Abstract
Background and purpose
To evaluate the current status of radiotherapy facilities, staffing, and equipment, treatment and patients in Poland for the years 2005–2011 following implementation of the National Cancer Programme.
Methods
A survey was sent to the radiotherapy centres in Poland to collect data on available equipment, staffing, and treatments in the years 2005–2011.
Results
In 2011, 76,000 patients were treated with radiotherapy at 32 centres vs. 63,000 patients at 23 centres in 2005. Number of patients increased by 21%. In 2011, there were 453 radiation oncologists – specialists (1 in 168 patients), 325 medical physicists (1 in 215 patients), and 883 radiotherapy technicians (1 in 86 patients) vs. 320, 188, and 652, respectively, in 2005. The number of linear accelerators increased by 60%, from 70 units in 2005 to 112 in 2011. The current linac/patient ratio in Poland is 1 linac per 678 patients. Waiting times from diagnosis to the start of treatment has decreased.
Conclusion
Compared to 2005, there are more treatment facilities, more and better equipment (linacs), and more cancer care specialists. There are still large differences between the 16 Polish provinces in terms of equipment availability and ease of access to treatment. However, radiotherapy services in Poland have improved dramatically since the year 2005.
Keywords: Radiotherapy facilities, Equipment, Staffing
1. Background
In recent years, major technological advances have improved the effectiveness of radiotherapy. Radiotherapy has become ever more precise, making it possible to deliver highly targeted therapy that spares the normal healthy tissue surrounding the tumour.1–3 As a result, radiotherapy is indicated in an increasing number of tumour locations and became highly complex.4–8 All of these factors, together with the rising incidence of certain cancers, have increased demand for radiotherapy services.7–12
According to the ESTRO (European Society for Radiation Oncology) and the OECI (Organization of European Cancer Institutes), approximately 70% of patients who undergo cancer treatment will receive radiotherapy (6). Delivery of radiotherapy services to so many patients obviously requires a large investment in infrastructure and personnel and the ESTRO recently published recommendations for appropriate levels of radiotherapy infrastructure and staffing.9
In the year 2011 approximately 76,000 patients underwent radiotherapy in Poland.13 Due to expected increases in demand, it is estimated that at least 100,000 patients per year will require radiotherapy treatment in Poland in the coming years. To assess the preparedness of Poland to meet this growing demand for radiotherapy services, we carried out a survey of all radiotherapy treatment centres in Poland, requesting data on infrastructure, staffing, and treatments from 2005 to 2011.13–18 We present the results here.
2. Materials and methods
The National Consultant for Radiotherapy, sent detailed, paper-based questionnaires to heads of departments of all radiotherapy centres providing radiotherapy in 2005–2011.13–18 The national consultants are medical specialists nominated by Scientific Societies and the Chamber of Physicians and formally appointed by the Minister of Health to advise in various aspects of health delivery in particular medical specialities. All known radiotherapy centres, both public and private, located in the 16 provinces (vovoidships) in Poland were surveyed. The survey was sent to the all radiotherapy treatment centres in Poland, all of which completed and returned the survey (100% response rate).
The survey (see Appendix A – Tables 3–5) included questions on personnel, equipment (external radiotherapy, brachytherapy, simulators and treatment planning devices), type of the centre, and number of patients treated. Respondents were asked to provide data for years 2005–2011. All centres were asked to report the number of radiation oncologists, medical physicists and radiotherapy technicians.
Table 3.
Number of megavoltage units (linacs + cobalt units) in radiotherapy centers in the years 2005–2011.
