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Setting Up a Cancer Centre:
A WHO–IAEA Framework
Edited by:
May Abdel-Wahab
Cherian Varghese
Cover photograph: ixpert/Shutterstock.com
SETTING UP A CANCER CENTRE:
A WHO–IAEA FRAMEWORK
The following States are Members of the International Atomic Energy Agency:
AFGHANISTAN GEORGIA OMAN

ALBANIA GERMANY PAKISTAN
ALGERIA GHANA PALAU
ANGOLA GREECE PANAMA
ANTIGUA AND BARBUDA GRENADA PAPUA NEW GUINEA
ARGENTINA GUATEMALA PARAGUAY
ARMENIA GUYANA PERU
AUSTRALIA HAITI PHILIPPINES
AUSTRIA HOLY SEE POLAND
AZERBAIJAN HONDURAS PORTUGAL
BAHAMAS HUNGARY QATAR
BAHRAIN ICELAND REPUBLIC OF MOLDOVA
BANGLADESH INDIA ROMANIA
BARBADOS INDONESIA RUSSIAN FEDERATION
BELARUS IRAN, ISLAMIC REPUBLIC OF RWANDA
BELGIUM IRAQ SAINT LUCIA
BELIZE IRELAND SAINT VINCENT AND
BENIN ISRAEL THE GRENADINES
BOLIVIA, PLURINATIONAL ITALY SAMOA
STATE OF JAMAICA SAN MARINO
BOSNIA AND HERZEGOVINA JAPAN SAUDI ARABIA
BOTSWANA JORDAN SENEGAL
BRAZIL KAZAKHSTAN SERBIA
BRUNEI DARUSSALAM KENYA SEYCHELLES
BULGARIA KOREA, REPUBLIC OF SIERRA LEONE
BURKINA FASO KUWAIT SINGAPORE
BURUNDI KYRGYZSTAN
SLOVAKIA
CAMBODIA LAO PEOPLE’S DEMOCRATIC
SLOVENIA
CAMEROON REPUBLIC
SOUTH AFRICA
CANADA LATVIA
SPAIN
CENTRAL AFRICAN LEBANON
SRI LANKA
REPUBLIC LESOTHO
SUDAN
CHAD LIBERIA
SWEDEN
CHILE LIBYA
CHINA LIECHTENSTEIN SWITZERLAND
COLOMBIA LITHUANIA SYRIAN ARAB REPUBLIC
COMOROS LUXEMBOURG TAJIKISTAN
CONGO MADAGASCAR THAILAND
COSTA RICA MALAWI TOGO
CÔTE D’IVOIRE MALAYSIA TRINIDAD AND TOBAGO
CROATIA MALI TUNISIA
CUBA MALTA TURKEY
CYPRUS MARSHALL ISLANDS TURKMENISTAN
CZECH REPUBLIC MAURITANIA UGANDA
DEMOCRATIC REPUBLIC MAURITIUS UKRAINE
OF THE CONGO MEXICO UNITED ARAB EMIRATES
DENMARK MONACO UNITED KINGDOM OF
DJIBOUTI MONGOLIA GREAT BRITAIN AND
DOMINICA MONTENEGRO NORTHERN IRELAND
DOMINICAN REPUBLIC MOROCCO UNITED REPUBLIC
ECUADOR MOZAMBIQUE OF TANZANIA
EGYPT MYANMAR UNITED STATES OF AMERICA
EL SALVADOR NAMIBIA URUGUAY
ERITREA NEPAL UZBEKISTAN
ESTONIA NETHERLANDS VANUATU
ESWATINI NEW ZEALAND VENEZUELA, BOLIVARIAN
ETHIOPIA NICARAGUA REPUBLIC OF
FIJI NIGER VIET NAM
FINLAND NIGERIA YEMEN
FRANCE NORTH MACEDONIA ZAMBIA
GABON NORWAY ZIMBABWE
The Agency’s Statute was approved on 23 October 1956 by the Conference on the Statute of the
IAEA held at United Nations Headquarters, New York; it entered into force on 29 July 1957.
The Headquarters of the Agency are situated in Vienna. Its principal objective is “to accelerate and enlarge
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SETTING UP A CANCER CENTRE:
A WHO–IAEA FRAMEWORK
JOINTLY PRODUCED BY THE
INTERNATIONAL ATOMIC ENERGY AGENCY
AND WORLD HEALTH ORGANIZATION

VIENNA, 2022
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STI/PUB/1989
IAEA Library Cataloguing in Publication Data

Names: International Atomic Energy Agency.
Title: Setting up a cancer centre : a WHO–IAEA framework / International Atomic
Energy Agency.
Description: Vienna : International Atomic Energy Agency, 2022. | Series: , ISSN ;
no. | Includes bibliographical references.
Identifiers: IAEAL 22-01477 | ISBN 978-92-0-100422-2 (paperback : alk. paper) |
ISBN 978-92-0-100122-1 (pdf) | ISBN 978-92-0-100222-8 (epub)
Subjects: LCSH: Cancer — Patients — Care. | Cancer — Prevention. | Cancer —
Treatment. | Cancer — Research.
Classification: UDC 616-006 | STI/PUB/1989
FOREWORD
Cancer is a leading cause of death worldwide, accounting for nearly

ten million deaths in 2020. The cancer burden is growing globally, exerting
tremendous physical, emotional and financial strain on individuals, families,
societies and health systems. Many of these systems in low and middle income
countries are being challenged in managing this burden, leading to large numbers
of cancer patients around the world without access to timely, high quality
diagnosis or the required treatment.
A proper diagnosis is a fundamental step for appropriate and effective
treatment because every type of cancer requires a specific treatment regimen.
Treatment usually includes radiotherapy, chemotherapy and/or surgery.
Determining the goals of treatment is an important step. The primary goal is
to cure cancer or to prolong life for a considerable period of time. Improving
the patient’s quality of life is also an important goal. This can be achieved by
supporting the patient’s physical, psychosocial and spiritual well-being and
providing palliative care during the terminal stages of cancer.
The basics of delivering cancer care involve empowering and engaging
communities; improving health literacy; enhancing diagnostic capacity, including
pathology and referral mechanisms; and arranging access to and coordinating
appropriate treatment. Cancer centres are a major resource in ensuring the
success of this comprehensive approach to dealing with cancer and can be
planned appropriately.
In 2018 the IAEA and the World Health Organization (WHO) decided to
issue a joint publication to guide the establishment of a cancer centre. The aim
was to help physicians, policy makers and programme managers develop cancer
treatment facilities in a phased manner. As many countries are developing or
expanding such facilities, the goal was to present the critical issues and factors to
be considered in planning and/or expanding cancer treatment services.
A group of experts from the IAEA and WHO and their Member States met
at an IAEA technical meeting in Vienna in February 2019. Follow-up meetings
were held in April, May and July 2019. A consultancy meeting of 25 experts
was organized in Vienna in November 2019, where the draft report was reviewed
and finalized. This guide is a supplement to a more comprehensive publication
and highlights the key elements of that version. It describes the features of
multidisciplinary cancer care and details the infrastructure, human resources
and equipment needed for different services, with the aim of helping national
programme managers and planners as they expand their cancer care capacity. This
framework is intended to be implemented in accordance with local conditions
and resources, thereby systematically improving the capacity for cancer care in a
particular country.
This publication was made possible by contributions and reviews from
a broad range of experts. The IAEA wishes to acknowledge in particular the
contributions of B. Mikkelsen and C. Varghese (project focal point) of WHO. The
technical officer responsible for this publication was M. Abdel-Wahab (IAEA).
EDITORIAL NOTE
Although great care has been taken to maintain the accuracy of information contained
in this publication, neither the IAEA nor its Member States assume any responsibility for
consequences which may arise from its use.
This publication does not address questions of responsibility, legal or otherwise, for acts
or omissions on the part of any person.
In this publication, ‘should’ statements are used to provide guidance based on expert
judgement. They do not stem from a consensus of IAEA and WHO Member States.
The use of particular designations of countries or territories does not imply any
judgement by the publisher, the IAEA, as to the legal status of such countries or territories, of
their authorities and institutions or of the delimitation of their boundaries.
The mention of names of specific companies or products (whether or not indicated as
registered) does not imply any intention to infringe proprietary rights, nor should it be construed
as an endorsement or recommendation on the part of the IAEA.
The IAEA has no responsibility for the persistence or accuracy of URLs for external or
third party Internet web sites referred to in this book and does not guarantee that any content
on such web sites is, or will remain, accurate or appropriate.
CONTENTS
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2. Objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.3. Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.4. Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2. ESTABLISHING A CANCER CENTRE . . . . . . . . . . . . . . . . . . . . 3
2.1. What is a cancer centre? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2.2. Framework for developing a cancer centre . . . . . . . . . . . . . . . 6
3. PATIENT CARE PATHWAYS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
3.1. Multidisciplinary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
4. INFRASTRUCTURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
4.1. Buildings and layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
5. DIAGNOSIS AND STAGING: FACILITY REQUIREMENTS . . 18
5.1. Laboratory medicine, pathology and blood bank . . . . . . . . . . 18

5.2. Medical imaging and nuclear medicine . . . . . . . . . . . . . . . . . . 20
5.3. Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
6. MULTIDISCIPLINARY AND MULTIMODALITY

TREATMENT: FACILITY REQUIREMENTS . . . . . . . . . . . . . . . 31
6.1. Cancer surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

6.2. Medical oncology and systemic therapy . . . . . . . . . . . . . . . . . 34
6.3. Paediatric oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
6.4. Radiation oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
6.5. Oncology nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
7. PALLIATIVE AND SUPPORTIVE CARE:
FACILITY REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
7.1. Palliative care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

7.2. Supportive and survivorship care . . . . . . . . . . . . . . . . . . . . . . 47
7.3. Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
7.4. Rehabilitation, physical and occupational therapies . . . . . . . . 51
7.5. Survivorship care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
8. PREVENTIVE ONCOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
8.1. Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
8.2. Human resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
8.3. Infrastructure and equipment . . . . . . . . . . . . . . . . . . . . . . . . . . 54
9. PAEDIATRIC CANCER SERVICES . . . . . . . . . . . . . . . . . . . . . . . 54
9.1. Early diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

9.2. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
10. INFORMATION SYSTEMS, MEDICAL RECORDS

AND REGISTRY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
10.1. Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
10.2. Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
10.3. Information technology and systems . . . . . . . . . . . . . . . . . . . . 56
10.4. Data protection and confidentiality . . . . . . . . . . . . . . . . . . . . . 58
10.5. Medical records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
10.6. Cancer registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
11. EDUCATION, TRAINING AND RESEARCH . . . . . . . . . . . . . . . 61
11.1. Training, ongoing education and accreditation . . . . . . . . . . . 61

11.2. Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
12. GOVERNANCE, ADMINISTRATION AND FINANCING . . . . 67
12.1. Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
12.2. Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
12.3. Financial management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
13. ADVOCACY, COMMUNITY ENGAGEMENT AND
PARTNERSHIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
13.1. Advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
13.2. Community engagement and partnerships . . . . . . . . . . . . . . . 70
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
ANNEX: CASE STUDY: A DISTRIBUTED CANCER

CARE MODEL FOR PATIENT ACCESS BY TATA
TRUSTS AND THE GOVERNMENT OF ASSAM,
INDIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
CONTRIBUTORS TO DRAFTING AND REVIEW . . . . . . . . . . . . . . . 101
EXECUTIVE SUMMARY
Cancer is a leading cause of death globally, and projections indicate that its
incidence rates will continue to increase over time. Late stage presentation and
inaccessible diagnosis and treatment are common. There is a substantial shortfall
around the world in the provision of cost effective cancer prevention, diagnostic
and treatment services. While there are interventions to address the burgeoning
cancer burden in low and middle income countries, they are not reaching the
people in need, leading to vast disparities in the availability of cancer services
between countries of different income levels around the world.
Cancer centres are facilities designed primarily for providing cancer care.
However, they are also essential for creating and implementing new evidence
through their engagement in research and education. In addition, they provide
guidance on all aspects of cancer within a country. While there is a wide variation
in access to cancer centres around the world, they are recognized as a critical
part of the health care system when developing a cancer control strategy. Cancer
centres include services relating to prevention, diagnosis, multidisciplinary
treatment, supportive care, research and education, and have core services
supporting these elements. The level at which these services are provided
depends on the local context and, as a result, are implemented step by step and
are constantly evolving to cope with the demands of the cancer burden.
1. INTRODUCTION
1.1. BACKGROUND
Cancer is an established public health priority and leading cause of death

globally. In 2020, there were more than 19 million new cases of cancer and
almost 10 million deaths from cancer worldwide [1]. Globally, approximately
one in six deaths is due to cancer [2].
The capacity to prevent and control the cancer burden varies significantly
between and within countries. In countries where health systems are not fully
developed and face resource constraints there is limited access to diagnosis and
treatment, resulting in late presentation. There are major deficits in the provision
of cancer services across the cancer continuum, from prevention to survivorship
care. In 2019, for example, only 26% of low income countries reported having
pathology services available in the public sector [3]. In contrast, more than
1
90% of high income countries reported that cancer treatment services were
available compared with fewer than 30% of low income countries [3].
The consequences of this inequity and insufficiency of capacity in
cancer care are avoidable deaths from cancer and a failure to achieve global
targets to reduce premature mortality and achieve universal health coverage, as
articulated in the WHO Global Action Plan for the Prevention and Control of
Noncommunicable Diseases 2013–2020 and in Target 3.4 of the UN Agenda
for Sustainable Development [4, 5]. The global cancer burden is predicted to
rise to between 29 and 37 million new cancer cases by 2040, with the greatest
increases in low and middle income countries [6]. The need to scale up capacity
is therefore immediate.
1.2. OBJECTIVE
The objective of this publication is to propose a framework to develop a

cancer centre and/or to strengthen the provision of services in an existing cancer
centre. This framework is expected to be used as a guide to implementation,
taking into consideration the local context and resources.
1.3. SCOPE
While not losing sight of necessary prioritization and planning of the

health care and cancer care sectors, this publication focuses on setting up a
cancer centre. Sections related to core cancer services specify human resources
and equipment in different domains. The levels of service are only a guide for
incremental improvement in capacity as the local context allows and are not to be
taken as predefined conclusions.
The purpose of this publication is to provide the context and requirements
for specific services in a cancer centre. It is not to define the level of cancer
care as a whole. Thus, it can be used as a tool to evaluate and improve the level
of services and build them up to a level required within an individual cancer
centre and also to support the planning of new cancer centres. An increase in
capacity in a cancer centre should be framed within a broader national context
of comprehensive cancer control planning and be cognizant of the potential
exacerbation of inequalities associated with higher cost, and with centralized
services being inaccessible to significant portions of the population.
2
1.4. STRUCTURE
This publication describes the essential elements of a cancer centre. After

the introduction and background information on cancer centres, an example of a
care pathway for a patient with cervical cancer is presented to demonstrate the
typical flow of the patient experience through a cancer centre. Sections on each
of the essential elements of a cancer centre are then presented, including:
— Establishing a cancer centre;

