The cost of providing high-quality radiotherapy services in a resource-limited setting: A case study of the Cameroon Oncology Center

The cost of providing high-quality radiotherapy services in a resource-limited setting: A case study of the Cameroon Oncology Center | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The cost of providing high-quality radiotherapy services in a resource-limited setting: A case study of the Cameroon Oncology Center Paul Mobit, Nicholas Ade, Christopher Njeh, Mary R. Nittala, Waleed Mourad, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6882369/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background : Understanding the cost of delivering radiotherapy in a resource-limited setting such as Cameroon in sub-Saharan Africa (SSA) is critical not only for expanding radiotherapy services in low- and middle-income countries (LMICs) but also for shaping future policy decisions. The Cameroon Oncology Center (COC), a privately owned oncology center located in Cameroon, has treated over 1000 patients on its sole medical linear accelerator since it began clinical operations in 2019. This work aimed to determine the operating cost estimate for providing radiotherapy in a private oncology center in the Republic of Cameroon, a study that could significantly impact and shape urgent policy decisions in the healthcare sector in this region. Methods : This cost estimate was calculated based on our experience over the course of one calendar year, specifically 2021. We focused on the ongoing operating costs of the radiotherapy facility, excluding capital expenditures (building and equipment). Our calculations assumed that 300 patients were treated in 2021, a number that did not significantly affect the ongoing operating costs, even though only 215 patients received radiation therapy at our institution that year. These assumptions were made to provide a comprehensive estimate of the operating costs, ensuring a high level of transparency and trust in our methodology. Results and conclusion : The average operating cost per patient was approximately $1750·00 for curative intent radiotherapy, which consisted of at least 25 fractions. The top three drivers of operating costs are labor at 41·1%, linear accelerator parts and service cost (17·7%), and power (14·8%). For a public radiotherapy facility, the minimum cost to patients is $1750 (1.1 million FCFA in the local currency) per course of curative radiotherapy. If one factor in the repayment plan (capital costs) is amortized for 12 years, the total cost per patient would be currently $3651 or 2.2 million FCFA locally. These findings highlight the need for cost-effective strategies to maintain high-quality radiotherapy services in LMICs. Cancer radiotherapy Linear accelerator Healthcare provision Radiotherapy cost Capital costs Operating costs Interest rate Service development Resource-limited setting Sub-Saharan Africa 1. Introduction Cancer is a significant public health problem in sub-Saharan Africa (SSA), and it is among the three leading causes of premature death (at ages 30–69 years) in many countries in sub-Saharan Africa [ 1 ]. The number of cancer cases is increasing in SSA, and the number of new cases was estimated to be greater than 800,000 in 2020 by the International Agency for Research on Cancer [ 2 – 5 ]. The data are estimated since there is a general lack of suitable cancer registries in SSA [ 2 ]. Globally, it is predicted that up to 70% of the projected 24 million people who will be diagnosed with cancer annually by 2050 will live in low- and middle-income countries [ 2 , 6 ]. Radiotherapy (RT) is integral in the management of most cancers, including breast, lung, prostate, head and neck, and cervical cancers, which together account for more than two-fifths of cases worldwide. Radiotherapy provides excellent local tumor control, which is not always achievable with surgery alone, and preserves standard form and function [ 8 ]. Approximately 50–60% of cancer patients should receive RT as a form of treatment in an ideal situation [ 9 , 10 ]. Nevertheless, this number is significantly low in SSA because of the unavailability of RT units [ 11 , 12 ]. There are several reasons why radiotherapy has not flourished in SSA or other low- and middle-income countries (LMICs) around the world. The chief reason is that RT establishment is capital intensive, and the running cost of an RT facility is significant. The second reason is that RT requires many allied health specialists who take years to train. There are very few domestic training programs for radiation oncology professionals, such as radiation therapists and medical physicists, so some must be trained outside the country, which is expensive. The Cameroon Oncology Center (COC) is a private and independent radiation oncology facility established in 2019. It operates as the only medical linear accelerator (linac) for cancer RT in the Republic of Cameroon. The installed model is a Varian Clinic 21EX medical linear accelerator (Varian Medical Systems, Palo Alto, CA) with photon and electron beams for radiotherapy administration. This model has a millennium multiple leave collimator and a portal imager for treatment position verification. The COC is the first and currently the only cancer center in Cameroon to operate a medical linear accelerator to deliver radiation treatment to cancer patients. The commissioning and clinical implementation of the medical linac, along with the workflow of the RT service, have been described in previous studies [ 15 – 17 ]. The Republic of Cameroon, located in the Central African subregion in SSA, has an estimated population of approximately 29 million. Currently, there is one additional radiation oncology unit with a Co60 teletherapy unit at Douala General Hospital. This results in two megavoltage machines for 29 million people or a ratio of approximately one megavoltage radiotherapy megavoltage treatment unit for every 15 million people. In high-income economies such as the U.S. or the UK, there are approximately 4 megavoltage units per million people. In response to the increasing burden of cancer and the shortage of RT facilities in the country and the sub-Saharan Africa region, the Cameroon Oncology Center was established. This center, the first and currently only one of its kind in Cameroon, was set up to supplement the efforts made by the Government of Cameroon. The center treats patients from all 10 regions of Cameroon and all neighboring countries, including Nigeria, Chad, Central Africa Republic, Gabon, Congo Kinshasa, and Congo Brazzaville. In 2021, COC was used with 515 cancer patients with various cancers. Approximately two-thirds of these patients were female, whereas the rest were male. The distribution of these cancer patients by tumor organ of origin is shown in Table 1 . Of the 515 patients who consulted in 2021, only 215 received radiation therapy, representing approximately 42% of the patient population that consulted. Some of the patients received only chemotherapy, and others received chemotherapy and radiation, but many were not treated for many reasons, including among other things, the lack of funds to pay for their treatment. Table 2 shows the radiation prescription protocol used at the Cameroon Oncology Center. Importantly, approximately 50% of the radiotherapy load is delivered using intensity-modulated radiation therapy (IMRT) for all curative prostate, cervix, rectum, and head and neck cancers. Table 1 Distribution of cancer patients according to the organ of origin of the tumor Organ of origin of cancer Number of cases Percentage (%) Breast 141 27·4 Cervix 132 25·6 Head and neck cancers 77 15·0 Prostate 61 11·8 Rectum 17 3·3 Bone 14 2·7 Skin 18 3·5 Gastro-intestinal tract 14 2·7 Others 41 8·0 Total 515 100 Table 2 Treatment technique and the dose fraction schedule used at the Cameroon Oncology Center Type of cancer Radiotherapy Technic and dose Standard fractionation used at Cameroon Oncology Center Comments Prostate IMRT 76 Gy in 38 fractions 66 Gy in 33 fractions for post prostate bed treatment. Breasts 3D Conformal Radiotherapy 50 Gy in 25 fractions followed by 10 Gy boost utilizing 6 or 9 MeV electrons for a total of 60 Gy. Cervix IMRT whole Pelvis SBRT-like (IMRT) boost IMRT for whole Pelvis (2Gy x23) Followed by 3Gy x 10 Re-CT patient after whole pelvis plan Head and neck IMRT 70 Gy in 35 fractions 66Gy in 33 fraction post- surgery rectum or colon IMRT 2 Gy x 25 plus boost of 6–9 Gy to the primary site. In Table 2 , 2 D or 3D represents the 2D or 3D radiation treatment planning technique, whereas IMRT indicates intensity-modulated radiation therapy. SBRT stands for stereotactic body radiation therapy. 