According to the official statistical data of National center for disease control and public health of Georgia incidence rate of malignant neoplasms is more than 10 000 new cancer cases per year (up to 280-300 cancer incidents per 100 000 population).
Based on current practice in high income countries (HIC) Radiotherapy utilization rate (RUR) is minimum 45–55% of the new patients, diagnosed with cancer. At the same time due to the ageing of the population and the anticipated increase in cancer incidence in coming decades, the number is expected to be increased by 1-1.5% per year in the next 20-30 years. Although, the ideal RUR, meaning more than 5000 patients treated with RT has not been reached the country yet.
What can be the reason of low RUR in the country? Fortunately this is not unavailability of advanced treatment techniques. The country has all state-of-art radiotherapy technologies for external beam radiotherapy, brachytherapy and intra-operative Radiotherapy. 0.4 Linac per 100 000 population is very attractive number, this can be seen only in the data of very high income countries. And this is statistics of country equipment in 10 different hospitals providing radiotherapy services, from which 8 are located in the capital city, Tbilisi.
Just some words about history of implementation process. IAEA (International Atomic Energy Agency) technical cooperation projects to improve radiotherapy service in the country were initiated at the beginning of 2000, although while only 1D planning was available during this time, improving practical skills and obtain appropriate knowledge was not so easy. The first HDR Brachytherapy procedure using 2D planning and the first Co-60 Unit external beam Radiotherapy procedure using 2.5D Planning were performed in 2007. 2009 is the beginning of new era, as installation of new Linear Accelerators, 3D Planning systems for External beam/Brachytherapy, Image guidance and Intra-operative Radiotherapy equipments were performed in a very short period of time. All these were followed with IMRT, VMAT, SRS/SBRT, respiratory gating and intra-fractional patient position verification techniques step by step till 2015 and all state –of –art techniques are available in the country now. And the most important achievement of our country is procurement of 2 proton therapy systems (IBA), which installation will be initiated at the end of 2023. These systems are aimed for clinical as well as for scientific and research purposes.
New advanced technologies require investments and of course the question will be asked, “how middle income country with limited resources managed to have such advances in such a short period of time”? The first step of course is investment and implementation, but population has to be able to afford such an expensive service. As program of insurance is not so well organized, like in high income countries, this would not be achievable, if not one great initiative from the government. Although the government did not participate in the procurement process of new equipment and techniques, since 2013 it initiated public insurance program and in collaboration with private insurance companies 100% of payment costs were reimbursed for all the patients. The reimbursement includes not only public, but also private sectors, so decision, in which hospital to go, is only on the patient herself/himself. This step was really great challenge for the hospitals, as it was a basis for healthy competition between them. Representatives of private sector started to care about the level of offered service, also its quality and safety as it was the main argument for the patient to refer. As a result, value of RUR has been increased with 600%, But unfortunately still has not reached to the ideal level of utilization, as plenty of challenges still remain in the field.
To fight against these challenges the country initiated a project, “Improve quality and safe radiation therapy within the network of city hospitals” in the frame of City Cancer Challenge Foundation. Under this project all aspects, necessities, challenges and limitations have been evaluated by local as well as international experts team (IAEA, ESTRO) and RT Development plan has been established, which recently is introduced to the ministry of health for overview and final acceptance. The development tasks have quite broad range and include: a) establishment of national cancer specific referral guidelines; b) patient referral policy at the national level; c) establishment of a comprehensive quality management system at the national level; d) establishment of risk assessment tools at official level in all radiotherapy departments; e) regulated policy about quality indicators at the national level by the Ministry of Health; f) implement LEAN methodology in all clinics; g) establish or improve academic programs for education and at the same time establish programs for CPD for the staff in the field of RT.