— Patient care pathways;
— Infrastructure;
— Diagnosis and staging: Facility requirements;
— Multidisciplinary and multimodality treatment: Facility requirements;
— Palliative and supportive care: Facility requirements;
— Additional disciplines: Preventive oncology and oncology nursing;
— Information systems, medical records and registry;
— Education, training and research;
— Governance, administration and financing;
— Advocacy, community engagement and partnerships.
2. ESTABLISHING A CANCER CENTRE
2.1. WHAT IS A CANCER CENTRE?
Cancer centres are an important element in the provision of services and

exertion of leadership in cancer care [7–9]. They are facilities for the control of
cancer, serve as a guiding institution for all aspects of cancer control and are
instrumental in operationalizing and achieving the goals of countries. Teaching,
guiding, capacity building, service model development and provision of technical
support for a government and its partners are some of the key responsibilities of
the cancer centre.
The term ‘cancer centre’ does not have an accepted definition. Nonetheless,
there are certain principles and functions that characterize these centres. At its
core, a cancer centre provides coordinated, multidisciplinary care that includes
all services generally available in a country, including for example, pathology,
radiotherapy, surgery and systemic therapy. It may thereby act as a ‘cancer centre’
even if other non‑oncology services are provided in the same facility. The term
3
‘accredited’ or ‘designated’ can be used, according to the mandate of a national
authority responsible for defining and assessing such requirements.
Additionally, cancer centres should have a broader scientific agenda. For
example, the United States National Cancer Institute defines cancer centres
as those that have a scientific agenda focused on three main areas: (1) basic
laboratory; (2) clinical; (3) prevention, cancer control and population based
science, or a combination of these areas [10].
The mainstays of cancer diagnosis are pathology, laboratory services and
medical imaging, for treatment includes cancer surgery, systemic therapy and
radiation therapy. One purpose of consolidating these three treatment modalities
within a single facility is to optimize seamless access to quality care. Equally
important is that cancer treatment requires multidisciplinary collaboration to
optimize treatment planning (therapy choices and sequencing). In addition,
concentrating care leads to higher volumes that support development of focused
expertise. Multiple studies have shown that centres with a higher surgical volume
have superior outcomes, with lower complication rates and higher 30 day
post‑operative survival. Cancer centres provide a venue for optimizing a patient
centric approach to cancer management and are part of the wider health care
system. They may be freestanding or part of larger organizations, such as a health
science faculty or school, hospital or group of hospitals that share infrastructure
and services. Basic cancer screening and diagnostic services should also be
available in the community, allowing timely access for patients suspected of
having cancer. Thoughtful organization of the wider health care system in
balancing centralized services with decentralized ones is vital in optimizing
cancer outcomes, especially in settings with limited resources (see Fig. 1).
As specialized facilities, cancer centres require considerable investment
to secure the appropriate facilities, human resources and equipment [11]. In
Cancer centre
Dedicated cancer care as part of

multidisciplinary hospital
Cancer care network–distributed

capabilities
Country context, resources available,
health system organization
FIG. 1. Wider health care system approaches for expanding cancer care capacity.
4
low resource settings, in particular, care is needed to ensure that a cancer
centre can promote equitable access and universal health coverage. It should
not be seen as diverting resources away from lower levels of the health care
system but rather as a resource for the entire community. The critical mass of
specialized professionals, facilities and equipment in cancer centres should act
as a catalyst for the development of similar resources and a high quality cancer
system comprising regional or satellite centres. It will support training health
professionals and leaders at all levels of the health system. Indeed, these benefits
can have a ripple effect on the other health sectors [12].
2.1.1. Benefits of a cancer centre
The benefits of cancer centres go far beyond clinical care. They contribute
to strengthening health systems by targeting cross‑cutting system‑related issues.
They should serve as hubs for the training of the health professionals and as
flagships for the implementation of a national strategy of quality care. Finally,
they should contribute to global cancer care by engaging in relevant research and
leveraging existing networks.
2.1.2. Role of a cancer centre in a cancer control programme
Cancer control programmes are public health programmes that aim to

reduce the number of cancer cases and deaths and improve the quality of life of
cancer patients globally. These programmes are driven by the National Cancer
Control Plan, a roadmap for implementing systematic, equitable and evidence
based strategies for prevention, early detection, diagnosis, treatment and
palliation [13].
Cancer centres are an integral part of a cancer control programme,
providing services and assistance in connecting the different components of the
National Cancer Control Plan. Collaboration at the national and international
levels is important in advancing cancer control, and cancer centres should help
lead the coordination of effective partnerships in cancer control.
Scaling up effective diagnostic and therapeutic services, including medical,
surgical, radiotherapy and palliative care, by establishing cancer centres could
bring substantial health, economic and societal benefits, and help close the global
equity divide in access to cancer care services. Just US $1.00 invested in cancer
care leads to a direct productivity return of $2.30 and a full return based on both
direct productivity and societal gains of $9.50 [14].
Although a cancer centre may operate as an independent institution, it is
very much part of the cancer control plan and architecture. The cancer centre
acts as the link between various components of cancer control, and helps to
5
interconnect all levels of care, other disease programmes, overall health systems
and services. Investments in cancer centres as part of a national strategy thus
capture synergies and opportunities to enhance care delivery.
2.2. FRAMEWORK FOR DEVELOPING A CANCER CENTRE
This guide describes the components of a cancer centre based on service

delivery and coordination among services and specialties. A country that has not
yet established a national cancer centre should strive to gradually expand services
using a phased implementation strategy. The details of how these services can be
implemented will vary depending on the specific cancers being treated and on
the existing resources that are already available in the country. Implementation
programming may differ among countries and require individualized planning,
the details of which go beyond the scope of this guide. An illustration of the
clinical processes along the cancer care continuum is shown in Fig. 2 [15].
Cancer centres are expected to cover the elements presented along the continuum
at different levels.
These services must be organized to deliver care that:
— Is evidence based;
— Is patient centred and multidisciplinary;
— Is well organized and coordinated;
— Ensures the safety and quality of care;
— Has a clinical and translational research capability.
A patient centred approach is a crucial component of high quality health

care. Cancer services should be respectful of, and responsive to, the preferences,
needs and values of patients and their caregivers.
Multidisciplinary care requires a highly trained team of medical, nursing
and allied health professionals who consider all relevant treatment options and
cooperative recommendations on individualized treatment and care policy for
every patient. The recommended treatment plans or interventions need to be
considered by the care team in consultation with patients and caregivers.
A successful multidisciplinary cancer service delivery model requires open
communication among team members. Transitions among providers and levels of
cancer care are sensitive, and flexible agreements should ensure the best interests
of patients. Education and training of providers in communication, teamwork
and processes of care are advised to improve capacity and outcomes. ‘Patient
navigators’ and ‘nursing case managers’ can help patients through the care
pathway and improve coordination and effectiveness [14].
6
GOVERNANCE, ADMINISTRATION, AND FINANCING
INFRASTRUCTURE BUILDINGS AND LAYOUT SUPPORT SERVICES
SERVICE COORDINATION AND CARE PLANNING
FOLLOW-UP/
DIAGNOSIS TREATMENT SURVIVORSHIP
PREVENTION CARE END OF CARE
SCREENING PALLIATIVE CARE
Systemic
TERTIARY (SH)
therapy
Nuclear
Nuclear medicine
medicine
Radio-
therapy
Medical Medical
imaging imaging
SECONDARY (DH)
& TERTIARY (SH)
Endoscopy Endoscopy
Surgery
Pathology Pathology
Clinical Clinical
laboratory laboratory
SECONDARY (DH)
PRIMARY (CL,HC),
& TERTIARY (SH)
Palliative care
Clinical Clinical
Vaccination
assessment assessment
FIG. 2. Component functions of the cancer care continuum show how clinical units are
interrelated and interdependent (partially adapted from Ref. [15]).
Both prevention and screening activities will benefit from an effective

educational programme to raise awareness of cancer risk factors, symptoms and
treatment options. This is particularly relevant for childhood cancer, where the
majority of cancers cannot be prevented. Early detection campaigns and training
of the health workforce in warning signs and symptoms contributes to timely
referrals, which has a positive impact on treatment outcomes [16, 17].
Clinical and translational research have critical roles in advancing cancer
care and improving outcomes. Clinical trials are the accepted scientific approach
for addressing clinical questions and establishing standards and evidence based
guidelines to secure effective and safe treatment interventions.
7
Governance, administration and financing
Services coordination and care planning
Diagnosis and treatment Prevention, supervisorship and palliative care
Medical imaging
Laboratory medicine, Palliative care and supportive Survivorship
and nuclear
Infrastructure pathology and blood banking care care
medicine
buildings and
Surgical Medical Occupational
Radiation oncology Nutrition Rehabilitation
layout support oncology oncology therapy
services
Medical records, information system and registry
Education, training and research
Advocacy, community engagement and partnership
FIG. 3. Schematic representation of the elements of a cancer centre.
In addition to the elements just described, there are many other elements
of a cancer centre. Figure 3 presents the schematic representation of these
different elements, such as medical records, the information system and registry,
education, training, research, advocacy, community engagement and partnership.
3. PATIENT CARE PATHWAYS
A care pathway is defined as “a complex intervention for the mutual

decision‑making and organisation of care processes for a well-defined group of
patients during a well-defined period” [18]. It differs from a clinical pathway (or
patient flow) [19] in that it also covers interventions preceding patient admission
to a clinic and following discharge, including activities in outpatient units and
other health care facilities.
The definition of care pathways is underpinned by the evidence and best
practice in key elements of care, as well as documentation, monitoring and
evaluation of variances and outcomes. The rationale for creating care pathways is
based on the standardization of clinical processes, which reduces variations in the
delivery of care, optimizes the use of available resources, and helps keep costs
to a minimum [20]. Connecting all activities along a care pathway facilitates
understanding of their sequencing, and of the roles and responsibilities of
different members of a multidisciplinary care team. Having a full picture can be
8
Treatment Survivorship care
Early detection Diagnosis and staging
Palliative care
Multidisciplinary team:
Cervical • Clinical decision to treat Follow up,
cancer
Long term survival

examination rehabilitation
suspected at Assessment • Speculum and
screening for the pelvic
probability Clinical,
examination radiological, Stage-appropriate
of cancer: • Colposcopy (if treatment (single
suspicious pathological
available) staging modality in combination):
lesions • Biopsy: - Surgery Relapse
and/or histological - Radiotherapy
persistent confirmation - Systemic therapy
symptoms of cancer
Presentation
to a health
facility with
Symptom management,
symptoms
physical, psychosocial End of life care
and spiritual support
FIG. 4. Early diagnosis and screening pathways using an example of cervical cancer care [22].
The sequencing of activities is organized along the continuum of cancer.
useful in minimizing diagnostic and treatment delays by scheduling some of the

activities at earlier times or in parallel [18, 21]. The main goal of care pathways is
to enhance the quality of care by improving coordination, reducing fragmentation
of services, enhancing patient safety and satisfaction, and optimizing the
use of resources.
Pathways related to two distinct cancer early detection strategies —
screening [16, 22] and presentation with symptoms — are presented in Fig. 4 [22].
Both pathways must be easily accessible for achieving two major goals of early
detection: prevention of pre‑cancerous cervical lesions developing into invasive
cancer; and identification of invasive cancers at early points of progression,
when treatment is more likely to achieve cure, is more feasible, better tolerated
and less expensive [23]. Once invasive cancer is detected, further sequencing of
diagnostic and treatment procedures is the same regardless of the access pathway.
Access to a pathology service is essential at this stage, as a definitive diagnosis
of cancer must be based on histopathological confirmation. Clinical, radiological
and pathological findings are evaluated to determine the extent of cancer spread
or the stage of cancer. Diagnosis and the stage, together with the patient’s
characteristics (age, co‑morbidities, etc.), will guide the choice of appropriate
treatment and the assessment of prognosis.
Evidence based clinical practice guidelines must be developed and
adopted in each cancer centre. Cancer pathways should be developed based on
national/regional normative guidance.
9
3.1. MULTIDISCIPLINARY CARE
Cancer services should be oriented towards a patient centric model of

care with multidisciplinary collaboration between pathology, radiology, surgery,
and medical and radiation oncology to determine the optimal multidisciplinary,
stage specific treatment plan for a given patient and cancer presentation. Many
cancers are treated with curative intent and require more than a single treatment
modality. For this reason, physical co‑location of cancer treatment services to
permit interdisciplinary collaboration is essential. In the case of childhood
cancer, the health systems should be prepared to respond to the special needs
of children through coordinated services, including the provision of family
centred multidisciplinary care [12]. Standardization of care based on evidence
based practice guidelines is a fundamental oncology management principle that
should be applied regardless of which professional is the first point of contact
within the centre.
An optimal approach to cancer planning is the ‘multidisciplinary clinic’
in which patients with newly diagnosed cancer are seen by surgical, medical
and radiation oncology specialists. When multidisciplinary collaboration is not
facilitated by co‑location of services, multidisciplinary team (MDT) meetings are
used to coordinate care. The MDT reviews the clinical, histological and staging
findings and makes consensus recommendations on and optimal treatment and
care plan for an individual patient. An MDT is composed of healthcare providers
specialized in different areas of cancer care. A core oncology MDT may comprise
surgeons, radiation oncologists, medical oncologists, pathologists, radiologists,
oncology nurses, and either a palliative care specialist or an oncologist with
palliative care training [24]. Other professionals, such as pharmacists, social
workers and nutrition specialists, among others, are usually included. MDTs are
critical in ensuring quality in cancer care and improving patient outcomes [25, 26].
Symptom control/palliative care must be included in the cancer care
considerations of all cancer patients; it is an approach that improves the quality
of patients’ life and their families through the prevention and relief of suffering
by assessing and treating distressing symptoms and other problems: physical,
psychological, social and spiritual. Early integration of palliative care into
treatment has been demonstrated to be beneficial for cancer patients [27].
Similarly, survivorship care is a core element of care provision at any cancer
centre. It focuses on health and the physical, psychological, social and economic
issues affecting cancer patients [28]. Survivorship care plans must be developed
and implemented, including clear guidance on post‑treatment care pathways.
10
4. INFRASTRUCTURE
A well-developed and functioning infrastructure is essential for delivering

the responsibilities of a cancer centre. A cancer centre’s infrastructure should
enable efficiency of movement, integration across levels and departments,
optimal use of resources and machinery, reduced waiting times, decreased length
of stay, cost efficiency improvements and improved patient and staff safety and
satisfaction. Infrastructure development should be incremental and coordinated
across different services. Provision for expansion should be made at the outset,
based on a set of defined interventions. Infrastructure must be maintained and be
responsive to the changing needs of the patient population and the requirements
should have metrics to evaluate its effectiveness that should be followed.
A cancer centre’s location and any evaluation of its infrastructure and
equipment must be based on a detailed analysis and ongoing evaluation of the
following attributes:
— Existing population;
— Cancer case numbers and established disease estimates and projections;
— Existing and planned healthcare infrastructure and growth estimates;
— Estimated number of patients expected to visit the hospital across various
departments: Out‑patient visits, in‑patient admissions, chemotherapy/day
care visits, radiation therapy visits, surgical cases, imaging and laboratory
visits;
— Operational assumptions to manage the estimated patient load;
— Bed capacity, equipment and human resource requirements;
— Phased construction of the comprehensive cancer centre and operation of
facilities.
Infrastructure planning should also take into account the following

specific situations:
— Setting up a stand‑alone cancer centre;

— Expanding an existing facility to include one or more components of cancer
care;
— Sequencing the setting up of various cancer care components in a location
in a phased manner;
— Creating an integrated care network where the organization is planning
multiple centres with similar or distinctive capabilities that rely on each
other operationally, such as:
● A network of hospitals across a region or country;
11
Referral hospitals which act as hubs, with smaller centres as spokes;
●
Centres catering to specific needs such as paediatric, ambulatory,
●
palliative care, diagnosis, screening and research.
— Including contingencies for future expansion, disaster preparedness, etc.
Additionally, when establishing or scaling up diagnostic imaging, nuclear

medicine and radiotherapy services, it is essential that appropriate legal,
regulatory frameworks and related national regulatory infrastructures are in place
for the safe and secure delivery of these services for diagnosis and treatment.
These must be in line with relevant international safety standards and nuclear
security guidance. The IAEA has issued several requirements and guidance
publications related to the legal and regulatory framework [29–31]. The radiation
protection of people and the safety of radiation sources need to be ensured in
line with the requirements of an IAEA publication on occupational radiation
protection [32]. This includes requirements related to the justification and
optimization of radiation protection of patients and prevention and management
of unintended and accidental medical exposure, as well as the guidelines provided
in an IAEA publication on radiation protection and safety in medical uses of
ionizing radiation [33].
The infrastructure required for specific needs is discussed, where
appropriate, throughout the following sections. The parameters listed in Table 1
can help in identifying the appropriate configuration of the cancer centre and
also in determining the specifications for contracting engineering services for
electrical, mechanical, plumbing, water, medical gases and drainage system needs.
TABLE 1. ESTIMATING INFRASTRUCTURE REQUIREMENTS
Scope of facility/ Key elements to

Evaluation criteria
service/network configure scope
Location, size Statistics Population, cancer burden, estimates and projections,

and phasing procedure caseloads, operational assumptions of
of facility beds, equipment and manpower, travel time analysis,
other existing and upcoming infrastructure, growth
estimates
Location, size Other key inputs Number and type of hospitals, specialties, beds,
and phasing from surveys dedicated allocations to oncology, geographies being
of facility served, patient footfall, equipment, diagnostics, lab
work and histopathology centres, details of treatment
modalities
12
TABLE 1. ESTIMATING INFRASTRUCTURE REQUIREMENTS (cont.)