2. Materials and methods Radiotherapy costs can be divided into two major components: upfront costs (capital expenditure or investment) to develop a new facility, including the building, equipment, and training of new staff, and operating costs (running expenses) to deliver treatments once the facility is commissioned for clinical use. Capital costs are affected by various factors, including facility size, level of treatment complexity, equipment, construction, personnel costs, and clinical operating conditions (such as the length of the working day and the time needed by staff for various activities). Since 2019, we have operated a computer-controlled Varian Clinac 21EX medical linear accelerator (Varian Medical Systems, Palo Alto, CA) with photon and electron beams for radiotherapy administration. The COC is the first and, currently, the only cancer center in Cameroon to operate a medical linear accelerator to deliver radiation treatment to cancer patients in the CEMAC (Economic and Monetary Community of Central Africa) zone of Central Africa. This state-of-the-art facility ensures efficient and effective treatment for our patients. Even though COCs have been providing radiotherapy services since 2019, we decided to perform this analysis for 2021. This analysis is crucial, as it provides a comprehensive understanding of the costs of providing these services. Importantly, the COC also offers medical oncology services with the administration of chemotherapy; therefore, none of those costs have been incorporated into the analysis. The Cameroon Oncology Center operates a basic clinical laboratory service, and a pharmacy stocked with most chemotherapy drugs. We also operated a small patient hospitalization service with 10 beds for the hospitalization of our cancer patients. In this work, we captured the associated costs associated with the provision of radiotherapy, which were grouped into 7 major categories, as shown in Table 3 . The cost captures are direct costs and do not include capital equipment or facility depreciation costs. The hospital has a borehole, which supplies the hospital with water, so there is no utility charges related to water. 3. Results and Discussion Table 3 shows the operating costs of the radiotherapy services of COCs for 2021. The operating costs are grouped under various categories (labor or employment), power consumption or expenses, etc.). The cost of servicing the medical linear accelerator consists of the monthly service fees paid to the Turkish Engineering team servicing the linear accelerator and the parts purchased generally from the U.S. by the founder. We also have a less experienced onsite engineer who works with a Turkish Engineering firm to maintain/service the linear accelerator. The Cameroon Oncology Center’s CT simulator fell into disrepair in 2020, and for all of 2021, the CT simulation was carried out at two outside facilities; therefore, the CT simulation fees are paid to these facilities. The electricity bills were charged monthly by the utility company (ENEO). Nevertheless, power was not always provided by a public utility company, so we also had a standby generator that consumed between 14 liters of diesel fuel per hour on a light load and 25 liters per hour when 80–90 was engaged. The fuel costs for the power generator set and the service of the generator set are shown in item number 4 of Table 3 . In 2021, the Cameroon Oncology Center had staff of approximately 20 consisting of two radiation oncologists (both part-time), 3 physician generalists, 3 radiation therapists, a medical physicist who was onsite and one medical physicist working remotely, and two radiation oncologists based in the United States who worked remotely through the use of telemedicine. Their services were not paid for and hence not accounted for in our analysis, as we assume that most of their function was to improve quality and that two-part-time radiation oncologists were still capable of treating the 215 patients. Salaries of three nurses, 2 laboratory technicians, two security personnel, an onsite linear accelerator engineer, a manager and two administrative staff were included in the analysis. Table 3 Annual operating costs Item Brief description of the cost Cost (USD, $ ) % of the cost 1 Linac maintenance service 157,675 34.8% 2 CT Simulation fees 15,570 3.4% 3 Power/Energy (electricity bills) 46,085 10.2% 4 Cost of Fuel/service for power generator 24,512 5.4% 5 Staff and contract labor cost 108,776 24.0% 6 Taxes and other fees 32,203 7.1% 7 Miscellaneous items 67,877 15.0% Total operating cost 452,698 100 Total operating costs per year, as presented in Table 3 , amount to $ 452,698. Table 3 shows that the highest operating cost for RT service at our facility is the maintenance cost of the medical liner, amounting to $ 157,675 (US), followed by the labor cost of $ 108,776. Additionally, it is important to note from Table 3 that the total cost of power (including utility bills and fuel costs for the power generator set is $ 70,597 per annum. Interestingly, the fuel cost constitutes more than a third of the total energy cost for the facility. In 2021, we treated 215 cancer patients via this medical linear accelerator, resulting in a cost per patient of $ 2105.6. Many researchers have investigated the cost of the delivery of radiotherapy in the past; for example, Van Dyk et al. [ 20 ] used the time-driven activity-based costing model (TD-ABC) to study the cost of radiotherapy in different income settings. A group of researchers estimated that the medical linear accelerator maintenance cost was approximately $ 200,000. Our cost of $ 157,675 (US) is approximately 20% lower than their estimate, demonstrating the cost-effectiveness of our facility. The cost of constructing and equipping a radiation therapy center with a single linear accelerator, as shown in Table 1 of Van Dyke et al. (20), is approximately $ 4.0 million for a resource-limited region such as Cameroon. Assuming a loan repayment term of 12 years and zero interest on the principal, the annual repayment amount would be $ 333,000. $ 4.0 million represents the capital cost (linac purchase and accessories, bunker construction cost, CT simulator cost and treatment planning system purchase, training). This means that the total yearly expenditure would be approximately $ 800,000. Therefore, if we consider the scenario in which the annual operating cost is $ 452,698 plus a capital repayment cost of $ 334,000 per annum, the total cost would be approximately $ 800,000. Therefore, in the case of the Cameroon Oncology Center, which treats 215 cancer patients a year, the average cost per patient is $ 3651. The calculated cost per patient is more than double the GDP per capita of Cameroon, which was approximately $ 1400 in 2021. This means that most patients struggle to afford radiotherapy expenses and therefore forgo treatment all together. With no grant provided by the government for cancer patients undergoing radiotherapy, many patients in Cameroon and most countries in SSA would simply not be treated. Private health insurance coverage for Cameroonians is limited, and public health insurance does not cover radiotherapy fees in Cameroon. Therefore, it may be necessary to lower costs and make treatment more accessible to more patients. A significant challenge COC faces in delivering high-quality RT is the inability of patients to afford their treatment costs. Owing to the lack of a public health insurance program in Cameroon, medical insurance coverage is very limited, forcing patients to pay out of pocket. Consequently, many patients take months to save the necessary funds for their treatment, during which time their cancer may continue to progress. COC prices for RT range between $ 0 and approximately $ 4000 (US), with the average being between $ 800 for palliative treatment (typically involving 5 to 10 fractions) and approximately $ 2500 for curative treatment. The costs that cancer patients incur for RT vary significantly from country to country and differ by tumor site [ 17 ]. Table 4 compares the average prices for RT for different tumor sites with those charged by other RT programs in West Africa in 2021. The RT treatment costs reported in Table 4 were obtained through private communications with managers and workers at these radiotherapy departments. The authors were able to verify the charges but did not succeed for all the radiotherapy departments, but we believe that the cost or charges presented in Table 4 are in line with charges billed by these facilities. Despite our low