Journal of Cancer Policy 39 (2024) 100459 Challenges in building radiotherapy capacity: A longitudinal study evaluating eight years of the Brazilian radiotherapy expansion plan Andre G. Gouveia a, b, 1 , Gustavo A. Viani b, c, 1 , Vanessa F. Bratti d , Gustavo N. Marta b, e , Samir A. Hanna e , Alexandre A. Jacinto f , Mauricio S. Silva b, g , Ana C. Hamamura c , Arthur A. Rosa b, h , Marcus S. Castilho i, j , Laura Carson k, l , Wilma M. Hopman m , Richard Sullivan n , Christopher M. Booth k, o , Ajay Aggarwal l, p, q , Timothy P. Hanna k, o, r , Fabio Y. Moraes b, k, o, * a Department of Oncology, Division of Radiation Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, ON, Canada b Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil c Ribeir˜ ao Preto Medical School, Department of medical imagings, hematology and oncology of University of S˜ ao Paulo (FMRP-USP), Ribeir˜ ao Preto, Brazil d Department of Public Health Sciences, Queen’s University, Kingston, ON, Canada e Department of Oncology, Division of Radiation Oncology, Sírio Libanes Hospital, S˜ ao Paulo, Brazil f Radiation Oncology Department, Barretos Cancer Hospital, Barretos, SP, Brazil g Radiation Oncology Unit, Santa Maria Federal University, Santa Maria; and Clínica de Radioterapia de Santa Maria, Brazil h Radiotherapy Department Oncoclinicas Salvador and Hospital Santa Izabel, Salvador, BA, Brazil i Radiotherapy Department of the Felicio Rocho Hospital, Belo Horizonte, MG, Brazil j President, Brazilian Radiotherapy Society - SBRT, Brazil k Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen’s University, Kingston, ON, Canada l Department of Oncology, Queen’s University, Kingston, ON, Canada m Kingston General Health Research Institute; Department of Public Health Sciences, Queen’s University, Kingston, ON, Canada n Institute of Cancer Policy, Global Oncology Group, King’s College London, London, UK o Department of Oncology, Kingston General Hospital, Queen’s University, Kingston, ON, Canada p Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK q Department of Clinical Oncology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK r Department of Medicine, Kingston General Hospital, Queen’s University, Kingston, ON, Canada A R T I C L E INFO Keywords: Radiotherapy access Public health Brazil ABSTRACT Background: In 2012, the Brazilian government launched a radiotherapy (RT) expansion plan (PER-SUS) to install 100 linear accelerators. This study assesses the development of this program after eight years. Methods: Offcial reports from the Ministry of Health (MoH) were reviewed. RT centres projects status, time- frames, and cost data (all converted to US dollars) were extracted. The time analysis was divided into seven phases, and for cost evaluation, there were fve stages. The initial predicted project time (IPPT) and costs (estimated by the MoH) for each phase were compared between the 18 operational RT centres (able to treat patients) and 30 non-operational RT centres using t-tests, ANOVA, and the Mann-Whitney U. A p-value < 0.05 indicates statistical signifcance. Results: A signifcant delay was observed when comparing the IPPT with the overall time to conclude each 48 RT centres project (p < 0.001), with considerable delays in the frst fve phases (p < 0.001 for all). Moreover, the median time to conclude the frst 18 operational RT centres (77.4 months) was shorter compared with the 30 non-operational RT centres (94.0 months), p < 0.001. The total cost of 48 RT services was USD 82,84 millions (mi) with a signifcant difference in the per project median total cost between 18 operational RT centres, USD1,34 mi and 30 non-operational RT centres USD2,11 mi, p < 0.001. All phases had a higher cost when comparing 30 non-operational RT centres to 18 operational RT centres, p < 0.001. The median total cost for expanding existing RT centres was USD1,30 mi versus USD2,18 mi for new RT services, p < 0.0001. * Correspondence to: Kingston Health Sciences Centre 25 King Street West Kingston, K7L 5P9 ON. E-mail address: fymoraes@gmail.com (F.Y. Moraes). 1 AGG and GAV contributed equally as frst authors. Contents lists available at ScienceDirect Journal of Cancer Policy journal homepage: www.elsevier.com/locate/jcpo https://doi.org/10.1016/j.jcpo.2023.100459 Received 5 April 2023; Received in revised form 12 November 2023; Accepted 23 November 2023 !"#$%#&%’ ()%$)’ *+ ,("’-&’. */*0 **10230+045 */*0 6%7’"$’. 89:; !%% .$<=97 .’7’."’:;