Evolution and Recent Radiation Therapy Advancement in Uganda: A Precedent on How to Increase Access to Quality Radiotherapy Services in Low- and Middle-Income Countries

The evolution of radiation therapy in Uganda has been a journey marked by significant milestones and persistent challenges. Since the inception of radiotherapy services in 1988-1989, there has been a concerted effort to enhance cancer treatment services. The early years were characterized by foundational developments, such as the installation of the first teletherapy units, low-dose-rate brachytherapy units, and conventional simulators, and the recognition of radiation oncologists and medical physicist professionals laid the groundwork for radiotherapy treatment modalities. With more support from the International Atomic Energy Agency, the acquisition of dosimetry equipment, treatment planning systems, and additional professional training signaled a new era in the fight against cancer. As we entered the second decade of the millennium, the Uganda Cancer Institute (UCI) witnessed a progression in sophisticated radiotherapy services, including high-dose-rate brachytherapy, initiation of intensity modulated radiation therapy (IMRT)/volumetric modulated arc therapy (VMAT), and use of artificial intelligence. These advancements improved the efficiency/precision of treatments and the time patients spent undergoing therapy. Around the second decade of radiotherapy services, about 600 new patients with cancer were annually treated compared with about 2,600 in 2023. Currently, an average of 1,440 brachytherapy insertions are done annually compared with 300 insertions for the first 20 years. Despite the technological strides, the UCI faced numerous obstacles, including limited equipment, knowledge gaps in appropriate tumor/organs at risk segmentations, treatment planning, and protocols. However, international support and collaboration efforts have led to significant improvement in the precision and effectiveness of treatments. Currently, about 51% of all patients are treated with image-guided techniques - IMRT/VMAT (42%) and three-dimensional conformal radiation treatment (10%). The Government has commenced the decentralization of radiotherapy services to other regions. This review can be a learning lesson for the more than 25 countries in Africa and other low-middle-income countries globally that do not have access to radiotherapy and/or are in the process of starting such facilities.