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Medical and Pediatric Oncology 33:563 (1999)
Another Way
In developed countries, the treatment of cancer by
chemo- and radiotherapy (RT) is increasing in complexity at a very fast rate. Greater intensity of chemotherapy
is causing more treatment-associated problems, particularly a rising incidence of infections secondary to myelosuppression. These complications can be lifethreatening, yet the risks are run for often only relatively
modest gains in local disease control or overall survival.
Moreover, such treatments are very expensive in terms of
the costs of drugs, the complex arrangements required for
their safe storage and utilization, and the number of personnel needed to deliver the treatments.
Similarly in the field of RT, machine design and construction is increasing in complexity. Such technical advances as three-dimensional planning and delivery are
considerably increasing costs. So far, relatively few clear
clinical gains can be documented, although dose escalation has proved feasible. These complicated RT techniques can be used only in advanced centers with adequate resources of manpower and equipment. Moreover, the workloads of departments of this kind are often
much smaller than those in nations where such complex
treatments are not available. RT is nonetheless relatively
inexpensive and remains after surgery the most effective
curative modality for cancer.
Leaders in oncology should begin to address the very
large number of patients worldwide who have no access
to advanced cancer chemotherapy or radiotherapy facilities. The RT apparatus available in such societies usually
is not of the latest design, yet it can still be used to
achieve very considerable gains for large patient populations overall. The International Society for Pediatric
Oncology (SIOP) has perhaps been the first cooperative
group to address the problems of less socioeconomically
favored countries specifically. Its Committee on Pediatric Oncology in Developing Countries meets yearly to
look at ways of developing appropriate low-cost but ef-
© 1999 Wiley-Liss, Inc.
fective systems of treatment, including a broader employment of RT for children with cancer.
The paper from Bulgaria in this issue (pp. 558–562)
describes a method of treating locally advanced breast
cancer with RT alone. The authors found that they could
not afford nor reliably obtain the resources necessary to
implement systemic chemotherapy for all patients. They
therefore designed therapy based on the known effectiveness of RT in controlling local disease. They also noted
data from an RTOG study suggesting that RT can produce a log cell kill of 1–3, which is probably comparable
to that achieved with many chemotherapy regimens.
They consequently implemented a careful study of the
tolerance of upper and lower hemibody irradiation given
in conjunction with tamoxifen. The authors used this as a
form of systemic therapy to be adopted in conjunction
with local irradiation for locally advanced breast cancer.
The work by Gocheva et al. has been carefully done and
is well documented. It therefore makes an important contribution to our understanding of a possible alternative
method of managing breast cancer patients. The technique they describe, i.e., the use of systemic RT, is particularly worthy of note by physicians in nations with
limited resources.
A continuing dialogue between such countries and
those of high socioeconomic status should be promoted.
The exchange of information is sure to be mutually beneficial. All clinicians working in the cancer field who feel
a responsibility for improving cancer care worldwide as
well as in their own particular environment are encouraged to participate.
Ann Barrett, MD, FRCR
Department of Radiation Oncology
University of Glasgow and Beatson Oncology Centre
Western Infirmary
Glasgow, Scotland
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