prices compared with those of other private centers in other African countries, less than 10% of the patients seen at the COC can afford to pay the full costs for radiotherapy. Importantly, these costs generally do not include chemotherapy, weekly laboratory tests, or CT scans, which may be needed to monitor treatment progress. While several studies have examined the cost of delivering radiotherapy in various settings [21–31], evaluating the costs of providing radiotherapy services in a resource-limited country such as Cameroon is important. Table 4 Prices in USD ( $ ) for prostate, cervix, breast rectum and head and neck cancers Disease site Coast Ivory Coast Ghana (Public Center) Ghana (Private Center) Senegal (Public) Senegal (Private Center) Cameroon Oncology Center Prostate 3636 2089 9000 273 4545 3091 Rectum 2818 1565 7200 273 2727 2816 H&N 3455 1984 8600 273 2727 3100 Cervix 3273 1879 8182 273 3273 2805 Palliative 1455 936 3600 91 1455 1450 The operational cost associated with the delivery of radiotherapy at the Cameroon Oncology Center does not consider our implementation of tele-radiation oncology services outside of the United States, as described by Mobit et al. 15 . Therefore, the costs associated with compensating radiation oncologists and medical physicists based in the U.S. have not been incorporated into these calculations as their time and expertise have volunteered. The top three operating cost drivers are labor, accounting for 41·1%; linac parts and service contracts, accounting for 17·7%; and power costs, accounting for 14·8%. Variability in these operating costs may not lead to significant changes, as they primarily represent ongoing operational expenses. Given that labor costs are expected to rise annually owing to inflation, they are unlikely to contribute to a reduction in overall running expenses. A discount for the linac parts and service contract would also help reduce the operating costs, but obtaining any discount depends on the manufacturer or vendor. The only driver that can help lower the annual operating cost is obtaining reliable power to reduce the cost of power. In the first year of operation, power expenses (electricity bills and fuel purchases for diesel generators when utility power was unavailable) constituted approximately 35% of our expenses. One possible solution to reduce the cost of power is to explore alternative sources of energy, such as solar energy, but the instantaneous power requirement of linear accelerators implies that it would be necessary to invest in a battery power bank for energy storage. With respect to international funding agencies, reducing the interest rate of any applicable loans used to finance RT projects is important. We note from Table 4 that reducing the interest rate from 14.4–3% reduces the average cost to the cancer patient by approximately $ 1000.00, which is significant. This means that many more patients, who may not otherwise afford, can afford treatment. Importantly, the Cameroon Oncology Center charges different amounts to different patients for the same disease site. We achieved this by offering different discounts depending on the patient’s ability to pay. 5. Conclusions The cost of providing high-quality radiotherapy services in a resource-limited setting such as Cameroon is driven primarily by capital expenditures and ongoing operating costs. Our calculations show that, assuming no investment benefits to the investor, the average cost per patient for patients treated on the medical linac per year is approximately $3550·00. Variation in operating costs or interest rates on capital investment would substantially affect the cost of radiotherapy. The top three drivers of operating costs are labor at 41·1%, medical linear accelerator parts and service contracts (17·7%), and power consumption (14·8%). Strategies to reduce these costs could lead to substantial savings. Declarations Contributors: Mobit P, Njeh C, and Mourad W were involved in the conceptualization of this study. Mobit P and Ade N were involved in the formal data analysis. Mobit P, Ade N, and Njeh C were involved in the methodology, data interpretation, literature survey, and writing of the original draft of the paper. Mobit P, Ade N, and Fonbah produced the manuscript tables. Nittala M. verified the data analysis and revised the manuscript to its final version. Mobit P and Fonbah AM accessed and verified the raw data used in this study. All authors reviewed and edited drafts of the manuscript, had full access to data in the study, and had final responsibility for the decision to submit for publication. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of interest: None. Data availability : Data collected for the study will be made available to others upon request via email to the corresponding author. Acknowledgments : The authors would like to thank the staff of the Cameroon Oncology Center for their collaboration. References Bray F, Laversanne M, Weiderpass E, Soerjomataram I. The ever-increasing importance of cancer as a leading cause of premature death worldwide. Cancer, 2021;127(16):3029–3030. Bray F, Parkin DM, African Cancer Registry Network. Cancer in sub-Saharan Africa in 2020: a review of current estimates of the national burden, data gaps, and future needs. Lancet Oncol, 2021;23(6):719–728. IARC, World Health Organization International Agency for Research on Cancer, 2021. GLOBOCAN 2020: Estimated cancer incidence, mortality and prevalence worldwide in 2020. https://gco.iarc.fr/today/fact-sheets-populations. Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Pineros M, et al. Global Cancer Observatory: Cancer Today. Lyon: International Agency for Research on Cancer; 2020 (https://gco.iarc.fr/today). Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemel A, Bray F. Global Can Statistics 2020: Globocan estimates of incidence and mortality for 36 cancers in 185 countries. CA Cancer Journal for Clinicians. 2021;71:209–249. Parkin DM, Bray FI, Devesa SS. Cancer burden in the year 2000. The global picture. Eur J Cancer, 2001;37 Suppl 8 :S4–66. Kingham TP, Alatise O, Vanderpuye V, et al. Treatment of cancer in sub-Saharan Africa. Lancet Oncol, 2013;14(4):e158–67. Atun R, Jaffray DA, Barton MB, et al. Expanding global access to radiotherapy. Lancet Oncol, 2015;16(10):1153–86. Organization and training in radiotherapy for developing countries in Africa. IAEA-TECDOC-614, 1991, IAEA, Vienna. Yao Q, Zou, L, Lan H, Luo S, Lu S, Lang J, Xu C. Initial experience of a tele-radiotherapy system for training radiation oncologists in rural areas. J Canc Educ. 2020;7(2):461–465. Abdel-Wahab M, Bourque JM, Pynda Y, Iżewska J, Van der Merwe D, Zubizarreta E, Eduardo R. Status of radiotherapy resources in Africa: an International Atomic Energy Agency analysis. Lancet Oncol, 2013;14:e168–e175. Burger H, Wyrley‑Birch B, Joubert N, Trauernicht CJ, et al. Bridging the Radiotherapy Education Gap in Africa: Lessons Learnt from the Cape Town Access to Care Training Programme Over the Past5 Years (2015–2019). J Cancer Education. 2021. https://doi.org/10.1007/s13187-021-02010-5. Mobit PN, Ade N. Commissioning Experience of a Medical Linear Accelerator in a Low-Resource Setting in Sub-Saharan Africa. Radiation Science and Technology. 2021;8:30–37. Mobit PN, Imandi PH, Ade N. End-to-End Test for a Radiotherapy Program Based on the Medical Linear Accelerator Installed in a Resource-Limited Oncology Centre in Sub-Saharan Africa. Radiation Science and Technology. 