Stereotactic radiotherapy in India: Cross-sectional survey of patterns and socio-economic insights

Abstract

Background:

In the context of the largest democracy of the world (India) with wide variations in the demographic and socio-economic parameters, there is an immense need for a wide reach of advanced radiotherapy facilities. We aim to study the patterns and socio-economic aspects of stereotactic radiosurgery in India.

Methods:

The study is based on an online survey consisting of 20 questions. The participants were all radiation oncology professionals in India.

Results:

An online questionnaire was prepared and sent to nearly 400 radiation oncologists across the country and we received responses from 78 members. The majority of the participants were practicing Stereotactic radiotherapy. 76% of the participants were located in urban regions. All centers are equipped with Linear accelerators. 89% of centers have facilities to practice SRS. 65% of them have less than 3 years of experience. There were wide variations in the cost of treatment with an average cost of between 1-3lakhs INR (1350-4100$). The majority of people with medical insurance reside in urban locations and those patients who go to small and medium private hospitals and government colleges have state-run health schemes. Participants gave various suggestions for the wider accessibility of SRS facilities across the nation.

Conclusions:

Initiatives are to be taken at multiple levels to make stereotactic radiotherapy easily and widely available across the country.

INTRODUCTION

Stereotactic radiotherapy (SRT) was invented by Leksell, a Swedish neurosurgeon, in Sweden in 1951. Gamma Knife was the first device used to deliver SRS. It was installed in the Karolinska Institute, Sweden in 1967.[1] Because of the costs associated with the Gamma Knife, LINACs (Linear accelerators) were modified for radio surgical use.[2] Though first reported Linac-based radiosurgery was done as early as 1983, it is the gradual technological innovations like the development of multi-leaf collimators, advanced planning systems, and its wide applications that made Linacs overtake Gamma knife in clinical practice. The LINAC is now the most frequently used device for delivery of conventional radiotherapy and radiosurgery apart from other advanced radiotherapy machines like Cyberknife, Tomotherapy. Particle therapy units like proton beams are now gaining popularity but their availability and cost are hindering its wider accessibility.

In India, as of 2020, an estimated 2.25 million people are living with cancer with over 1.1 million new cases being added every year. [3] While the majority of socio-economic parameters and concerns of SRS were addressed in the literature, they were most pertinent to the developed world. Most of the available literature refers to a retrospective assessment of cost-effectiveness, incremental cost-effective analysis, and cost-utility analysis of SRS in terms of QALY (quality-adjusted life years), LYS (life years saved), etc., but none of the available socio-economic studies perceived individual clinician inputs while assessing socio-economic implications of SRS. [4]

While radiotherapy is used to treat malignant lesions in the majority of cases, there are numerous benign lesions where it is the standard of care. It is estimated, more than 35% of patients with systemic malignancy will develop brain metastases in their lifetime.[5] Indications of SRS/SRT were mainly categorized into 4 subgroups; a) Primary malignant lesions of the brain. b) Metastatic lesions from primary solid tumors. c) Benign intracranial lesions. d) Re-irradiation.

In our study, we intend to analyze trends of SRS practice in India, cost, availability, accessibility and to provide insights on cost regulation and minimization of operational cost based on clinician suggestions.

MATERIALS AND METHODS

We have conducted an internet survey-based, cross-sectional study among Radiation oncologists (RO) practicing in India, to find out the practice patterns and socio-economic implications regarding the use of cranial SRT.

The total study duration was 1 month (May 2020). Online survey link (through survey portal: SurveyMonkey, which is an online survey portal with the features of real-time results, text analysis, SPSS integration, custom reporting, etc.) was sent randomly to nearly 400 Radiation Oncologists (RO) practicing across India who were members of different radiation oncology groups via e-mail, Whatsapp, Telegram and Facebook. We also sent a second round of surveys 15 days after the first round. The participants were asked to answer 20 questions prepared by authors. The questions were mainly aimed at all practicing radiation oncologists irrespective of the availability of SRS facilities at their centers. The responses were anonymous. We anticipated a response rate of at least 30-40%.

