Original Reports | Radiation Oncology

Status of Government-Funded Radiotherapy Services

in Nigeria
Simeon C. Aruah, MBBS, MPH, MD1,2 ; Runcie C.W. Chidebe, BSc, MSc3,4,5 ; Tochukwu C. Orjiakor, PhD3,6 ; Fatima Uba, MBBS, FMCR, MD7;
Uchechukwu N. Shagaya, MBBS, MD1; Charles Ugwanyi, MBBS, MD8; Aisha A. Umar, MBBCh, FMCR, MD9; Taofeeq Ige, PhD10 ;
Obinna C. Asogwa, BSc10,11; Oiza T. Ahmadu, MBBS12; Musa Ali-Gombe, MBBS13,14 ; Alabi Adewumi, MBBS15; Vitalis C. Okwor, MBBS, MSc, MD16;
Jimoh A. Mutiu, MBChB, MSc, MD17 ; Basheer Bello, MBBS18; Lucy O. Eriba, MBBS, MD19; Yusuf A. Ahmed, PhD20,21; Awwal Bisalla, MBBS21;
Ukamaka Itanyi, MBBS, MD22; Ramatallah A. Balogun, MBBS23; Suleiman Alabi, MBBS7; David Pistenmaa, MD, PhD24;
C. Norman Coleman, MD24 ; and Dosanjh Manjit, MD, PhD25,26

DOI https://doi.org/10.1200/GO.22.00406

Accepted April 18, 2023

Copyright © 2024 American Society of Clinical Oncology. See https://ascopubs.org/go/authors/open-access for reuse terms.

ABSTRACT
Published June 22, 2023

PURPOSE Access to radiotherapy (RT) is now one of the stark examples of global cancer JCO Global Oncol 9:e2200406
inequities. More than 800,000 new cancer cases require potentially curative or © 2023 by American Society of
palliative RT services in Africa, arguably <15% of these patients currently have Clinical Oncology
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access to this important service. For a population of more than 206 million,
Nigeria requires a minimum of 280 RT machines for the increasing number of
cancer cases. Painfully, the country has only eight Government-funded RT
machines. This study aimed to evaluate the status of the eight Government-
funded RT services in Nigeria and their ability to deliver effective RT to their
patients.
METHODS A survey addressing 10 critical areas was used to assess the eight Government-
funded RT services in Nigeria.
RESULTS Unfortunately, six of the eight centers (75%) surveyed have not treated pa-
tients with RT because they do not have functioning teletherapy machines in
2021. Only two RT centers have the capability of treating patients using ad-
vanced RT techniques. There is no positron emission tomography-computed
tomography scan in any of the Government-funded RT centers. The workforce
capacity and infrastructure across the eight centers are limited. All of the
centers lack residency training programs for medical physicists and radiation
therapy technologists resulting in very few well-trained staff.
CONCLUSION As the Nigerian Government plans for the new National Cancer Control Plan,
there is an urgent need to scale up access to RT by upgrading the RT equipment,
workforce, and infrastructure to meet the current needs of Nigerian patients
with cancer. Although the shortfall is apparent from a variety of RT-capacity
databases, this detailed analysis provides essential information for an imple-
mentation plan involving solutions from within Nigeria and with global
partners. Licensed under the Creative
Commons Attribution 4.0 License

INTRODUCTION non-Hodgkin lymphoma—5.9%, and other cancers—53.1%4

Radiotherapy (RT) is an essential component of the curative
and palliative treatment of patients with cancer. However, this
important modality is not readily available in many African
countries including Nigeria.1 More than 800,000 new cancer
cases require potentially curative or palliative RT services in
Africa, arguably <15% of these patients currently have
access to this important service.2,3 With 125,000 new cancer
cases and 79,000 cancer death in 20204 in Nigeria, cancer
is becoming a growing public health challenge for its pop-
ulation of 206 million people.5 The four most common cancers
were breast—22.7%, prostate—12.3%, colorectal—6%,
while the most common cancers treated with RT were breast
(37.5%), uterine cervix (16.3%), head and neck (11.9%), and
prostate (10.9%).6
Access to RT is a significant challenge globally because of
deficiencies in equipment and RT workforce.7 In addition to
workforce shortages, another critical challenge in delivering
quality RT services in Nigeria is poor RT infrastructure. This
makes transition from the two-dimensional (2D) to three-
dimensional (3D) RT treatment technique difficult in most of
the Government-established RT services.6 There is also a
lack of Government commitment especially in terms of

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 Aruah et al

CONTEXT

Key Objective
This study evaluated the status of Government-funded radiotherapy (RT) services in Nigeria regarding equipment and
workforce and quantified their ability to deliver effective RT to patients.

Knowledge Generated
Only two Government-funded RT centers have modern three-dimensional computed tomography (CT) simulation
equipment.
There are limited service contracts or maintenance engineers to repair linear accelerators (LINACs) in Nigeria. Thus, when a
LINAC breaks down, there is a long waiting time for maintenance which, in turn, leads to treatment delay.
Copyright © 2024 American Society of Clinical Oncology. See https://ascopubs.org/go/authors/open-access for reuse terms.

There is no positron emission tomography-CT scan in any of the Government-funded RT centers.