2021;8(2):22–29. Mobit P, Mourad W, Folefac E, Yan W, Ade N, et al. Introduction of a Hybrid Tele-oncology Program in a Low-Resource Setting in Sub-Saharan Africa. In Press, International Journal of Clinical Oncology and Cancer Research, 2021 ;7(3):70–75. Bentzen SM, et al. Toward evidence-based guidelines for radiotherapy infrastructure and staffing needs in Europe: the ESTRO QUARTS project. Radiother Oncol, 2005;75(3):355–65. Paravati AJ, Boero IJ, Triplett DP, et al. Variation in the cost of radiation therapy among medicare patients with cancer. Journal of Oncology Practice, 2015;11:403–410. Ploquin NP, Dunscombe PB. The cost of radiation therapy. Radiother Oncol 2008;86:217–23. Defourny N, Perrier L, Borras JM, et al: National costs and resource requirements of external beam radiotherapy: A time-driven activity-based costing model from the ESTRO-HERO project. Radiother Oncol 2019;138:P187–194. Van Dyk J, Zubizarreta E, Lievens Y: Cost evaluation to optimize radiation therapy implementation in different income settings: A time-driven activity-based analysis. Radiother Oncol 2017;125:178–185. Datta N R, MD, M Heuser, Stephan Bodis, MD “A Roadmap and Cost Implications of Establishing Comprehensive Cancer Care Using a Teleradiotherapy Network in a Group of Sub-Saharan African Countries With No Access to Radiation Therapy” J Radiation Oncol Biol Phys 95(5):1334–1343, 2016. Defourny N, Dunscombe P, Perrier L, Grau C, Lievens Y. Cost evaluations of radiotherapy: What do we know? An ESTRO-HERO analysis. Radiother Oncol 2016;121:468–74. Van der Giessen P-H, Alert J, Badri C, et al. Multinational assessment of some operational costs of teletherapy. Radiother Oncol 2004;71:347–55. Lievens Y, Van Den Bogaert W, Kesteloot K. Activity-based costing: A practical model for cost calculation in radiotherapy. Int J Radiat Oncol Biol Phys 2003;57:522–525. Atherton L. The cost of radiotherapy treatments on a linear accelerator. Br J Radiol 1984;57:106–7. Greene D. The cost of radiotherapy treatments on a linear accelerator. Br J Radiol 1983;56:189-191. Barbera L, Walker H, Foroudi F, Tyldesley S, Mackillop W. Estimating he benefit and cost of radiotherapy for lung cancer. International Journal of Technology Assessment in Health Care 2004;20:545­551. Read G. Estimating the cost of radiotherapy. Clin Oncol 1994;6:35–9. Penn CRH. Megavoltage irradiation in a district general hospital remote from a main oncology center: the Torbay experience reviewed. Clin Oncol 1992;4:108–13. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 28 Jul, 2025 Reviews received at journal 28 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviews received at journal 08 Jul, 2025 Reviewers agreed at journal 08 Jul, 2025 Reviewers invited by journal 08 Jul, 2025 Editor assigned by journal 13 Jun, 2025 Submission checks completed at journal 13 Jun, 2025 First submitted to journal 12 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6882369","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":482317217,"identity":"1f68bbee-c7aa-44d8-9a8f-3eac0f498181","order_by":0,"name":"Paul Mobit","email":"","orcid":"","institution":"Cameroon Oncology Center","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"","lastName":"Mobit","suffix":""},{"id":482317219,"identity":"e813c76e-adf8-4562-a458-c5023bb98926","order_by":1,"name":"Nicholas Ade","email":"","orcid":"","institution":"Cameroon Oncology Center","correspondingAuthor":false,"prefix":"","firstName":"Nicholas","middleName":"","lastName":"Ade","suffix":""},{"id":482317220,"identity":"a844ce37-7426-46fd-ba09-876454ed3c2e","order_by":2,"name":"Christopher Njeh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAoElEQVRIiWNgGAWjYHCCBGaGCgkQw4AULWdI1MLAzNjGQIIW/tkNDx8XzrNIbGBv3iZBlBaJOweSjWduk0hs4DlWRpwWA4mENGlekBaJHDOitaT/5p0D1CL/hngtacy8DSBbeIjUInEjIVma55iEcRtPWrEFUVr4Z+QkfuapqZPtZz+88QZRWhgYeBLAFBuRykGA/QAJikfBKBgFo2BEAgDGWSetVuMcYAAAAABJRU5ErkJggg==","orcid":"","institution":"University of Indiana School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Christopher","middleName":"","lastName":"Njeh","suffix":""},{"id":482317221,"identity":"fe9ba370-8c3f-46a7-9469-e5169ce9bf7c","order_by":3,"name":"Mary R. Nittala","email":"","orcid":"","institution":"University of Mississippi Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Mary","middleName":"R.","lastName":"Nittala","suffix":""},{"id":482317222,"identity":"56d273bd-eef5-4c30-966e-cb8b88bbd050","order_by":4,"name":"Waleed Mourad","email":"","orcid":"","institution":"University of Kentucky Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Waleed","middleName":"","lastName":"Mourad","suffix":""},{"id":482317223,"identity":"9ed6b9e3-a978-43e3-b1b3-e58a8f15d1fa","order_by":5,"name":"Anyang Mesack Fonbah","email":"","orcid":"","institution":"Cameroon Oncology Center","correspondingAuthor":false,"prefix":"","firstName":"Anyang","middleName":"Mesack","lastName":"Fonbah","suffix":""},{"id":482317224,"identity":"16da6faa-942f-44bb-9350-8e8a686a5499","order_by":6,"name":"Isabella Fri Tayong","email":"","orcid":"","institution":"Cameroon Oncology Center","correspondingAuthor":false,"prefix":"","firstName":"Isabella","middleName":"Fri","lastName":"Tayong","suffix":""}],"badges":[],"createdAt":"2025-06-12 17:08:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6882369/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6882369/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86403051,"identity":"6477df74-e9bb-410c-a9ec-41878b29ca50","added_by":"auto","created_at":"2025-07-10 09:19:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":667753,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6882369/v1/aff00ecb-c438-4100-bd32-63243ded1f3f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The cost of providing high-quality radiotherapy services in a resource-limited setting: A case study of the Cameroon Oncology Center","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eCancer is a significant public health problem in sub-Saharan Africa (SSA), and it is among the three leading causes of premature death (at ages 30\u0026ndash;69 years) in many countries in sub-Saharan Africa [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The number of cancer cases is increasing in SSA, and the number of new cases was estimated to be greater than 800,000 in 2020 by the International Agency for Research on Cancer [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The data are estimated since there is a general lack of suitable cancer registries in SSA [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Globally, it is predicted that up to 70% of the projected 24\u0026nbsp;million people who will be diagnosed with cancer annually by 2050 will live in low- and middle-income countries [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRadiotherapy (RT) is integral in the management of most cancers, including breast, lung, prostate, head and neck, and cervical cancers, which together account for more than two-fifths of cases worldwide. Radiotherapy provides excellent local tumor control, which is not always achievable with surgery alone, and preserves standard form and function [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Approximately 50\u0026ndash;60% of cancer patients should receive RT as a form of treatment in an ideal situation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Nevertheless, this number is significantly low in SSA because of the unavailability of RT units [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. There are several reasons why radiotherapy has not flourished in SSA or other low- and middle-income countries (LMICs) around the world. The chief reason is that RT establishment is capital intensive, and the running cost of an RT facility is significant. The second reason is that RT requires many allied health specialists who take years to train. There are very few domestic training programs for radiation oncology professionals, such as radiation therapists and medical physicists, so some must be trained outside the country, which is expensive.\u003c/p\u003e\u003cp\u003eThe Cameroon Oncology Center (COC) is a private and independent radiation oncology facility established in 2019. It operates as the only medical linear accelerator (linac) for cancer RT in the Republic of Cameroon. The installed model is a Varian Clinic 21EX medical linear accelerator (Varian Medical Systems, Palo Alto, CA) with photon and electron beams for radiotherapy administration. This model has a millennium multiple leave collimator and a portal imager for treatment position verification. The COC is the first and currently the only cancer center in Cameroon to operate a medical linear accelerator to deliver radiation treatment to cancer patients. The commissioning and clinical implementation of the medical linac, along with the workflow of the RT service, have been described in previous studies [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The Republic of Cameroon, located in the Central African subregion in SSA, has an estimated population of approximately 29\u0026nbsp;million. Currently, there is one additional radiation oncology unit with a Co60 teletherapy unit at Douala General Hospital. This results in two megavoltage machines for 29\u0026nbsp;million people or a ratio of approximately one megavoltage radiotherapy megavoltage treatment unit for every 15\u0026nbsp;million people. In high-income economies such as the U.S. or the UK, there are approximately 4 megavoltage units per million people.