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How many new cancer patients in Europe will require radiotherapy by 2025? An ESTRO-HERO analysis

Published:February 24, 2016DOI:https://doi.org/10.1016/j.radonc.2016.02.016

      Abstract

      Background

      The objective of this HERO study was to assess the number of new cancer patients that will require at least one course of radiotherapy by 2025.

      Methods

      European cancer incidence data by tumor site and country for 2012 and 2025 was extracted from the GLOBOCAN database. The projection of the number of new cases took into account demographic factors (age and size of the population). Population based stages at diagnosis were taken from four European countries. Incidence and stage data were introduced in the Australian Collaboration for Cancer Outcomes Research and Evaluation (CCORE) model.

      Results

      Among the different tumor sites, the highest expected relative increase by 2025 in treatment courses was prostate cancer (24%) while lymphoma (13%), head and neck (12%) and breast cancer (10%) were below the average. Based on the projected cancer distributions in 2025, a 16% expected increase in the number of radiotherapy treatment courses was estimated. This increase varied across European countries from less than 5% to more than 30%.

      Conclusion

      With the already existing disparity in radiotherapy resources in mind, the data provided here should act as a leverage point to raise awareness among European health policy makers of the need for investment in radiotherapy.

      Keywords

      The number of newly-diagnosed cancer patients that would require radiotherapy treatment using an evidence-based approach was estimated for all European countries for the year 2012 within the framework of the ESTRO-HERO (Health Economics in Radiation Oncology) project [
      • Borras J.M.
      • Lievens Y.
      • Dunscombe P.
      • et al.
      The optimal utilization proportion of external beam radiotherapy in European countries: an ESTRO-HERO analysis.
      ]. The estimate was based on optimal utilization of radiation oncology according to the CCORE methodological approach [
      • Barton M.
      • Jacob S.
      • Shafiq J.
      • et al.
      Estimating the demand for radiotherapy from the evidence: a review of changes from 2002 to2012.
      ], using incidence data for European countries as estimated by the International Agency for Research on Cancer (IARC) [
      • Ferlay J.
      • Sterialova-Foucher E.
      • Lortet-Tieulent J.
      • et al.
      Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012.
      ,

      Ferlay J, Soerjomataram I, Erwick M, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and mortality worldwide: IARC Cancer Base n 11. Lyon: International Agency for Research on Cancer, 2013. (Available from http://globocan.iarc.fr, accessed on 10/8/2015).

      ], and combined with data on stage at diagnosis from four population-based cancer registries (The Netherlands, Slovenia, Grater Poland region of Poland, and Belgium) available in the categories required [
      • Borras J.M.
      • Barton M.
      • Grau C.
      • et al.
      The impact of cancer incidence and stage on optimal utilization of radiotherapy: methodology of a population-based analysis by the ESTRO-HERO group.
      ].
      This estimation provides a useful tool for planning the required equipment and staff needs. One of the critical results was the observed gap between the optimal utilization and the actual use of radiotherapy, with most countries covering less than 80% of the evidence-based demand for treatment compared with actual use [
      • Borras J.M.
      • Lievens Y.
      • Dunscombe P.
      • et al.
      The optimal utilization proportion of external beam radiotherapy in European countries: an ESTRO-HERO analysis.
      ]. This evidence could be immediately applied to improve cancer control planning with respect to placing the necessary investments required to cope with the demand of cancer patients.
      Long-term planning is required for radiotherapy facilities as well as for the staff needed, due to the significant interval between the time of making decisions for facility investments and training of personnel and the time when they become a clinical reality. A forecast of the anticipated changes in terms of new cancer patients that would need radiotherapy in the short- to medium-term time horizon seems rational, and fits within the objectives of the ESTRO-HERO project.
      The aim of this paper is then to assess the number of new cancer patients by tumor site that will require radiotherapy in 2025 as compared to the 2012 data, using the national cancer incidence estimates based on data from the population-based cancer registries available in each European country together with projections carried out by IARC in GLOBOCAN [
      • Ferlay J.
      • Soerjomataran I.
      • Dikshit R.
      • et al.
      Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012.
      ].