| Province | Population as of 31.12.2010 | Cities | LINACS/Cobalt-60 units |
|||||
|---|---|---|---|---|---|---|---|---|
| 2005 | 2007 | 2008 | 2009 | 2010 | 2011 | |||
| POLAND | 38,200,037 | 70/12 | 85/8 | 95/7 | 99/5 | 106/5 | 112/3 | |
| DOLNOŚLĄSKIE | 2,877,840 | Wrocław | 5 | 7 | 6 | 6 | 6 | 6 |
| Wałbrzych | – | – | 2 | 2 | 2 | 2 | ||
| KUJAWSKO-POMORSKIE | 2,069,543 | Bydgoszcz | 3/1 | 5/1 | 5 | 5 | 6 | 7 |
| LUBELSKIE | 2,151,895 | Lublin | 3/1 | 4 | 5 | 5 | 6 | 6 |
| LUBUSKIE | 1,011,024 | Zielona Góra | 1/1 | 2/1 | 2/1 | 2/1 | 2/1 | 3 |
| ŁÓDZKIE | 2,534,357 | Łódź | 4/1 | 6 | 6 | 5 | 6 | 6 |
| MAŁOPOLSKIE | 3,310,094 | Kraków COOK | 4 | 4 | 4 | 4 | 4 | 4 |
| Kraków SU | 1a | 1a | 1a | 1a | 1a | 1a | ||
| Kraków USD | 1 | 1 | 1 | 2 | 2 | 2 | ||
| Tarnów | – | 1 | 2 | 2 | 2 | 3 | ||
| MAZOWIECKIE | 5,242,911 | Warszawa CO | 10/1 | 11 | 11 | 11 | 12 | 11 |
| Wieliszew | – | – | – | 2 | 2 | 2 | ||
| Warszawa Allenort | – | – | – | – | – | 0/1 | ||
| OPOLSKIE | 1,028,585 | Opole | 2/1 | 2/1 | 2/1 | 2/1 | 2/1 | 2/1 |
| PODKARPACKIE | 2,103,505 | Rzeszów | 1/1 | 1/1 | 2/1 | 2 | 2 | 2 |
| Brzozów | 1/1 | 1/1 | 2/1 | 3 | 3 | 3 | ||
| PODLASKIE | 1,188,329 | Białystok | 3/1 | 4/1 | 4/1 | 3/1 | 4/1 | 4/1 |
| POMORSKIE | 2,240,319 | Gdańsk | 3 | 3 | 3 | 3 | 3 | 3 |
| Gdynia | 3 | 4 | 4 | 3 | 3 | 3 | ||
| ŚLĄSKIE | 4,635,882 | Bielsko-Biała | 2 | 2 | 2 | 3 | 3 | 3 |
| Gliwice | 7 | 8 | 9 | 9 | 10 | 11 | ||
| Katowice | 2 | 2 | 2 | 2 | 2 | 2 | ||
| Częstochowa | 1 | 1 | 1 | 2 | 2 | 2 | ||
| ŚWIĘTOKRZYSKIE | 1,266,014 | Kielce | 3/1 | 4 | 4 | 4 | 4 | 4 |
| WARMIŃSKO-MAZURSKIE | 1,427,241 | Olsztyn | 2 | 3 | 3 | 3 | 3 | 3 |
| WIELKOPOLSKIE | 3,419,426 | Poznań WCO | 4/1 | 4/1 | 5/1 | 6/1 | 7/1 | 7 |
| – | – | 1a | 1a | 1a | 1a | |||
| Poznań MCO | – | – | 2 | 2 | 2 | 2 | ||
| ZACHODNIOPOMORSKIE | 1,693,072 | Szczecin | 4/1 | 4/1 | 4/1 | 4/1 | 4/1 | 5 |
| Koszalin | – | – | – | – | – | 2 | ||
LINACS used only for intra-operative radiotherapy (the calculation not included the population for 1 MV units).
Table 4.
Number of population for 1 MV units (linacs + cobalt units) in the years 2005, 2007, 2009, 2010, 2011.
