title: A systematic review of radiotherapy capacity in low- and middle-income countries.
abstract: OBJECTIVE
  The cancer burden in low- and middle-income countries (LMIC) is substantial. The purpose of this study was to identify and describe country and region-specific patterns of radiotherapy (RT) facilities in LMIC.
  
  
  METHODS
  A systematic review of the literature was undertaken. A search strategy was developed to include articles on radiation capacity in LMIC from the following databases: PubMed, Embase, CINAHL Plus, Global Health, and the Latin American and Caribbean System on Health Sciences Information. Searches included all literature up to April 2013.
  
  
  RESULTS
  A total of 49 articles were included in the review. Studies reviewed were divided into one of four regions: Africa, Asia, Eastern Europe, and South America. The African continent has the least amount of resources for RT. Furthermore, a wide disparity exists, as 60% of all machines on the continent are concentrated in Egypt and South Africa while 29 countries in Africa are still lacking any RT resource. A significant heterogeneity also exists across Southeast Asia despite a threefold increase in megavoltage teletherapy machines from 1976 to 1999, which corresponds with a rise in economic status. In LMIC of the Americas, only Uruguay met the International Atomic Energy Agency recommendations of 4 MV/million population, whereas Bolivia and Venezuela had the most radiation oncologists (>1 per 1000 new cancer cases). The main concern with the review of RT resources in Eastern Europe was the lack of data.
  