      Materials and methods

      European country-specific cancer incidence by tumor type was extracted from the GLOBOCAN database [

      Ferlay J, Soerjomataram I, Erwick M, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and mortality worldwide: IARC Cancer Base n 11. Lyon: International Agency for Research on Cancer, 2013. (Available from http://globocan.iarc.fr, accessed on 10/8/2015).

      ] for the year 2012. The detailed description of the data and the methods used to compute these estimates is given elsewhere [
      • Ferlay J.
      • Sterialova-Foucher E.
      • Lortet-Tieulent J.
      • et al.
      Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012.
      ]. To summarize, statistical models were developed to predict incidence rates for the year 2012 from recent trends, wherever possible. The country, sex, and site estimated incidence rates in 2012 were then applied to the corresponding population estimates to obtain the estimated numbers of new cancers in each European country in 2012. Projections for the year 2025 were computed using the facility available at the GLOBOCAN website [

      Ferlay J, Soerjomataram I, Erwick M, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and mortality worldwide: IARC Cancer Base n 11. Lyon: International Agency for Research on Cancer, 2013. (Available from http://globocan.iarc.fr, accessed on 10/8/2015).

      ]. The projected numbers of new cancer cases have been derived by applying the age-specific incidence rates estimated for 2012 to the corresponding forecast population in 2025. Therefore, the projected incident cases for 2025 took into account the demographic changes (age structure and size), but not the potential impact of the changes in risk factors.
      Tumor sites included in the analysis were as follows: bladder, brain, breast, cervix, colon, gallbladder, head and neck (lip, oral cavity, larynx, oropharynx, hypopharynx and nasopharynx), kidney, leukemia, lung, lymphoma (including Hodgkin and non-Hodgkin lymphoma), melanoma, multiple myeloma, esophagus, ovary, pancreas, prostate, rectum, stomach, testis and corpus uteri). It has been necessary to adapt the categories provided by GLOBOCAN to fulfill the requirements of the radiotherapy evidence-based Optimal Utilization Proportion (OUP) [
      • Barton M.
      • Jacob S.
      • Shafiq J.
      • et al.
      Estimating the demand for radiotherapy from the evidence: a review of changes from 2002 to2012.
      ]. “Colon and rectum” cancer was partitioned into colon and rectal cancers, “lip and oral cavity” into lip and oral cavity and the category “other pharynx” into oropharynx and hypopharynx. In order to do this, we extracted data from population-based cancer registries available in the last volume of Cancer Incidence in Five Continents [

      Forman D, Bray F, Brewster DH, Gombe Mbalawa C, Kohler B, Piñeros M, Steliarova-Foucher E, Swaminathan R, Ferlay J, editors (2014). Cancer Incidence in Five Continents, Vol. X, IARC Scientific Publication No. 164. Lyon: International Agency for Research on Cancer.

      ] for as many European countries as possible and computed proportions of each individual category. When no data were available in a particular country (such as Albania, Macedonia or Luxembourg), the data from a neighboring country was used. The same proportions were used in the 2012 and 2025 estimates.
      OUP of radiotherapy by tumor site was obtained from the Australian Collaboration for Cancer Outcomes Research and Evaluation (CCORE) review [
      • Barton M.
      • Jacob S.
      • Shafiq J.
      • et al.
      Estimating the demand for radiotherapy from the evidence: a review of changes from 2002 to2012.
      ], which provided radiotherapy indications for all tumor sites according to the relevant evidence-based clinical guidelines by tumor site and stage at diagnosis, updated to 2012. The stage at diagnosis originally used in the CCORE was from the Australian cancer registry. Four different European cancer registries provided data fitted to the CCORE decision trees structure (Slovenia, Grater Poland region of Poland, Belgium and The Netherlands) in order to estimate the OUP using a range of stage at diagnosis from distinct European countries. The methodological details of this analysis have been provided elsewhere [
      • Borras J.M.
      • Barton M.
      • Grau C.
      • et al.
      The impact of cancer incidence and stage on optimal utilization of radiotherapy: methodology of a population-based analysis by the ESTRO-HERO group.
      ]. The same OUPs were used in the 2012 and 2025 estimates. For the correct interpretation of the OUPs it is necessary to know that each patient is counted only once, even if he or she subsequently required further treatment for the particular cancer. Brachytherapy treatments were not considered.

