation oncology units within existing cancer centers or dedicated pediatric cancer centers strategically located across the country. Oncology centers and institutions should encourage and support personnel training in pediatric RT, thereby elevating the quality of care for pediatric patients. Innovative approaches to workforce training should also be explored, including potential collaborations with established training centers to introduce a pediatric radiation oncology fellowship program. While investment in infrastructure has shown improvement in the country, it is important to note that expertise, workforce expansion, and continuous education must match the pace of infrastructure. Investment in human resource needs to be prioritized for infrastructural changes to make a real impact. By uniting approaches and leveraging technology, the landscape of pediatric radiation oncology in Nigeria can be transformed.

AUTHOR CONTRIBUTIONS

Conception and design: Adedayo Joseph, Adeseye M. Akinsete, Nwamaka N. Lasebikan, Opeyemi M. Awofeso, Aishat T. Oladipo, Azeezat O. Ajose, Oluwatimileyin Ojo, Wilfred Ngwa, Adedayo A. Onitilo

Administrative support: Adedayo Joseph, Aishat T. Oladipo, Azeezat O. Ajose, Adedayo A. Onitilo

Collection and assembly of data: Adedayo Joseph, Nwamaka N. Lasebikan, Opeyemi M. Awofeso, Aishat T. Oladipo, Oluwatimileyin Ojo

Data analysis and interpretation: Adedayo Joseph, Nwamaka N. Lasebikan, Samuel Adeneye, Opeyemi M. Awofeso, Aishat T. Oladipo, Oluwatimileyin Ojo, Kenneth Merrell, David S. Puthoff

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

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