| Province | City/center | Population per 1 MV units |
||||
|---|---|---|---|---|---|---|
| 2005 | 2007 | 2009 | 2010 | 2011 | ||
| POLAND | 471,127 | 414,407 | 366,691 | 343,850 | 338,053 | |
| DOLNOŚLĄSKIE | Wrocław | 578,089 | 411,760 | 359,632 | 359,578 | 359,730 |
| Wałbrzych | ||||||
| KUJAWSKO-POMORSKIE | Bydgoszcz | 516,927 | 344,395 | 413,584 | 344,847 | 295,649 |
| LUBELSKIE | Lublin | 545,547 | 543,192 | 432,366 | 359,534 | 358,649 |
| LUBUSKIE | Zielona Góra | 504,596 | 336,173 | 336,321 | 336,682 | 337,008 |
| ŁÓDZKIE | Łódź | 516,427 | 427,700 | 509,772 | 423,639 | 422,393 |
| MAŁOPOLSKIE | Kraków COOK | 652,588 | 545,201 | 410,892 | 412,284 | 367,788 |
| Kraków SU | ||||||
| Kraków USD | ||||||
| Tarnów | ||||||
| MAZOWIECKIE | Warszawa CO | 468,203 | 470,155 | 400,346 | 373,012 | 374,494 |
| Warszawa CR Allenort | ||||||
| Wieliszew | ||||||
| OPOLSKIE | Opole | 349,847 | 347,314 | 344,347 | 343,699 | 342,862 |
| PODKARPACKIE | Rzeszów | 524,449 | 524,391 | 419,899 | 420,346 | 420,701 |
| Brzozów | ||||||
| PODLASKIE | Białystok | 300,250 | 239,220 | 297,868 | 237,946 | 237,666 |
| POMORSKIE | Gdańsk | 366,167 | 314,799 | 369,919 | 371,683 | 373,387 |
| Gdynia | ||||||
| ŚLĄSKIE | Bielsko-Biała | 391,121 | 359,164 | 290,354 | 272,984 | 257,549 |
| Gliwice | ||||||
| Katowice | ||||||
| Częstochowa | ||||||
| ŚWIĘTOKRZYSKIE | Kielce | 321,596 | 319,960 | 318,196 | 317,530 | 316,504 |
| WARMIŃSKO-MAZURSKIE | Olsztyn | 714,240 | 475,628 | 475,691 | 475,706 | 475,747 |
| WIELKOPOLSKIE | Poznań WCO | 672,505 | 675,700 | 377,513 | 340,828 | 379,936 |
| Poznań MCO | ||||||
| ZACHODNIO-POMORSKIE | Szczecin | 338,856 | 338,568 | 338,591 | 338,640 | 241,867 |
| Koszalin | ||||||
Table 5.
Features of radiotherapy centers in the brachytherapy devices in the years 2005–2011.
| Provinces | Total population as of 31.12.2010 | City/center | Total number of BT devices |
Population/BT device in 2011 | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2005 | 2007 | 2008 | 2009 | 2010 | 2011 | ||||||||||||||||
| Poland | 38,200,037 | 42 devices, 21 LDR/MDR, 16 HDR, 5 PDR | 45 devices, 18 LDR/MDR, 21 HDR, 6 PDR | 41 devices, 8 LDR/MDR, 27 HDR, 6 PDR | 42 devices, 5 LDR/MDR, 31 HDR, 6 PDR | 42 devices, 1 LDR/MDR, 35 HDR, 6 PDR | 44 devices, 1 LDR/MDR, 37 HDR, 6 PDR | 868,183 | |||||||||||||
| LDR/MDR | HDR | PDR | LDR/MDR | HDR | PDR | LDR/MDR | HDR | PDR | LDR/MDR | HDR | PDR | LDR/MDR | HDR | PDR | LDR/MDR | HDR | PDR | ||||
| DOLNOŚLĄSKIE | 2,877,840 | Wrocław DCO | 1 | 1 | 1 | 1 | 1 | 1 | 1,438,920 | ||||||||||||
| Wrocław SPSK | 1 | 1 | 1 | ||||||||||||||||||
| Wałbrzych MCO | 1 | 1 | 1 | 1 | |||||||||||||||||
| KUJAWSKO-POMORSKIE | 2,069,543 | Bydgoszcz | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1,034,772 | ||||
| LUBELSKIE | 2,151,895 | Lublin | 1 | 1 | 1 | 1 | 1 | 2 | 2 | 1,075,948 | |||||||||||
| LUBUSKIE | 1,011,024 | Zielona Góra | 1 | 1 | 1 | 1 | 1 | 1 | 1,011,024 | ||||||||||||
| ŁÓDZKIE | 2,534,357 | Łódź | 2 | 1 | 2 | 1 | 1 | 2 | 2 | 2 | 1,267,179 | ||||||||||