The survey includes questions regarding the availability of SRT facilities in their institutes, patient load, the average cost of SRT, average socioeconomic status of patients, the status of medical insurance or government scheme, insights on accessibility and affordability of SRT to maximum patients. The response to the survey was evaluated and results were analyzed.

RESULTS

Surveys were sent to 400 Radiation Oncologists across the nation. Total respondents were 19.5% (78). Of which 19% (n=76) responses were complete.

Q1. Designation

Among all respondents (76) 73.7% (56) were radiation oncology consultants, 10.5% (8) were senior residents or senior registrars and 15.8% (12) were postgraduate students (answered on behalf of consultants).

Q2. Working Location

Among respondents (76) 55.3% (42) were working in metropolitan cities like Delhi, Mumbai, Kolkata, Chennai, Bengaluru, and Hyderabad, whereas 21% (16) were working in urban settings. 18.4% (14) were practicing at semi-urban localities and 5.3% (4) were working in rural radiation centers. This was anticipated as the resources required to set up radiotherapy facilities were limited in rural areas. This distribution may also suggest a variance in the responses given by the participants.

Q3. Type (Nature) of Centre

Among respondents (76) 15.8% (12) were working in Medical colleges or Regional cancer centers, 5.2% (4) were working in Trust hospitals, whereas 63.2% (48) participating radiation oncologists were working in corporate hospitals and 15.8% (12) were working in small to medium private oncology centers.

Q4-6. Equipment and technical specifications

Among respondents (76) 93.4% (71) claimed to have Linear accelerators (Linac) or multiple machines one of which is a Linac at their centers. 3.9% (3) respondents claimed to have cyberknife at their Institute and 2.7% (2) has Tomotherapy at their center. 86.9% (66) of respondents said their machines are equipped with technical specifications to perform cranial SRT. Among the 13.1% (10) of respondents who said they don’t have technical specifications to perform SRT, the nearest center with this facility is less than 50km for 60% (6) of the participants and as per the rest of the 4 (40%) respondents, patients have to travel more than 100km to avail this facility.

Q7. Work experience

Among 76 respondents, 72 members answered a question asked about their experience. 25% (18) members had the experience of less than 1 year of treating SRT patients, 8 postgraduate students were included among them. 30.6% (22) were 1-2 years experienced, 33.3% (24) participants were 3-5 years experienced and 11.1% (8) were more than 5 years experienced.

Q8. Incidence

When we asked about the incidence of patients presenting to their center (among 76 respondents) with indications of cranial SRT, 89.5% (68) reported less than 10 cases per month, of which 42.1% (32) participants reported an incidence of fewer than 2 patients per month. Whereas 10.5% (8) reported an incidence of more than 11 cases per month of which, 7.9% (6) asserted they are seeing more than 20 patients per month.

Q9. Indications

We have asked respondents to describe the percentage of patients presenting with different indications, grouped into 4 categories. 74 out of 76 respondents answered the question. The average distribution includes- 20.8% benign lesions, 20.1% brain metastases, 48.3% re irradiation, and 10.8% primary malignant tumors of the brain.

Q10. Average Cost of treatment

74 members responded out of 76 participants. 24.3% (18) of oncologists were treating SRT at a cost of less than INR 1 lakh (1350 USD), the majority of them are located in semi-urban and rural regions working in medical colleges, RCC, and trust hospitals. 67.6% (50) were charging between INR 1-3 Lakhs (1350-4100 USD) and 8.1% (6) were charging more than 3 lakhs (4100 USD) per patient. On detailed analysis, it is found all those charging more than INR 3 lakhs per patient were working in corporate centers located in metro cities.

Q11. Average socio-economic status

Among respondents (76) 7.9% (6) were seeing predominantly upper class patients, 26.3% (20) Upper middle class, 18.4% (14) Lower middle class, 18.4% (140 lower class. The rest of the 29% (22) reported their patient population has mixed socio-economic groups.