      Results

      About 4 million new cancer patients are predicted in 2025 in Europe based on demographic changes. This represents a 15.9% increase in the absolute number of cases compared to the 3.4 million diagnosed in 2012, assuming overall cancer rates remain unchanged (Table 1). Using the lowest OUP estimated for each country, the absolute number of patients that would have an indication for radiotherapy at least once during the course of the disease would increase from 1,700,000 patients approximately in 2012 to 2,000,000 in 2025. This represents a 16.1% increase over the entire period.
      Table 1Cancer cases with an evidence based indication for external radiotherapy 2012 and 2025.
      CountryTotal cancers (n)
      All cancers excl. non-melanoma skin cancer. Globocan 2012/2025.
      OUP (%)
      OUP: optimal utilization proportion.
      Optimal radiotherapy courses (n)
      20122025% Var. 2012–25
      20122025Min.Max.OUP min.OUP max.OUP min.OUP max.OUP min./max.
      Albania71439,53252.654.3375838795014517733.4
      Austria41,11750,1674950.320,15520,69824,59125,25322
      Belarus32,42233,64948.550.315,73816,29316,33316,9093.8
      Belgium65,34578,48853.254.834,79235,79941,79043,00020.1
      Bosnia Herzegovina991111,53852.854.4523653956096628016.4
      Bulgaria32,05331,79251.35316,43416,97716,30116,838−0.8
      Croatia22,89025,14351.252.711,71712,05512,87013,2429.8
      Cyprus343847245152.3175317992409247137.4
      Czech Republic57,62770,55348.550.227,94328,94534,21135,43722.4
      Denmark36,11943,55752.854.319,06419,60022,99023,63620.6
      Estonia6117631049.150.830043104309932023.2
      Finland28,42834,46052.153.414,81015,18917,95218,41221.2
      France371,676446,67051.953.3192,769198,107231,665238,07920.2
      Germany493,780568,89250.151.6247,419254,735285,056293,48515.2
      Greece40,97146,62152.554.221,52322,21324,49125,27613.8
      Hungary50,47554,05150.351.925,41226,20927,21228,0657.1
      Iceland1449199750.751.87347501,0121,03437.8
      Ireland20,80828,43251.552.910,71411,01714,64015,05336.6
      Italy354,456411,51548.249.3170,821174,764198,320202,89716.1
      Latvia10,347956749.951.45166531547774914−7.5
      Lithuania14,52013,51449.951.57244748367426965−6.9
      Luxembourg2476323150.652125212891634168230.5
      Macedonia7330909752.654.3385639814786494124.1
      Malta1902256351.953.398810141331136734.8
      Moldova989410,37150.252.149695151520853994.8
      Montenegro2115234152.253.8110511391223126010.7
      Norway28,21436,3344950.513,81814,24817,79518,34928.8
      Poland152,216181,0725253.479,13981,29494,14296,70519
      Portugal49,17457,43649.751.124,43825,15128,54329,37716.8
      Romania78,76087,6235051.839,38340,80543,81445,39711.3
      Russian Federation458,382487,6824748.6215,507222,922229,282237,1726.4
      Serbia42,22144,39252.253.822,05022,73323,18423,9015.1
      Slovakia24,04529,91148.250.211,59912,07114,42815,01624.4
      Slovenia11,45714,20749.651.3568058747044728424
      Spain215,534268,96049.751.1107,018110,159133,545137,46524.8
      Sweden50,48159,41051.452.825,92826,66230,51431,37817.7
      Switzerland42,04655,08850.65221,29421,86527,90028,64731
      The Netherlands93,448117,99952.353.948,88650,32461,72963,54626.3
      Ukraine140,999140,92850.252.170,81173,40370,77573,366−0.1
      United Kingdom327,812398,4715354.4173,612178,405211,034216,86021.6
      Global3,439,5983,988,28850.251.71,727,5381,778,8162,005,4802,064,73916.1