There is a lack of residency training programs for medical physicists and radiation therapy technologists in Nigeria.

Relevance
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This study provided empirical evidence of the poor state of Government-funded RT centers and the need for more budgetary
allocation.
The findings will guide clinicians, patient advocates, health care leaders, and the Nigeria Federal Ministry of Health as they
plan for the new National Cancer Control Plan.

budget allocation, budget releases, monitoring, and imple-
mentation of financing for RT infrastructure. The current
widely accepted standard for a basic RT center includes at
least two teletherapy units, a high-dose rate (HDR) after-
loading brachytherapy system, a treatment planning system
(TPS), a mould room, a computed tomography (CT) simu-
lator, adequate dosimetry, and quality assurance equip-
ment.8 Arguably, there is no Government-funded RT center
in Nigeria that meets this standard. Presently, most of the
Government-funded centers have yet to experience an up-
grade of their RT services as seen in other African countries
such as South Africa and Egypt.
one of the largest technology gaps in health care today with
many patients with cancer lacking access to RT.
To the best of our knowledge, many of the studies published
on the status of RT in Nigeria have not taken a close look at
the status of the existing Government-funded RT services.
There is a lack of holistic assessment of the status of RT
machines, workforce, and other elements of the RT infra-
structure for centers in Nigeria. To update this information,
we have surveyed the current status of RT machines,
workforce, and infrastructure in the eight Government-
funded RT centers in Nigeria.

The Nigeria Federal Ministry of Health established the Na- METHODS

tional Cancer Control Program (NCCP) in 2006 to develop,
coordinate, and implement activities, policies, and programs
to address the trend of increasing cancers in Nigeria.9 To
achieve its goals, the NCCP launched a National Cancer
Control Plan for 2008-2013 and another plan for 2018-2022
with priorities for treatment and for hospice and palliative
care as goals 2 and 3, respectively. The objectives of goal 2
were to increase by at least 50% the functionality of the
comprehensive cancer care centers (which includes RT) and
to increase the workforce by 60% by the year 2022 with a
budget of N59,508,662.50 ($188,916.39 [USD]).10 However,
such an important national policy has not taken a firm stand
in addressing the challenge of access to cancer care, espe-
cially RT services. Arguably, RT is one of the most important
parts of a cancer control plan, and its availability to patients
globally is quite desirable.11 It is also a critical and cost-effective
component of a comprehensive cancer control plan that offers
the potential for cure, control, and palliation of disease in>50%
of patients with cancer.12,13 Yet, the disparities in RT access are
This was a multicenter study of the eight Government-
funded RT centers encompassing all six geopolitical zones
of Nigeria as of 2021. The RT centers surveyed are the Na-
tional Hospital Abuja (NHA), the Usman Danfodio University
Teaching Hospital (UDUTH) Sokoto, the Ahmadu Bello
University Teaching Hospital (ABUTH) Zaria, the University
of Nigeria Teaching Hospital (UNTH) Ituku Ozalla—the
Enugu, Nigeria Sovereign Investment Authority—Lagos
University Teaching Hospital (NSIA-LUTH) Lagos, the
Federal Teaching Hospital (FTH) Gombe, the University
College Hospital (UCH) Ibadan, and the University of Benin
Teaching Hospital (UBTH) Benin (Fig 1). The study involved
multistage sampling of services in the RT centers. A survey
tool was developed by the investigators to assess 10 critical
areas pertaining to the status of RT machines, the RT
workforce, and the RT infrastructure in the eight centers. A
pilot study of the survey tool was conducted in ABUTH,
UNTH, and LUTH to ascertain the feasibility of a national

2 | © 2023 by American Society of Clinical Oncology

 Status of Public Radiotherapy in Nigeria

Sokoto

Katsina
Jigawa

Zamfara Yobe
Borno
Kebbi
Kano
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Kaduna Bauchi Gombe

Niger

Adamawa
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Federal Capital Plateau

Territory
Kwara

Nasarawa
Oyo
Taraba
Ekiti
Osun Kogi
Benue
Ogun
Ondo Enugu
Lagos Edo Ebonyi
Anambra

Cross Key:
Delta Abia
Imo River Red = COBALT (EBT)

Green = LINACS (EBT)

Rivers Akwa Blue = Brachytherapy(INT)
Bayelsa Ibom

FIG 1. Map showing the location of the Government-funded radiotherapy centers located in all the six geopolitical zones of Nigeria. EBT,
External Beam Therapy; INT, Intracavitary Brachytherapy for Gynaecological Cancers; LINACS, linear accelerators

study. After the analysis of the results of the pilot study, the
tool was expanded with the addition of items assessing
electron energies and diagnostic radiology support. The
survey tool was completed by radiation oncologists and
medical physicists in the centers in 2021. Six surveys were
completed online while two were completed in paper copies.
The collected data were double-checked, cleaned, and an-
alyzed using descriptive statistics. The results of the pilot
study are not included in the results of the main study.
RESULTS
working in the Government-funded RT centers. None of the
RT centers has a medical physics residency training program
(Table 1). Six of the eight RT centers have radiation oncology
residency programs, the exceptions being FTH and UBTH.
Seventy-five (75%) of the Government-funded RT centers
do not have a designated dosimetrist including UNTH Enugu,
FTH, NHA, ABUTH, NSIA-LUTH, and UCH. There were no
nuclear medicine physicians in FTH and UBTH. There is no
mould room technician in FTH, NSIA-LUTH and UCH. NHA
has the highest number of oncology nurses. There was no
input from UCH regarding the number of oncology nurses.