\u003c/p\u003e\u003cp\u003eIn response to the increasing burden of cancer and the shortage of RT facilities in the country and the sub-Saharan Africa region, the Cameroon Oncology Center was established. This center, the first and currently only one of its kind in Cameroon, was set up to supplement the efforts made by the Government of Cameroon. The center treats patients from all 10 regions of Cameroon and all neighboring countries, including Nigeria, Chad, Central Africa Republic, Gabon, Congo Kinshasa, and Congo Brazzaville. In 2021, COC was used with 515 cancer patients with various cancers. Approximately two-thirds of these patients were female, whereas the rest were male. The distribution of these cancer patients by tumor organ of origin is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Of the 515 patients who consulted in 2021, only 215 received radiation therapy, representing approximately 42% of the patient population that consulted. Some of the patients received only chemotherapy, and others received chemotherapy and radiation, but many were not treated for many reasons, including among other things, the lack of funds to pay for their treatment. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the radiation prescription protocol used at the Cameroon Oncology Center. Importantly, approximately 50% of the radiotherapy load is delivered using intensity-modulated radiation therapy (IMRT) for all curative prostate, cervix, rectum, and head and neck cancers.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of cancer patients according to the organ of origin of the tumor\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOrgan of origin of cancer\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of cases\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercentage (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBreast\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e141\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27\u0026middot;4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCervix\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e132\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u0026middot;6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHead and neck cancers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15\u0026middot;0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProstate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11\u0026middot;8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u0026middot;3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u0026middot;7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSkin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u0026middot;5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGastro-intestinal tract\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u0026middot;7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u0026middot;0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e515\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e100\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTreatment technique and the dose fraction schedule used at the Cameroon Oncology Center\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of cancer\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRadiotherapy Technic and dose\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStandard fractionation used at Cameroon Oncology Center\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eComments\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProstate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIMRT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76 Gy in 38 fractions\u003c/p\u003e\u003cp\u003e66 Gy in 33 fractions for post prostate bed treatment.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBreasts\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3D Conformal Radiotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50 Gy in 25 fractions followed by 10 Gy boost utilizing 6 or 9 MeV electrons for a total of 60 Gy.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCervix\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIMRT whole Pelvis\u003c/p\u003e\u003cp\u003eSBRT-like (IMRT) boost\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIMRT for whole Pelvis (2Gy x23)\u003c/p\u003e\u003cp\u003eFollowed by 3Gy x 10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRe-CT patient after whole pelvis plan\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHead and neck\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIMRT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70 Gy in 35 fractions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e66Gy in 33 fraction post- surgery\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003erectum or colon\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIMRT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e2\u003c/b\u003e Gy x 25 plus boost of 6\u0026ndash;9 Gy to the primary site.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eIn\u003c/em\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD \u003cem\u003eor 3D represents the 2D or 3D radiation treatment planning technique, whereas IMRT indicates intensity-modulated radiation therapy. SBRT stands for stereotactic body radiation therapy.\u003c/em\u003e\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cp\u003eRadiotherapy costs can be divided into two major components: upfront costs (capital expenditure or investment) to develop a new facility, including the building, equipment, and training of new staff, and operating costs (running expenses) to deliver treatments once the facility is commissioned for clinical use. Capital costs are affected by various factors, including facility size, level of treatment complexity, equipment, construction, personnel costs, and clinical operating conditions (such as the length of the working day and the time needed by staff for various activities). Since 2019, we have operated a computer-controlled Varian Clinac 21EX medical linear accelerator (Varian Medical Systems, Palo Alto, CA) with photon and electron beams for radiotherapy administration. The COC is the first and, currently, the only cancer center in Cameroon to operate a medical linear accelerator to deliver radiation treatment to cancer patients in the CEMAC (Economic and Monetary Community of Central Africa) zone of Central Africa. This state-of-the-art facility ensures efficient and effective treatment for our patients.\u003c/p\u003e\u003cp\u003eEven though COCs have been providing radiotherapy services since 2019, we decided to perform this analysis for 2021. This analysis is crucial, as it provides a comprehensive understanding of the costs of providing these services. Importantly, the COC also offers medical oncology services with the administration of chemotherapy; therefore, none of those costs have been incorporated into the analysis. The Cameroon Oncology Center operates a basic clinical laboratory service, and a pharmacy stocked with most chemotherapy drugs. We also operated a small patient hospitalization service with 10 beds for the hospitalization of our cancer patients. In this work, we captured the associated costs associated with the provision of radiotherapy, which were grouped into 7 major categories, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The cost captures are direct costs and do not include capital equipment or facility depreciation costs. The hospital has a borehole, which supplies the hospital with water, so there is no utility charges related to water.\u003c/p\u003e"},{"header":"3. Results and Discussion","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the operating costs of the radiotherapy services of COCs for 2021. The operating costs are grouped under various categories (labor or employment), power consumption or expenses, etc.). The cost of servicing the medical linear accelerator consists of the monthly service fees paid to the Turkish Engineering team servicing the linear accelerator and the parts purchased generally from the U.S. by the founder. We also have a less experienced onsite engineer who works with a Turkish Engineering firm to maintain/service the linear accelerator. The Cameroon Oncology Center\u0026rsquo;s CT simulator fell into disrepair in 2020, and for all of 2021, the CT simulation was carried out at two outside facilities; therefore, the CT simulation fees are paid to these facilities. The electricity bills were charged monthly by the utility company (ENEO). Nevertheless, power was not always provided by a public utility company, so we also had a standby generator that consumed between 14 liters of diesel fuel per hour on a light load and 25 liters per hour when 80\u0026ndash;90 was engaged. The fuel costs for the power generator set and the service of the generator set are shown in item number 4 of Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. In 2021, the Cameroon Oncology Center had staff of approximately 20 consisting of two radiation oncologists (both part-time), 3 physician generalists, 3 radiation therapists, a medical physicist who was onsite and one medical physicist working remotely, and two radiation oncologists based in the United States who worked remotely through the use of telemedicine. Their services were not paid for and hence not accounted for in our analysis, as we assume that most of their function was to improve quality and that two-part-time radiation oncologists were still capable of treating the 215 patients. Salaries of three nurses, 2 laboratory technicians, two security personnel, an onsite linear accelerator engineer, a manager and two administrative staff were included in the analysis.