Evaluation criteria
Clinical Clinical Demographic mix (%), radiotherapy, chemotherapy,

drivers assumptions systemic therapy, number of cycles/sessions,
surgeries, average length of stay, conversion to
diagnostics, repeat out-patient department (OPD)
ratios, etc., late stage patients and/or concomitant risk
factors such as chronic obstructive pulmonary
disease, heart failure and coronary diseases,
metabolic disorders
Clinical Key clinical Weighted average % radiotherapy, chemotherapy,

drivers outputs systemic therapy, number of cycles/sessions per
patient, average length of stay, conversion ratios, etc.
Centre Capacity Inputs around average duration of treatments, etc.,

configurations utilization and capacity utilization limits for key equipment,
limits beds, etc.
Centre Detailed
Configurations based on utilizations
configurations configuration
Centre Existing Inputs on extent of current infrastructure available

configurations infrastructure/ which can be used. Incremental configuration to be
upgrade plans built
Network Network and Inputs for defining a centre in each location or town
design referral Key assumptions for distributed care (cycles in
principles centre 1 versus centre 2,
% radiation in every centre,
% brachy in every centre, % patients to repeat
diagnostics, dropout rates, etc.)
Distributing care based on patient geographical
location; define consortia and sustained partnerships
for referral and financial compensation when human
and physical resources are scarce; integrating skilled
facilities with cancer centres, for referral in remote
areas
Network Demographics Population, affluence metrics

design and patient Inflow, outflow from state
flows Distribution into districts
Share of patients likely to be covered
13
TABLE 1. ESTIMATING INFRASTRUCTURE REQUIREMENTS (cont.)

Evaluation criteria
Network Key network Total cancer patients, OPD, radiotherapy,

design volume outputs chemotherapy, systemic therapy, diagnostic volumes
and bed nights.
4.1. BUILDINGS AND LAYOUT
As mentioned earlier in this guide, a framework for a cancer centre involves

a spectrum of activities. Therefore, the clinical programme for cancer centres must
make provision for the following clinical departments in its design and should be
physically designed to optimize patient flow with a patient centric model of care:
— Urgent care and emergency care with easy access and connectivity to
diagnostic areas, operating theatres (OTs) and in‑patient facilities.
— Out‑patient consultation area, which includes consultation chambers,
support departments for counselling, nutrition and physiotherapy that can
be planned as per the disease management groups. The out‑patient facility
and diagnostic services experience maximum footfall and hence are ideally
located closest to the main entrance. In centres where the out‑patient services
are mainly designed for adults, some areas should accommodate children’s
needs (e.g. imaging) [34].
— Critical and acute care services, including intensive care units for both
medical and surgical care.
— Diagnostic modalities should be located so they are accessible to the
emergency room (ER) and out‑patient as well as in‑patient facilities:
● Radiology modalities. Magnetic resonance imaging (MRI),
computed tomography (CT), ultrasonography, X ray, fluoroscopy and
mammography.
● Nuclear medicine. Positron emission tomography/computed
tomography (PET–CT), single photon emission computed tomography/
computed tomography.
● Endoscopy areas.
● Laboratory facilities, which include haematology, blood bank,
biochemistry, cytopathology, surgical pathology, molecular pathology,
microbiology, molecular biology and immunohistochemistry.
14
●Non‑invasive cardiology.
— Treatment modalities:
● Systemic therapy (chemotherapy, immunotherapy, targeted therapy).
Provided through in‑patient care or day care facility delivery, where
patients walk in pre‑scheduled for a few hours every day, or continuous
infusion as per their plan over several days.
● Bone marrow transplantation unit.
● Radiation therapy. A day care facility that must adhere to specific
regulatory requirements with the necessary complement of support
areas.
● Nuclear medicine. Radiopharmaceutical therapy, which also needs to
comply with regulatory guidelines.
● Interventional radiology.
● Surgical oncology. OTs, admission and recovery areas, anaesthesiology.
— Pharmacy facilities:
● Out‑patient dispensary. This would be best placed close to the
out‑patient consultation area for the convenience of patients.
● In‑patient pharmacy services, if required.
● Parenteral therapy (chemotherapy, immunotherapy, targeted therapy,
parenteral nutrition, fluids) preparation facilities. These would be best
placed close to the day care administration area for convenience and
ease of transportation.
— Nursing, palliative, supportive care and rehabilitation:
● Nursing services.
● Palliative care.
● Psychosocial care.
● Nutritional services.
● Survivorship care.
● Supportive care.
● Rehabilitation.
Based on estimated footfall, the hospital must plan adequate waiting areas,
washroom facilities, elevators and staircases, billing and registration counters.
The calculation of loads on support services, such as a central sterile services
department (CSSD), medical gases, kitchen, dining, water, housekeeping, sewage
treatment plants, laundry and access to a Wi‑Fi network are made based on the
number and area of all clinical departments.
Depending upon individual preference, available space, size of hospital
and future plans, these departments are arranged and planned in a manner that
optimizes patient, staff and material flow. The various components of a cancer
centre are shown in Fig. 5, with one suggested layout presented of various
15
Comprehensive Cancer Centre
Support areas Diagnostic areas

Out-patient Admin areas
Critical areas In-patient areas
Patient beds
Palliative care Patient beds
STAFF/DIRTY/CLEAN ELEVATORS
Admin/cancer Change, SICU/HDU
Research OT complex
PATIENT ELEVATORS
registry/MRD pre-/post-op critical unit
Waiting Interventional
Kitchen Dining CSSD Lab
area radiology/endoscopy
PUBLIC ELEVATORS
EXIT STAIRS
Lobby/
Chemotherapy Rehabilitation Dialysis Blood bank
OP pharmacy
OPD clinics/phlebotomy/ X ray/USG/

Main entrance Registration/billing/coffee shop
counselling mammo/CT/MRI
Nuclear medicine, Brachy Simulator/

Emergency Waiting areas minor OT dosimetry/ Radiation Radiation
PET–CT and gamma
planning
IT, mortuary, laundry, stores, parking, biomedical waste management, HVAC, medical gas pipeline system, electricity and power backup, water
supply, treatment and RO, security and CCTV, fire safety, building management systems, clinical engineering
Note: Satellite services, e.g. pharmacy and surgical services, can be used to support patient
centric care.
Pharmacy aseptic unit/preparation facilities (close to the systemic anticancer
treatment (SACT) administration area).
FIG. 5. Representative stacking of various services and departments at a comprehensive

cancer centre.
departments along with other essential hospital services such as academic areas,
IT, mortuary, stores, laundry, food services, engineering services, such as heating,
ventilation and air conditioning, power backup, drainage system, biomedical
waste management system, supply of medical gases, parking, risk management
— security, fire safety, infection control and radiation safety, etc., in order to
enhance efficiency.
Furthermore, cancer centres should explore key technological
enhancements, such as a pneumatic chute system to transport samples, supplies
and medicines, thereby conserving human resources, central monitoring stations
and building management systems that suits their requirements. However, the
chute system should not be used to transport hazardous medicines. A proper flow
between departments is essential; Fig. 6 shows the optimal circulation pattern in
a cancer centre, integrating specialties in the environment to effectively deliver
multidisciplinary and comprehensive cancer care [35].
16
• Patient centric zoning
• Controlled zone access
• Out-patient areas easily accessible with
monitored movement
• Transition between out-patient and
Main clinical activities more efficient
Drop off lobby
• Compactly arranged public space
reduces travel distances
• Ideal circulation area: 15%
• Ideal public spaces: 20%
Patient movement Patient and visitor elevator core
FIG. 6. Circulation pattern in a comprehensive cancer centre.
4.1.1. General planning considerations
All designs must have a state of the art, comfortable, well‑lit scheme, with
departmental zoning facilitated by clear zones of movement for patient, staff,
materials and use of intuitive signage to facilitate the following:
— A good patient experience. Focusing on ensuring dignity, privacy,

convenience, optimizing treatment compliance and better outcomes.
— Infection control. Clear segregation of dirty and clean material movement
to ensure highest standards of hygiene and adherence to standards,
specifically in areas such as OTs, ICUs and immunocompromised wards.
Proper isolation facilities should be provided, including laminar flow rooms
and positive/negative pressure rooms for severely immunosuppressed
patients, and central sterile services department. Biomedical waste must
be segregated, collected and disposed of in compliance with regulatory
requirements and national standards.
— Movement. Segregated entry, passages and exits for emergencies, regular
patients, staff supplies and waste, as well as compliance with standards for
necessary space for accessibility, corridor widths, distances, sizes of unit
and access controls.
— Building safety. Adherence to all national building norms as well as all
other regulatory requirements for radiation, area specification, etc. Cancer
centres include complex medical equipment, and it is essential that they are
in compliance with national fire safety norms and hold up to date licences
and certificates.
17
— Hospital standards. These must comply with applicable national standards
and requirements of the relevant atomic energy authorities.
— Efficient and green hospital design.
— Scalability. Modular, flexible and adaptable designs are needed.
— Standardization. Should have the same look, feel and touch schemes across
platforms and programs within the cancer centre, and potentially across
cancer centres, within the overarching cancer network.
— Engineering and support services. Comprehensive and scalable engineering
support services for efficient, automated management of heating, ventilation
and air conditioning (HVAC), medical gas pipeline system, water treatment,
specific drainage norms, IT and communications, storage spaces, etc., in
compliance with national and international hospital norms. HVAC systems
are a key requirement of the manufacturers of specialized equipment such as
linear accelerators (linacs), PET–CT, MRI and other radiology equipment
as well as surgical suites and the laboratory facilities.
Pharmacy aseptic facilities will require an air handling unit with appropriate
specifications (refer to Section 5.3.4) to ensure aseptic conditions for parenteral
therapy (chemotherapy, immunotherapy, targeted therapy, parenteral nutrition,
fluids). Uninterrupted electricity supply and temperature maintenance in defined
ranges for the equipment are important considerations.
5. DIAGNOSIS AND STAGING:

FACILITY REQUIREMENTS
5.1. LABORATORY MEDICINE, PATHOLOGY AND BLOOD BANK
5.1.1. Rationale
The evolving management of cancer patients aims to develop a tailored

treatment plan for each patient. The diagnostic part of this process involves
up to date laboratory and imaging work. The clinical laboratory is therefore
an essential department in any cancer care centre. The role of pathology and
laboratory medicine (PALM) services includes:
— Diagnosis by examination of patient samples, such as blood, urine, bodily

fluids and tissue.
18
— Assessment of the cancer and the general health status of the patient by
examination of blood, urine and other bodily fluid specimens.
— Monitoring of the progression and treatment response of the patient’s cancer
by checking various laboratory parameters.
— Blood banking is an important part of pathology and laboratory medicine.
The cancer patients receiving cytotoxic therapies are at risk of developing
different types of cytopenia. They may require whole blood or blood
component transfusion.
5.1.2. Key features
The key features of pathological and laboratory services include human

resources, physical infrastructure and equipment, laboratory information systems
with a monitoring and evaluation framework, quality assurance (QA) and
management processes. Specific attention must be paid to documentation at all
phases: pre‑analytical, analytical and post‑analytical; and timely communication
of findings, especially critical results. Access to a blood bank (either internally or
externally) is required, including storage and administration of blood components.
It is important to comply with all regulatory requirements, in particular those
related to mandatory reporting and adherence to confidentiality regulations.
WHO provides guidance on establishing a pathology laboratory in the
context of cancer control [36] and selection on essential in vitro diagnostics
including for cancer [37].
5.1.3. Human resources
A PALM department requires specialized accredited physicians including

a pathologist, cytologist and microbiologist. It also requires biomedical
laboratory technologists, clerical and other support staff, biomedical engineers,
IT specialists, phlebotomists, etc.
5.1.4. Infrastructure and equipment
The department should be organized and arranged according to the

laboratory’s workflow, allowing maximum efficiency. Care should be taken
to establish and maintain a strict, quality controlled environment, such as
the humidity level, room temperature, an uninterrupted power supply, etc.
Adequate equipment and technologies should be selected according to services
provided [15, 36]. Inventory management and supply chain availability are key
features for uninterrupted and timely laboratory services. This section organizes
laboratory services into different levels. They are indicative and are not based
19
on a strict definition. There are three levels that describe the facilities needed.
These levels refer specifically to laboratory services, and not the level of the
cancer centre as a whole. The first level represents the most basic laboratory
services. Upgrading to the second and third levels depends on the complexity and
extent of the care practised in the organization. In all centres, even in the most
sophisticated centres in highly rated institutions, the first level is the foundation
and the second and third levels must be fully functional and highly automated to
accommodate the high workload. Moreover, there are no clear‑cut lines between
levels within departments (see Table 2).
5.1.5. Quality assurance
Reliable and reproducible results from PALM services can only be

achieved through implemented QA programmes. All tests performed are
closely monitored and quality controlled. Standardized, structured reporting
using available templates developed by international or national bodies is
recommended. Accreditation of PALM services by a national accreditation
body is recommended. Though not every cancer centre has the capacity for the
secondary review of cancer diagnosis, some national accreditation standards
suggest that every patient should have two pathologists (one primary, one
secondary reviewer) examine their specimen for QA prior to initiating treatment
in order to confirm a cancer diagnosis [36, 38].
5.2. MEDICAL IMAGING AND NUCLEAR MEDICINE
5.2.1. Rationale
Medical imaging and nuclear medicine are essential services in the

establishment or improvement of any cancer centre. A Lancet Oncology
Commission co‑authored by the IAEA shows that scaling up access to nuclear
medicine and medical imaging services would avert nearly 2.5 million cancer
deaths worldwide by 2030 and yield global lifetime productivity gains of
US $1.41 trillion — a net return of over $200 per $1 invested [39, 40].
Specifically, medical imaging and nuclear medicine are essential for achieving
the best outcomes for patients with cancer, as cancer imaging spans the health
care pathway — from early diagnosis, staging (location and potential spread of
the disease) and therapeutic planning, assessment of therapeutic response, image
guidance for interventions, evaluation of complications or co‑morbidities, and
planning/image guidance of palliation.
20
TABLE 2. LIST OF EQUIPMENT FOR ESTABLISHING A CLINICAL
LABORATORY
Device category Instruments
Infrastructure Specimen refrigerator and freezer, reagent refrigerator and freezer

for all levels Deionized water source
Clean hoods, dirty hoods
Thermometers
Centrifuges
Water baths
Heating blocks, heating stages
pH meter
Racks, flasks, tubes, heaters, slides, slide covers
Microscopes: upright, phase contrast, stereo, inverted, etc.
Incubators, atmospheric air and 5% CO2 incubators
Monitor and alarm systems
Backup electric generator
Computers, laboratory information system, and electronic medical
record
Laboratory by service level
Level 1 Complete blood count analyser with auto differential 5 diff or 3