Oncology Workforce in the Radiotherapy Centers Technologies Available in the Radiotherapy Centers

Our results showed that Nigeria has 44 radiation oncologists,
45 radiation oncology residents, 44 medical physicists, eight
dosimetrists, 42 radiation therapy technologists (RTTs), 57
oncology nurses, seven mould room technicians, 15 bio-
medical engineers, and eight nuclear medical physicians
Number of Teletherapy Machines
Only five of the eight RT centers have linear accelerators
(LINACs) namely NHA, NSIA-LUTH, UDUTH, UBTH, and
UNTH. Only three (60%) of the five centers have functional

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 Aruah et al

TABLE 1. Workforce in the Radiotherapy Centers

UNTH, FTH, UBTH, NHA, ABUTH, NSIA-LUTH, UDUTH, UCH,

Cancer Center Workforce Enugu Gombe Benin Abuja Zaria Lagos Sokoto Ibadan Total
No. of radiation 4 2 5 7 5 9 3 9 44
oncologists
Radiation oncologist 4 0 0 7 10 12 2 10 45
residents
Medical physicists 6 2 3 10 5 7 5 8 44
Dosimetrists 0 0 3 0 NA 0 5 NA 8
Therapy radiographers 5 3 5 7 7 9 2 6 42
Oncology nurses 6 4 2 23 9 7 6 No input 57
Mould room technicians 1 0 1 1 1 0 3 NA 7
Biomedical engineers 2 1 1 3 1 2 1 4 15
Copyright © 2024 American Society of Clinical Oncology. See https://ascopubs.org/go/authors/open-access for reuse terms.

Nuclear medicine 1 0 0 1 1 1 2 2 8
physicians
Medical physics residents 0 0 0 0 0 0 0 0 0
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Abbreviations: ABUTH, Ahmadu Bello University Teaching Hospital; FTH, Federal Teaching Hospital; NA, not applicable; NHA, National Hospital
Abuja; NSIA-LUTH, Nigeria Sovereign Investment Authority-Lagos University Teaching Hospital; UBTH, University of Benin Teaching Hospital; UCH,
University College Hospital; UDUTH, Usman Danfodio University Teaching Hospital; UNTH, University of Nigeria Teaching Hospital.

LINACs, namely UNTH, NHA, and NSIA-LUTH. Thirty
percent of the LINACs have broken down. Two centers,
UCH and ABUTH, have old unused cobalt-60 teletherapy
machines. Four (50%) of the Government-funded RT
centers (UBTH, ABUTH, UDUTH, and UCH) do not have a
functional teletherapy machine. FTH has neither a cobalt-
60 machine nor a LINAC. In total, in the Government-
funded RT centers in Nigeria, there are nine teletherapy
machines, seven LINACs, and two cobalt-60 machines
(Table 2 and Fig 1).
Energy of photons
Radiotherapy Treatment Planning
Availability of Simulation Equipment in the RT Centers
Only NHA and NSIA-LUTH have modern 3D CT simulation
equipment, a requirement for modern RT treatment plan-
ning. Other centers, UNTH, UBTH, UCH, UDUTH, FTH, and
ABUTH, have only 2D conventional simulators using both
static and fluoroscopic modes, which are typically limited.
Without a CT simulator, it is impossible to deliver a 3D
treatment.14 The latter technique allows more precise
treatment, dose escalation, and reduction of radiation to
organ at risk (Table 4).

Only three of the eight RT centers, UNTH, NHA, and

NSIA-LUTH, have multienergy photon LINACs. Having only
monoenergy LINACs limits treatment capability.
Electron Therapy
Only NHA and NSIA-LUTH have electron capability for
treatment of superficial cancers and benign skin diseases. Six
(75%) of the Government-funded RT centers cannot treat
superficial tumors adequately because they lack the necessary
treatment machine capabilities.
Availability of Brachytherapy Machines
Although all the RT centers have brachytherapy machines,
only UCH, FTH, and UBTH have functional HDR brachy-
therapy machines. Five (63%) of the RT centers with bra-
chytherapy have yet to migrate from 2D to 3D brachytherapy
because of lack of CT or magnetic resonance imaging (MRI)
simulators which are necessary for image acquisition for
their TPSs (Table 3 and Fig 1).
Availability of TPS
Computerized TPSs are used in teletherapy to generate
precise external beam radiation therapy dose distributions
that deliver tumoricidal doses to the tumor while sparing
normal organs at risk. This important RT system is only
available in NHA and NSIA-LUTH. UDUTH has a PRECISE
TPS, but it is not functional. UCH has a TPS for brachytherapy
(HDR). Four (50%) of the RT centers (UNTH, FTH, UBTH,
and ABUTH) have no TPS. Thus, it is possible less accurate
dose calculations could compromise treatment delivery
(Table 5).
3D Conformal RT Capacity
Of the eight RT centers, only two centers, NHA and NSIA-
LUTH, can provide 3D conformal RT services. Only NSIA-
LUTH has the capacity to provide advanced techniques such
as volumetric-modulated arc therapy and intensity-
modulated RT (IMRT). Thus, six (75%) of the RT centers
do not have the capacity to deliver modern RT treatments.

