The introduction of brachytherapy to the country of Botswana
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Low and middle-income countries (LMICs) around the world are experiencing a global cancer crisis. For treatable disease, cancer specific mortality in LMICs is much higher than in high-income countries. Botswana is a middle-income country in Sub-Saharan Africa that had its population decimated by the AIDS epidemic. In the aftermath and due to the successful implementation of an anti-retroviral program, patients are living longer and are developing cancer. Cervical cancer is one of the leading causes of death in women around the world, but it is curable. Patients in Botswana live far from treatment centers and therefore often present with locally advanced disease that can be cured with a combination of chemotherapy, external beam radiation therapy and brachytherapy. The goal of this present study is to describe the challenges and implementation of brachytherapy in the country of Botswana in 2012 and to report its uses within the cervical cancer population between 2012 and 2014. The government of Botswana recognized that there was a need for in country brachytherapy to help reduce the cervical cancer burden. A public-private partnership was negotiated through the government of Botswana in order to bring brachytherapy into the country. In March 2011, a Nucletron HDR-Brachytherapy unit that uses Ir-192 was installed at Gaborone Private Hospital. Longitudinal support from international partners provided instruction in insertion, dosimetry, physics and management of complications. The initial burden of patients presented with severe cervical fibrosis and vaginal stenosis due to late presentation of disease. This resulted in numerous complications in the first treatments, which included failed insertions, perforations and bleeding. Following training and support from international partners, complications have been reduced. There are about 45 insertions performed each month, with an average of 3 insertions per patient. Introduction of HDR Brachytherapy to Botswana has led to decreased treatment time, reduced complications, increased patient compliance and projected improved survival. Implementation of brachytherapy was facilitated by a public-private partnership and onsite mentorship by expert clinicians. Further research is needed to evaluate impact on patient quality of life and survival, and whether this experience can be replicated for other tumor sites.