Biopsy collection Chemistry analyser
and management Coagulation analyser
of local patient Automated immunoassay analyser
treatment (up Urine analysis
to 250 000) Microscope with phase contrast
Spectrophotometer
Electrophoresis
Manual nucleic acid extraction tools and polymerase chain
reaction (PCR)
Level 2 Histology services

Complete cancer Flow cytometer
diagnostics suite Automated immunohistochemistry system
(up to 1 million Automated PCR purification
patients) Fluorescent microscope
Digital pathology slide scanner
Fluorescence in situ hybridization slide cycler
PCR microtube DNA cycler
21
LABORATORY (cont.)
Level 3 DNA extraction and liquid handling

Cancer referral/ PCR and real time quantitative PCR
reference testing Genetic analyser and sequencing reactions
(more than Image analysis system with software for chromosome pathology
1 million patients) and haematopathology
Confocal microscope
Image analysis and tracking software
Research support devices:
● Binding studiesa
● X ray crystallography structurea
● Super resolution microscopea
● Single molecule localization biplane nanoscopea
Equipment required by departments
Haematology Complete blood count with differential counts (level 2)

laboratory unit Bone marrow and cerebrospinal fluid aspirate (level 2)
Cytochemistry (level 2)
Bone marrow biopsy:
Blood cell counter with auto diff (level 1)
Image analysis system with software for:chromosome pathology
and haematopathology (level 3)
Flow cytometry system for immunophenotyping, providing state
of the art single cell analysis technology (level 2)
Automated immunohistochemistry system (level 2)
Clinical Spectrophotometry (level 1)

chemistry unit Electrophoresis equipment (level 1)
Immunoassay (level 1)
Histopathology Cytopathology (level 2)

unit Chromosome pathology (level 2)
Surgical pathology (level 2)
Immunohistochemistry (level 2)
Histology (level 2)
Tissue procurement facility (level 2)
Fixing, staining equipment and microtome (level 2)a
Super resolution microscope (level 3)a
Single molecule localization biplane nasoscope (level 3)a
Confocal microscope (level 3)a
Image analysis and tracking software (level 3)
22
LABORATORY (cont.)
Molecular Manual DNA extraction (level 1)

biology core PCR processes, PCR product cleanup and liquid handling tasks
facility (levels 1 and 2)
Electrophoresis equipment (levels 1 and 2)
Genetic analyser and sequencing reactions (level 3):
● Next generation sequencing analyser
Core for Protein expression and purification (level 3) and protein

biomolecular characterizationa
structure and Binding studiesa
function X ray crystallography structurea
Blood bank IT and registry system of donors

facility Area and supplies for blood donation
Temperature controlled storage and barcoding system
Equipment for blood component separation and storage
a
Devices required for research purposes.
Imaging includes therapeutic interventions, together with image guided

procedures such as radiofrequency tumour ablation, vertebroplasty and image
guided nerve blocks. Moreover, molecular imaging has emerged rapidly, with
diagnostic and therapeutic applications of nuclear medicine becoming more
common in oncology. The IAEA’s Medical Imaging and Nuclear Medicine
Global Resources Database (IMAGINE) maps imaging resources currently
available as estimated per country and territory.1
5.2.2. Key features
The cancer centre should be equipped with the appropriate number and types
of imaging instruments that best serve the population. And while the complexity
and sophistication of the imaging equipment selected will depend upon available
1
The IAEA provides consultations and training fellowships for Member States, on
request and in compliance with country policies (note that the sophistication of such training
programmes varies according to the complexity of the planned cancer centre and the expected
patient case mix).
23
resources, mapping the local epidemiological cancer landscape will help calculate
the estimated number of patients the cancer centre should expect.
The imaging department should develop specific processes for handling
referrals, providing timely appointments, and providing patient instruction and
nursing care, if needed. It should have a rigorous process for managing images,
standards for reporting and turnaround time, communication back to referring
physicians, etc. The process needs to secure storage of images, appropriate
radiation protection and MRI safety procedures [7].
Running an imaging department requires the advance hiring of adequate

numbers of skilled personnel, including medical doctors specializing in radiology
and nuclear medicine. As telemedicine services become increasingly common,
expansion of telemedicine, especially teleradiology services, may provide
multidisciplinary support for centres [41].
The basic skilled human resources required for a medical imaging
department include a general radiologist, radiographer and a medical physicist
qualified in diagnostic radiology. The general radiologist should be capable
of interpreting ordinary radiographs (X rays), ultrasound and CT. In facilities
providing care for infants and small children, personnel should be available
to provide sedation and anaesthesia services. Expanded medical imaging and
nuclear medicine services require similar personnel, particularly radiologists
specializing in areas such as breast imaging, chest and abdominopelvic,
neurological, musculoskeletal and basic interventional radiology.
More sophisticated imaging and nuclear medicine services would also
have an interventional radiologist and a spectrum of image guided interventions;
a nuclear medicine physician or radiologist specializing in hybrid imaging; and
a physician with special qualifications in therapy with non‑sealed radioactive
probes. They should be capable of performing advanced applications in CT, MRI
and ultrasound, advanced interventional radiology and hybrid imaging such as
PET–CT and perhaps PET–MRI, as appropriate. Additional specialists will be
needed according to the cancer imaging provided, such as a clinical engineer,
radiopharmacist and radiochemistry specialist(s) if molecular imaging research
programmes are implemented.
5.2.4. Equipment
Medical imaging and nuclear medicine will require a variety of equipment.

It is expected that with the expansion of services there will be an incremental
increase in equipment, human resources and related support services. The
24
full range of equipment for medical imaging and nuclear medicine function
is listed below:
— Plain radiography (X ray) units are the baseline equipment. They are cost
effective, have a relatively small footprint and do not require complex
planning. X ray units can handle different applications such as skeletal,
chest and abdominopelvic imaging, and are easily operated.
— Fluoroscopy uses plain X rays to acquire real time images, much like a
‘video‑clip’. It is a key modality for many image guided procedures.
Interventional radiologists use fluoroscopy frequently, and fluoroscopy
units are central to interventional radiology areas.
— Mammography’s are key to screening programmes for early detection
of non‑palpable breast lesions, and for guiding stereotactic biopsies of
suspicious lesions. Mammography units have a small footprint and do not
require complex construction.
— Ultrasound, sonography or echography use sound waves rather than
ionizing radiation to produce an image. A wide range of instruments and
transducers is available — from basic to complex. Ultrasound has proven
clinical value for the detection of breast, thyroid, kidney, pancreatic, uterine,
ovarian, adrenal, gall bladder, spleen and liver cancers, as well as those
in other locations and organs. While it has a small footprint and simple
infrastructure, ultrasound requires skilled physicians and technologists or
sonographers. Wherever breast imaging is implemented, ultrasound is a
requisite modality.
— CT is essential for cancer detection as well as for staging, monitoring of
treatment response, guiding therapy and biopsies, and detecting recurrence.
Also, the sophistication of multidetector CT can range from a single detector
to 640 detector rows, with single or dual X ray tubes. For the majority of
oncological applications, a lower cost unit with at least 16 detector rows
will be enough to cover some imaging indications for the brain/head and
neck, chest, abdomen, pelvis, extremities, and bone and soft tissue tumours.
However, to increase image resolution and lesion detectability (and to
enable multipurpose use of the CT scanner, as for imaging pulmonary
thromboembolic complications or pathological fractures), more detector
rows, for example, 64 are warranted. The number of CT units will depend
on the size of the cancer centre, its complexity, and the number of patients
(including out-patients) to be covered. One multidetector CT scanner can
perform at least 1500–2000 examinations per month if operating hours are
extended. CT has a larger footprint than X ray, mammography or ultrasound
machines.
25
— MRI is more sophisticated and is superior for brain, cerebral metastasis
detection, local detection, staging of bone, soft tissue cancers, colorectal
cancer local staging and liver metastasis detection. It serves a complementary
role in breast cancer detection, is becoming important in prostate cancer,
and for gynaecological tumours. MRI requires a larger footprint and more
complex infrastructure, and therefore carries a higher cost. A 1.5 T machine
is the minimum advised magnetic field strength. One single state of the art
MRI can perform about 800–1200 examinations a month.
— Angiography is the visualization of vessels or lumina, often following
injection of contrast. Today, conventional angiography (often through
fluoroscopy) is used mostly for guiding therapy, such as embolization
or chemoembolization, catheter placement, and special interventional
radiology procedures such as cryoablation and radiofrequency ablation
of tumours. Angiography can guide surgery and hybrid therapies. Most
diagnostic angiography applications are now addressed by the vascular
imaging capacity of ultrasound, CT and MRI.
— Nuclear medicine and molecular imaging are used for diagnosis and staging
as well as for therapeutic purposes. ‘Theranostic’ modalities require the
administration of radiopharmaceuticals inside the bodies of patients to
generate images and are considered for specified indications. For example,
patients with thyroid cancer and, more recently, neuroendocrine tumours or
metastatic prostate cancer may benefit from these therapies. The technique
uses radiation and requires complex infrastructure. The footprint is larger
compared with X rays, ultrasound, mammography and even compared
with CT and MRI, since these modalities require specialist personnel,
special areas for radioactive waste disposal, a hot lab, a radiopharmacist to
manipulate radioactive material, an injected patient’s room and other special
spaces.
Nuclear medicine and molecular imaging are of proven clinical value for
staging, therapy monitoring, recurrence detection, biopsy guidance or planning
interventions, though resource requirements and relative value must be taken
into account. The level of sophistication can range from a basic SPECT (single
photon emission computed tomography) camera to digital hybrid systems — a
decision that will depend on the level of complexity of the cancer centre, budget
and logistics. Hybrid PET–CT has become a frequent imaging method to stage
cancer and assess therapeutic response. It is important to secure timely access to
(18)F‑fluorodeoxyglucose, the most common radiotracer used in PET–CT.
A single PET–CT can perform up to 400 exams per month. Furthermore,
when the run‑time of the unit is extended, with standardized and optimized
acquisition protocols, up to 600 exams per month can be conducted. The IAEA
26
has published technical reports on establishing a comprehensive nuclear medicine
and PET–CT service. Using PET–CT as an example (as the majority of PET–CT
examinations relate to cancer), the IAEA publication Planning a Clinical PET
Centre [42] includes recommendations for space requirements and layout,
including the infrastructure needed for appropriate functioning of the centre [43].
The radiology information system, picture archiving and communications
system, and digital imaging and communications system format images, and
workstation areas where the imaging professionals view and interpret images
are described in an IAEA publication on Worldwide Implementation of Digital
Imaging in Radiology [44]. Anticipated digital imaging and communications
and picture archiving and communications system software and user licence
renewals/updates and related costs can potentially be negotiated up front, or at
least clarified as part of the initial procurement contract. Overlooking long term
hardware maintenance and software contracts can hinder the functioning of the
medical imaging unit. There are many such examples in low resource settings of
unexpected long term post‑procurement costs [15].
Quality management in medical imaging is essential to avoid unnecessary

and repeated exposure or suboptimal image quality as a result of a failure to
optimize systems. This includes selection of the appropriate technical exposure
parameters and scan protocols during imaging, as well as assurance that the
acquisition systems are functional, the correct image processing is performed, and
the viewing devices are optimized to facilitate reporting. As a result, significant
resources must be invested to ensure safe, quality and effective services. The
core imaging team must be engaged in QA activities. This includes timely and
accurate reporting. Double reading of a proportion of certain imaging studies
(e.g. some mammography studies) is a common QA procedure. Similarly, within
a facility containing sources of radiation and radiation emitting equipment,
medical physicists are usually responsible for radiation safety and the protection
of patients, staff and the general public who have access to the premises [45–47].
5.3. PHARMACY
5.3.1. Rationale
Cancer treatment involves the use of a wide variety of powerful and often
very expensive pharmaceuticals. The pharmacy service plays a critical role in
27
cancer treatment, including providing information and advice, and helping select
appropriate pharmaceutical therapies and monitor for drug to drug interactions.
The pharmacy service is responsible for safe, cost effective and appropriate
procurement, compounding, prescription verification, preparation and dispensing
of SACT, including cytotoxic chemotherapy, biological therapy, immunotherapy,
targeted therapy and associated supportive medicine. These tasks must be
completed in accordance with legislative requirements, adhering to professional
and national standards and local policy. Pharmacists who provide pharmaceutical
care to patients with cancer need to have the appropriate skills and competencies
to ensure the safe use of these medicines. The complexity of cancer patient care,
SACT cost, toxicity potential, medication errors, safe preparation, administration
and disposal of cytotoxic medicines highlight the fundamental function of
pharmacies in cancer centres, regardless of a country’s resource level.
5.3.2. Key features
Pharmacy resources and needs may vary, but key features for all cancer
pharmacy services include human resources, infrastructure, consistent access to
medicines, devices, equipment, educational resources for both staff and patients,
QA and management processes. In‑patient and out‑patient medicine management
needs must be addressed, as well as the needs of patients transitioning beyond
the cancer centre. It is mandatory to comply with all regulatory requirements,
including requirements for personal protective equipment, safe handling,
preparation and disposal of cytotoxic medicine waste.
Adequate human resources to deliver the service are important. The

cancer pharmacy workforce consists of a range of professionals, including
qualified pharmacists and support staff (technicians/technologists/assistants) for
both clinical and non‑clinical tasks (including aseptic and technical services).
Pharmacy staff form part of the multidisciplinary team, which includes cancer
specialists, nursing staff, allied health professionals and other support staff.
5.3.4. Equipment
Cancer pharmacy services cover several equally important areas:
— Clinical pharmacy focuses on patient care and medicine optimization, both

for in‑patients and out‑patients. This involves working with the health care
team to develop the patient’s initial care plan, monitoring the patient’s
28
compliance and therapeutic response to their medicines (e.g. side effects and
allergies), and providing ongoing consultation and advice to prescribers on
adjustments to the medication regime. Cancer pharmacists are an important
part of the patient care team and contribute highly specialized knowledge
about the medicines used for cancer. Pharmacists advise on best practices,
appropriate dosages, the formulation of cancer drugs, routes of administration
and delivery techniques, therapeutic windows, acute and long term drug
toxicities, the management of cancer and drug related complications and
side effects, drug interactions and safe handling of hazardous drugs.
— Dispensary services obtain, store and distribute medicines, review
prescriptions and medication orders for appropriateness and accuracy,
perform medication reconciliation and report adverse drug reactions and
events. For a cancer centre this includes oral SACT as well as supportive
medicines such as antiemetics and granulocyte colony stimulating factor.
Pharmacists and pharmacy support staff should ensure that all medicines
dispensed by the pharmacy are stored, handled and distributed reliably and
safely. This should be standardized across all dispensary areas.
— Inventory management involves procuring good quality and cost effective
medicines, managing the formulary of available and allowed medications,
securely storing, distributing and disposing of medicine waste. Pharmacists
should also play a role in the local formulary committee (e.g. the drugs and
therapeutics committee) to take part in the decision making process on the
range of medicines to be used, and guidelines related to their use.
— Aseptic preparation of medications is an important facet of the service.
Cytotoxic chemotherapy is designated as hazardous and should be prepared
in a controlled environment by trained staff. It is mandatory to comply with
all regulatory requirements, including facilities, equipment and personal
protective equipment for the safe handling, preparation and disposal
of cytotoxic medicine waste. All preparation must take place under the
supervision of a pharmacist, who will ensure that robust standard operating
procedures are in place for every aspect of that service, including cleaning,
maintenance and monitoring of the facilities and equipment, staff training,
prescription verification, worksheet and label production, aseptic technique,
final product checking and release. Where preparation facilities are not
available or lack capacity, it may be possible to buy pre‑prepared products
from a commercial provider.
— Educating patients and caregivers about prescribed medicines is where
the cancer pharmacist plays an optimal role to provide patient directed
education, information, advice and tools to improve medication adherence
with complicated regimes. Private areas for confidential discussion about
SACT and supportive care medicines are important.
29
— Educating health care professionals in the safe and effective use of medicines.
— Electronic prescribing: SACT regimens (a combination of one or more
SACT agents typically used to treat patients) are complex and prescribing
them is a specialized process. Even simple regimes such as those used in
out‑patient practice frequently require intravenous administration of several
different SACT medicines. These medicines require individualized doses
according to patient size and toxicity from previous treatments, together
with the administration of both intravenous and oral antiemetics. The
complexity of SACT regimens, the narrow therapeutic window of the
medicines themselves and the intermittent nature of treatment makes the
implementation of computerized SACT ePMA (electronic prescribing and
administration of medicines) or eP (electronic prescribing) packages a vital
component of a modern and efficient service. Where IT systems are in place
within the health care setting it is important that SACT ePMA is carried
out on a system that is designed for this purpose. Where IT systems are not
in place within the health care setting, then paper pro forma prescriptions
should be available with sufficient governance structures to allow safe
prescribing of recommended treatments for that specific cancer type —
i.e. to facilitate standardization and prevent errors. The cancer pharmacy
service will usually take on the responsibility for the set‑up and maintenance
of an ePMA system or a paper pro forma system, and this should be taken
into account when planning the pharmacy workforce.
Quality assurance and management are an essential part of any cancer