4 | © 2023 by American Society of Clinical Oncology

 JCO Global Oncology

TABLE 2. Technologies in Use in the Radiotherapy Centers

Technology Information UNTH, Enugu FTH, Gombe UBTH, Benin NHA, Abuja ABUTH, Zaria NSIA-LUTH, Lagos UDUTH, Sokoto UCH, Ibadan
a. Type of radiotherapy machine
LINAC 1 0 1 2 0 2 1 0
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Cobalt-60 0 0 0 0 1 0 0 1
LINAC 1 cobalt-60 1 (cobalt-60, 1 (cobalt-60,
nonfunctional/ nonfunctional/
obsolete since obsolete)
2017)
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Functionality Yes 0 0 Yes 0 Yes 0 0

b. Treatment techniques available
1 0 1
3D CRT 0 0 1 N/F 1 0 1 0 0
2D conventional 1 NF 0 1 NF 1 NF 0 0 1 1 NF
Hand marking 1 0 0 0 0 0 1 0

Status of Public Radiotherapy in Nigeria

IMRT 0 0 0 0 0 1 0 0
VMAT 0 0 0 0 0 1 0 0
IGRT 0 0 0 0 0 0 0 0
NA 1
Functionality
c. Manufacturer and model of machine
Name of manufacturer Elekta 0 Elekta Elekta Cobalt Cirus Varian Elekta Bhabhatron
Panacea
Medical
Model Elekta Precise 0 Elekta Precise Elekta Synergy 1. Vitalbeam 3638 Elekta Precise Bhabhatron II
2. Halcyon 1040
Year acquired 2007 0 2010 2019 2000 Vitalbeam 4150, 2019,201 2008 2011
9, 2020
d. Available photon beam energies, MV
1.25 No. 1 NF 1 NF
4 1 1
6 1 1 NF 1 1 1
10 1 1 1
15 1 NF 1 1 1
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25 1 1
NA 1
e. Electron energies, MeV
4 1 1
(continued on following page)
 TABLE 2. Technologies in Use in the Radiotherapy Centers (continued)
6 | © 2023 by American Society of Clinical Oncology

Technology Information UNTH, Enugu FTH, Gombe UBTH, Benin NHA, Abuja ABUTH, Zaria NSIA-LUTH, Lagos UDUTH, Sokoto UCH, Ibadan
6 1 1 1 1
9 1 1
10 1 1
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12 1 1 1
15 1 16 1
18
20
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25 1
1
Functionality NF 0 0 Yes 0 Yes NF 0

Abbreviations: 0, not available; 2D, two-dimensional; 3D, three-dimensional; ABUTH, Ahmadu Bello University Teaching Hospital; CRT, conformal external beam radiation therapy; FTH, Federal
Teaching Hospital; IGRT, image-guided radiotherapy; IMRT, intensity-modulated radiotherapy; LINAC, linear accelerator; NA, not applicable; NF, not functional; NHA, National Hospital Abuja;
NSIA-LUTH, Nigeria Sovereign Investment Authority-Lagos University Teaching Hospital; UBTH, University of Benin Teaching Hospital; UCH, University College Hospital; UDUTH, Usman Danfodio
University Teaching Hospital; UNTH, University of Nigeria Teaching Hospital; VMAT, volumetric-modulated arc therapy.

Aruah et al
 JCO Global Oncology
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TABLE 3. Brachytherapy Machines Available in the Radiotherapy Centers

Machine Information UNTH, Enugu FTH, Gombe UBTH, Benin NHA, Abuja ABUTH, Zaria NSIA-LUTH, Lagos UDUTH, Sokoto UCH, Ibadan

Status of Public Radiotherapy in Nigeria

HDR Yes Yes Yes Yes Yes No Yes Yes
Name of manufacturer Eckert & Ziegler Bebig Varian Eckert & Ziegler Bebig Eckert & Ziegler Bebig Eckert & Ziegler Bebig Eckert & Ziegler Bebig Eckert & Ziegler Bebig Eckert & Ziegler Bebig
Year of acquisition 2018 2010 2018 2018 2018 2018 2018 2018
Functionality NF F F NF NF NF NF F
LDR 0 0 0 Amra Ceasium Cis-Bio 0 0 Bhabhatron-II
Name of manufacturer Panacea Medical Technologies Ltd India
Year of acquisition 1999 1998 2013
Functionality NF NF NF

