Brachytherapy is the placement of radiation sources inside of, or next to, an area of a patient's body that requires treatment. Brachytherapy allows for a tumour to be treated with high doses of localized radiation, while reducing the probability of unnecessary exposure to surrounding healthy tissue. For example, in the case of cervical cancer, radioactive sources can be placed directly into the uterus in order to target a cervical mass.
El Salvador is the smallest and most densely populated country in Central America. Similar to other countries in the neighbouring region, it has one of the highest incidence rates of cervical cancer in the world with 25 cases per 100,000 population in 2015.
The Cancer Institute of El Salvador Dr. Narciso Diaz Bazan is a private centre for public service financed by a non-profit foundation (Liga Contra el Cancer de El Salvador). The institute should theoretically provide radiotherapy services to 80% of the population of El Salvador, while the other 20% would be covered by the Social Security system which has another treatment centre. Since the finalization of the project, two new private radiotherapy centres have opened their doors in the city of San Salvador providing modern external beam radiotherapy but not brachytherapy.
Illustration of a brachytherapy treatment plan. (Photo: E.Zubizarreta)
Up until 2005, the Cancer Institute of El Salvador was using radium sources (Ra-226) for gynaecological brachytherapy applications. In 2005 the use of Ra-226 sources was stopped. Following the decommissioning of the radium sources for brachytherapy, the IAEA assisted the institute in transitioning from the use of these sources to a modern high dose-rate (HDR) brachytherapy system. A series of national projects through collaboration between the IAEA Department of Technical Cooperation and the Government of El Salvador, with technical support from the IAEA Division of Human Health, were initiated in 1997.
The project included the building of a modern facility to house the unit, waiting rooms, applicator insertion room, imaging and purchase and installation of equipment and training of staff.
The construction of the building was completely covered from Government funds. The IAEA project delivered a high dose-rate (HDR) 3-channel unit suitable for gynaecological applications as well as a contract to deliver Ir-192 sources for a period of five years. In addition, the package included a treatment planning system for brachytherapy, a ceiling mounted X-ray machine for imaging, applicators and dosimetry instruments for quality assurance and training.
A total of eight fellowships, two scientific visits and 12 expert missions were organized and financed by the IAEA including radiation oncologists, medical physicists and technologists.
To overcome the lack of previous experience with the use of HDR brachytherapy, the Agency hired two experienced professionals (a radiation oncologist and a medical physicist) from a neighbouring country, to assist the local staff in the initial running of the unit. These two professionals remained in El Salvador for three months. During this period, they drafted a local treatment protocol with assistance from IAEA experts and initiated the actual treatment of a series of patients while simultaneously training local staff.
The new HDR unit became fully operational in 2010 and is currently treating an average of 600-680 patients per year. The introduction of HDR brachytherapy has reflected in a reduction of waiting lists, faster and more convenient treatment for patients and an improvement in the clinical outcomes in terms of toxicity and patient survival. The centre underwent a full IAEA quality audit in March 2010.