| MAŁOPOLSKIE | 3,310,094 | Kraków COOK | 1 | 1 | 1 | 1 | 1 | 2 | 1 | 2 | 2 | 1 | 2 | 1 | 2 | 1 | 662,019 | ||||
| Kraków SU Gin. | 1 | 1 | 1 | ||||||||||||||||||
| Tarnów | 1 | 1 | 1 | ||||||||||||||||||
| MAZOWIECKIE | 5,242,911 | Warszawa | 2 | 2 | 3 | 1 | 3 | 1 | 3 | 1 | 3 | 1 | 3 | 1 | 1,048,582 | ||||||
| Wieliszew | 1 | 1 | 1 | ||||||||||||||||||
| OPOLSKIE | 1,028,585 | Opole | 2 | 1 | 2 | 1 | 1 | 1 | 1 | 1 | 1,028,585 | ||||||||||
| PODKARPACKIE | 2,103,505 | Rzeszów | 2 | 2 | 2 | 2 | 1 | 1 | 525,876 | ||||||||||||
| Brzozów | 1 | 1 | 1 | 1 | 2 | 1 | 2 | 1 | |||||||||||||
| PODLASKIE | 1,188,329 | Białystok | 1 | 1 | 1 | 1 | 1 | 1 | 1,188,329 | ||||||||||||
| POMORSKIE | 2,240,319 | Gdańsk | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 2 | 1 | 1 | 1,120,160 | ||||||||
| Gdynia | 1 | 1 | 1 | 1 | 1 | 1 | |||||||||||||||
| ŚLĄSKIE | 4,635,882 | Bielsko-Biała | 1 | 1 | 1 | 1 | 772,647 | ||||||||||||||
| Gliwice | 2 | 1 | 2 | 2 | 2 | 3 | 3 | ||||||||||||||
| Katowice | 1 | 1 | 1 | 1 | 1 | 1 | |||||||||||||||
| Częstochowa | 1 | 1 | 1 | 1 | 1 | 1 | |||||||||||||||
| ŚWIĘTOKRZYSKIE | 1,266,014 | Kielce | 1 | 1 | 1 | 2 | 1 | 2 | 1 | 2 | 1 | 2 | 1 | 2 | 422,005 | ||||||
| WARMIŃSKO-MAZURSKIE | 1,427,241 | Olsztyn | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1,427,241 | ||||||||||
| WIELKOPOLSKIE | 3,419,426 | Poznań WCO | 2 | 1 | 1 | 2 | 1 | 1 | 2 | 2 | 1 | 2 | 1 | 2 | 1 | 2 | 1 | 683,885 | |||
| Poznań MCO | 1 | 1 | 1 | 2 | |||||||||||||||||
| Poznań PSK UM | 1 | 1 | |||||||||||||||||||
| ZACHODNIOPOMORSKIE | 1,693,072 | Szczecin | 2 | 1 | 2 | 1 | 1 | 1 | 1 | 1 | 846,536 | ||||||||||
| Koszalin | 1 | ||||||||||||||||||||
To make analysis of the data easier we provide map of Poland with all provinces shown (Fig. 1) and structure of the Polish population in the years 2005–2010 (Fig. 2).19,20
Fig. 1.
Provinces and province capital cities in Poland.
Fig. 2.
Structure of the Polish population in the years 2005–2010.19,20
2.1. Statistical analysis
In this descriptive study categorical variables were described as percentages and continuous variables by means ± standard error (SE). The Statistical Package for the Social Sciences, version 13.0 (SPSS Inc., Chicago, Illinois, USA) was used to perform the statistical analysis.
3. Results
3.1. Radiotherapy facilities
The number of cancer care centres in Poland increased from 23 in 2005 to 32 in 2011. Table 1 shows all centres that perform radiotherapy and the treatment methods (EBRT, BT, etc.) available at those centres. Almost all centres that offered external beam radiotherapy (EBRT) also provide brachytherapy. Some centres also provided selective radiotherapy in cooperation with the larger centres. Of the 32 centres that provide radiotherapy, 3 are scientific research institutes, 5 are university clinics specialising in radiotherapy, 8 are regional cancer centres, 10 are radiotherapy centres that are part of regional or municipal hospitals, and 6 are private.
Table 1.
Methods used in oncology centres in Poland.
