A radiation oncology professional in a workshop on implementing image-guided brachytherapy, held during the IAEA International Conference on Advances in Radiation Oncology in June 2025. (Photo: IAEA)
An IAEA-led study has revealed that image-guided brachytherapy can be implemented in hospitals with limited resources, offering better outcomes for cervical cancer patients worldwide.
Cervical cancer is the fourth most common cancer among women globally, and it is a leading cause of cancer death in many countries with limited medical resources. An IAEA coordinated research project involving 15 cancer institutions worldwide has shown that transitioning to image-guided brachytherapy - an advanced, precise technique for treating cervical cancer - is feasible in resource-challenged settings, which could help bridge the gap in global cancer care.
While eliminating cervical cancer has become a global health priority, especially following the World Health Organization's initiative - most women in resource-limited regions are diagnosed at an advanced stage when the cancer has already spread to nearby tissues. While brachytherapy remains an essential part of standard therapy for advanced cervical cancer, image-guided brachytherapy (IGBT) has been shown to further improve tumour control and patient survival.
By using 3D imaging techniques to guide the placement of a miniaturized radioactive source, IGBT delivers radiation with more precision, which reduces exposure to adjacent tissues, minimizes side effects and enhances patients' quality of life.
However, IGBT requires specialized staff, imaging equipment, advanced brachytherapy applicators and enhanced operating rooms. In addition, IGBT procedures can take three times longer than conventional brachytherapy, placing potential strain on existing radiation oncology infrastructure in low- and middle-income countries. Understanding and optimizing current treatment workflows - the steps and processes involved in delivering radiation therapy - can help make IGBT more feasible.
About the Coordinated Research Project
To understand how IGBT could be scaled up in resource-challenged contexts, in 2019 the IAEA launched a coordinated research project (CRPE33042) to study the effects that treatment processes have on access, resource utilization and overall efficiency.
"Implementation studies like this one help to bridge the gap between technology and practice by accounting for local health systems and their complexities, identifying the factors that affect adoption, and defining strategies to facilitate real-world application," said May Abdel-Wahab, Director of the IAEA's Division of Human Health .
Cancer centres from 14 countries - Azerbaijan, Plurinational State of Bolivia, Brazil, Croatia, India, Kyrgyzstan, Mongolia, Morocco, Pakistan, the Philippines, the United Republic of Tanzania, Türkiye, Ukraine and Zambia - participated, contributing treatment workflows observations for 365 patients collected over a three-month period. These workflows consisted of either conventional 2D X ray-guided brachytherapy, standard 3D IGBT or advanced 3D image-guided adaptive brachytherapy. In the latter, treatment plans are adjusted to reflect changes that occur in the tumour and surrounding tissues.
The IAEA collected information on each centre's infrastructure, operating hours, staff shifts, equipment, radiation source type, anaesthesia techniques, imaging modalities, workflow distribution, treatment planning methodology, treatment timing, machine demand, patient throughput and resource utilization.
Impact and Relevance
By comparing workflow observations, the IAEA identified how each factor affected procedure time - from patient entry into the operating room to the moment a brachytherapy applicator was inserted. "Through on-the-ground data on existing workflows, the IAEA's feasibility study offers context-specific recommendations which can guide institutional and national-level strategies for implementing IGBT," said Supriya Chopra, radiation oncologist and professor at Tata Memorial Centre, the Rays of Hope Anchor Centre in India.
Centres with sufficient capacity - those with low to moderate demands per brachytherapy machine - were recommended to transition to advanced IGBT workflows. In addition to ensuring adequate training, support and infrastructure, these centres can benefit from the mentorship of others under a peer-assisted learning model.
Centres with limited capacity were recommended to undertake a phased transition to IGBT. Workflow modifications such as pre-defined dose distributions, streamlined decision-making and the use of fewer implants but multiple smaller doses (fractions) could help with meeting existing brachytherapy need while supporting a gradual, scalable transition. Improved workspace layouts that separate planning and treatment areas could also reduce bottlenecks, allowing for multiple patients and procedures at the same time.
Centres with high demand were recommended to strengthen existing workflows through increased investments and specialized training for staff.
"For healthcare providers and policymakers alike, these insights on a sustainable transition to IGBT ultimately help to bridge the gap in global cancer care by ensuring that locally advanced cervical cancer patients in resource-limited settings receive timely and effective care," said Abdel-Wahab.
The study's findings have been presented at the 2025 annual meeting of the European Society for Radiation Oncology. The CRP also produced a meta-analysis of 5488 patient records that showed the benefit of transitioning to 3D planning; analysis of clinical workflow scenarios in 19 countries; and a national impact analysis which showed that unplanned transitions could reduce treatment capacity and increase waiting lists.