Q12-13. Status of Medical Insurance or Government health schemes

Among 76 respondents 36.8% (28) reported less than 25% of people do have medical insurance. The majority of them go to medical colleges, RCC, or small to medium private hospitals. In corporate hospitals, the scenario is different with the majority of the patients going there would have medical insurance as reported by 15.8% (12) with over 75% covered under insurance. Whereas, when we asked about patients qualifying for state and central government schemes 22.2% reported less than 25% incidence, 22.2% reported 25-50% incidence and 55.6% reported more than 50% incidence.

Q14-16. Treatment under government health schemes (free treatment sponsored by the state or central government for socio-economically backward population)

While those with medical insurance and affordable patients are not under financial stress to receive treatment, the concern is about patients with health schemes who otherwise not affordable for SRS/SRT. When we asked whether SRS/SRT was treated under health schemes, 52.6% (40) responded Yes and 47.45 (36) said No.

Among 40 respondents who said they treat SRT under health schemes, 35% (14) find it financially viable for the institution, and of the 36 participants who don’t treat SRS patients 24 members responded to the question asked for possible reasons. 27.8% (10) felt the package for SRT under the health scheme is low, 27.8% (10) asserted it is their institutional policy, and the rest of the 44.4% (16) respondents didn’t want to specify any reason.

Q17-19. Affordability, regulations, and accessibility

When we ask about options for non-affordable patients, not treated under schemes 13.5% (10) said they will refer to other center and 29.7% (22) said they will suggest those patients alternate treatment options like surgery or fractionated radiotherapy while 51.4% (38) asserted they will give maximum discounts to push for SRS/SRT and lastly only 5.4% (4) said they will look for NGO or other financial assistance for those patients.

When we asked about regulating treatment cost, 74 participants responded. Among them, 59.5% (44) opined to regulate price to maximize availability. Whereas 40.5% (30) either refused to regulate prices or said it is not cost-effective to regulate the price.

Of the 44 respondents who said yes to cost regulation, when we asked for suggestions, 11 responded with different opinions. (Table 1)

Q20. Minimizing operational cost

When we asked opinions to decrease the operational cost of SRS/SRT, 20 participants were responded. While most of them said nothing much can be done, some important suggestions were also received. (Table 2)

Table 1.

Suggestions on cost regulation of SRT

a)	Majority of the respondents opined on the need for increasing package amounts in health schemes.
b)	Insisting managements to enroll in central and state government health schemes.
c)	All training institutes should be equipped with SRS facilities.
d)	Those machines which are capable of SRS but not included in the list of packages should be enrolled (e.g. Cyberknife).

Table 2.

Suggestions to minimise operational cost of SRT

a)	Trying to keep it single session treatment wherever possible to minimize hospital stay, transportation charges, and machine time.
b)	Limiting MRI sequences as per requirement by making adequate protocols.
c)	Keeping templates for SRS planning of solitary lesions to reduce planning time in TPS.
d)	Collaborating with nearby non-SRS centers to increase patient numbers to make it financially viable under schemes.
e)	Frame-less treatment, use of a single layer (instead of 3 layered brain lab mask) thermoplastic devices in experienced hands can be useful.
f)	An increasing number of treatment centers by encouraging government subsidy on treatment machines.
g)	Careful selection of patients (not to be over enthusiastic in borderline indications)

DISCUSSION

The study got a lesser response rate than the anticipated value but, it might be sufficient enough to draw some important conclusions. The majority of respondents are practicing consultants; most of them were working at metro cities and urban locations at private and corporate hospitals with facilities suitable for stereotactic radiotherapy. In most of the centers, the average cost of treatment is around 1-3Lakks INR (1350-4100 USD) and the average socio-economic status of the population is the middle-class income group. Patients with medical Insurance were going to corporate and private hospitals and those with state or national health schemes were going to all sorts of centers where the scheme is available. It is good to see many centers are implementing health schemes for the treatment of stereotactic radiotherapy. Study participants also gave some very good insights on enhancing the availability and affordability of SRS.