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAnnual operating costs\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBrief description of the cost\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCost (USD, \u003cspan\u003e$\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e% of the cost\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLinac maintenance service\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e157,675\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34.8%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCT Simulation fees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15,570\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePower/Energy (electricity bills)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46,085\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCost of Fuel/service for power generator\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24,512\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStaff and contract labor cost\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e108,776\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTaxes and other fees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32,203\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMiscellaneous items\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67,877\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal operating cost\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e452,698\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTotal operating costs per year, as presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, amount to \u003cspan\u003e$\u003c/span\u003e452,698. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows that the highest operating cost for RT service at our facility is the maintenance cost of the medical liner, amounting to \u003cspan\u003e$\u003c/span\u003e157,675 (US), followed by the labor cost of \u003cspan\u003e$\u003c/span\u003e108,776. Additionally, it is important to note from Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e that the total cost of power (including utility bills and fuel costs for the power generator set is \u003cspan\u003e$\u003c/span\u003e70,597 per annum. Interestingly, the fuel cost constitutes more than a third of the total energy cost for the facility.\u003c/p\u003e\u003cp\u003eIn 2021, we treated 215 cancer patients via this medical linear accelerator, resulting in a cost per patient of \u003cspan\u003e$\u003c/span\u003e2105.6. Many researchers have investigated the cost of the delivery of radiotherapy in the past; for example, Van Dyk et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] used the time-driven activity-based costing model (TD-ABC) to study the cost of radiotherapy in different income settings. A group of researchers estimated that the medical linear accelerator maintenance cost was approximately \u003cspan\u003e$\u003c/span\u003e200,000. Our cost of \u003cspan\u003e$\u003c/span\u003e157,675 (US) is approximately 20% lower than their estimate, demonstrating the cost-effectiveness of our facility.\u003c/p\u003e\u003cp\u003eThe cost of constructing and equipping a radiation therapy center with a single linear accelerator, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e of Van Dyke et al. (20), is approximately \u003cspan\u003e$\u003c/span\u003e4.0\u0026nbsp;million for a resource-limited region such as Cameroon. Assuming a loan repayment term of 12 years and zero interest on the principal, the annual repayment amount would be \u003cspan\u003e$\u003c/span\u003e333,000. \u003cspan\u003e$\u003c/span\u003e4.0\u0026nbsp;million represents the capital cost (linac purchase and accessories, bunker construction cost, CT simulator cost and treatment planning system purchase, training). This means that the total yearly expenditure would be approximately \u003cspan\u003e$\u003c/span\u003e800,000. Therefore, if we consider the scenario in which the annual operating cost is \u003cspan\u003e$\u003c/span\u003e452,698 plus a capital repayment cost of \u003cspan\u003e$\u003c/span\u003e334,000 per annum, the total cost would be approximately \u003cspan\u003e$\u003c/span\u003e800,000. Therefore, in the case of the Cameroon Oncology Center, which treats 215 cancer patients a year, the average cost per patient is \u003cspan\u003e$\u003c/span\u003e3651. The calculated cost per patient is more than double the GDP per capita of Cameroon, which was approximately \u003cspan\u003e$\u003c/span\u003e1400 in 2021. This means that most patients struggle to afford radiotherapy expenses and therefore forgo treatment all together. With no grant provided by the government for cancer patients undergoing radiotherapy, many patients in Cameroon and most countries in SSA would simply not be treated. Private health insurance coverage for Cameroonians is limited, and public health insurance does not cover radiotherapy fees in Cameroon. Therefore, it may be necessary to lower costs and make treatment more accessible to more patients.\u003c/p\u003e\u003cp\u003eA significant challenge COC faces in delivering high-quality RT is the inability of patients to afford their treatment costs. Owing to the lack of a public health insurance program in Cameroon, medical insurance coverage is very limited, forcing patients to pay out of pocket. Consequently, many patients take months to save the necessary funds for their treatment, during which time their cancer may continue to progress. COC prices for RT range between \u003cspan\u003e$\u003c/span\u003e0 and approximately \u003cspan\u003e$\u003c/span\u003e4000 (US), with the average being between \u003cspan\u003e$\u003c/span\u003e800 for palliative treatment (typically involving 5 to 10 fractions) and approximately \u003cspan\u003e$\u003c/span\u003e2500 for curative treatment. The costs that cancer patients incur for RT vary significantly from country to country and differ by tumor site [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e compares the average prices for RT for different tumor sites with those charged by other RT programs in West Africa in 2021. The RT treatment costs reported in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e were obtained through private communications with managers and workers at these radiotherapy departments. The authors were able to verify the charges but did not succeed for all the radiotherapy departments, but we believe that the cost or charges presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e are in line with charges billed by these facilities.\u003c/p\u003e\u003cp\u003eDespite our low prices compared with those of other private centers in other African countries, less than 10% of the patients seen at the COC can afford to pay the full costs for radiotherapy. Importantly, these costs generally do not include chemotherapy, weekly laboratory tests, or CT scans, which may be needed to monitor treatment progress. While several studies have examined the cost of delivering radiotherapy in various settings [21\u0026ndash;31], evaluating the costs of providing radiotherapy services in a resource-limited country such as Cameroon is important.