Abbreviations: ABUTH, Ahmadu Bello University Teaching Hospital; FTH, Federal Teaching Hospital; HDR, high dose rate; LDR, low dose rate; NF, not functional; NHA, National Hospital Abuja; NSIA-
LUTH, Nigeria Sovereign Investment Authority-Lagos University Teaching Hospital; UBTH, University of Benin Teaching Hospital; UCH, University College Hospital; UDUTH, Usman Danfodio University
Teaching Hospital; UNTH, University of Nigeria Teaching Hospital.
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TABLE 4. Simulation Equipment Available in the Radiotherapy Centers
Simulation Type UNTH, Enugu FTH, Gombe UBTH, Benin
CT simulator 1 NF 0 1 NF
Conventional simulator 0 1 1 NF
Hand marking 1 0 0 0
Abbreviations: ABUTH, Ahmadu Bello University Teaching Hospital; CT, computed tomography; FTH, Federal Teaching Hospital; NF, not functional;
NHA, National Hospital Abuja; NSIA-LUTH, Nigeria Sovereign Investment Authority-Lagos University Teaching Hospital; UBTH, University of Benin
Teaching Hospital; UCH, University College Hospital; UDUTH, Usman Danfodio University Teaching Hospital; UNTH, University of Nigeria Teaching
Hospital.
Copyright © 2024 American Society of Clinical Oncology. See https://ascopubs.org/go/authors/open-access for reuse terms.
Availability of Record and Verify Systems
Record and verify (R&V) systems were developed to reduce
the risk of treatment errors in radiation oncology. These
have evolved into complete RT information management
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systems integrating treatment planning computers and
treatment delivery systems. Only two centers, NHA and
NSIA-LUTH, have R&V systems. NHA uses the Mosaiq
system while NSIA-LUTH uses ARIA oncology information
system. Six (75%) of the RT centers (UNTH, UDUTH, UCH,
FTH, UBTH, and ABUTH) do not have R&V systems. Hence,
they are more likely to experience errors in their treatment of
patients with cancer.
Diagnostic Imaging Resources
Availability of radiological imaging support
Radiological imaging is critical in making cancer diagnoses,
for treatment planning, and for follow-up to assess the
results of curative and palliative RT. All the centers sur-
veyed have functional ultrasound, x-ray, and fluoroscopy
machines. All except UNTH have functional CT scanners.
MRI is available only in NHA, FTH, NSIA-LUTH, and
UDUTH. There is no MRI in UNTH, ABUTH, nor UCH. Our
results show that most of the radiology imaging machines
in the RT centers are not linked by digital communication in
medicine (Table 6).
Availability of radionuclide scans
Only NHA and UCH have single photon emission tomography
(SPECT) machines although the current imaging of choice is
with positron emission tomography (PET)-CT scanners
because of their molecular characterization of cancer. None
of the Government-funded RT centers have a PET-CT
scanner, hence making diagnoses and follow-up of treat-
ment challenging in those RT centers (Table 6).
Number of Patients Treated With RT and Their Cancer
Types in the Past 2 Years
As of 2021, only two centers, NHA and NSIA-LUTH, have
been consistently treating patients with cancer with
teletherapy machines. FTH has only a functional HDR
8 | © 2023 by American Society of Clinical Oncology
Aruah et al
NHA, Abuja ABUTH, Zaria NSIA-LUTH, Lagos UDUTH, Sokoto UCH, Ibadan
1 Available but not installed 1 1 NF 0
0 0 0 0 0
0 0 0 1
brachytherapy machine for the treatment of gynecological
malignancies such as cervical, vaginal, and endometrial
cancers. In both NHA and NSIA-LUTH, the most common
cancer treated by teletherapy was breast cancer. Because
of frequent downtime and treatment delays, UNTH Enugu
has been inconsistent in treating patients. According to
the hospital-based cancer registries at five (63%) of the
RT centers (UBTH, UCH, ABUTH, UDUTH, and FTH), they
have not treated patients with cancer with RT in most of
2021 (Table 7).
Estimated Cost of Radiotherapy Treatment in
the Government-Funded RT Centers
Only FTH, NHA, and NSIA-LUTH reported cost estimates for
both curative and palliative treatments. FTH Gombe pre-
sented costs for only gynecological treatments. NSIA-LUTH
is a public-private partnership (PPP) RT center with higher
cost of treatment compared with NHA which is completely
funded by the Government and whose services are provided
at subsidized rates. There is no price uniformity for tele-
therapy services hence making affordability a huge challenge
for much of the population. There were no available records
from UNTH although it is being operated as PPP. Four (50%)
of the RT centers (UBTH, ABUTH, UDUTH, and UCH) have no
records on the cost of RT services as these centers have not
been treating patients.
DISCUSSION
Across all the Government-funded RT centers in Nigeria,
there is an overall picture of poor workforce strength relative
to the number of patients with cancer being managed at the
various centers. This has resulted in high clinical workload,
treatment delays, and long waiting times to start treatment.
Our results show that Nigeria lacks well-structured training
programs for the essential oncology workforce for RT de-
livery such as those for medical physicists, RTTs, and bio-
medical engineers. Some RT centers lack radiation oncology
residency training programs necessitating their sending
trainees to other RT centers. Our results suggest that there is
an urgent need for RT workforce training and continuing
education which would be of great benefit to patients. This is
in line with a previous study which identified that expert
knowledge has an impact on quality of patient care at all
 JCO Global Oncology
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TABLE 5. TPSs Available in the Radiotherapy Centers

Treatment Planning System (TPS) UNTH, Enugu FTH, Gombe UBTH, Benin NHA, Abuja ABUTH, Zaria NSIA-LUTH, Lagos UDUTH, Sokoto UCH, Ibadan

Status of Public Radiotherapy in Nigeria

Monaco 1
Eclipse 1
Orbit
Pinnacle
Brainlab’s iPlan
XiO
NA 1 1 1 (available but not yet installed) Precise HDR plus TPS (for brachytherapy)