service, including pharmacy and the aseptic preparation service. The consequences
of errors cannot be understated. Quality of care is ensured by the establishment of
standard operating procedures, so a significant investment in resources must be
included to ensure safe and effective delivery of SACT. Cancer pharmacists are
often involved as part of the core team in the development of standards related
to patient safety, including clinical governance. Cancer pharmacists serve as
members of policy making committees that impact medication use and safety,
and regularly evaluate and report on the performance of the pharmacy service.
30
6. MULTIDISCIPLINARY AND MULTIMODALITY
TREATMENT: FACILITY REQUIREMENTS
An optimal approach for cancer care is the ‘multidisciplinary clinic’ in

which patients with newly diagnosed cancer are seen together by the surgery,
radiation oncology and medical oncology departments to plan their treatment,
supported by pathology and medical imaging expertise. The formulation of a
treatment plan is a critical starting point in the management of people diagnosed
with cancer and must be done in a coordinated way, facilitated by the structures
and functions of cancer centres.
6.1. CANCER SURGERY
6.1.1. Rationale
Surgery is the most important part of cancer diagnosis and curative

treatment. It fulfils various functions, including obtaining tissue for pathological
evaluation for diagnosis and staging, primary curative tumour resection and for
palliation of symptoms related to cancer or cancer treatment.
Data suggest that by 2030, out of 21.6 million patients with cancer, roughly
80% (17.3 million) will require surgery. Of these, more than half (10 million)
will reside in low and middle income countries [48], where the access to complex
surgery is very limited.
6.1.2. Key features
It is important to integrate surgery effectively with diagnosis and treatment

(see multidisciplinary care). At facilities with minimal surgical capacity, trained
providers may perform biopsies of abnormal masses, including lesions of the
skin, breast, oral cavity and uterine cervix, as well as enlarged lymph nodes.
Histological materials must be preserved, processed and analysed promptly by
pathologists. Additionally, these providers may also be able to perform basic
palliative procedures, such as tracheostomy, drainage of pleural effusions, and
repair of non‑functioning colostomies.
Most cancer centres should be able to perform curative and palliative
surgical procedures, such as local excisions, mastectomy, hysterectomy and
colectomy. More complex surgical care, such as pancreaticoduodenectomy,
esophagectomy, and lung resections, may be performed at higher volume facilities
by surgeons trained in the appropriate subspecialties and with more capacity for
31
imaging, critical care, peri‑operative nurses, interventional radiology, symptom
management, and post‑operative rehabilitation services. The volume of a cancer
centre and the complexity of its accompanying services is important in planning
surgical capacity, as more favourable cancer outcomes are associated with a
greater volume of cancers treated and the extent of training for cancer health
care professionals.
To deliver safe and effective cancer surgery, the educational and health care
systems in a country must train and retain adequate numbers of individuals in the
fields of surgery, anaesthesia, critical care, nursing and the relevant technicians
for these fields. For childhood cancer, surgical competencies vary according to
the different levels of complexity. For level 1 settings, adult subspecialty surgeons
include neurosurgeons and orthopaedic surgeons. For level 2, some paediatric
subspecialty surgeons (neurosurgeon, orthopaedic surgeon, ophthalmologist)
should be available while for level 3, a full range of paediatric subspecialty
surgeons should be available to provide care for children [34]. Specialized
training in cancer surgery generally requires dedicated time at tertiary referral
hospitals. A workforce strategy linked to a labour market analysis should be
used to ensure that an adequate number of cancer health care professionals are
trained to the full scope of their practice, retained and their capacity built. At a
minimum, retention requires an adequate salary, supportive working conditions
and opportunities for professional development that also enhance competencies.
Surgeons and other health care providers involved in cancer care should receive
education in professional schools and postgraduate settings on the principles of
clinical research and evidence based medicine.
6.1.4. Equipment
Even in resource constrained settings where many patients present with

advanced disease and may not be candidates for curative surgery, palliative
surgery, such as relief of intestinal obstruction or creation of a tracheostoma
for airway obstruction, can play an important role in relieving suffering. Other
services need to be in place to ensure that cancer surgery is safe and effective.
These services include imaging, laboratory medicine, anaesthesia, blood banking,
pre‑ and post‑operative care, critical care, nursing, anatomical pathology,
symptom management and rehabilitation, as well as a reliable supply chain
for the myriad supplies and instruments necessary for anaesthesia, surgery and
hospital care [15].
32
Accurate pre‑operative planning includes evaluating and optimizing the
cancer patient’s overall health, functional status and nutrition. The operative
approach is often informed by pre‑operative imaging and/or endoscopy, as
well as an understanding of the tumour biology from a pathology review.
Peri‑operative care relies on safe anaesthesia tailored to the operation, as well
as nursing care responsive to the potential complexities of an operation and
the potential co‑morbidities of individual patients. Safe blood products must
be available for safe surgery. When possible, however, administration of blood
products should be avoided, given potential short and long term risks. Specialty
nursing, physical therapy, occupational therapy and nutritional support greatly
impact peri‑operative outcomes and recovery.
Anaesthesia expertise available at facilities with varying levels of
surgical services (levels 1–3 surgical services) will inevitably vary. Basic safety
standards and guidelines for pre‑ and post‑anaesthesia care and monitoring
should be ensured.
Quality assessment and monitoring require real time capture of standardized

metrics as well as evaluation of adherence to guidelines for cancer diagnosis,
treatment and symptom management. Guidelines may be national, international or
developed by medical professional societies. Commonly tracked metrics include
time from biopsy to pathological diagnosis; time from diagnosis to definitive
surgical treatment; and time from surgery to start of adjuvant therapy. Standards
of synoptic reporting have been developed for imaging, pathology and surgery.
Metrics evaluating quality of cancer specific surgeries may include lymph node
evaluation, tumour margins, success in removing all gross tumour, organ sparing
and incidence of post‑operative infection and 30 day post‑operative mortality.
Quality assurance should be introduced through routine conferences on
morbidity and mortality that allow for review of any peri‑operative complications
and provide an opportunity to identify system factors that contribute to those
complications. Within a surgical department, efforts should be made to identify
a surgeon responsible for promoting quality and implementing evidence based
quality standards, such as a safety timeout before and after an operation.
Such morbidity and mortality conferences may also be useful in evaluating
multidisciplinary cancer management. Institutions with level 2 and level 3
surgical services should routinely assess quality of cancer care prospectively and
retrospectively through audits.
33
6.2. MEDICAL ONCOLOGY AND SYSTEMIC THERAPY
6.2.1. Rationale
Medical oncology is an essential component of multidisciplinary cancer

care. Systemic therapy can be delivered alone, concomitant with radiotherapy or
sequentially to surgical or radiotherapy procedures for neoadjuvant, adjuvant or
palliative treatments and reinforcing the need for a multidisciplinary approach.
Where potential cure, overall survival and quality of life gains are the main
goals, treatment choice should be based on medicines that confer meaningful
clinical benefit and, according to institutional guidelines, national medicine
lists [49, 50]. Systemic therapy prescription (such as chemotherapy, endocrine
therapy, immunotherapy and targeted therapy), supportive care and monitoring
of symptoms and outcomes during and after treatment are essential activities for
trained providers in medical oncology, who are generally medical oncologists
or haematologists. Systemic therapy is an essential curative treatment for most
haematological and solid tumour diagnoses, though indications will depend on
the extent of disease [51]. For paediatric oncology services, as for adult oncology
services, coordination of care with other essential multidisciplinary services,
including surgery, radiotherapy and supportive services, is essential.
6.2.2. Key features
While the needs and resources of countries will differ significantly, key
features for a medical oncology service include human resources, infrastructure,
consistent access to medicines, devices and equipment, blood banking, a
monitoring and evaluation framework, QA and management processes. In‑patient
and out‑patient oncology needs must be addressed, with attention to the extended
monitoring and hospitalization needs of patients, intensification of care as
well as coordination with emergency/acute and intensive care, rehabilitation
and palliative care services. It is mandatory to comply with all regulatory
requirements, including for personal protective equipment and safe handling,
prescribing, dispensing and disposal of systemic therapy agents [52].
The core team generally involves medical oncologists and/or

haematologists; medical officers and trainees (physicians with some training
in oncology care but practising under the supervision of trained oncologists);
nurses trained in administration of cancer therapies and supporting patients
before, during and after cancer treatment; pharmacy staff trained in preparing
34
and monitoring systemic therapy; multidisciplinary staff (including psychosocial
staff) and other support staff (including data and ward clerks). Where possible,
staff should include nutritionists and palliative care specialists. For paediatric
oncology services, the core team members are as noted above, with the need
for paediatric oncologists. In many settings, paediatricians join the roster
of providers to support continuity of care, and it is helpful for nurses and
multidisciplinary providers to receive dedicated training in the management of
children with cancer. Access to specialized paediatric providers (e.g. a paediatric
anaesthesiologist) — where feasible — ensure safe, effective care for intravenous
therapy administration and procedures (e.g. bone marrow aspirates/biopsies and
imaging studies in infants).
6.2.4. Equipment
Medical oncology services typically span three main areas:
— In‑patient area. This includes beds for complex/infusion chemotherapy and

laboratory monitoring of drug levels (e.g. methotrexate); appropriate facility
and support for patients with febrile neutropenia; and an isolation area for
immune suppression during a bone marrow transplantation. In the most
advanced centres, specialized in‑patient units provide dedicated services,
such as bone marrow transplant services.
— Out‑patient clinic area. This area includes space for out‑patient consultations
(e.g. for disease evaluations or laboratory monitoring), and ideally an area
for isolation and a dedicated area for acute care (for patients pending
evaluation with suspected febrile neutropenia or resuscitation needs).
— Day care/chemotherapy administration area. Examples include beds,
couches, chairs (e.g. 30 of a 250 bed hospital [53]).
Properties common to these three areas include:
— General. Attention to hand hygiene (e.g. bedside pumps for hand hygiene
products and/or sinks with soap accessible to each patient) and isolation
areas for specific conditions, such as bone marrow transplantation or highly
contagious conditions (i.e. herpes zoster virus infections) to optimize
infection prevention and care.
— Equipment. Fully equipped crash cart and automated emergency devices
to run emergency codes for immediate resuscitation and stabilization prior
to ICU, if needed [15]. Infusion pumps/syringe pumps commonly used for
daily continuous infusion chemotherapy protocols, parenteral nutrition,
opioid titre for severe and uncontrolled oncological pain.
35
The following areas may be centralized within a centre, or be located within
the three medical oncology areas listed above:
— Systemic therapy preparation area. This location should be a dedicated area

with safe handling facilities to protect staff from repeated exposure to SACT
agents (see Section 5.3.4).
— Secure storage areas for systemic and supportive therapy. This location
includes cold chain and secured access (e.g. locked cabinets for opioids).
— Access to the point of care laboratory area. Where appropriate, this area
provides access to process and/or review quick complete blood count, or
tumour analysis laboratory results.
— Area with accessible personal protective equipment. Includes gowns, gloves
and masks for providers and/or family members and patients.
— Counselling area. Private area for confidential discussions with families.
— Procedure area. A separate area for procedures (such as venepuncture,
lumbar punctures), particularly for children.
— Respite, play and recreation areas. Patient and family centred areas
for respite (e.g. areas for families to prepare their own meals), play and
recreation (e.g. adolescent specific areas) where no medical procedures or
activities occur, can enhance the quality of life, particularly in centres caring
for children or adolescents.
Other services that communicate with the medical oncology service include:
— Laboratory, biochemistry, haematology, microbiology, histopathology,

immunophenotyping and immunohistochemistry and molecular testing.
All results should preferably be available through a common information
system platform. Sample core services are outlined in the WHO publication
Model List of Essential In‑Vitro Diagnostics [37].
— Medical record system and information technology. The health management
information system should preferably be electronic and include all
chemotherapy protocols, antineoplastic prescriptions and laboratory
examination results, and they should be reviewed at least annually to ensure
compliance with institutional guidance.
Quality management is essential in medical oncology, given the potentially

serious (debilitating to lethal) consequences of misadministration of systemic
therapy and supportive care. Consequently, significant resources must be invested
to ensure safe, quality and effective delivery of systemic therapy, point of care
36
monitoring before, during and after therapy, and documentation and review of
adverse events affecting patients, families or providers. The entire core medical
oncology team must be engaged in QA activities. Patients should be involved
in QA processes, with institutional resources committed for patient education,
engagement and feedback. Sample resources are available to guide set up in
different resource settings [54, 55].
6.3. PAEDIATRIC ONCOLOGY
6.3.1. Rationale
Paediatric oncology is an essential component of multidisciplinary cancer

care for children. Acute leukaemia, particularly acute lymphatic leukaemia is the
commonest childhood malignancy (28%) and, if treated properly cure rates over
90% can be achieved. Brain and spinal cord tumours constitute the next largest
group (26%), and Wilms tumour, rhabdomyosarcomas, lymphomas and bone
cancers make up the rest. A multidisciplinary team led by a paediatric oncologist
is necessary for the optimal management of childhood cancer. The paediatric
oncologist should have a postgraduate qualification in paediatrics followed
by training in a specialized paediatric oncology unit for two to three years in
a tertiary centre or a cancer hospital. Knowledge of comprehensive clinical
diagnosis, cancer staging and management of children, including integrated
treatment planning according to tested clinical protocols, are essential. Systemic
therapy which includes chemotherapy, endocrine therapy, immunotherapy and
targeted therapy, supportive care and monitoring of symptoms and outcomes
during and after treatment are essential activities for the paediatric oncologist.
Coordination of cases with surgeons, radiotherapists and other health care
professionals is necessary.
6.3.2. Key features
Provision of a state of the paediatric oncology services required a good

diagnostic service since treatment protocols are now risk adapted. For a child
with leukaemia, basic haematology, immunophenotyping, cytogenetics,
including fluorescent in situ hybridization and molecular tests, are necessary
for comprehensive diagnosis and risk stratification to choose the appropriate
protocol. Response to treatment and subsequent management requires monitoring
of minimal residual disease by flowcytometry or molecular tests, and this is true
for all other childhood cancers. A good paediatric oncology service would require
human resources, infrastructure, consistent access to medicines, devices and
37
equipment, blood banking, including components, a monitoring and evaluation
framework, and QA and management processes. Follow‑up is essential since
childhood leukaemia has a two year maintenance period during which the child
must be given oral medication with periodic review of blood counts.
The core team generally involves: medical paediatric oncologists

and/or haematologists; medical officers and trainees (physicians with training
in general paediatrics but practicing under the supervision of trained paediatric
oncologists); nurses trained in the administration of cancer therapies and
supporting patients before, during and after cancer treatment; pharmacy staff
trained in preparing and monitoring systemic therapy; multidisciplinary staff
(including psychosocial staff) and other support staff (including data and ward
clerks). Where possible, multidisciplinary staff should include trained nutrition
and palliative care specialists. Access to specialized paediatric providers (e.g. a
paediatric anaesthesiologist) — where feasible — ensures safe, effective care
for intravenous therapy administration and procedures (e.g. bone marrow
aspirates/biopsies, imaging studies in infants).
6.3.4. Equipment
The equipment list for paediatric oncology is similar to medical oncology.