| Province | Total population as of 31.12.2010 | City/center | EBRT | Brachytherapy | Intraoperative EBRT accelerator | Intraoperative EBRT X-ray | Gammaknife | Cyberknife | Cyclotron protons + brachytherapy eye | I-125 – seeds |
|---|---|---|---|---|---|---|---|---|---|---|
| POLAND | 38,200,037 | |||||||||
| DOLNOŚLĄSKIE | 2,877,840 | Wrocław DCO | ■ | ■ | ||||||
| Wrocław WSS | ■ | |||||||||
| Wałbrzych MCO | ■ | ■ | ||||||||
| KUJAWSKO-POMORSKIE | 2,069,543 | Bydgoszcz | ■ | ■ | ||||||
| LUBELSKIE | 2,151,895 | Lublin COZL | ■ | ■ | ||||||
| Lublin AM | ■ | |||||||||
| LUBUSKIE | 1,011,024 | Zielona Góra | ■ | ■ | ||||||
| ŁÓDZKIE | 2,534,357 | Łódź | ■ | ■ | ||||||
| MAŁOPOLSKIE | 3,310,094 | Kraków COOK | ■ | ■ | ||||||
| Kraków SU | ■ | ■ | ■ | |||||||
| Kraków USD | ■ | |||||||||
| Tarnów | ■ | ■ | ||||||||
| MAZOWIECKIE | 5,242,911 | Warszawa CO | ■ | ■ | ||||||
| Warszawa CR Allenort | ■ | |||||||||
| Wieliszew | ■ | ■ | ||||||||
| OPOLSKIE | 1,028,585 | Opole | ■ | ■ | ||||||
| PODKARPACKIE | 2,103,505 | Rzeszów | ■ | ■ | ||||||
| Brzozów | ■ | ■ | ||||||||
| PODLASKIE | 1,188,329 | Białystok | ■ | ■ | ||||||
| POMORSKIE | 2,240,319 | Gdańsk | ■ | ■ | ||||||
| Gdynia | ■ | ■ | ||||||||
| ŚLĄSKIE | 4,635,882 | Bielsko-Biała | ■ | ■ | ||||||
| Gliwice | ■ | ■ | ■ | ■ | ||||||
| Częstochowa | ■ | ■ | ||||||||
| Jastrzębie Zdrój | ■ | |||||||||
| Katowice | ■ | ■ | ||||||||
| ŚWIĘTOKRZYSKIE | 1,266,014 | Kielce | ■ | ■ | ||||||
| WARMIŃSKO-MAZURSKIE | 1,427,241 | Olsztyn | ■ | ■ | ||||||
| WIELKOPOLSKIE | 3,419,426 | Poznań WCO | ■ | ■ | ■ | |||||
| Poznań MCO | ■ | ■ | ||||||||
| ZACHODNIOPOMORSKIE | 1,693,072 | Szczecin | ■ | ■ | ■ | |||||
| Koszalin | ■ | ■ | ||||||||
3.2. Equipment
As shown in Fig. 3, from 2005 to 2011, the number of accelerators increased by 60% (from 70 to 112 units) while installed Cobalt-60 units decreased by 75% (from 12 to 3). Of the 70 accelerators in use in 2005, only 1 was for intraoperative radiotherapy; by early 2012, there were 2 accelerators for intra-operative radiotherapy and 1 CyberKnife accelerator (particulars see Appendix A Table 3).
Fig. 3.
Total number of accelerators and Cobalt-60 units in the years 2005–2011.
Table 2 shows population per 1 MV units (accelerators + cobalt units) for whole country. As the table clearly shows, the population/megavoltage units ratio improved (i.e., declined from 471,127/megavoltage units to 338,053/megavoltage units) markedly over this period due to the large investment in new accelerators (particulars see Appendix A – Table 4).
Table 2.
Population in Poland per 1 MV units (accelerators + cobalt units) in the years 2005–2011.
| Population per 1 MV units (accelerators + cobalt units) |
|||||
|---|---|---|---|---|---|
| Years | 2005 | 2007 | 2009 | 2010 | 2011 |
| POLAND | 471,127 | 414,407 | 366,691 | 343,850 | 338,053 |
Fig. 4 shows population per 1 MV units (accelerators + cobalt units) by province in Poland for the years 2005–2011.
Fig. 4.
Comparison of the number of inhabitants per 1 MV units (accelerators + cobalt units) in the provinces in years 2005, 2007, 2009, 2010 and 2011 (see map in Fig. 1).
Fig. 5 shows the number of megavoltage units (accelerators + cobalt units) and related equipment in use from 2005 to 2011. Over this time period, many existing accelerators were upgraded and many more new machines were purchased. Many of the new machines came fully equipped with multileaf collimators (MLC), micro multileaf collimations (microMLC), intensity modulated radiation therapy (IMRT), electronic portal imaging devices (EPID), Volumetric Modulated Arc Therapy (VMAT), image-guided radiation therapy (IGRT), and respiratory gating. Cobalt units were replaced by linear accelerators: in 2005 12 Cobalts were in operation and in 2011 only 3.
Fig. 5.
Number of linacs and related equipment in use from 2005 to 2011 (no data for year 2006).
Linac indicates linear accelerator; MLC, multileaf collimator; EPID, electronic portal imaging devices; IGRT, image-guided radiotherapy; and IMRT, intensity-modulated radiotherapy.