Abbreviations: ABUTH, Ahmadu Bello University Teaching Hospital; FTH, Federal Teaching Hospital; HDR, high-dose rate; NA, not applicable; NHA, National Hospital Abuja; NSIA-LUTH, Nigeria
Sovereign Investment Authority-Lagos University Teaching Hospital; TPS, treatment planning system; UBTH, University of Benin Teaching Hospital; UCH, University College Hospital; UDUTH, Usman
Danfodio University Teaching Hospital; UNTH, University of Nigeria Teaching Hospital.
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 Aruah et al

TABLE 6. Radiological Imaging Available to the Radiotherapy Centers

Radiological
Imaging System UNTH, Enugu FTH, Gombe UBTH, Benin NHA, Abuja ABUTH, Zaria NSIA-LUTH, Lagos UDUTH, Sokoto UCH, Ibadan
Ultrasound Yes Yes Yes Yes Yes Yes Yes Yes
X-ray machines Yes Yes Yes Yes Yes Yes Yes Yes
CT scan Yes (not functional) Yes Yes Yes Yes Yes Yes Yes
MRI No Yes No Yes No Yes Yes (not functional) No
Fluoroscopy Yes Yes Yes Yes Yes Yes Yes Yes
SPECT 0 0 0 1 0 0 0 1
PET-CT 0 0 0 0 0 0 0 0
NA 1 1 1 1 1
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NOTE. Percentage for no. of dosimetrist. No. of centers without dos 5 6. N 5 8. 6/8 3 100/1 5 75.
Abbreviations: ABUTH, Ahmadu Bello University Teaching Hospital; CT, computed tomography; FTH, Federal Teaching Hospital; MRI, magnetic
resonance imaging; NA, not applicable; NHA, National Hospital Abuja; NSIA-LUTH, Nigeria Sovereign Investment Authority-Lagos University
Teaching Hospital; PET, positron emission tomography; SPECT, single-photon emission tomography; UBTH, University of Benin Teaching Hospital;
UCH, University College Hospital; UDUTH, Usman Danfodio University Teaching Hospital; UNTH, University of Nigeria Teaching Hospital.
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levels.15 A radiation oncology center should have at least a
teletherapy machine, a radiation oncologist, a medical
physicist, and two RTTs per 250,000 people.8,16 Our results
showed that there is no Government-funded RT center in
Nigeria that has all the recommended workforce needed for
RT services based on that International Atomic Energy
Agency recommendation. Clearly, in Nigeria, there is
shortage of necessary workforce for effective RT service
delivery.
Our reported findings depict an abysmal state of access to RT
services in Nigeria. As of 2021, only two Government-funded
RT centers, NHA and NSIA-LUTH, were delivering tele-
therapy services using LINACs. Most of the Government-
funded RT centers in Nigeria do not have a service contract or
maintenance engineers to repair LINACs. Thus, when a
LINAC breaks down, there is a long waiting time for
maintenance which, in turn, leads to treatment delay. Our
results agree with reports from other investigators.6,17-19 Our
findings also showed that Nigeria has a total of nine
Government-funded teletherapy machines, seven LINACs,
and two cobalt-60 machines. However, maintaining func-
tionality of these RT machines is a huge challenge. NHA and
NSIA-LUTH have LINACs with multienergy photons and
electrons, 3D conformal RT capability, modern CT simula-
tors, TPSs, and R&V systems for optimal RT service delivery.
Although NHA and NSIA-LUTH are the most modern
Government-funded RT centers in Nigeria, the other 75% of
the Government-funded RT centers do not have the capacity
or capability to deliver RT with modern techniques. Our
findings are consistent with previous studies.6,20 Although
we found that there were no working cobalt-60 as of 2021, a
study found that all cobalt-60s were in clinical use in 2020
and that all four cobalt-60 machines in Nigeria are
Government-funded.21 Our finding further confirms the
frequent breakdown of RT machines in Nigeria. On the other
hand, we argue that only two cobalt-60 machines are
Government-funded in Nigeria.
RT involves potential risks because even a small error in
treatment planning (dosimetry) or treatment can lead to
significant negative consequences. These potential risks are
magnified in the use of modern radiation therapy techniques
such as IMRT, image-guided RT, and stereotactic radio-
surgery that represent an entirely new paradigm that also
requires extensive knowledge and understanding of the
latest imaging systems, set up uncertainties, radiobiological
response of healthy tissues, 3D dose calculations, optimi-
zation of variable intensity beam delivery, and internal organ
motion.22 More than 75% of the RT centers in our survey
lacked all the necessary equipment to deliver treatment with
complex advanced RT techniques. Our findings are sup-
ported by other studies.16,18
Our survey showed that Nigerian patients with cancer have
limited access to radionuclide scans. Only two centers offer
SPECT services, but they rely on importation of the radio-
pharmaceuticals from overseas. There is no PET-CT scanner
in the Government-funded RT centers. This lack of avail-
ability of modern imaging for the diagnosis of cancer and for
RT treatment planning adversely affects treatment out-
comes, including survival, has been reported by several
researchers.23,24 As of the time of writing this report, MeCure
Healthcare, a private center, started operating a PET/CT
scanner in Lagos, Nigeria (September 2021). However, major
barriers to its use are the cost of the procedure and a lack of
awareness by the public of its importance.
Our survey highlights the total number and the most
common types of patients with cancer treated with tele-
therapy machines in the past 2 years in the Government-
funded RT centers in Nigeria. Our results show that breast
cancer is the most common cancer treated in the functional
RT centers. Our results are in congruity with GLOBOCAN and
other studies whose findings showed that breast cancer is
among the five most common cancers seen in Nigerian
cancer centers.4

10 | © 2023 by American Society of Clinical Oncology

 JCO Global Oncology
Copyright © 2024 American Society of Clinical Oncology. See https://ascopubs.org/go/authors/open-access for reuse terms.