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePrices in USD (\u003cspan\u003e$\u003c/span\u003e) for prostate, cervix, breast rectum and head and neck cancers\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisease site Coast\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIvory\u003c/p\u003e\u003cp\u003eCoast\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGhana (Public Center)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGhana (Private Center)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSenegal\u003c/p\u003e\u003cp\u003e(Public)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSenegal (Private Center)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCameroon Oncology Center\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProstate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3636\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2089\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e273\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4545\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3091\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2818\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1565\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7200\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e273\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2727\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2816\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH\u0026amp;N\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3455\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1984\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8600\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e273\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2727\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCervix\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3273\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1879\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8182\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e273\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3273\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2805\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePalliative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1455\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e936\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3600\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1455\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1450\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe operational cost associated with the delivery of radiotherapy at the Cameroon Oncology Center does not consider our implementation of tele-radiation oncology services outside of the United States, as described by Mobit et al. \u003csup\u003e15\u003c/sup\u003e. Therefore, the costs associated with compensating radiation oncologists and medical physicists based in the U.S. have not been incorporated into these calculations as their time and expertise have volunteered.\u003c/p\u003e\u003cp\u003eThe top three operating cost drivers are labor, accounting for 41\u0026middot;1%; linac parts and service contracts, accounting for 17\u0026middot;7%; and power costs, accounting for 14\u0026middot;8%. Variability in these operating costs may not lead to significant changes, as they primarily represent ongoing operational expenses. Given that labor costs are expected to rise annually owing to inflation, they are unlikely to contribute to a reduction in overall running expenses. A discount for the linac parts and service contract would also help reduce the operating costs, but obtaining any discount depends on the manufacturer or vendor. The only driver that can help lower the annual operating cost is obtaining reliable power to reduce the cost of power. In the first year of operation, power expenses (electricity bills and fuel purchases for diesel generators when utility power was unavailable) constituted approximately 35% of our expenses. One possible solution to reduce the cost of power is to explore alternative sources of energy, such as solar energy, but the instantaneous power requirement of linear accelerators implies that it would be necessary to invest in a battery power bank for energy storage.\u003c/p\u003e\u003cp\u003eWith respect to international funding agencies, reducing the interest rate of any applicable loans used to finance RT projects is important. We note from Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e that reducing the interest rate from 14.4\u0026ndash;3% reduces the average cost to the cancer patient by approximately \u003cspan\u003e$\u003c/span\u003e1000.00, which is significant. This means that many more patients, who may not otherwise afford, can afford treatment. Importantly, the Cameroon Oncology Center charges different amounts to different patients for the same disease site. We achieved this by offering different discounts depending on the patient\u0026rsquo;s ability to pay.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThe cost of providing high-quality radiotherapy services in a resource-limited setting such as Cameroon is driven primarily by capital expenditures and ongoing operating costs. Our calculations show that, assuming no investment benefits to the investor, the average cost per patient for patients treated on the medical linac per year is approximately $3550·00. Variation in operating costs or interest rates on capital investment would substantially affect the cost of radiotherapy. The top three drivers of operating costs are labor at 41·1%, medical linear accelerator parts and service contracts (17·7%), and power consumption (14·8%). Strategies to reduce these costs could lead to substantial savings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eContributors:\u0026nbsp;\u003c/strong\u003eMobit P, Njeh C, and Mourad W were involved in the conceptualization of this study. Mobit P and Ade N were involved in the formal data analysis. Mobit P, Ade N, and Njeh C were involved in the methodology, data interpretation, literature survey, and writing of the original draft of the paper. Mobit P, Ade N, and Fonbah produced the manuscript tables. Nittala M. verified the data analysis and revised the manuscript to its final version. Mobit P and Fonbah AM accessed and verified the raw data used in this study. All authors reviewed and edited drafts of the manuscript, had full access to data in the study, and had final responsibility for the decision to submit for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of interest:\u0026nbsp;\u003c/strong\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e: Data collected for the study will be made available to others upon request via email to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e: The authors would like to thank the staff of the Cameroon Oncology Center for their collaboration.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBray F, Laversanne M, Weiderpass E, Soerjomataram I. The ever-increasing importance of cancer as a leading cause of premature death worldwide. Cancer, 2021;127(16):3029\u0026ndash;3030.\u003c/li\u003e\n \u003cli\u003eBray F, Parkin DM, African Cancer Registry Network. Cancer in sub-Saharan Africa in 2020: a review of current estimates of the national burden, data gaps, and future needs. Lancet Oncol, 2021;23(6):719\u0026ndash;728.\u003c/li\u003e\n \u003cli\u003eIARC, World Health Organization International Agency for Research on Cancer, 2021. GLOBOCAN 2020: Estimated cancer incidence, mortality and prevalence worldwide in 2020. https://gco.iarc.fr/today/fact-sheets-populations.\u003c/li\u003e\n \u003cli\u003eFerlay J, Ervik M, Lam F, Colombet M, Mery L, Pineros M, et al. Global Cancer Observatory: Cancer Today. Lyon: International Agency for Research on Cancer; 2020 (https://gco.iarc.fr/today).\u003c/li\u003e\n \u003cli\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemel A, Bray F. Global Can Statistics 2020: Globocan estimates of incidence and mortality for 36 cancers in 185 countries. CA Cancer Journal for Clinicians. 2021;71:209\u0026ndash;249.\u003c/li\u003e\n \u003cli\u003eParkin DM, Bray FI, Devesa SS. Cancer burden in the year 2000. The global picture. Eur J Cancer, 2001;37 Suppl\u003cstrong\u003e\u0026nbsp;8\u003c/strong\u003e:S4\u0026ndash;66.\u003c/li\u003e\n \u003cli\u003eKingham TP, Alatise O, Vanderpuye V, et al. Treatment of cancer in sub-Saharan Africa. Lancet Oncol, 2013;14(4):e158\u0026ndash;67.\u003c/li\u003e\n \u003cli\u003eAtun R, Jaffray DA, Barton MB, et al. Expanding global access to radiotherapy. Lancet Oncol, 2015;16(10):1153\u0026ndash;86.\u003c/li\u003e\n \u003cli\u003eOrganization and training in radiotherapy for developing countries in Africa. IAEA-TECDOC-614, 1991, IAEA, Vienna.\u003c/li\u003e\n \u003cli\u003eYao Q, Zou, L, Lan H, Luo S, Lu S, Lang J, Xu C. Initial experience of a tele-radiotherapy system for training radiation oncologists in rural areas. J Canc Educ. 2020;7(2):461\u0026ndash;465.\u003c/li\u003e\n \u003cli\u003eAbdel-Wahab M, Bourque JM, Pynda Y, Iżewska J, Van der Merwe D, Zubizarreta E, Eduardo R. Status of radiotherapy resources in Africa: an International Atomic Energy Agency analysis. Lancet Oncol, 2013;14:e168\u0026ndash;e175.