      [a] All cancers excl. non-melanoma skin cancer. Globocan 2012/2025.
      [b] OUP: optimal utilization proportion.
      This increase in the number of expected cases is not distributed evenly across European countries (Table 1 and Fig. 1). Eastern European countries exhibited, broadly speaking, the lowest percentile increases, with Bulgaria, Ukraine, Latvia and Lithuania expecting decreases in the number of new cancer cases, while the incidence burden in many of the rest of Eastern countries is predicted to increase by less than 10%. The exceptions were Poland, the Czech Republic and Slovakia with increases of around 20% or above. However, when the focus is on the absolute in numbers, as shown in Fig. 2, it is clear that the greater increases are estimated in the most densely populated countries.
      Figure thumbnail gr1
      Fig. 1Increase in new cancer patients that would require radiotherapy by 2025 by country (%).
      Figure thumbnail gr2
      Fig. 2Optimal number of courses of radiotherapy in 2012 and estimated absolute increase in optimal number of courses by 2025.
      South-Eastern European countries showed a diversity of estimated changes in the number of patients, from a relative decrease in Bulgaria (−0.8%) to an increase of 33.4% in Albania. The highest relative increases were observed among small countries with no clear geographic pattern (Iceland, Ireland and Cyprus) with increases above 35%, while the incidence rises in more populated countries such as The Netherlands, Switzerland and Norway were between 25% and 31%. The countries of Western Europe, including France, Germany, Italy, Spain or the UK, with the highest volume of population, exhibited increases in the number of new cases from 2012 to 2025 by between 15% and 25%.
      Relative changes by tumor site and for all countries combined are presented in Table 2. It is worth noting that prostate cancer produced the highest increase over the period considered with a 24.4% rise followed by bladder cancer and multiple myeloma, while female breast cancer, lymphomas and head and neck cancer were below average. Importantly, cervical cancer only increased by 1.1% while the numbers of patients with a radiotherapy indication for cancer of the testis declined.
      Table 2Cancer cases with an evidence based indication for external radiotherapy 2012 and 2025.
      Tumor siteOptimal radiotherapy courses (n)
      2012 (OUP min.)
      OUP: optimal utilization proportion.
      Increase in number of radiotherapy courses 2025
      n%
      Bladder70,67914,84221.0
      Brain45,717462210.1
      Breast396,89140,52410.2
      Cervix36,3844051.1
      Colon9090174019.1
      Esophagus33,292595517.9
      Gall bladder349066719.1
      Head and neck108,19413,33712.3
      Kidney14,242213915.0
      Leukemia244236615.0
      Lung315,19756,55817.9
      Lymphoma74,852987113.2
      Melanoma11,725134011.4
      Myeloma17,821362920.4
      Ovary12681249.8
      Pancreas40,144719817.9
      Prostate243,66959,49324.4
      Rectum99,49318,31418.4
      Stomach37,185567515.3
      Testis738−45−6.1
      Thyroid23651074.5
      Uterus33,341414612.4
      [a] OUP: optimal utilization proportion.