The number of simulators increased by only 11% (from 36 in 2005 to 40 in 2011). This increase was smaller than might be expected due to (1) removal of old and worn simulators, and (2) a tendency to replace standard, dedicated radiotherapy computed tomography (CT) simulators with virtual simulation stations (CT-VSIM stations). In 2011, there were a total of 27 CT scan stations equipped with virtual simulation in the 32 oncology centres. Fig. 6 shows the available equipment for planning radiotherapy (simulators, CT scanners, and CT simulators) from 2005 to 2011. Note that no data is available on virtual simulation for the years 2005 and 2007.
Fig. 6.
Features of radiotherapy centres in Poland in simulators and CT scanners for select years from 2005 to 2011.
The brachytherapy equipment available from 2005 to 2011 is shown in Fig. 7. As this graphic illustrates, the number of high-dose rate (HDR) afterloaders more than doubled between the years 2005 and 2011 (from 16 to 37, an increase of 131%). Although low-dose rate/medium-dose rate (LDR/MDR) machines were the most common equipment in 2005, by 2011 only 1 remained in service. The number of pulsed-dose rate (PDR) machines increased slightly (from 5 to 6) (particulars see Appendix A – Table 5).
Fig. 7.
Features of radiotherapy centres in Poland – brachytherapy devices in the years 2005–2011.
Fig. 8 shows the population per brachytherapy device in 2011, by province. As is clear from the figure, the ratio varies widely by province.
Fig. 8.
Population per brachytherapy device in 2011, by province (see map in Fig. 1).
3.3. Personnel and staffing levels
Between 2005 and 2011, the number of radiation oncologists in Poland increased by more than 40% (from 320 to 453), and the number of medical residents specialising in Radiation Oncology increased by 15% (from 149 to 171). The number of medical physicists increased by over 70% (from 188 to 325), and the number of radiotherapy technologists increased by almost 36% (from 652 to 883). Fig. 9 shows the number of radiation oncologists (specialists), medical physicists and radiotherapy technicians (RTTs) employed in radiotherapy centres.
Fig. 9.
Personnel in radiotherapy centres from 2005 to 2011.
Fig. 10 shows the number of employed physician staff in radiation oncology in radiotherapy centres during the years 2005–2011 (specialists in radiation oncology and physicians in training).
Fig. 10.
Radiation oncologists and physicians in trainee (residents in radiotherapy) employed in oncology centres in the years 2005–2011.
3.4. Patients
As the number of linacs and brachytherapy equipment increased, so too did the number of patients. From 2007 to 2011, the number of treated patients increased from 63,000 to 76,000, a 21% increase in 5 years (Fig. 11, particulars see Appendix A – Table 4).
Fig. 11.
Number of patients treated by radiotherapy in radiotherapy centers in Poland in the years 2007–2011.
Fig. 12 shows the number of treated patients, radiotherapy method utilized for treatment (i.e., brachytherapy and/or EBRT) by province for the years 2007–2011.
Fig. 12.
Number of patients treated with radiotherapy in the provinces in years 2007, 2008, 2009, 2010 and 2011 (see map in Fig. 1).
4. Discussion
In 2011, Poland had a total of 325 medical physicists and 453 radiation oncologists (physicians specialists) who treated 76,000 radiotherapy patients, a ratio of 1 medical physicist per 234 patients and 1 radiation oncologist per 168 patients. It should be noted that in the matter of staff situation in Poland improved significantly over last eight years and reached the level that meets, ESTRO, QUARTS recommendations for staffing (1 radiation oncologist per 200–250 patients, and 1 physicist per 450–500 patients).8,9,12 However there is some concern about these figures. Particularly the QUARTS study referred to the level of radiotherapy before 2005. Since that time complexity of all procedures has increased thus more staff is required.2,3,21–29 This is why ESTRO launched new project on Health Economics in Radiation Oncology (HERO).28 Medical physicists in Poland are still more involved in treatment planning than in West European countries, where dominantly these duties are carried by dosimetrists or physics assistants.7,8,21 Moreover residency programme in medical physics speciality has started in Poland only few years ago and total number of physicists working in radiotherapy does not portrait well staffing level in this category, as only small portion was able to pass the required certification up to date. In some of the cancer centres staff participate in undergraduate teaching and research, which reduces time dedicate to clinical work.2,21,27,30 We have not revised these factors for the current analysis and further study is required.
