Moraes Fabio Y, Gouveia Andre G, Freitas Bratti Vanessa, Dee Edward C, Fernandes Pavoni Juliana, Carson Laura M, de Sousa Cecília Félix Penido Mendes, Sullivan Richard, Nader Marta Gustavo, Hopman Wilma M, Booth Christopher M, Aggarwal Ajay, Jemal Ahmedin, Hanna Timothy P, Wilson Brooke E, Arruda Viani Gustavo
Department of Oncology, Queen's University, Kingston, ON, Canada; Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, ON, Canada.
Division of Radiation Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada.
Lancet Oncol. 2025 Feb;26(2):239-248. doi: 10.1016/S1470-2045(24)00678-8. Epub 2025 Jan 17.
The Linear Accelerator Shortage Index (LSI) is a practical tool for prioritising the deployment of linear accelerators (LINACs) in various regions within a country. The LSI reflects the ratio of LINAC demand to current availability. The aim of this study was to use the LSI to predict global LINAC needs and classify countries according to the degree of radiotherapy shortage (LINAC shortage grade).
In this cross-sectional, population-based study of globally representative, country-level data, we sourced regional LINAC distribution, numbers of radiotherapy centres, and cancer incidence data for 181 countries from the Directory of Radiotherapy Centers and Global Cancer Observatory 2022 databases. Current gross domestic product and gross national income per capita in US dollars were obtained from the World Bank. We calculated an LSI for each country to assess the relative demand and supply of radiotherapy by dividing LINAC use by 450 and multiplying by 100. An LSI of 100 or less indicates no shortage (450 or fewer patients per LINAC), whereas an LSI greater than 100 signals a shortage, with higher values indicating more severe deficits. We categorised countries by LINAC shortage grade: grade 0 (LSI ≤100, no shortage), grade 1 (LSI 101-130, low need), grade 2 (LSI 131-300, high need), grade 3 (LSI >300, excessive need), or grade 4 (no existing LINACs). We estimated LINAC requirements until 2045 using the LSI and Global Cancer Observatory data. We determined future investment costs according to the LSI for each country.
As of the data cutoff on Sept 15, 2024, the global median LSI was 130 (IQR 96-319), suggesting a shortage of 30% in radiotherapy capacity. Significant disparities in median LSI were observed across income levels: low-income countries had a median LSI of 1523 (528-2247), lower-middle-income countries 399 (183-685), upper-middle-income countries 133 (104-198), and high-income countries 96 (83-127; p<0·0001). The distribution of countries across LINAC shortage grades was 40 (22%) of 181 as grade 0, 32 (18%) as grade 1, 35 (19%) as grade 2, 38 (21%) as grade 3, and 36 (20%) as grade 4 (no LINACs). Most LINAC shortage grade 4 countries were low income (12 [33%]) or lower-middle income (16 [44%]). The median number of new LINACs needed per country by 2045 was estimated at 6 (1-13) for grade 0, 21 (4-102) for grade 1, 22 (8-80) for grade 2, 52 (26-113) for grade 3, and three (2-14) for grade 4. To meet these demands, also including the replacement of obsolete devices, an estimated 30 470 LINACs will be needed by 2045. The median total investment required for new and replacement machines and radiotherapy centres to meet the 2045 demand is projected at US$162 million (49-369) for grade 0, $216 million (54-772) for grade 1, $143 million (64-580) for grade 2, $238 million (126-561) for grade 3, and $16 million (9-59) for grade 4. A significant change in LINAC shortage grade composition between 2020 and 2045 is predicted, with distribution of 40 (22%) versus seven (4%) for grade 0, 32 (18%) versus 23 (13%) for grade 1, 35 (19%) versus 63 (35%) for grade 2, 38 (21%) versus 52 (29%) for grade 3, and 38 (20%) versus 38 (20%) for grade 4 (p<0·0001).
The LSI and LINAC shortage grade systems are effective for evaluating, monitoring, and forecasting global LINAC needs. The LSI and LINAC shortage grade highlight the substantial disparities in radiotherapy availability and underscore the urgent need for investment in radiotherapy capacity building, particularly in many low-income and middle-income countries.
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直线加速器短缺指数（LSI）是一种实用工具，用于在一个国家内的不同地区对直线加速器（LINAC）的部署进行优先级排序。LSI反映了LINAC需求与当前可用量的比率。本研究的目的是使用LSI预测全球LINAC需求，并根据放射治疗短缺程度（LINAC短缺等级）对各国进行分类。
在这项基于全球代表性国家层面数据的横断面研究中，我们从放射治疗中心目录和《2022年全球癌症观察》数据库中获取了181个国家的区域LINAC分布、放射治疗中心数量和癌症发病率数据。以美元计算的当前国内生产总值和人均国民收入来自世界银行。我们通过将LINAC使用量除以450再乘以100来计算每个国家的LSI，以评估放射治疗的相对需求和供应。LSI为100或更低表示无短缺（每台LINAC治疗450名或更少患者），而LSI大于100则表明存在短缺，数值越高表明短缺越严重。我们根据LINAC短缺等级对国家进行分类：0级（LSI≤100，无短缺）、1级（LSI 101 - 130，低需求）、2级（LSI 131 - 300，高需求）、3级（LSI>300，过度需求）或4级（无现有LINAC）。我们使用LSI和《全球癌症观察》数据估计了到2045年的LINAC需求。我们根据每个国家的LSI确定未来投资成本。
截至2024年9月15日的数据截止日期，全球LSI中位数为130（IQR 96 - 319），表明放射治疗能力短缺30%。在不同收入水平之间观察到LSI中位数存在显著差异：低收入国家的LSI中位数为1523（528 - 2247），中低收入国家为399（183 - 685），中高收入国家为133（104 - 198），高收入国家为96（83 - 127；p<0·0001）。181个国家中，处于LINAC短缺等级0级的有40个（22%），1级的有32个（18%），2级的有35个（19%），3级的有38个（21%），4级（无LINAC）的有36个（20%）。大多数LINAC短缺等级为4级的国家是低收入国家（12个[33%]）或中低收入国家（16个[44%]）。估计到2045年，每个国家所需的新LINAC中位数为：0级6个（1 - 13个），1级21个（4 - 102个），2级22个（8 - 80个），3级52个（26 - 113个），4级3个（2 - 14个）。为满足这些需求，包括更换过时设备，到2045年估计将需要30470台LINAC。为满足2045年需求，新机器和更换机器以及放射治疗中心所需的总投资中位数预计为：0级1.62亿美元（4900万 - 3.69亿美元），1级2.16亿美元（5400万 - 7.72亿美元），2级1.43亿美元（6400万 - 5.8亿美元），3级2.38亿美元（1.26亿 - 5.61亿美元），4级1600万美元（900万 - 5900万美元）。预计2020年至2045年LINAC短缺等级构成将发生显著变化，0级的分布为40个（22%）对7个（4%），1级为32个（18%）对23个（13%），2级为35个（19%）对63个（35%），3级为38个（21%）对52个（29%），4级为38个（20%）对38个（20%）（p<0·0001）。
LSI和LINAC短缺等级系统对于评估、监测和预测全球LINAC需求是有效的。LSI和LINAC短缺等级突出了放射治疗可及性方面的巨大差异，并强调了迫切需要投资于放射治疗能力建设，特别是在许多低收入和中等收入国家。
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