      The tumors that make up the highest percentage of patients in a radiotherapy department, namely breast, rectum, head and neck, lung and prostate cancers are shown in Table 3 for each European country with their absolute and relative increase. Some relative increases are noteworthy and deserve close analysis at national level. For instance, countries such as Spain, The Netherlands or the Czech Republic show an increase higher than 25% for rectal cancer patients with a radiotherapy indication, while Belgium, UK or Denmark have an estimated increase above 20%. Also, the estimated increase for prostate or lung cancer is very important in many western European countries, higher than 20%; while the observed increases for breast cancer patients are moderate in comparison.
      Table 3Increase in the number of new cancer cases that would require radiotherapy by 2025 and relative percentage increase between 2012 and 2025 for the 5 most frequent indications.
      CountryBreastHead and neckLungProstateRectum
      IncreaseIncreaseIncreaseIncreaseIncrease
      n%n%n%n%n%
      Albania14616.710339.637043.69649.33237.1
      Austria58413.022719.986824.7101929.924825.8
      Belarus772.4554.02146.9766.1696.6
      Belgium102011.534316.5140123.4153728.037022.5
      Bosnia Herzegovina818.27817.527420.611227.75719.4
      Bulgaria−125−3.7−12−1.100.0423.9201.7
      Croatia813.6677.928712.225821.810713.1
      Cyprus14528.11533.48740.913748.82942.1
      Czech Republic81513.925215.8119723.3127531.852526.7
      Denmark53812.012513.778822.483127.324524.8
      Estonia−12−2.174.5275.5498.284.4
      Finland3138.27315.150626.483626.616025.6
      France625313.5159913.6599419.510,84625.2199424.2
      Germany53768.814319.5677517.3916123.0287218.0
      Greece3959.413214.588016.631916.811915.2
      Hungary1844.21465.24946.922812.32019.6
      Iceland5327.6838.95443.27446.51539.5
      Ireland74430.014634.071440.990540.915540.7
      Italy432310.0130316.3575720.1559621.5176318.2
      Latvia−92−9.4−18−6.2−55−6.1−47−5.4−12−6.4
      Lithuania−75−5.9−14−3.2−68−5.7−80−9.0−23−6.4
      Luxembourg6821.91423.56733.37940.22631.9
      Macedonia16917.24823.026627.39637.64427.7
      Malta5018.82337.66748.16353.51937.7
      Moldova434.5−6−1.0464.94216.1379.3
      Montenegro125.489.13111.12022.9913.3
      Norway45118.312325.668431.3117934.824532.0
      Poland152410.379713.4444222.0215633.486523.7
      Portugal52110.034015.262119.389323.132519.4
      Romania6568.555012.8123113.738814.725012.9
      Russian Federation22284.58285.23,4258.0200312.712959.1
      Serbia2535.5533.13295.91679.1786.8
      Slovakia37616.618518.854327.945540.331330.0
      Slovenia12711.86218.528026.836639.811328.7
      Spain367817.0197927.6584128.4502130.8215526.9
      Sweden62311.013315.954218.11,28318.926822.2
      Switzerland109122.230127.9107332.9172737.632533.8
      The Netherlands155213.149122.5264128.7282536.386232.4
      Ukraine−124−0.9−5−0.12091.6381.0821.6
      United Kingdom640114.3134918.1765624.7741927.9204924.4
      Global40,52410.213,33712.356,55817.959,49324.418,31418.4
      Range−9.4 to 30.0−6.2 to 39.6−6.1 to 48.1−9.0 to 53.5−6.4 to 42.1
      Fig. 3 provides a visual representation of the cancer types with the highest absolute number of radiotherapy indications, projected for the 2025. Interestingly, in several countries bladder cancer ranks among the most frequent cases according to the evidence-based indications, due to its high incidence in these countries. A similar observation can be made for lymphoma (estimates by country for all tumor types can be consulted in the web-based Supplementary material).
      Figure thumbnail gr3
      Fig. 3Top 5: Ranking by absolute number of cancer patients requiring radiotherapy by 2025 (using min OUP).