The following areas should be provided for children with cancer:
— Procedure area. A separate area for procedures (such as venepuncture,

lumbar punctures) is preferred, particularly for children.
— Respite, play and recreation areas. Patient and family centred areas
for respite (e.g. areas for families to prepare their own meals), play and
recreation (e.g. adolescent specific areas) where no medical procedures or
activities occur, can enhance the quality of life, particularly in centres caring
for children or adolescents.
Apart from what has been listed for medical oncology, monitoring of
the quality of venous access and infections related to central venous devices is
essential in children with cancer. Also, documentation of all episodes of febrile
neutropenia and its management is required. Disease free survival for all children
treated at a centre must be recorded and reviewed periodically. Long term
38
follow‑up with evaluation of drug toxicity and endocrine function is essential for
all survivors of childhood cancer.
6.4. RADIATION ONCOLOGY
6.4.1. Rationale
Radiation oncology is an essential component of cancer management

and part of multidisciplinary cancer care. In optimal settings, over 50% of all
cancer patients need radiation as part of their treatment management plan, as it
contributes significantly to improvements in local tumour control and overall
survival in many disease sites, and can also be used for disease palliation [56].
Access to radiotherapy is limited in some regions, primarily in low and middle
income countries, due to many barriers including perceived high capital
investment and maintenance costs, the need for a complex infrastructure and
a lack of human resources and services [57–59]. These disparities in access to
radiotherapy can also be seen in high income countries [60, 61].
6.4.2. Key features
The needs and resources of countries will differ significantly, but the list
below provides an overall framework of the processes in radiation oncology.
Key features to be considered for a radiation oncology service include human
resources, infrastructure and equipment, a monitoring and evaluation framework,
QA and management processes. External beam radiation therapy (EBRT) and
brachytherapy (BT) are standard modalities [62]. It is mandatory to comply with
all regulatory requirements, in particular radiation protection and safety.
The following list provides an overview of the radiation oncology process:
(1) Clinical evaluation of the patient. If possible, all patients should be evaluated
in a multidisciplinary setting. This should involve assessment and staging
of the tumour through a physical examination, evaluation of all available
imaging, and a decision on whether to prescribe radiation therapy.
(2) Therapeutic decision making. Care goals (curative or palliative) should
be determined next. If curative, a decision should be made as to whether
treatment is given neoadjuvantly or adjuvantly. Radiation prescription
and dose time, as well as the volumes to be treated, should be determined.
All patients should be asked for their consent for radiation therapy and be
informed about its benefits and potential adverse effects.
39
(3) Patient immobilization. The need for immobilization for simulation and
treatment should be determined and planned for.
(4) Patient simulation. Simulating the patient in the treatment position,
localization and selecting position of simple field arrangements.
(5) Target volume determination. Tumour volume, potential tumour extent
and potential routes by which it may have spread should be determined.
Sensitive organs and tissues should be identified. Tumour volumes and
organs at risk should be contoured.
(6) Treatment planning and evaluation. Treatment technique, fields, modality
and energies should be selected. Custom beam modifiers or compensating
filters should be developed as needed. Dose distribution should be computed
and verified for accuracy. Dose volume histograms should be evaluated to
ensure that the tumour is receiving an adequate dose and that organs are
receiving doses below the threshold they can tolerate.
(7) Simulation of treatment. Radiographic documentation of treatment ports
should be done to verify the fields.
(8) Treatment. Treatment data should be transferred to the treatment machine
and initial verification of treatment set‑up should be done. The accuracy of
repeated treatments and record keeping should be verified.
(9) Patient evaluation during treatment. All patients should be evaluated during
treatment at least weekly to manage the adverse effects of treatment and to
assess response to treatment. A standardized grading system should be used
to grade toxicities weekly so that they can be easily compared from week
to week. When needed, the palliative therapy team and supportive therapy
team (e.g. dietician for head and neck cancer patients) should be involved
to ensure patients are well supported to be able to continue and complete
treatment as planned.
(10) Follow‑up evaluation. All patients should be followed up after radiation
for evaluation of treatment response/recurrence and management of late
toxicities. All recurrences should be discussed in a multidisciplinary setting
to design the best possible treatment plan for the patient and to counsel
the patient appropriately. Interval for follow‑up will be determined by the
tumour type and resources available at the centre but is generally every 3–6
months for the first two years and then every 6–12 months for at least five
years.
A core radiation oncology team consists of radiation oncologists, medical

physicists, and radiation therapy technicians. The expanded team also includes
other health professionals involved in multidisciplinary cancer management,
40
such as specialist nurses and anaesthesiologists with training and expertise in
paediatrics, to provide sedation and anaesthesia services for infants and children
receiving radiotherapy. Staffing levels are dependent on the complexity of the
radiotherapy procedures (the IAEA has extensive, publicly accessible, guidelines
on staffing a radiotherapy centre [63]).
Core team practitioners must have undergone structured, practical,
competency based training, as well as formal academic education [64]. The
IAEA has issued guidance publications, including syllabuses, on the education
and training of all professionals involved in radiotherapy [65, 66]. The timeline
for the education and training of professionals lasts several years, so careful
planning is needed when setting up or expanding a radiotherapy programme [64].
Additional requirements are applicable to paediatric radiation oncology services,
including specialized training for management of children, incorporation of staff
for anaesthesia, childcare and other psychosocial staff, and multidisciplinary
service delivery with paediatric oncology service providers.
The IAEA recommends that radiotherapy facility design allows for

future expansion without disrupting existing services. It has published a report
that introduces the concept of five functional areas: reception; administration
and waiting areas; clinical consulting areas; external beam radiotherapy;
brachytherapy; and the imaging and treatment planning area [67]. These areas
together constitute an overall footprint of approximately 1450 m2 and should
be positioned in accordance with the preferred workflow of the staff and the
patients. The radiotherapy facility should be conveniently sited in the centre’s
infrastructure. As rooms containing radiotherapy treatment equipment (EBRT
and BT bunkers) are highly specialized, a core implementation team with
adequate expertise needs to be constituted to design the facility and to manage
the construction. The IAEA has issued extensive guidelines on the appropriate
buildings and essential equipment for a radiation therapy unit [68–70].
The equipment required for the comprehensive cancer centre’s radiotherapy
facility includes external beam and brachytherapy treatment units; imaging for
treatment planning and simulation; computerized treatment planning systems;
oncology information system; dosimetry; quality control and safety equipment;
mould room equipment, and positioning and immobilization devices including
consumable equipment [70–72].
41
Quality management in radiation oncology is essential because of the

potentially serious and lethal consequences of radiotherapy misadministration.
As a result, significant resources must be invested to ensure safe, high quality and
effective services, and the core radiotherapy team as a whole must be engaged
in quality control activities. Within a facility containing radiation emitting
equipment, medical physicists are usually responsible for the radiation safety
and protection of patients, staff and the general public who have access to the
premises [73, 74].
6.5. ONCOLOGY NURSING
6.5.1. Rationale
Oncology nursing is an important part of cancer control as the role of the

nurse extends across the cancer continuum. Oncology nurses play an important
role in cancer prevention, screening, detection, treatment, survivorship,
palliative care and research [75]. In some settings, the primary functions of
oncology nurses are to provide direct patient care in acute care hospitals,
radiation and medical oncology clinics and hospice/home based settings, where
they practice in association with surgical, radiation, medical, paediatric and
gynaecological oncology [76].
6.5.2. Key features
Oncology nurses ease the burden of the cancer treatment journey by

delivering evidence based, person centred care to both the patients and the
family/caregiver [77]. The key responsibilities include:
— Cancer treatment. Deliver systemic anticancer treatments, assess and

manage treatment specific symptoms from surgery, radiation therapy,
systemic anticancer treatments and other treatments, such as peripheral stem
cell transplantation, and assess patients for oncology emergencies.
— Supportive/palliative care. Provide such care to both the patient and the
family/caregiver, including education of the patient and family/caregiver,
assessment and management of pain and other symptoms, provision
of psychosocial and spiritual care in a culturally sensitive manner and
empowerment of patients and their families to accept the responsibility for
the self‑management of the disease.
42
— Survivorship care. Provide psychosocial support, education about the late
side effects of cancer treatments and the physical changes resulting from
cancer and its treatment.
— Research. Develop new knowledge that can improve the outcomes of the
patient and the family/caregiver [78–80].
In addition, as combined modality treatments are often used, the

radiation oncology nurse assesses and manages patients experiencing
overlapping symptoms [81].
Although oncology nursing is an established field of nursing, it is still

underdeveloped in certain low and middle income countries [82–84], where
nurses often practice in the field of oncology without having had specialist
education and training [85, 86]. In addition, there is no universal standard for
oncology nursing education and training. Also, this education and training
may range from hospital based certification to post‑registration diploma level,
baccalaureate degree, postgraduate diploma in oncology nursing and clinical
Master’s degrees. The roles of the clinical nurse specialist, nurse practitioner
and advanced practice nurse are also confusing, and there is a lack of clarity
about the competencies and responsibilities linked to the specific roles [87]. At
a minimum, nurses caring for people with cancer should receive an oncology
focused orientation, be educated and trained to handle, reconstitute (if applicable)
and administer anticancer drugs safely and manage side effects, and receive
continuing professional education to update clinical practice and maintain quality
care [66, 88–90]. Clarifying roles, competencies, developing or adapting existing
clinical guidelines and standard operating procedures and implementing them
can enhance the best evidence based care.
6.5.4. Infrastructure and human resources
The goal of staffing norms in oncology is to ensure the provision of

safe health care delivery. When calculating registered nurse to patient ratios,
the number of patients, intensity level of the care needed, the availability of
technology, the characteristics of the unit and the experience and knowledge and
skills of the nurses should be considered [91]. Although definite guidelines do
not seem to be available, suggested guidelines for in‑patient unit staffing for both
day and night shifts can be found in the literature.
43
7. PALLIATIVE AND SUPPORTIVE CARE:
FACILITY REQUIREMENTS
7.1. PALLIATIVE CARE
7.1.1. Rationale
Cancer and its treatment can cause physical symptoms and side effects. It
can also lead to emotional, social and financial challenges. Palliative care aims
to treat the patient as a whole, not only the sickness. The objective of palliative
care is to prevent and treat the symptoms and side effects of the disease and its
treatment at the earliest stage, in addition to any related psychological, social and
spiritual problems.
7.1.2. Key features
Palliative care should be accessible at all levels of the health care system
and can be delivered alongside therapies such as surgery, radiotherapy and
chemotherapy. Policies and resources should reinforce the appropriate integration
of palliative care, ensure access to pain medications (including opioids) with the
aim of improving the quality of life of patients and families, and should not be
seen as being synonymous with end of life care [92]. All staff involved in the care
of patients with cancer should receive at least basic training in palliative care.
7.1.3.1. Cancer centre based palliative care
Facility based palliative care should include an out‑patient palliative care

clinic, a palliative care consultation service for in‑patients, a palliative care day
care service, an in‑patient palliative care unit and a palliative care outreach/home
care service. An out‑patient palliative care clinic can provide low cost care to
patients and, when included with an in‑patient consultation service, can be a
particularly effective model where resources are limited.
An in‑patient palliative care unit offers palliative care beds and allocates
staff trained in palliative care available 24 hours a day. The required professionals
include doctors and nurses with at least basic training in palliative care, ideally
supplemented by consistent access to team members with specialist palliative
care training. A full complement of multidisciplinary providers to serve the
holistic needs of patients and families — such as psychologists, pharmacists,
44
physiotherapists, spiritual care providers, dieticians and volunteers — can
strengthen the team and the service offered. Access to treatment options offering
palliation of distressing cancer symptoms, such as interventional radiology,
radiotherapy and salvage surgery, can be part of care from the cancer centre.
7.1.3.2. Home based palliative care
Many patients feel more comfortable in their home than in a health care
setting, especially while under treatment or towards the end of their life. Through
a home based approach, family members can receive advice and support as
caregivers and referral to additional services can be facilitated by the home care
team. Resources for transport and communication are vital to continuity of care.
A full time nurse and a part time doctor are the minimum requirements for a home
care team, depending upon the resources available. A multidisciplinary team of
nurses, doctors, psychologists/counsellors, social workers and community health
workers, or well-trained volunteers, are needed. Each patient should have a health
record in place, ideally integrated with centre and community based service
records. Records of prescriptions and use of all medicines (especially morphine
and other opioids) should be maintained in line with local laws and regulations.
Minimum basic training in palliative care for doctors, nurses, community health
workers and lay volunteers is essential to provide home care services, along with
access to staff with specialized training in palliative care.
7.1.3.3. Community based palliative care service
Health care professionals, community health workers and/or lay volunteers

typically provide community based palliative care services. These services at a
community health centre can include out‑patient services offered during defined
hours, home based support and, in some cases, in‑patient services. Health care
professionals based at a community health centre can offer out‑patient services
such as more advanced symptom assessment and management and respite
services for families. They can support home based services by supervising
community health workers and volunteers and visiting patients at home when
needed. Mobile phones can also be used in order to keep in touch with patients
and family members.
Additionally, community health centres with in‑patient beds can provide
short term respite, additional symptom management, or uncomplicated end of
life care for a few in‑patients at any one time to better support the preferences
and needs of patients and families, often in a more home‑like environment than
a hospital in‑patient setting. Training should be provided to medical doctors,
clinical officers or assistant doctors, nurses and nursing aides, and they should
45
receive the minimum hours of training in basic palliative care, in alignment with
national and international recommendations. The nurse(s) and doctor(s) can then
provide training to community health workers or volunteers. The latter groups,
supported by health care professionals, can be trained to provide or to support
community based services in continuity with home based services.
7.1.3.4. Paediatric palliative care
Palliative care for children involves care of the child’s body, mind and spirit,
recognizing age appropriate developmental needs, distinct disease trajectories
and treatment needs in children and adolescents. It also involves supporting the
family. Building on general palliative care principles and practices, providers of
paediatric palliative care also require distinct competencies alongside different
assessment tools and pharmacological and non‑pharmacological management
approaches for children and adolescents with cancer. The minimum staff required
for paediatric palliative care services includes a nurse and a doctor, supported by
community health care workers, all of whom should have at least basic paediatric
palliative care knowledge and competence. If resources allow a team will ideally
include providers with specialist training in paediatric palliative care, including
paediatricians, paediatric nurses, psychologists, social workers and other allied
health therapists, such as child life workers, music and art therapists, and
rehabilitation specialists.
Regardless of whether the service is hospital based, community based,
and/or home based, the core team could be the same, with services ideally offered
in a child friendly environment. In addition to facilitating discussion of goals of
care with families and age appropriate assessment and management of symptoms,
providers of paediatric palliative care can often facilitate care coordination and
access to other therapies as necessary [93].
Establishing and implementing clinical guidelines and standard operating