As of 2020 more than 3600 doctors were registered under the association of radiation oncologists of India, which holds the directory of all radiation oncologists in the country. This includes clusters of postgraduate students, senior residents, and practicing consultants. [6] We have a high turnout of consultant radiation oncologists in the surveys (73%), who are the prime contact points for SRS patients, as trainee doctors are less experienced in handling such patients. 82% of respondents have more than 1 year of experience in handling SRS patients.

In our study, we found a maximum number of respondents practice in metro cities followed by urban localities. Only 1/4th of radiation oncologists are practicing in semi-urban and rural regions where the bulk of the population is distributed and the necessity of radiotherapy facilities are more (Table.3). We weren’t surprised to see maximum respondents working in private corporate hospitals because of the fact, this survey is pertinent to SRS and most centers practicing SRS are corporate hospitals. The radiotherapy utilization rate (RTU, the proportion of cancer patients requiring at least one treatment course of radiotherapy during the evolution of their disease) in developing countries such as India, is widely believed to be higher than the optimal RTU (i.e., >55%), and that it may reach 70%–80% in some situations.[7] As per the 2011 census, nearly 2/3rd of the population in India reside in rural areas, the rest of the 1/3rd distributed among metro cities, urban, and semi-urban regions.[8]

Table 3.

Comparison of responses between Urban and Rural centres.

(N=76)	Metro cities and Urban region (n=58)	Semi-Urban and Rural areas (n=18)
Distribution	58 (76.3%)	18 (23.7%)
Availability of Linac	58 (76.3%)	18 (23.7%)
Presence of SRS facilities	54 (93%)	14 (77.7%)
Workplace of the participants
Medical colleges/RCC/ Trust hospitals	10 (17.2%)	8 (45%)
Corporate hospitals	42 (72.4)	2 (10%)
Small-medium private hospitals	6 (10.4%)	8 (45%)
Experience of treating Physicians
<3years	40 (69%)	10 (55%)
>3years	18 (31%)	8 (45%)
Average cost of SRS
<1 Lacs INR	10 (17.2%)	10 (55%)
1-3Lacs INR	42 (72.4%)	4 (22.2%)
3-5Lacs INR	6 (10.4%)	0
Percentage of people having Medical Insurance
<25%	12 (20.6%)	14 (77.7%)
25-50%	20 (34.4%)	4 (22.3%)
50-75%	14 (24.4%)	0
>75%	12 (20.6%)	0
Percentage of people having Government health schemes
<25%	14 (24.4%)	0
25-50%	14 (24.4%)	0
50-75%	12 (20.6%)	6 (33.3%)
>75%	8 (13.6%)	12 (66.7%)

Based on the findings of Inter-society council for radiation oncology (ISCRO) guidelines, it is recommended to have one megavoltage therapy equipment for every 120,000 population,[9] In India the number is less than one machine per 2 million population with approximately 640 teletherapy machines (180 telecobalt units and 460 linear accelerators) and 22 advanced therapy machines (7 Gamma knife units, 8 Tomotherapy machines, 7 Cyber-knife machines and 2 intra-operative radiotherapy machines).[7] Of which, 211 teletherapy machines are located in 6 metro cities (listed in our survey) including one proton therapy center. [10] The study findings co-relate very well with the present scenario of the nation. 93.4% reported they have a linear accelerator at their center. None of the respondents have a stand-alone cobalt machine at their center. We expect this doesn’t cause any bias in the interpretation of results as the survey mainly focused on the treatment facilities and participants practicing SRS.