TABLE 7. Number and Types of Patients With Cancer Treated With RT in the Past 2 Years

Cancer Type UNTH, Enugu FTH, Gombe UBTH, Benin NHA, Abuja ABUTH, Zaria NSIA-LUTH, Lagos UDUTH, Sokoto UCH, Ibadan
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Cancer type No available data No available data

Head and neck Not available M 5 120 No available data M 5 35 No available data No available data
F 5 54 F 5 25
Total 5 174 Total 5 60
Gynecological oncology for Brachy M50 M50 M50
F 5 202 F 5 211 F 5 135
Total 5 202 Total 5 211 Total 5 135

Status of Public Radiotherapy in Nigeria

GI malignancies Not available M 5 24 M 5 34
F 5 16 F 5 20
Total 5 30 Total 5 54
Sarcomas M 5 10 M 5 26
F59 F59
Total 5 19 Total 5 35
Blood cancers M58 M 5 10
F56 F53
Total 5 14 Total 5 13
Breast cancer M55 M50
F 5 229 F 5 150
Total 5 234 Total 5 150
Prostate M 5 68
F50
Keloid
Lungs

NOTE. Only FTH Gombe, NHA, and NSIA-LUTH have available data on RT treatment for the past 2 years.
Abbreviations: ABUTH, Ahmadu Bello University Teaching Hospital; F, female; FTH, Federal Teaching Hospital; M, male; NHA, National Hospital Abuja; NSIA-LUTH, Nigeria Sovereign Investment
Authority-Lagos University Teaching Hospital; RT, radiotherapy; UBTH, University of Benin Teaching Hospital; UCH, University College Hospital; UDUTH, Usman Danfodio University Teaching
Hospital; UNTH, University of Nigeria Teaching Hospital.
ascopubs.org/journal/go | 11
 Aruah et al

Our study confirmed nonuniformity in the cost of RT services
in Nigeria. For instance, in NHA the cost of RT ranges from
$760 in US dollars (USD) for palliative treatment to $1,304
(USD) for radical treatment. While in NSIA-LUTH, which is PPP
RT center, the cost of RT ranges from $1,300 (USD) for pal-
liative treatment to $2,200 (USD) for radical treatment. That
such a price variation exists between Government-funded and
PPP RT centers was supported by a previous study that found
that the average cost of a 20-fraction course of external beam
RT (EBRT) using PPP RT equipment was $1,810 (USD), which
represents a 335% increase when compared with EBRT in
Government-funded RT facilities where the average cost is
$416 (USD).21 Our findings were further strengthened by re-
Copyright © 2024 American Society of Clinical Oncology. See https://ascopubs.org/go/authors/open-access for reuse terms.
RT centers. In addition, some of the data are likely to change
on the basis of RT workforce migration and installation of
new HDR brachytherapy centers that were not captured in
our report. Poor record keeping by hospital-based cancer
registries has influenced the accuracy of patient numbers.
The use of only quantitative research methodology is also a
limitation. An exploratory qualitative data set can match the
quantitative data with robust meaning to the challenges and
generate sustainable solutions. Hence, future studies should
consider using mixed-method research approach.
In conclusion, Nigerian RT services are in crisis mode as noted
in this study. However, there is great potential to improve

ports from other studies.25 The high cost of RT treatment has
been a major challenge for patients in accessing RT
treatment when the treatment machines are operational,
a status often jeopardized by frequent breakdown of RT
machines. 22 To improve access to RT, we recommend that
Downloaded from ascopubs.org by 182.2.166.209 on April 2, 2024 from 182.002.166.209
these services in this country of 206 million people. Therefore,
there is a need to scale up the number of medical LINACs,
improve workforce capacity through training and education
programs, and strengthen basic infrastructure in all the
Government-funded RT centers using national resources,

the cost of RT services be subsidized in Government-
funded and PPP RT centers, and there is a need for a
new model where availability and affordability needs can
be met while maintaining high standard of care.
Part of the limitations of this study was noninclusion of
private RT centers. We are seeking funds to survey the private
donors, nongovernmental organizations’ support, PPP,21 and
other private investment. RT is a critical component of a
comprehensive national cancer control plan and health in-
vestment. We hope that our findings will stimulate increased
budget allocations in the future for health care in general and
especially for RT centers to bring the best RT services possible
to patients with cancer in Nigeria.

