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April, 2011 Opportunistic Inflection By Michael J. Katin, MD

"Most people don't recognize opportunity when it comes, because it's usually dressed in overalls and looks a lot like work."
Thomas A. Edison

Each day brings new concern about the future of radiation oncology in the United States. Our specialty involves expensive, complicated equipment which requires support by multiple professionals. Treatments should not be done without quality assurance and careful documentation, and constant maintenance, both requiring even more time and effort. The high expenses make it difficult to consider reducing reimbursement without driving many practices out of business and thereby restricting access to care. It also has to be recognized that intensity-modulated-therapy and image-guided therapy are becoming standard rather than exceptional, especially considering there could be liability by trying to simplify someone's treatment for the sake of cost containment, even if that type of treatment may actually be adequate. The final blow may be when reimbursement is changed to a "bundling" arrangement in which a total amount is designated to treat a disease regardless of the techniques used. When specialists start to turn on each other like starved rats, it is improbable that the radiation oncologist will turn out to be the alpha rat.

This makes the future very uncertain not only for those of us in practice but especially for those just entering the field. As you recall, suggestions to maintain our viability include developing the subspecialty of cosmetic irradiation, by treatment of food products, or as an expensive but effective means of pest control. It would be nice to not have to abandon our basic techniques, however, and now, as if by magic, a solution may have shown itself.

It is ironic that for years other countries have benefited from having their citizens travel to the United States to earn money and send it back to their relatives. The time may have come that radiation oncology centers may need to designate several of their physicians, physicists, dosimetrists, therapists, and nurses to go abroad to earn enough to keep the mother ship afloat. This idea has been dramatically aided by the publication of the March/April 2011 issue of CA, A Cancer Journal for Clinicians. It was not even necessary to open the issue to see the solution, for on the cover is a map of the world indicating the number of people served by each radiotherapy center by country!!!!!

The cover picture is, in fact, Figure 3 from a meticulously detailed report by Ahmedin Jemal, DVM, PhD, Freddie Bray, PhD, Melissa M. Center, MPH, Jacques Ferlay, ME, Elizabeth Ward, PhD, and David Forman, PhD entitled "Global Cancer Statistics." The fact that none of the authors is an MD makes it even more likely to be accurate. Not only does this paper address the incidence and mortality of types of cancer throughout the world, but it actually seems to consider radiation therapy a necessary treatment and demonstrates the availability in each country. A basic rule of business is to direct your efforts where there is the greatest demand. This "roadmap," so to speak, has just been handed to us.

The article documents that cancer is a world-wide problem definitely not confined only to industrialized societies. This seems to torpedo the notion that living in a natural, bucolic environment is beneficial to your health. It also means that even in the absence of public awareness campaigns, buddy checks , and screening fairs that cancer can still be diagnosed. Mortality from cancer may be somewhat lower due to intervening causes, although the risk of premature death in Camden , New Jersey, may not be that much different.

The map very nicely illustrates, by color coding, the relative number of persons served by each radiotherapy center. This ranges from fewer than 500,000 in Japan, the United States, most of Europe, Australia, and Uruguay to 20,000,000 or more in the Democratic Republic of the Congo, Sudan, and Yemen, for example. There then remain the cream of the crop: the countries shown as having no radiotherapy centers at all.

These are the areas in which entrepreneurism should flourish. This is somewhat of a heterogeneous group, but I have taken the liberty of selecting several of these as examples.

• Afghanistan: After endless years of being the targets of the most highly technically developed weapons the world can design, why is it necessary to go to Pakistan to get prostate brachytherapy?
• Somalia: Good location, large population. Could be a problem with pirating of treatment planning software . . . if not pirating of the actual equipment.
• Mozambique : Rising GDP until recent drop in sugar exports ; trying to switch to aspartame. Official language is Portuguese, allowing guest workers to be better prepared for vacations in Rio .
• Turkemenistan: Making economic progress. Major downside: 80% of the country is occupied by the Karakum Desert. Major upside: essentially no problems with mildew.
• Chad : Major problem for alphabetizing since it is also known as Tchad. Often listed as the most corrupt country in the world and one of the poorest. These qualities should make guest workers from the Chicago area feel at home. There is only one paved road but seventeen red light cameras .
• Burkina Faso: Only 10 doctors per 100,000 people, making it easy to get to schmooze referring physicians. Largest cities are Ouagadougou, Bobo-Dioulasso, and Koudougou, which could be both a challenge and a source of amusement for transcriptionists unless they happen to come from Schenectady, Albuquerque, or Cucamonga.
• Lesotho: The only country in the world with an elevation entirely above 1400 meters. Potential for long golf drives. Radiation therapy plans need to factor in contribution from cosmic rays.
• Ivory Coast: distinguished by having two presidents at the same time, but this makes political contributions more complicated. Two presidents but not even one radiation oncology center. This needs to be corrected. May need to watch out for satellite units from Institut Gustave-Roussy and Institut Curie since the French seem to feel free to invade whenever they want.

These are but a few of the opportunities available to allow us to continue to use our skills and earn a living even as conditions in the United States deteriorate. There seems to be little question that our efforts can be successful. Growing awareness in developing countries of diagnosis and treatment options for cancer, due to increasing access to the internet, will lead to an exploding demand for our services. As long as that's the only thing that will be exploding.