procedures, adapted to the local context, ensures best available evidence based
care. Prescribing and administration of palliative care interventions, including
opioids, should be carefully documented and monitored as per national
regulations. Patient reported outcomes and validated quality of life questionnaires
should be used to guide interventions and programmes.
46
7.2. SUPPORTIVE AND SURVIVORSHIP CARE
7.2.1. Rationale for supportive care
Supportive (or psychosocial) care for patients with cancer includes

assessment and anticipatory management of the needs of patients and families
from diagnosis and throughout the disease trajectory, encompassing emotional,
spiritual, interpersonal and material/financial needs. Given the sustained duration
of many treatments for cancer, support to reduce patient and family distress and
to promote treatment adherence are vital.
Psychosocial services based in a comprehensive cancer centre may:
— Be provided by trained social workers and psychosocial professionals,

starting with part time staff (staff that have responsibilities for other patient
populations, or are available for consultation) who may receive added
training and peer support to manage serious chronic illness.
— Be complemented by lay volunteers and support staff.
— Include patient and family education and counselling, including group
education; needs assessment and provision of resources and support,
including for financial burdens, housing, transportation and meal support;
support preparing for procedures; assessment and support for treatment
adherence.
— Include efforts to provide individualized psycho‑education (to help people
understand how to cope with the impact of cancer) and counselling,
assessment and management; psychosocial follow‑up in survivorship;
child life, social interaction, recreation and respite support; support for
siblings of children and adolescents with cancer; and consultation services
involving legal and ethics experts; support for reintegration into schools and
workplaces.
— Be provided in conjunction with palliative services.
— Have specialized training and education where children are involved and be
accredited to provide developmentally appropriate assessment.
— Be used for managing cases of children with cancer and their families [94].
Community based psychosocial services may:
— Be provided by or with non‑governmental organizations (NGOs), and with

support from parent/family advocacy groups or councils.
47
— Provide patient and family education and counselling, including group
education; needs assessment and provision of resources and support,
including for housing, transport, and meal support.
— Include services linked with school programmes, community based
legal/health services; vocational programmes for families; integrative health
services, and links with traditional and complementary medicine providers
and services, as appropriate (based on the local context); recreation and
respite support.
7.2.3. Rationale for survivorship care
Survivorship care is an integral component of mature cancer programmes.

In addition, support through ostomy, prosthetics and rehabilitation services are
essential [95] as well as access to occupational therapy [96].
7.2.4. Key features
Core survivorship care services include anticipating any issues around

managing the physical and functional effects of a cancer diagnosis and therapy,
and early recognition of cancer recurrence or second malignancies. This includes
providing appropriate counselling, and engaging patients and families in decision
making, treatment planning and follow‑up; optimizing patient function; and
incorporating patient values and preferences in any further treatment they may
need. Expanded services can include long term follow‑up monitoring and care
after completion of treatment, as well as surveillance and research.
An example that highlights the need for these care services is noted in
childhood cancer survivors who require lifelong surveillance. Evidence based
guidelines for long term follow‑up of late effects should be developed and
followed to guide the management of the specific domains related to childhood
cancer survivorship care: physical effects, psychosocial effects, chronic medical
conditions, prevention and surveillance of relapse disease and risk of developing
new cancers, as well as education regarding health promotion for a better
quality of survivorship. Core actions regarding childhood cancer survivor care
include adequate multidisciplinary infrastructure, individualized care plans and
strengthening referral pathways between the paediatric subspecialties and the
primary care provider.
48
Cancer centre based survivorship services may:
— Be provided by the multidisciplinary professionals available, while expanded

services can be provided with specialists in late effects of diagnosis and
survivorship.
— Include provision of patient centred documentation to summarize the
diagnosis and treatment received (e.g. a survivorship passport); patient
empowerment and education; and management based on symptoms/signs
of late effects (e.g. ototoxicity, cardiotoxicity).
— Include engagement and follow‑up with fertility services; comprehensive
and anticipatory long term follow‑up monitoring and care (e.g. for
neurophysiological function, gonadotoxicity, functional outcomes and
coping); research programmes (such as long term surveillance research);
and risk reduction and health promotion.
Community based survivorship services may:
— Be provided by or with NGOs, as well as by trained multidisciplinary

professionals.
— Include support at the primary health care level for core preventive and
health maintenance activities, such as re‑establishing immunization
after patients complete therapy, as appropriate; and the history, physical
examination and patient education to recognize signs of recurrence/relapse
or second malignancies.
— Include attention to the needs of family caregivers, and to transitional and
care needs for paediatric, adolescent/young adult and older adult survivors,
including communication and exchange of data with cancer centre based
services for identified needs.
7.3. NUTRITION
7.3.1. Rationale
Malnutrition, both undernutrition and obesity, is highly prevalent in cancer

patients and thus requires particular attention as part of comprehensive services
provided at cancer centres. Cancer patients who are malnourished have lower
survival rates and face other long term consequences such as reduced functional
capacity, decreased bone density and increased risk of metabolic syndrome.
49
Malnutrition in cancer patients may result from treatment induced effects on oral
intake such as nausea, vomiting, constipation, diarrhoea, xerostomia, mucositis,
dysphagia and loss of appetite, or it may come from site specific, tumour
induced effects on energy balance, including hypermetabolism, malabsorption,
dysmotility and obstructions. The short term consequences of malnutrition
may include decreased treatment tolerance, increased treatment delays, fatigue,
susceptibility to infections, increased hospitalization and treatment cost.
7.3.2. Key features
The awareness of the importance of nutritional support in treating cancer

patients is growing, and cancer centres must plan to incorporate medical
nutrition therapy (MNT), either as an MNT unit, or integrated resources
considering the level of complexity of the planned cancer centre. MNT should
include three phases: nutrition screening, nutrition assessment and nutrition
management. Nutrition screening is the first step in identifying patients who
may be malnourished or who are at risk of developing malnutrition. There
are many malnutrition screening tools available for cancer patients and a tool
should be chosen that is validated in the setting in which the tool is intended
for use. Nutrition assessment should be undertaken in all cancer patients who
are identified by nutrition screening as being at high risk of malnutrition. The
nutritional assessments should justify, inform and guide nutrition management.
There are several aspects to nutrition assessment that require varying levels of
assessment tools and capacities: dietary intake, nutrition impact symptoms and
body composition. Nutritional management should be provided at some level to
all patients identified with reduced dietary intake, nutrition related symptoms and
changes in body composition. The goals of nutrition management are to preserve
lean mass, prevent fat mass gain, prevent nutrient deficiencies, minimize nutrition
related complications, maintain functional capacity and maximize quality
of life. Nutrition management includes nutrition counselling, oral nutrition
supplements, supportive feeding and drug therapy.
MNT should be a mandatory component of supportive care for all cancer

centres. All components of MNT (screening, assessment and management) can
be offered in a cancer centre and customized to the staff, funds and nutrition
resources available. There are many nutrition resources available for cancer
centres, and centres should consult with national, regional or international
nutrition and dietetics organizations and available consensus guidelines for
assistance when establishing an MNT module within the cancer centre. Standard
50
operating procedures for all levels of cancer centres should be centre specific
and based on evidence, guidelines and resources. Procedures should cover the
continuum from diagnosis to survivorship.
Cancer centre based nutrition services may:
— Be provided by a variety of personnel, including nurses, practitioner,

dietician, or an oncology specialist dietician;
— Include a range of nutrition assessments which require varying levels of
equipment, including scales, stadiometers, tape measures, or dual energy
X ray absorptiometry;
— Have resources to offer a range of nutrition support, including nutrition
counselling, oral nutrition supplements, enteral or parental nutrition and
drug therapy.
Clinical nutrition guidelines and standard operating procedures should be

adapted to the local context and be in line with best available evidence. Prescribing
and administration of nutrition support should be carefully documented and
monitored as per national regulations. Nutrition assessment should be used to
guide interventions for patients. Body composition measurements should always
be undertaken according to standard operating procedures and regular quality
control checks.
7.4. REHABILITATION, PHYSICAL AND OCCUPATIONAL

THERAPIES
7.4.1. Rehabilitation
The aim of cancer rehabilitation is to help patients return to the highest

level of function and independence possible, at the same time improving the
overall quality of life — physically, emotionally and socially. Cancer centres
should set up a service for physical therapy and occupational therapy services
for out‑patients and in‑patients. Specially designed orthosis and prosthesis are
required and may be manufactured on‑site or procured as needed. Specially
trained staff are critical to the running of these services.
51
7.4.1.1. Stoma care
People with abdominal, bowel or bladder cancers may need a temporary or

permanent ostomies part of their treatment. Stoma clinics with trained providers
are an integral part of the cancer services. The services provided by these
clinics include:
— Management of urinary and faecal incontinence;

— Management of draining wounds, fistulas and non‑healing wounds (pressure
sores, leg ulcers);
— Pre‑operative counselling for ostomy surgery;
— Stoma siting;
— Arrangement of an ostomy visitor;
— Post‑operative counselling;
— Selection of appliances and teaching appropriate pouching technique;
— Irrigation procedures for colostomies;
— Practical education for patient and family;
— Nutritional guidance for ostomates;
— Discussion of pregnancy, sex problems and vocational needs of ostomates;
— Follow‑up care;
— In‑service education;
— Training programme in enterostomal therapy.
7.4.1.2. Prosthetics
There are various types of prostheses, some of which can be worn on the
outside of the body. They can be put on and taken off (external prostheses) and
other prostheses are inserted during surgery. For instance, cancer patients may
require a prosthesis due to loss of a breast, eye, leg, or arm. An implant may be
used in the penis, or in a breast, testicle, or bone. An electronic voice device may
be also required if the larynx has been affected by cancer. Wigs that are used due
to hair loss from some types of chemo are seen as prostheses as well.
7.5. SURVIVORSHIP CARE
After active treatment for cancer, a plan can be developed to monitor for
cancer recurrence or spread, follow‑up and management of health problems
related to cancer diagnosis or cancer treatment, and to assess for the development
of other types of cancer [14]. These services are essential to manage the
52
consequences of cancer diagnosis and treatment and they comprise routine
examinations and/or tests.
8. PREVENTIVE ONCOLOGY
8.1. RATIONALE
WHO ‘best buys’ for control of the main risk factors for non‑communicable
diseases (NCDs) are relevant for the primary prevention of cancer and should
be used for setting priorities in countries [97].2 Activities should be selected
according to the country’s cancer burden, contextual cost effectiveness, ensuring
equity and acceptability. Population wide interventions generally have a greater
potential impact. Individual interventions should be part of a broad integrated
national strategy and not be implemented in isolation. Cancer centres should
include services for cancer prevention and leverage the status of a comprehensive
centre which will attract a large clientele. A cancer prevention unit can help to
coordinate the work in the cancer centre with activities in the wider community.
This unit could be set up with a separate entrance to make it less intimidating
for walk‑in clients. The clinic can offer advice to questions from the public and
highlight cancer prevention and detection messages. Staff trained in community
medicine with skills in cancer prevention and screening can lead such services.
Comprehensive cancer centres have a significant role in cancer prevention.
The centre should provide evidence based guidance on prevention relevant to
the local context. All departments will have a role in prevention, especially
cancer epidemiology and cancer registry. The role of preventive oncology in a
comprehensive cancer centre includes:
— Development and dissemination of information related to cancer risk factors;

— Technical support for local and national government cancer control
programmes;
— Tobacco cessation programme;
— On‑site cancer detection and screening services;
— Cancer related health check‑up;
— Screening services for walk‑in clients;
— Outreach programmes;
2
WHO has identified a set of affordable, feasible and cost effective intervention
strategies to reduce the economic burden of NCDs on societies, known as NCD ‘best buys’.
53
— Patient support groups;
— Early cancer detection centres in peripheral hospitals;
— Training and utilization of community pharmacists and other providers to
promote healthy behaviour and to identify ‘red flag’ symptoms that may
represent cancer.
8.2. HUMAN RESOURCES
A preventive oncology department generally requires trained providers

in preventive oncology or community medicine, counsellors, social scientists
and communication specialists, and may also include providers for carrying out
community based cancer interventions such as screening.
8.3. INFRASTRUCTURE AND EQUIPMENT
Basic screening facility capacities such as for cervical cancer, may also
need to be available. Linkages with other departments and services should also
be promoted. Outreach activities are important and a mobile team could be used
to reach out to the population.
9. PAEDIATRIC CANCER SERVICES
Because it is generally not possible to prevent cancer in children, the most

effective strategy to reduce the burden of cancer in them and improve outcomes
is to focus on a prompt and correct diagnosis followed by effective and evidence
based therapy with tailored supportive care.
9.1. EARLY DIAGNOSIS
When identified early, cancer is more likely to respond to effective

treatment and result in a greater probability of survival, with less suffering as
well as less expensive and less intensive treatment. Significant improvements
can be made in the lives of children with cancer by detecting cancer early and
avoiding delays in care. A correct diagnosis is essential to treat children with
54
cancer because each cancer requires a specific treatment regimen that may
include surgery, radiotherapy and chemotherapy.
Early diagnosis consists of three components [16]:
(1) Awareness of symptoms by families and primary care providers;

(2) Accurate and timely clinical evaluation, diagnosis and staging (determining
the extent to which a cancer has spread);
(3) Access to prompt treatment.
Early diagnosis is relevant in all settings and improves survival for

many cancers. Programmes to promote early and correct diagnosis have been
successfully implemented in countries of all income levels, often through the
collaborative efforts of governments, civil society and NGOs, with vital roles
played by parent groups. Childhood cancer is associated with a range of warning
symptoms that can be detected by families and by trained primary health
care providers.
Screening is generally not helpful for childhood cancers. In some select
cases, it can be considered in high risk populations. For example, some eye
cancers in children can be caused by a mutation that is inherited, so if that
mutation or disease is identified in the family of a child with retinoblastoma,
genetic counselling can be offered and siblings monitored with regular eye
examinations early in life. The genetic causes of childhood cancers are relevant
in only a handful of children with cancer. There is no high quality evidence to
support population based screening programmes in children.
9.2. TREATMENT
A correct diagnosis is essential to enable appropriate therapy to be

prescribed for the type and extent of the disease. Standard therapies include
chemotherapy, surgery and/or radiotherapy. Children also need special attention
for their continued physical, cognitive growth and nutritional status, which
requires a dedicated multidisciplinary team. Access to effective diagnosis,
essential medicines, pathology, blood products, radiation therapy, technology and
psychosocial and supportive care are variable and inequitable around the world.
However, cure is possible for more than 80% of children with cancer
when childhood cancer services are accessible. Pharmacological treatment, for
example, includes inexpensive generic medications included on the WHO List
of Essential Medicines for Children (27 cytotoxic agents, five targeted therapies
and four hormone treatments for childhood cancer). Children who complete
55
treatment require ongoing care to monitor for cancer recurrence and to manage
any possible long term impact of treatment [12].
10. INFORMATION SYSTEMS, MEDICAL RECORDS