      Discussion

      Projections of the incidence of cancer are helpful in assessing the future burden of cancer and in order to establish appropriate cancer control plans to cope with the challenge posed by a growing number of cancer patients. The projections carried out in GLOBOCAN by IARC, combined with the evidence-based data on radiotherapy indications offer a unique opportunity to undertake long-term radiotherapy resource planning. The obtained data, by tumor site and by country within Europe, give guidance for making the necessary investments in services and equipment and for setting-up training of dedicated personnel, necessary actions to adequately manage the increased radiotherapy demands expected in the near future.
      Other groups have performed similar exercises. Datta and colleagues made estimates of the additional number of treatment units and personnel – radiation oncologists, medical physicists and radiation technologists – required in 39 European countries by 2020 [
      • Datta N.R.
      • Samiei M.
      • Bodis S.
      Radiotherapy infrastructure and human resources in Europe – present status and its implications for 2020.
      ]. Actual radiotherapy resources were obtained from the DIRAC (Directory of Radiotherapy Centres) database; whereas actual and future needs were computed using actual and projected cancer incidence data from GLOBOCAN, combined with the assumption that 62.5% of all cancer patients would require RT (50% of new cancer patients plus 25% of these for re-irradiation) and with required machine and staffing levels based on ESTRO-QUARTS [
      • Slotman B.J.
      • Cottier B.
      • Bentzen S.M.
      Overview of national guidelines for infrastructure and staffing of radiotherapy. ESTRO- QUARTS: work package 1.
      ] and IAEA recommendations [

      International Atomic Energy Agency. IAEA Human Health Series Nos. 14. Planning national radiotherapy services: a practical tool. Vienna: International Atomic Energy Agency; 2010. Available from: http://www-pub.iaea.org/MTCD/Publications/PDF/Pub1462_web.pdf (accessed 23.09.13). .

      ]. In contrast to their approach, our projections are restricted to the number of cancer patients that can be expected to benefit from radiotherapy by 2025, hence courses that should be delivered, without making assumptions – as yet – about the resources that would be required to make this possible. Our previously published HERO-analysis has indeed demonstrated that the available European radiotherapy guidelines do not sufficiently take into account the rapid technology evolution in radiotherapy, hence in our view do not provide sufficiently robust estimates to correctly predict the real resource needs for each individual country [
      • Dunscombe P.
      • Grau C.
      • Defourny N.
      Guidelines for equipment and staffing of radiotherapy facilities in the European countries: final results of the ESTRO-HERO survey.
      ]. With their activity-based approach using time-based estimates for diverse activities within the radiotherapy treatment process (instead of using average throughput estimates), the Global Task Force on Radiotherapy for Cancer Control has taken an important step in forecasting radiotherapy resource needs for a given patient population, requiring a certain number of radiotherapy courses [
      • Atun R.
      • Jaffray D.A.
      • Barton M.B.
      • et al.
      Expanding global access to radiotherapy.
      ]. The HERO-project is now adopting a similar activity-based approach to develop a productivity and costing model that can be tailored to the specific needs of each European jurisdiction, based on the actual radiotherapy needs down to the level of each cancer type, and accounting for the evolving radiotherapy practice in terms of complexity and fractionation schedules.
      The effects taken into account by the methodology used in the projections of cancer incidence are demographic (age structure changes and population size), the major contributor to future increasing number of new cancer cases in Europe [