The current linac/patient ratio in Poland (1 linac per 678 patients) does not comply with the ESTRO recommendation of 1 linac per 450 patients.8 In general, however, it is safe to say that radiotherapy services, facilities, and staffing have made major progress since the year 2005.25,26
The government of Poland has made a concerted effort in recent years to improve cancer care and prevention in order to bring Poland in line with other European countries. To this end, the National Cancer Programme (NCP) was approved by the Polish parliament on July 1, 2005. The NCP is an ambitious and well-financed plan 3 billion zloty (approximately €715 million allocated for the years 2006–2015) and encompasses a multipronged approach to cancer prevention, treatment, and awareness. One of the major thrusts of the NCP involves significant funding to equip and modernize radiotherapy departments throughout the country. As the results of our survey show, the additional investments made by the NCP have dramatically improved access to care in Poland and quality of care. In fact, one of the biggest improvements is still to come with the planned launch, in the year 2014, of the National Centre for Hadron Therapy at the Institute of Nuclear Physics in Cracow. This is an exciting and important development, as hadron therapy has several advantages that promises to further improve treatment outcomes in some tumour localizations.23
4.1. Radiotherapy equipment
The World Health Organization (WHO) recommends a standard of 250,000–300,000 inhabitants per linac.7,10,18 Viewed in this way, the number of linacs in Poland is still insufficient. The current ratio is 1 MV linac per 338,053 inhabitants. However, this is a major improvement from 2005, when there were 471,127 inhabitants per linac. Under the NCP, a total of 60 linacs were purchased and installed between 2008 and 2011 at public centres (8 linacs at private centres). Nevertheless, the number of linacs in use actually increased by only 42 machines over this period due to decommissioning of outdated machines, including Cobalt-60 therapy units (of which only 2 are still in use in Poland). Likewise, newer technologies, including the GammaKnife and CyberKnife, have been added. Currently, there are 112 linacs for a treatment population of 76,000 patients (1 linac per 678 patients). To meet the ESTRO QUARTS guidelines of 1 linac per 450 patients (for a patient population of 76,000, this implies 168 linacs), Poland would need a net increase (after accounting for decommissioned units) of at least 44 linacs. That is, under these standards, there is a current shortfall of 56 linac units in Poland without taking into consideration the expected increase in demand in the next few years. In terms of equipment, Poland has made vast improvements in a very short time, but more will need to be done in coming years. The demand for new radiotherapy machines may exceed the current estimate, which is based on the models of staffing revised in 2005, so it is likely that introduction of new technologies will require more staff and more equipment to be dedicated to radiotherapy. Fortunately, NCP funding is scheduled to continue through 2016 and we will be able to continue modernising and expanding radiotherapy facilities and equipment during this period.
4.2. Regional differences
There are still large differences between the 16 provinces in terms of equipment availability and ease of access to treatment. For example, in terms of brachytherapy devices per million population, some provinces have more than 1.4 million inhabitants per device while others have as few as 400,000 inhabitants per device. The same is true for linacs. In some provinces, the population to linac ratio is over 422,000:1 (Lodzkie and Podkarpackie provinces) and in one province the ratio is 476,000:1 (Warminsko-Mazurskie). In contrast, in other regions, such as Slaskie, Podlaskie, and Zachodniopomorskie, this ratio does not exceed 258,000:1. The reasons for such wide regional differences are the same as observed in most countries: population density and wealth. Notwithstanding these regional differences, access to advanced radiotherapy has been improved since 2005 and will continue improving.
5. Conclusion
As this survey shows, radiotherapy facilities in Poland have been substantially improved and upgraded. Although there is still a gap between Poland and western EU countries in many health measures, including life expectancy, the gap is closing quickly as Poland has invested heavily in improving health care services. Nevertheless the National Cancer Programme has to be continued after year 2015 as a support to regular reimbursement for the radiotherapy procedures.
Compared to 2005, there are more comprehensive centres (32 vs. 23), more equipment with improved technology, and more cancer care specialists. As a result, access to treatment has improved markedly. Moreover, investment in advanced technologies and techniques (IMRT, tomotherapy, and SBRT-CyberKnife) now allows us to offer patients the most effective treatments to improve outcomes. Finally, one important, and perhaps underappreciated, improvement resulting from the increase in available human and technological resources is in waiting times from diagnosis to the start of treatment has decreased. Waiting time is an important indicator of quality, and this dramatic reduction confirms that radiotherapy services in Poland have improved dramatically in recent years. For both patients and cancer care professionals, this is welcome news.