AFFILIATIONS 20
Centre for Energy Research and Training, Ahmadu Bello University,
1 Zaria, Nigeria
Radiation Oncology Department, National Hospital Abuja, Abuja, 21
Nigeria Atomic Energy Commission (NAEC), Abuja, Nigeria
Nigeria 22
2 Radiology Department, University of Abuja Teaching Hospital (UATH),
College of Medicine, University of Abuja, Gwagwalada, Abuja, Nigeria
3 Gwagwalada, Abuja, Nigeria
Project PINK BLUE—Health & Psychological Trust Centre, Abuja, 23
University of Abuja Teaching Hosiptal (UATH), Gwagwalada, Abuja,
Nigeria
4 Nigeria
Department of Sociology & Gerontology, Miami University, Oxford, OH 24
5 International Cancer Expert Corps (ICEC) Inc, Washington, DC
Scripps Gerontology Center, Miami University, Oxford, OH 25
6 University of Oxford, Oxford, United Kingdom
Department of Psychology, University of Nigeria Nsukka, Enugu, 26
European Centre for Nuclear Research (CERN), Geneva, Switzerland
Nigeria
7
Radiation and Clinical Oncology Department, National Hospital Abuja,
Abuja, Nigeria CORRESPONDING AUTHOR
8
Neurosurgery Department, National Hospital Abuja, Abuja, Nigeria Runcie C.W. Chidebe, BSc, MSc, Project PINK BLUE—Health &
9
Department of Radiology, National Hospital Abuja, Abuja, Nigeria Psychological Trust Centre, 11 Moses Majekodunmi Crescent, Utako,
10
Medical Physics Department, National Hospital Abuja, Abuja, Nigeria Abuja 900001, Nigeria; e-mail: runcie.chidebe@projectpinkblue.org.
11
Radiotherapy Department, Asi Ukpo Comprehensive Cancer Center,
Calabar, Nigeria AUTHOR CONTRIBUTIONS
12
Radiation Oncology Department, Ahmadu Bello University Teaching
Conception and design: Simeon C. Aruah
Hospital (ABUTH), Zaria, Nigeria
13 Provision of study materials or patients: Simeon C. Aruah, David
Radiology Department, Gombe State University, Gombe, Nigeria
14 Pistenmaa, Dosanjh Manjit
Department of Radiotherapy and Oncology, Federal Teaching Hospital
Collection and assembly of data: Simeon C. Aruah, Runcie C.W. Chidebe,
Gombe, Gombe, Nigeria
15 Tochukwu C. Orjiakor, Fatima Uba, Uchechukwu N. Shagaya, Charles
Radiation Oncology Department, Nigeria Sovereign Investment
Ugwanyi, Aisha A. Umar, Taofeeq Ige, Obinna C. Asogwa, Oiza T.
Authority-Lagos University Teaching Hospital (NSIA-LUTH), Lagos,
Ahmadu, Musa Ali-Gombe, Alabi Adewumi, Vitalis C. Okwor, Jimoh A.
Nigeria
16 Mutiu, Basheer Bello, Lucy O. Eriba, Yusuf A. Ahmed, Awwal Bisalla,
Radiation Oncology Department, University of Nigeria Teaching
Ukamaka Itanyi, Ramatallah A. Balogun, Suleiman Alabi
Hospital (UNTH), Ituku Ozalla, Enugu, Nigeria
17 Data analysis and interpretation: Simeon C. Aruah, Runcie C.W. Chidebe,
University of Ibadan/University College Hospital Ibadan, Ibadan,
Tochukwu C. Orjiakor, David Pistenmaa, C. Norman Coleman, Dosanjh
Nigeria
18 Manjit
Radiation Oncology Department, Usman Danfodio University
Manuscript writing: All authors
Teaching Hospital (UDUTH), Sokoto, Nigeria
19 Final approval of manuscript: All authors
Radiation Oncology Department, University of Benin Teaching
Accountable for all aspects of the work: All authors
Hospital (UBTH), Edo State, Nigeria

12 | © 2023 by American Society of Clinical Oncology

 Status of Public Radiotherapy in Nigeria

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS Consulting or Advisory Role: Novartis

OF INTEREST Research Funding: Roche Product Limited (Nigeria) (Inst)
Travel, Accommodations, Expenses: Novartis, Janssen
The following represents disclosure information provided by authors of
Uchechukwu N. Shagaya
this manuscript. All relationships are considered compensated unless
Honoraria: AstraZeneca, Janssen Oncology
otherwise noted. Relationships are self-held unless noted. I 5
Speakers’ Bureau: Roche
Immediate Family Member, Inst 5 My Institution. Relationships may
Travel, Accommodations, Expenses: AstraZeneca
not relate to the subject matter of this manuscript. For more information
about ASCO’s conflict of interest policy, please refer to www.asco.org/ C. Norman Coleman
rwc or ascopubs.org/go/authors/author-center. This author is a member of the JCO Global Oncology Editorial Board. Journal
policy recused the author from having any role in the peer review of this
Open Payments is a public database containing information reported by
manuscript.
companies about payments made to US-licensed physicians (Open
Consulting or Advisory Role: International Cancer Expert Corps, Inc
Payments).
No other potential conflicts of interest were reported.
Runcie C.W. Chidebe
Copyright © 2024 American Society of Clinical Oncology. See https://ascopubs.org/go/authors/open-access for reuse terms.

Honoraria: Janssen, Novartis (Inst)

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