\u003c/li\u003e\n \u003cli\u003eBurger H, Wyrley‑Birch B, Joubert N, Trauernicht CJ, et al. Bridging the Radiotherapy Education Gap in Africa: Lessons Learnt from the Cape Town Access to Care Training Programme Over the Past5 Years (2015\u0026ndash;2019). J Cancer Education. 2021. https://doi.org/10.1007/s13187-021-02010-5.\u003c/li\u003e\n \u003cli\u003eMobit PN, Ade N. Commissioning Experience of a Medical Linear Accelerator in a Low-Resource Setting in Sub-Saharan Africa. Radiation Science and Technology. 2021;8:30\u0026ndash;37.\u003c/li\u003e\n \u003cli\u003eMobit PN, Imandi PH, Ade N. End-to-End Test for a Radiotherapy Program Based on the Medical Linear Accelerator Installed in a Resource-Limited Oncology Centre in Sub-Saharan Africa. Radiation Science and Technology.\u003cem\u003e\u0026nbsp;\u003c/em\u003e2021;8(2):22\u0026ndash;29.\u003c/li\u003e\n \u003cli\u003eMobit P, Mourad W, Folefac E, Yan W, Ade N, et al. Introduction of a Hybrid Tele-oncology Program in a Low-Resource Setting in Sub-Saharan Africa. In Press, International Journal of Clinical Oncology and Cancer Research,\u003cem\u003e\u0026nbsp;2021\u003c/em\u003e;7(3):70\u0026ndash;75.\u003c/li\u003e\n \u003cli\u003eBentzen SM, et al. Toward evidence-based guidelines for radiotherapy infrastructure and staffing needs in Europe: the ESTRO QUARTS project. Radiother Oncol, 2005;75(3):355\u0026ndash;65.\u003c/li\u003e\n \u003cli\u003eParavati AJ, Boero IJ, Triplett DP, et al. Variation in the cost of radiation therapy among medicare patients with cancer. Journal of Oncology Practice, 2015;11:403\u0026ndash;410.\u003c/li\u003e\n \u003cli\u003ePloquin NP, Dunscombe PB. The cost of radiation therapy. Radiother Oncol 2008;86:217\u0026ndash;23.\u003c/li\u003e\n \u003cli\u003eDefourny N, Perrier L, Borras JM, et al: National costs and resource requirements of external beam radiotherapy: A time-driven activity-based costing model from the ESTRO-HERO project. Radiother Oncol 2019;138:P187\u0026ndash;194.\u003c/li\u003e\n \u003cli\u003eVan Dyk J, Zubizarreta E, Lievens Y: Cost evaluation to optimize radiation therapy implementation in different income settings: A time-driven activity-based analysis. Radiother Oncol 2017;125:178\u0026ndash;185.\u003c/li\u003e\n \u003cli\u003eDatta N R, MD, M Heuser, Stephan Bodis, MD \u0026ldquo;A Roadmap and Cost Implications of Establishing Comprehensive Cancer Care Using a Teleradiotherapy Network in a Group of Sub-Saharan African Countries With No Access to Radiation Therapy\u0026rdquo; J Radiation Oncol Biol Phys 95(5):1334\u0026ndash;1343, 2016.\u003c/li\u003e\n \u003cli\u003eDefourny N, Dunscombe P, Perrier L, Grau C, Lievens Y. Cost evaluations of radiotherapy: What do we know? An ESTRO-HERO analysis. Radiother Oncol 2016;121:468\u0026ndash;74.\u003c/li\u003e\n \u003cli\u003eVan der Giessen P-H, Alert J, Badri C, et al. Multinational assessment of some operational costs of teletherapy. Radiother Oncol 2004;71:347\u0026ndash;55.\u003c/li\u003e\n \u003cli\u003eLievens Y, Van Den Bogaert W, Kesteloot K. Activity-based costing: A practical model for cost calculation in radiotherapy. Int J Radiat Oncol Biol Phys 2003;57:522\u0026ndash;525.\u003c/li\u003e\n \u003cli\u003eAtherton L. The cost of radiotherapy treatments on a linear accelerator. Br J Radiol 1984;57:106\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eGreene D. The cost of radiotherapy treatments on a linear accelerator. Br J Radiol 1983;56:189-191.\u003c/li\u003e\n \u003cli\u003eBarbera L, Walker H, Foroudi F, Tyldesley S, Mackillop W. Estimating he benefit and cost of radiotherapy for lung cancer. International Journal of Technology Assessment in Health Care\u003cbr\u003e2004;20:545\u0026shy;551.\u003c/li\u003e\n \u003cli\u003eRead G. Estimating the cost of radiotherapy. Clin Oncol 1994;6:35\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003ePenn CRH. Megavoltage irradiation in a district general hospital remote from a main oncology center: the Torbay experience reviewed. Clin Oncol 1992;4:108\u0026ndash;13.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"radiation-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"raon","sideBox":"Learn more about [Radiation Oncology](http://ro-journal.biomedcentral.com/)","snPcode":"13014","submissionUrl":"https://submission.nature.com/new-submission/13014/3","title":"Radiation Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cancer radiotherapy, Linear accelerator, Healthcare provision, Radiotherapy cost, Capital costs, Operating costs, Interest rate, Service development, Resource-limited setting, Sub-Saharan Africa","lastPublishedDoi":"10.21203/rs.3.rs-6882369/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6882369/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Understanding the cost of delivering radiotherapy in a resource-limited setting such as Cameroon in sub-Saharan Africa (SSA) is critical not only for expanding radiotherapy services in low- and middle-income countries (LMICs) but also for shaping future policy decisions. The Cameroon Oncology Center (COC), a privately owned oncology center located in Cameroon, has treated over 1000 patients on its sole medical linear accelerator since it began clinical operations in 2019. This work aimed to determine the operating cost estimate for providing radiotherapy\u003cstrong\u003e \u003c/strong\u003ein a private oncology center in the Republic of Cameroon, a study that could significantly impact and shape urgent policy decisions in the healthcare sector in this region.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This cost estimate was calculated based on our experience over the course of one calendar year, specifically 2021. We focused on the ongoing operating costs of the radiotherapy facility, excluding capital expenditures (building and equipment). Our calculations assumed that 300 patients were treated in 2021, a number that did not significantly affect the ongoing operating costs, even though only 215 patients received radiation therapy at our institution that year. These assumptions were made to provide a comprehensive estimate of the operating costs, ensuring a high level of transparency and trust in our methodology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults and conclusion\u003c/strong\u003e: The average operating cost per patient was approximately $1750·00 for curative intent radiotherapy, which consisted of at least 25 fractions. The top three drivers of operating costs are labor at 41·1%, linear accelerator parts and service cost (17·7%), and power (14·8%). For a public radiotherapy facility, the minimum cost to patients is $1750 (1.1 million FCFA in the local currency) per course of curative radiotherapy. If one factor in the repayment plan (capital costs) is amortized for 12 years, the total cost per patient would be currently $3651 or 2.2 million FCFA locally. These findings highlight the need for cost-effective strategies to maintain high-quality radiotherapy services in LMICs.\u003c/p\u003e","manuscriptTitle":"The cost of providing high-quality radiotherapy services in a resource-limited setting: A case study of the Cameroon Oncology Center","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-10 09:11:24","doi":"10.21203/rs.3.rs-6882369/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-28T13:30:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-28T13:04:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"249057187888599150610852006789820470173","date":"2025-07-10T09:07:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-08T10:34:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"174086325837405583584852164790546641609","date":"2025-07-08T08:43:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-08T07:42:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-13T12:28:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-13T08:39:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"Radiation Oncology","date":"2025-06-12T17:00:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"radiation-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"raon","sideBox":"Learn more about [Radiation Oncology](http://ro-journal.biomedcentral.com/)","snPcode":"13014","submissionUrl":"https://submission.nature.com/new-submission/13014/3","title":"Radiation Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0c024078-87e4-4c30-bf89-4e99af01d6ba","owner":[],"postedDate":"July 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-24T11:53:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-10 09:11:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6882369","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6882369","identity":"rs-6882369","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}