By: Aryeh J. Price
Dr. Arno J. Mundt is Professor and Chair of the Department of Radiation Medicine and Applied Sciences at the University of California San Diego (UCSD) Moores Cancer Center and the President of the American College of Radiation Oncology. A prolific researcher and practicing radiation oncologist, Dr. Mundt recently served as Senior Editor (Gynecologic Cancers) for the International Journal of Radiation Oncology, Biology and Physics and has authored over 150 articles and is the editor of 3 textbooks. A graduate of Stanford University and the University of Michigan, Dr. Mundt completely his residency in Radiation Oncology at the University of Chicago.
Dr. Mundt has had a long-held interest in improving cancer care in the Developing World. He served as the ASTRO representative at an IAEA training course focused on cervical cancer held in Sudan in 2011 and is on the Board of multiple charity organizations focused on cancer, including Radiating Hope and the Cure Cervical Cancer Foundation. He has participated on several Radiating Hope missions to Africa including in Senegal and Tanzania. In light of his involvement as well as that of multiple fellow UCSD faculty including John Einck MD, Catheryn Yashar MD and Derek Brown PhD who have travelled with Dr. Mundt to Africa, UCSD was recently named a Radiating Hope “Center of Excellence”.
Through his article in the International Journal of Radiation Oncology, Biology and Physics entitled “Radiation Oncology in Africa: Improving Access to Cancer Care on the African Continent”, Dr. Mundt and colleagues shed light on the scarcity of radiotherapeutic resources in Africa and its implications for health care delivery. The article emphasizes the role radiation oncologists ought to play in combatting the emerging cancer crisis in developing countries and depicts an optimistic, yet realistic view of its transformative potential.
In your article, you mention that radiation therapy is cost-effective for both curative and palliative cancer therapy. Why is the cost-effectiveness of radiation therapy largely unknown (or unacknowledged)?
I am not entirely sure. It is truly amazing to think how much good one could do by placing linacs – not the high tech expensive ones we have in this country but more basic ones- around the developing world. One such machine over its lifetime could treat thousands of patients, young and old alike, not only for cure but also for palliation. It’s hard to imagine a more cost-effective and versatile treatment approach.
How can donor support be garnered when the investment is perceived as outweighing the benefits?
I think the key is education. We need to teach donor organizations about the high value of supporting efforts to bring radiation equipment to the developing world. Groups like Radiating Hope are vital to this effort.
You invoke the concept of long distance travel being a barrier to obtaining care. What is currently being done to help patients with transport or in what ways do you think this issue can be alleviated?
Certainly focusing on transportation is important. However, an equally important approach is the development of shorter course treatment regimens. Simply using the same protracted treatment courses common in the United States is not acceptable in the Developing World. Consider cervical cancer. Radiotherapy treatment involves 4-5 weeks of external beam followed by 4 or 5 brachytherapy insertions. This is fine in this country, but in Africa, one needs to develop more hypofractionated external beam treatment combined with a more limited number of brachytherapy insertions. Such an approach would increase the number of women able to undergo treatment and it would be a better use of a limited resource.
While medical missions such as Radiating Hope’s efforts to bring radiation therapy to Senegal have helped to expand and improve cancer care in Africa, how do you envision these efforts becoming sustainable in the long run?
Sustainability requires money and it requires individuals. The leadership of Radiating Hope has acknowledged from its inception that the key to successfully bringing radiation equipment to the developing world is not simply just getting it there but also training the local professionals on its use and ensuring the financial means to keep the equipment working properly. Fundraising is vital to provide the monies needed for upgrading and servicing equipment. But individuals are needed to aid in training and education. Several faculty members of mine here at UCSD have gone on multiple trips to Senegal with Radiating Hope to help the individuals there become more comfortable with the use of the equipment that we brought on our initial trip.
What are the unique advantages of radiotherapy and brachytherapy in Africa as opposed to chemotherapy or surgical resection alone?
In terms of cervical cancer, radiotherapy (external beam and brachytherapy) offer great advantages over chemotherapy or surgery. Chemotherapy, unlike radiation, is not a curative approach and, by far, radiation is a more effective means of palliation in women with metastatic disease. While surgery is highly effective in early stage patients, the great majority of cervical cancer patients in Africa present with locally advanced disease and aren’t amenable to surgery. Such women are readily treated with radiation.
Besides the cost barrier, are there any cultural or religious stigmas against radiation therapy in Africa that have prevented patients from seeking treatment?
Certainly there may be concerns regarding whether a patient “becomes” radioactive potentially harming her husband and/or family. Interestingly enough, I have encountered similar concerns treating poor, uneducated patients in the United States. Overall, I have not encountered major cultural or religious stigmas to radiation.
The Senegal medical mission took several months of preparation, requiring multiple site visits from teams of physicists and radiation oncologists. What were some of the challenges in putting together the core team and some of the obstacles that had to be overcome during the mission?
I don’t recall many difficulties putting the core team together. Once radiation oncologists and physicists were identified who had a commitment to this project, the core team came readily together and has largely stayed together over multiple visits. There were obstacles, however, during the mission. One of the biggest was to gain the trust and buy in of the physicians and other professionals on site. However, once they realized that we were not simply “medical tourists” but instead professionals who were in it for the long run and committed to raising the quality and safety of cancer care in Africa, everything changed.
In addition to a lack of radiation therapy machines, there is also a shortage of radiation oncology specialists. Have there been any efforts to increase or improve the education required to provide radiotherapy care?
Training is a vital link in transforming radiotherapy care in the developing world. Several academic centers in North America have developed programs to bring individuals to their centers providing valuable training opportunities. However, focus also needs to be on remote training approaches via the internet and, perhaps, most importantly, on-site training. On-site training was the focus of the second Radiating Hope Senegal mission where multiple patients were treated by the Senegalese physicians themselves. It is my hope that Radiation Oncology Professional Organizations and Vendors will help support interested radiation oncologists and physicists on such trips throughout the Developing World in the coming years.