      • Bray F.
      • Moller B.
      Predicting the future burden of cancer.
      ]. Risk factor changes and their potential consequences on incidence or, more simply, trends-based approaches have however not been considered. All factors taken into account, the projection methodology applied here could be considered conservative, assuming that changes in age-specific rates beyond 2012 were assumed to remain constant through 2025. The uncertainties associated with possible determinants in the future – the risk profile and diagnostic changes – may be considered sufficiently high as to make reliable predictions of their impact on future trends a difficult and potentially misleading exercise [
      • Cleries R.
      • Martinez J.
      • Moreno V.
      • et al.
      Predicting the change in breast cancer deaths in Spain by 2019: a Bayesian approach.
      ].
      The second source of data used in this study has been the OUP. Any possible change in the evidence-base of the radiotherapy indications in the coming future, and consequently in the OUP for any particular tumor site, will have implications for the expected number of cases for radiotherapy treatment. However, the OUP has been quite robust when considered for all cancers together when the update of 2012 was compared to the evaluation of the clinical guidelines up to the year 2003 [
      • Barton M.
      • Jacob S.
      • Shafiq J.
      • et al.
      Estimating the demand for radiotherapy from the evidence: a review of changes from 2002 to2012.
      ,
      • Delaney G.
      • Jacob S.
      • Featherstone C.
      • Barton M.
      The role of radiotherapy in cancer treatment: estimating optional utilization from a review of the evidence-based clinical guidelines.
      ]. In fact, the expansion of conservative approaches to organ preservation, and the increased combination of radiotherapy and chemotherapy in tumor sites such as cervical, rectal or lung cancer [
      • Thariat J.
      • Hannoun-Levi J.M.
      • Sun Mynt A.
      • Vuong T.
      • Gerard J.P.
      Past, present and future of radiotherapy for the benefit of the patients.
      ], related to an earlier stage at diagnosis, will most probably expand the number of candidates for radiotherapy. Moreover, new radiotherapy techniques that involve more precision in the delivery of the dose and less toxic effects on the surrounding tissue jointly with new combinations with chemotherapy could also influence the number of candidates for radiotherapy treatments [
      • Coleman N.
      • Lawrence T.S.
      • Kirsch D.G.
      Enhancing the efficacy of radiation therapy: premises, promises and practicality.
      ]. In summary, a decrease in the number of patients due to a reduction in indications is highly improbable.
      The main result of this study is that the absolute number of new cancer patients with a radiotherapy indication will increase in the immediate future in almost all European countries, although there are variations in their relative magnitude between the countries and regions of Europe. As mentioned, the driver of the predictions utilized here are the projected population aging and population growth. Classical drivers of such demographical changes are fertility, mortality and migration. The latter is the least predictable and is more prone to short-term changes. However the impact of migration is usually mainly seen in younger age groups, who have a relatively low cancer risk. From a global viewpoint, EU countries exhibit a very moderate short-term increase in the size of the population (0.8% between 2015 and 2020 and 1.2% between 2020 and 2030). The Nordic and some western countries (e.g. France, the UK), are the only countries to clearly indicate an increase in the size of the population in the mid- and longer-term projections [