  
  CONCLUSIONS
  There is a dearth of publications on RT therapy infrastructure in LMIC. However, based on limited published data, availability of RT resources reflects the countries' economic status. The challenges to delivering radiation in the discussed regions are multidimensional and include lack of physical resources, lack of human personnel, and lack of data. Furthermore, access to existing RT and affordability of care remains a large problem.
authors: Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA.
authors: Surbhi
authors: S
authors: Grover
authors: Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA.
authors: Melody J
authors: MJ
authors: Xu
authors: Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA.
authors: Alyssa
authors: A
authors: Yeager
authors: Johns Hopkins School of Public Health , Baltimore, MD , USA.
authors: Lori
authors: L
authors: Rosman
authors: Department of Gynecology and Obstetrics, Johns Hopkins Hospital , Baltimore, MD , USA.
authors: Reinou S
authors: RS
authors: Groen
authors: Department of Surgery, University of Western Ontario , London, ON , Canada.
authors: Smita
authors: S
authors: Chackungal
authors: Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada.
authors: Danielle
authors: D
authors: Rodin
authors: Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA.
authors: Margaret
authors: M
authors: Mangaali
authors: Johns Hopkins School of Public Health , Baltimore, MD , USA.
authors: Sommer
authors: S
authors: Nurkic
authors: Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA.
authors: Annemarie
authors: A
authors: Fernandes
authors: Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA.
authors: Lilie L
authors: LL
authors: Lin
authors: Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada.
authors: Gillian
authors: G
authors: Thomas
authors: Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons , New York, NY , USA.
authors: Ana I
authors: AI
authors: Tergas
keywords: global health; low- and middle-income countries; radiation capacity; radiation oncology access; systematic review
references: Radiother Oncol. 1999 Jul;52(1):79-84
references: 10577690
references: Radiother Oncol. 2001 Jul;60(1):81-9
references: 11410308
references: J Med Assoc Thai. 2001 Jun;84 Suppl 1:S216-27
references: 11529337
references: Radiother Oncol. 2002 May;63(2):147-50
references: 12063003
references: Br J Cancer. 2003 Jul 7;89(1):65-9
references: 12838301
references: S Afr Med J. 1992 Nov;82(5):351-4
references: 1448718
references: Radiat Med. 2004 Jan-Feb;22(1):12-6
references: 15053169
references: Radiother Oncol. 2004 Oct;73(1):97-100
references: 15465152
references: Afr J Med Med Sci. 2004 Mar;33(1):1-4
references: 15490784
references: J Obstet Gynaecol. 2000 Nov;20(6):624-7
references: 15512681
references: Radiother Oncol. 2005 Jun;75(3):349-54
references: 15893832
references: J Med Assoc Thai. 2005 Aug;88(8):1035-44
references: 16404829
references: J Indian Med Assoc. 2005 Sep;103(9):486-8
references: 16493870
references: Ann Oncol. 2006 Jun;17 Suppl 8:viii15-viii23
references: 16801335
references: Lancet Oncol. 2006 Jul;7(7):584-95
references: 16814210
references: World J Surg Oncol. 2006 Nov 13;4:77
references: 17101048
references: Trop Doct. 2007 Apr;37(2):67-70
references: 17540080
references: J Gynecol Oncol. 2009 Mar;20(1):11-6
references: 19471671
references: J Med Phys. 2009 Apr;34(2):63-5
references: 20098538
references: J Obstet Gynaecol. 2010 Apr;30(3):299-301
references: 20373936
references: Int J Gynecol Cancer. 2010 Aug;20(6):1092-100
references: 20683424
references: Lancet. 2010 Oct 2;376(9747):1186-93
references: 20709386
references: Radiother Oncol. 2010 Dec;97(3):514-20
references: 20950878
references: Biomed Imaging Interv J. 2008 Jul;4(3):e42
references: 21611007
references: Biomed Imaging Interv J. 2008 Jan;4(1):e29
references: 21614313
references: Curr Opin Oncol. 2011 Sep;23(5):469-74
references: 21734579
references: Gynecol Oncol. 2012 Mar;124(3):395-8
references: 22138228
references: Asian Pac J Cancer Prev. 2011;12(9):2157-62
references: 22296349
references: Oncology. 2012;82(5):269-74
references: 22538443
references: Int J Radiat Oncol Biol Phys. 1990 Nov;19(5):1257-61
references: 2254121
references: Int J Radiat Oncol Biol Phys. 1990 Nov;19(5):1263-6
references: 2254122
references: Int J Radiat Oncol Biol Phys. 1990 Nov;19(5):1267-70
references: 2254123
references: Australas Radiol. 1990 Aug;34(3):238-40
references: 2275682
references: PLoS One. 2012;7(6):e40299
references: 22768273
references: Cancer Epidemiol Biomarkers Prev. 2012 Sep;21(9):1434-8
references: 22806169
references: Lancet Oncol. 2013 Feb;14(2):e79-86
references: 23352499
references: Niger Postgrad Med J. 2012 Dec;19(4):208-14
references: 23385675
references: Lancet Oncol. 2013 Apr;14(4):e168-75
references: 23561748
references: Indian J Med Paediatr Oncol. 2012 Oct;33(4):216-20
references: 23580822
references: Rep Pract Oncol Radiother. 2012 Oct 04;18(2):57-60
references: 24416531
references: Ecancermedicalscience. 2014 Feb 03;8:396
references: 24550997
references: Int J Radiat Oncol Biol Phys. 2014 Jul 1;89(3):448-57
references: 24751411
references: Oncologist. 2014 Jul;19(7):e1-2
references: 24928614
references: Int J Radiat Oncol Biol Phys. 2014 Jul 1;89(3):446-7
references: 24929153
references: Int J Radiat Oncol Biol Phys. 2014 Jul 1;89(3):458-61
references: 24929154
references: Int J Radiat Oncol Biol Phys. 2014 Jul 1;89(3):462-7
references: 24929155
references: J Contemp Brachytherapy. 2011 Jun;3(2):96-105
references: 27895676
references: Int J Radiat Oncol Biol Phys. 1989 Feb;16(2):293-5
references: 2921128
references: J Natl Med Assoc. 1972 Jul;64(4):366-9
references: 5042999
references: Int J Radiat Oncol Biol Phys. 1984 Jun;10 Suppl 1:69-72
references: 6735800
references: Am J Public Health. 1981 Oct;71(10):1158-61
references: 7270764
references: S Afr Med J. 1994 Jun;84(6):349-51
references: 7740382
references: Int J Radiat Oncol Biol Phys. 1996 Nov 1;36(4):941-3
references: 8960524
references: Clin Oncol (R Coll Radiol). 1998;10(4):219-25
references: 9764372