A study by Manir et al, [10] in 2016 had interestingly shown that only 26% of centers supported SRS treatment in India. However, as per 2012 statistics of AERB only 10% of centers were equipped with SRS facilities. In our study, we found 87% of respondents equipped with SRS facilities at their centers. This is a major leap in terms of advancement in radiotherapy facilities. We should take this number with a pinch of salt as there may be respondent bias in these results. The higher percentage is owing to maximum respondents being from metro cities working in corporate hospitals but we also cannot avoid the fact there are more than 129 new machines added in India as per DIRAC (directory of radiotherapy centers) data in the last 4 years, most of which are advanced machines. A study by Munshi A et al, [7] reported the presence of 22 advanced therapy machines capable of performing SRS (Gamma knife, Cyberknife, and Tomotherapy) as per DIRAC data.[11] This data rules out the common perception of SRS facilities being available only in metro cities as the case a few years back. There is a substantial rise in SRS facilities in recent times and they seem to be concentrating on uniform distribution.

In the 13% who said they don’t have SRS facilities. They were mostly located in rural and semi-urban regions. If they encounter a patient with a potential indication for SRS, the nearest center is at a distance of more than 100km in 40% of them. This signifies the lack of wide reach, short-sightedness of rural and semi-urban centers, and fear of the operational cost of the SRS facility.

The incidence of SRS cases is variable across the centers. This includes a variety of indications. In contrast to normal expectation, only 20% of treatments include metastatic lesions of the brain despite a larger incidence. 48% of the lesions treated are of re-irradiation. Owing to their rare presentation, very few centers reported treating benign lesions with an overall share of 20%. While surgical resection is the modality of choice for primary malignant tumors of the brain, 10% of them were treated with SRS. This might be because of the eloquent locations and risks of morbidity associated with surgery.

In the literature, there are no direct cost estimation studies for SRS in India. We have found an average treatment cost of INR 1-3 lakhs (approximately 1300-4000 USD) based on the inputs of the majority of respondents. This is mostly applicable to corporate centers and small to medium private centers. In those who are treating SRS patients under schemes, the average cost is less than 1 Lakh per patient.

India is listed as a Lower middle-income country (gross national income [GNI] per capita ≤ the US $12,615) as per the World Bank database with GNI per capita of US$ 6620. It has a 21.9% population below the poverty line.[12] Our survey demonstrates a 28% incidence of the lower middle class and lower class income groups among all SRS patients, whose level of healthcare expenditure is expected to be less. The upper and upper-middle-class can easily afford these treatments.

Unlike the western countries, the public awareness to avail Medicare/medical insurance facilities is low in India. Only 12% of respondents said they have seen most of the patients with medical insurance, again this is grossly limited to corporate hospitals in metro cities. At the same time, the Government of India and a lot of other state governments in the country offer SRS under health schemes that can be availed by all those below the poverty line. This is evident in the survey as 56% of respondents saying their patient pool consists of more than 50% of scheme patients. While it is important everyone deserves equal opportunity to receive treatment, up to 48% said they are not treating SRS under health schemes due to multiple reasons. Although 50% of participants treating SRS patients under health schemes 65% of them felt it is not financially viable.

We have summarised opinions and suggestions by participants regarding cost regulation (Table 1) and minimizing operational cost (Table 2). While these suggestions are worthwhile, they are in similar lines suggested by Munshi et al. [7]

The limitations of the study are less response rate. Being an online survey there might be an inherent response bias.

CONCLUSIONS

In a country with wide disparities among living class and skewed spread of radiotherapy facilities, it is important to take some novel steps in giving access to such life-saving treatment options. The rise in radiotherapy facilities is a good sign but it is yet far from the recommended numbers. Still, people have to travel hundreds of miles to get proper treatment. Initiatives at multiple levels are required. Subsidy on machines, public-private partnerships, financial assistance in schemes to motivate rural and semi-urban centers, incentives to Institutions for enrolling in schemes, providing awareness and encouraging the public to take medical insurance, increasing package amounts in schemes at par with standard rates are the few suggestions that can be implemented. Stereotactic radiotherapy is gaining popularity at a rapid pace among the radiation oncology community. With wide applications and a vast spectrum of indications, it should not only be seen as a cancer treatment modality but above it.