      Eurostat. http://ec.europa.eu/eurostat accessed on 10/8/2015.

      ] until 2050 or later. Eastern European countries show a decrease in population size in the mid- and longer-term, however the main decrease is predicted beyond 2025 for all these countries, including the Russian Federation and Ukraine [

      United Nations, Department of Economic and Social Affairs, Population division. World population prospects: Key findings and advance tables, 2015 revision. New York: United Nations, 2015 (working paper ESA/P/WP.241; available http://esa.un.org/unpd/wpp/ accessed on 10/8/2015).

      ].
      Aging of the European population, due to the increases in longevity and low fertility levels, is a parallel process that explains the increase in number of cases. One consequence of this process is that the very old (80 years or older) are the fastest growing population age group in Europe. Age and cancer incidence are strongly associated, hence the aging process has a strong impact on the cancer incidence in countries with the highest percentage of older age groups, such as Germany, Italy or Spain. The main consequence for radiotherapy as well as for the multidisciplinary management of this aged patient group is the growing prevalence of patients with multi-morbidities including cancer, which influences clinical decision-making. Indeed, one of the most relevant factors that explains lower than expected indications for radiotherapy is the presence of comorbidity and old age [
      • Janssen-Heijnen M.L.
      • Maas H.
      • Houterman S.
      • et al.
      Comorbidity in older surgical patients: influence on patient care and outcomes.
      ,
      • Janssen-Heijnen M.L.
      • Houterman S.
      • Lemmens V.E.
      • et al.
      Prognostic impact of increasing age and co-morbidity in cancer patients: a population based approach.
      ,
      • De Ruysscher D.
      • Botterweck A.
      • Dirx M.
      • et al.
      Eligibility for concurrent chemotherapy and radiotherapy of locally advanced lung cancer patients: a prospective, population-based study.
      ]. These clinically-related factors – coupled with patient preferences – could in part explain the gap between the optimal and actual use of radiotherapy observed in different analyses [
      • Borras J.M.
      • Lievens Y.
      • Dunscombe P.
      • et al.
      The optimal utilization proportion of external beam radiotherapy in European countries: an ESTRO-HERO analysis.
      ,
      • McKillop W.
      • Wong W.
      • Brundage M.
      • et al.
      A comparison of evidence based estimates and empirical benchmarks of the appropriate rate of use of radiation therapy in Ontario.
      ]. Other factors are more policy-related and include accessibility problems due to the distance to radiotherapy departments, lengthy waiting lists, a lack of resources and/or old therapeutic technologies [
      • Borras J.M.
      • Lievens Y.
      • Dunscombe P.
      • et al.
      The optimal utilization proportion of external beam radiotherapy in European countries: an ESTRO-HERO analysis.
      ], which are all more amenable to health policy efforts. Indeed, differences between evidence-based indications and clinical practice could be observed in the relative importance of bladder cancer or lymphoma as indication, which is not in line with the actual demand for radiotherapy in our clinical departments. These discrepancies may reflect shortcomings of the model or an indication that some patients with indications for radiotherapy are not being treated appropriately [
      • Koshy M.
      • Rich S.E.
      • Mahmood U.
      • Kwok Y.
      Declining use of radiotherapy in type I and II Hodgkin’s disease and its effect on survival and secondary malignancies.
      ]. These observations should be the target for health services research in this field in the coming future in order to refine the projections.
      The projections of the new cancer patients are useful to assess the expected increase in cancer burden and the related impact for radiotherapy services by country and type of tumor. This analysis has been done under reasonable and conservative assumptions regarding the projections of cancer incidence. Considered globally, the resources required to cope with the challenge posed by these projections are important, especially as important differences in the capital resources and staff among European countries have been documented [
      • Grau C.
      • Defourny N.
      • Malicki J.
      • et al.
      Radiotherapy equipment and departments in European countries: final results of the ESTRO-HERO survey.
      ,
      • Lievens Y.
      • Defourny N.
      • Coffey M.
      • et al.
      Radiotherapy staffing in European countries: final results of the ESTRO-HERO survey.
      ], as well as the gap between optimal and actual use [
      • Borras J.M.
      • Lievens Y.
      • Dunscombe P.
      • et al.
      The optimal utilization proportion of external beam radiotherapy in European countries: an ESTRO-HERO analysis.
      ]. The fact that such a gulf has been identified in the majority of European countries and that the need for radiotherapy has been estimated for optimal utilization, could suggest that a more conservative target for planning radiotherapy equipment and staff should be proposed. In this respect, 80% of the optimal demand may be a reasonable first policy target [
      • Borras J.M.
      • Lievens Y.
      • Grau C.
      The need for radiotherapy in Europe in 2020: not only data but also a cancer plan.
      ]. Additionally, the resources required should be invested within the framework of a national cancer control plan [
      • Borras J.M.
      • Lievens Y.
      • Grau C.
      The need for radiotherapy in Europe in 2020: not only data but also a cancer plan.
      ,
      • Overgaard J.
      Radiotherapy: gazing at the crystal ball of European radiotherapy.
      ].
      In conclusion, the study has shown that the need for radiotherapy in Europe on average is expected to increase with 16% from 2012 to 2025. The expected changes in demand varied considerably between countries (range 0–35%). With the already existing disparity in radiotherapy resources in mind, the data provided here should act as a leverage point to raise awareness among European health policy makers of the need for investment in radiotherapy.

      Funding sources

      This project was supported by the European Society for Radiotherapy and Oncology.

      Conflicts of interest

      The authors have no conflict of interest.

      Acknowledgments

      We would like to acknowledge the support of Chiara Gasparotto from ESTRO in the preparation of the figures included in this paper and to Ramon Cleries for his comments. The HERO project is supported by the European Society for Radiotherapy and Oncology.

      Appendix A. Supplementary data

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