Continuous study is needed to estimate the required number of therapeutic machines and staff, as the rapid development in science and technology modifies the techniques used.
To our knowledge, this is the first comprehensive study of radiotherapy facilities and staffing in Poland. A follow-up study should be performed to identify changes in infrastructure, human resources, and treatments that are sure to occur in the next few years.
Conflict of interest
None declared.
Financial disclosure
None declared.
Appendix A.
See Tables 3–6.
Table 6.
Number of patients treated with radiotherapy in provinces in 2007–2011.
| Province | Population as of 31.12.2010 | City | Number of patients treated |
||||
|---|---|---|---|---|---|---|---|
| 2007 | 2008 | 2009 | 2010 | 2011 | |||
| Poland | 38,200,037 | 63,452 | 67,260 | 69,463 | 73,566 | 75,879 | |
| DOLNOŚLĄSKIE | 2,877,840 | Wrocław | 3801 | 3931 | 3782 | 3616 | 3736 |
| Wrocław SPSK | 17 | – | – | – | – | ||
| Wrocław WSS | – | – | – | – | 10 | ||
| Wałbrzych | – | 32 | 865 | 1277 | 1435 | ||
| KUJAWSKO-POMORSKIE | 2,069,543 | Bydgoszcz | 4228 | 4489 | 4638 | 5086 | 5156 |
| LUBELSKIE | 2,151,895 | Lublin | 2674 | 2586 | 2887 | 3309 | 3444 |
| Lublin UM | 54 | 43 | 34 | 40 | 16 | ||
| LUBUSKIE | 1,011,024 | Zielona Góra | 932 | 1291 | 1289 | 1177 | 1265 |
| ŁÓDZKIE | 2,534,357 | Łódź | 2728 | 3072 | 3071 | 3199 | 3314 |
| MAŁOPOLSKIE | 3,310,094 | Kraków COOK | 2602 | 2821 | 2532 | 2852 | 2544 |
| Kraków SU | 211 | 189 | 315 | 336 | 374 | ||
| Kraków USD | 321 | 286 | 325 | 384 | 477 | ||
| Tarnów | – | 316 | 813 | 1107 | 1325 | ||
| MAZOWIECKIE | 5,242,911 | Warszawa | 9423 | 9911 | 10,198 | 9287 | 9177 |
| Wieliszew | – | – | – | 469 | 1392 | ||
| Warszawa Allenort | – | – | – | – | 243 | ||
| OPOLSKIE | 1,028,585 | Opole | 1021 | 1022 | 989 | 1157 | 1206 |
| PODKARPACKIE | 2,103,505 | Rzeszów | 1409 | 1303 | 1798 | 1361 | 1154 |
| Brzozów | 1892 | 2057 | 1853 | 1830 | 2258 | ||
| PODLASKIE | 1,188,329 | Białystok | 1833 | 1947 | 2025 | 1893 | 2064 |
| POMORSKIE | 2,240,319 | Gdańsk | 1695 | 1750 | 1748 | 1949 | 2198 |
| Gdynia | 1290 | 1441 | 1382 | 1699 | 1488 | ||
| ŚLĄSKIE | 4,635,882 | Bielsko-Biała | 1224 | 1320 | 1415 | 1558 | 1594 |
| Częstochowa | 1113 | 1662 | 1728 | 1959 | 1879 | ||
| Gliwice | 7020 | 7381 | 7104 | 8137 | 8036 | ||
| Jastrzębie Zdrój | – | – | – | 14 | 31 | ||
| Katowice | 2275 | 2418 | 2085 | 2532 | 2489 | ||
| ŚWIĘTOKRZYSKIE | 1,266,014 | Kielce | 3170 | 2557 | 2900 | 3268 | 3368 |
| WARMIŃSKO-MAZURSKIE | 1,427,241 | Olsztyn | 1806 | 2132 | 2353 | 2236 | 2219 |
| WIELKOPOLSKIE | 3,419,426 | Poznań WCO | 7003 | 7528 | 6929 | 6371 | 5709 |
| Poznań PSK UM | 110 | 88 | – | – | – | ||
| Poznań MCO | – | – | 693 | 1651 | 1964 | ||
| ZACHODNIOPOMORSKIE | 1,693,072 | Szczecin | 3600 | 3687 | 3712 | 3812 | 3847 |
| Koszalin | – | – | – | – | 467 | ||
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