AND REGISTRY
10.1. RATIONALE
Information systems, the medical records department and hospital based

cancer registries (HBCR) are closely related and are essential capacities of a
cancer centre.
10.2. GOVERNANCE
Cancer centres should have a multidisciplinary medical records and

an HBCR committee that periodically reviews reports. The medical records
committee must cover audit findings, gross death rate, net death rate, quality
indicators, and proposals for the disposal of any records, and should review a
defined number of files each from medical, surgical, radiation, medico‑legal
cases and cases of death. They are also expected to review reports on data to
external agencies, any missing files, nil reports, completion of medico‑legal
cases and death files, International Statistical Classification of Diseases and
Related Health Problems coding, and the percentage of incomplete files. The
HBCR committee oversees annually the reports generated to establish evaluation
of outcomes according to cancer types, stage and clinical protocols with the aim
of improving patient care.
10.3. INFORMATION TECHNOLOGY AND SYSTEMS
Information technology and management systems should outline

the hardware requirements and software modules that can be aligned and
incorporated into the functional specifications of their design and architecture.
This will range from various clinical, operational and business modules of the
hospital information system (HIS) to a comprehensive approach to solutions that
integrates HIS with modules/packages such as the computerized patient record
system, radiology information system, laboratory and pathology information
56
system, pharmacy inventory management system, eP (if available), customer
relationship module, patient portal as well as applications such as enterprise
resource planning and asset management frameworks. HIS and electronic medical
records (EMR) are currently considered an important part of every hospital and
health care network and are relied on by all the care delivery processes depend.
The HIS automates clinical, EMR, administrative and inventory functions
for the hospital to successfully handle in‑patients, out‑patients, emergencies,
day care and patient referral, along with specific modules to manage human and
financial resources and provide an uninterrupted supply chain. Figure 7 shows
the components of the technology that can be utilized in a cancer centre.
The HIS should ideally include the following components:
— Help desk, scheduling and patient registration;

— Admissions, discharges and transfers;
— Physician orders and clinical support;
— Billing, package, contract management and accounts;
— In‑built enterprise resource planning interface;
— Laboratory and pathology information system:
● Contract management, registration, accounts receivables and billing;
● Procedures, reporting and work list;
● Quality control;
● Printing, reading and barcode generation;
● Interface with most equipment.
CLINICAL PRODUCTIVITY QUALITY OF CARE ROBUST TECHNOLOGY
Bar coding/ Identity and access

Electronic health record Patient self service
RFID/BCMA management
Clinical decision support Command centre Patient communication Robust network
Computerized physician order Kiosk and mobility Smart cards Business continuity
Customer relationship Remote care/

LIS, RIL, MMS, CDR Disaster recovery
management Telemed and Telerad
PACS Query and complaint Monitoring system and

management Information security
nursing care plans
Learning management/ Hospital based cancer
Electronic prescribing system Wi-Fi and remote access
ML/AL registries (HBCR)
Hospital information system
FIG. 7. Information technology that can be applied to a comprehensive cancer centre.
57
— Radiology Information System:
● Registration, scheduling, billing, contract management and accounts
receivables;
● Procedures, reporting and work list;
● Interface with Picture Archiving and Communications System;
● Built‑in enterprise resource planning interface.
— Material Management System:
● Item master maintenance;
● Item indents and issues;
● Reorder level, reorder quantity, minimum and maximum stock levels
for each store;
● Quotations and preferred vendor, purchase requests, orders creation
and approval process;
● Consignment stock receipt, consumption and regularization;
● Expired stock and quarantine;
● Last in, first out; first in, first out; first expiry, first out methods;
● Periodic physical stock taking and adjustments with tracking.
— Clinical Data Repository:
● Must integrate with the chosen HIS;
● Access to patient medical records.
— Pharmacy Inventory Management System:
● Medicine stock control;
● Medicine ordering;
● Patient specific record of medication supply;
● Management of formulary;
● Aseptic worksheet and labelling system.
— eP:
● Ideally integrate with EMR and pharmacy inventory management
system;
● eP record for patients;
● Standardized prescribing for SACT;
● In‑patient eP medication charts/out‑patients, where available.
10.4. DATA PROTECTION AND CONFIDENTIALITY
As well as preventing unauthorized access, the aims of confidentiality

measures in cancer registration are to ensure: (a) the preservation of anonymity
for individuals reported to the registry and, if necessary, also for those making
such notifications; (b) that cancer registry data are of the best quality possible;
58
and (c) that the best possible use of cancer registry data is made for the benefit of
cancer patients, for cancer control and for medical research [98].
All patient records are governed by data protection acts to be kept secure
and confidential [99]. It is also a condition of registration with medical councils
to respect patient confidentiality. Every facility must comply with a legally
permitted and documented access to the records process.
10.5. MEDICAL RECORDS
The medical records department is responsible for the maintenance of

medical records and medical record services. Medical records are used to
inform the HBCR tasked with the monitoring and planning of patient care at the
institutional level. The major functions of a medical records department include:
— Admissions procedure, including patient identification and the development

and maintenance of the master patient index;
— Retrieval of medical records for patient care and other authorized uses;
— Discharge procedure and completion of medical records after an in‑patient
has been discharged or died;
— Coding diseases and operations of patients discharged or having died;
— Filing medical records;
— Evaluation of the medical record service;
— Completion of monthly and annual statistics;
— Medico‑legal issues relating to the release of patient information and other
legal matters.
The main uses of the medical records are:
— To use the master patient index to identify the patient and locate the patient’s
medical record;
— To document and store the entire course of the patient’s illness and treatment;
— To communicate between attending doctors and other health care
professionals providing care to the patient;
— For the continuing care of the patient;
— Maintenance and regulatory intimation of deaths and other statistics;
— For research of specific diseases and treatment;
— The collection of health statistics [100].
59
Medical records are increasingly relevant for:
— Helping create management scorecards to improve operational performance,

provide health care statistics and aid medical research.
— Helping judicial authorities, insurance authorities, investigating officials,
enquiry officials, by providing required documents/information in time. The
key to disposing of any medical negligence claim rests almost entirely on
the quality of medical records [101, 102].
10.6. CANCER REGISTRIES
There are two main types of cancer registry: (a) hospital based cancer
registries record information on all cancer patients observed in a particular
hospital. Their main aim is to plan, monitor and improve patient care at an
institutional level. Their data are of limited value for epidemiology because it is
not possible to define the population from which their cases arise. (b) Population
based cancer registries seek to collect data on all new cases of cancer which
occur in a well-defined population. As a result, and in contrast to hospital
based cancer registries, they can provide data on the occurrence of cancer in a
particular population. Thus, they are of particular value for epidemiology and
public health [101].
Population based cancer registries (PBCRs) play an important role in
epidemiology by quantifying the incidence and prevalence of the disease
in the community and as a source to ascertain the number of cancer cases in
intervention, cohort and case‑control studies. Their data are also important in
planning and evaluating cancer‑control programmes by: helping to establish
priorities and forecast future needs; monitoring cancer occurrence in relation
to the prevalence of important risk factors; helping to assess and monitor the
effectiveness of screening programmes; and evaluating cancer care through
survival statistics. The data items to be collected by a population based cancer
registry are determined by their aims, the data collection methods to be used
and the resources available. The emphasis should be on the quality of the data
rather than their quantity. The completeness and validity of the data should be
monitored regularly. Population based cancer registries are particularly useful in
countries where reliable, cause specific mortality data are largely unavailable.
One of the main advantages of hospital registries is that they have
ready and instant access to medical records, the primary source of cases.
A comprehensive cancer centre should have a HBCR that facilitates planning and
monitoring cancer care of the consulting population. Data collected by an HBCR
are also used for physician education, for some types of research, for facility
60
utilization assessment and as an important source for PBCRs in the area. The data
items collected by a hospital registry are more extensive than those collected by
a PBCR. It is important to clarify that an HBCR does not attempt to register all
cancer cases occurring in any defined population; thus, incidence rates cannot
be determined. Changes over time in the numbers of any type of cancer or
patient characteristics may only reflect shifts by patients (or doctors) from one
institution to another. The cancer cases in any one hospital (or group of hospitals)
may not be representative of all cancer cases that are occurring in the area. For
instance, certain institutions are referral centres for specific types of cancer or for
particularly difficult or extensive tumours.
Hospital cancer registries produce reports on the numbers of cancers seen
in the hospital per year by cancer site, stage, age and sex. These results may
be presented as proportional incidence ratios (i.e. the frequency of cancers of
a particular site in relation to the total number of cancer cases). They may also
provide information on methods of diagnosis, treatment methods, response to
treatment and survival at an institutional level. The hospital registry data may
also be used to forecast future demands for services, equipment and manpower in
a given hospital. Although these registries cannot provide incidence rates in the
general population, they may be used for epidemiological purposes. For instance,
case control studies may be set up to investigate the aetiology of a particular
cancer by comparing the characteristics of cases with those of a control group.
This control group may be formed by patients with other types of cancer or by
other hospital patients [103].
11. EDUCATION, TRAINING AND RESEARCH
11.1. TRAINING, ONGOING EDUCATION AND ACCREDITATION
It is recommended that all health care professionals involved in the work

of a cancer centre receive adequate academic education and clinical training.
National or international guidelines typically lay the basis for the definition of the
path to be followed to become a professional competent to work independently in
one or more specialties.
The types of education and training include structured and supervised
clinical training, workshops, lectures and on‑line education courses, continuous
professional development and courses to prepare for certification exams or to
give continuous professional development credits. Training programmes should
be developed in collaboration with an academic university in the country.
61
Develop
Map current
optimization
Define Establish health
strategies to
services and required professionals
increase
interventions competencies against
quality and
competencies
coverage
FIG. 8. Path to continuing professional development for cancer care professionals.
Curriculums should be developed in line with national accreditation and local

needs. IAEA and WHO curriculums are available in handbooks and can be
adapted to fit local needs [66, 104–111]. Before initiating a training programme,
objectives, curriculums, time frame, and distribution of responsibilities should be
outlined and approved in writing by the local health and professional counsels.
The centre also needs to ensure there are sufficient patients and faculty in order to
accomplish the goals of training. Exchange programmes in the region and various
e‑learning resources offered through the IAEA and professional societies can be
used to supplement educational activities. Figure 8 summarizes the key steps for
identifying potential areas for continuing professional development activities.
When setting up a cancer centre it is important to:
— Identify the required professionals and other services that will be offered by
the centre;
— Refer to international or national standards and guidelines to define the
responsibilities of each group of professionals;
— Identify the appropriate competencies that must be met, as well as the
relevant educational and training paths;
— Establish a roadmap and timeline for planning, recruiting and providing
ongoing training, where necessary.
11.2. RESEARCH
11.2.1. Rationale
A clinical research programme is an essential component in any cancer

centre. It has an intrinsic goal of generating or contribute to generate knowledge,
but also adds value by: contributing to the clinical training programmes; creating
multicentred research networks; leveraging other available resources; and
strengthening quality and safety culture in the centre. It can also be a vehicle to
accurately assess outcomes as a continuous quality improvement tool. Research
is also key for integrated medical training. The complexity and organization
62
of the research programme will vary according to the characteristics of the
cancer centre.
11.2.2. Introduction
In the context of a cancer centre, research can be defined as a structured

and systematic way of producing new knowledge that provides the foundation
for better patient care and community benefit. Research in health covers a wide
scope, on a continuum from basic research through clinical research to health
economics and patterns of care research that supports changes in policy making.
Basic research involves extensive in vitro or in vivo studies to identify
new disease mechanisms, response pathways to treatments or new molecules or
treatments with potential clinical use. Translational research links basic research
to later phases of clinical research.
Clinical research is often the biggest research component in cancer centres.
It can be defined as any health related research that involves human subjects,
their tissues or data. WHO defines clinical trials as any research study that
prospectively assigns human participants or groups of humans to one or more
health related interventions to evaluate the effects on health outcomes. In this
context, interventions include, but are not restricted to, drugs, cells and other
biological products, surgical procedures, radiological procedures, devices,
behavioural treatments, process of care changes, preventive care, etc. [112].
Clinical trials are usually conducted in four phases that build on each
another: phase I studies, where the safety of a new intervention is tested; phase II,
where interventions proven to be safe in phase I are tested for efficacy to test
the benefit or response; phase III trials compare the safety and effectiveness of
an experimental intervention against a reference treatment; and finally phase IV,
where studies test approved interventions on a larger scale over a longer period
of time to obtain complete knowledge of the performance of these interventions.
Community based research concentrates on structural, social and physical
environmental matters, in addition to implementation research, over active
involvement of society members, organizational representatives and researchers
in all aspects of the research process [113]. In this case, the centre of gravity
is displaced towards the community centres, while the cancer centre provides
research coordination and support, sometimes in collaboration with other
partners, such as local universities.
Research is one of the pillars that build the activity in a modern hospital
(and cancer centre). It is not optional and cannot be ignored in the design of a
comprehensive cancer centre.
63
11.2.3. Governance
Research is a controlled, formalized and institutionalized activity. It is also

highly regulated in order to protect vulnerable individuals, research ethics and to
preserve accountability in the funding institutions [114].
Research governance is needed to safeguard investigators and participants
in the research by providing a clear framework within which to work. Research
governance is a comprehensive and integrated system for administration and
supervision of a research programme. The concept goes beyond the administrative
and operations related activities and includes a more broad set of regulations,
principles and standards of good practice used to: achieve and continuously
improve research quality; preserve and enhance scientific quality and reduce
fraud and misconduct; mitigate possible risks associated with proposed
interventions; monitor and evaluate performance; promote good practices; ensure
accountability of the funding institutions; resolve ethical issues associated with
the research question or method; and protect vulnerable groups [115, 116].
The basis for the development of a research governance policy is given by
the good clinical practice (GCP) guideline, a global ethical and scientific standard
for designing, conducting, recording and reporting trials that involve human
subjects [117]. The foundation for the guideline is the Declaration of Helsinki, a
set of ethical principles regarding human experimentation developed and adopted
by the World Medical Association at the 18th World Medical Assembly in 1964
in Helsinki and amended in 1975, 1983, 1989 and 1996. Research Governance
Frameworks have been tested in various income and regional settings [116,
118, 119]. Research programmes are often enhanced and improved with the
implementation of these Research Governance Frameworks.
Central to the Research Governance Frameworks is the ethics committee,
or institutional research boards. The Declaration of Helsinki states that
research protocols have to be reviewed by an ethics committee, which must be
independent of the investigator, the sponsor, or any other type of body that may
exert undue influence. The International Council on Harmonisation describes
an institutional research board as a group that protects the rights, safety and
well‑being of people involved in clinical research by reviewing and approving
all aspects of the research protocol. The institutional research board has the
authority to approve, disapprove, monitor, or require modifications in all research
activities under its jurisdiction. These boards are also called independent ethics
committees in Europe.
64
In setting a sustainable human resources model for research in a cancer

centre, it is important to create a qualified research team and a team based
approach to research. Staffing a research programme requires an understanding
of the type of research that will be performed. Human resources fall into three
different staff categories: research, support and administration.
The research staff is responsible of the scientific component of the research
programme. The principal investigators, or coordinating study investigators, are
also responsible of the overall integrity of the research conducted.
Staff research associates or research staff assistants, perform tasks or
procedures to support supervised research. They play a very important role in
ensuring the continuity of the research programme. Study/research coordinators,
sometimes in association with the study nurse, connect the research protocol with
the needs and reality of the patients — the subject of the study. Depending on the
research profile performed at the cancer centre, the profile of the support staff
varies from laboratory technicians to data management specialists, pathology
laboratory technicians, cancer registry data collection specialists and statisticians,
and dedicated pharmacy staff.
The administrative staff will support the research activities by providing
administrative support to the research programme. This includes document
management, coordination and communication support.
Training human resources is essential for a successful and sustainable
cancer research programme. The Association of Clinical Research Professionals,
in collaboration with the Joint Task Force for Clinical Trial Competency,
have developed a framework of eight core competency domains designed to
standardize the professional development of the workforce involved in clinical
research [120, 121].
Infrastructure comprises physical structures and facilities that are crucial

and/or should support activity leading to successful research processes and
outcomes. This includes buildings, transport and communication, water and
power supply, etc. The infrastructure and equipment needed for setting up a
research programme in a cancer centre depends on the type of research planned.
Clinical research requires core treatment facilities, access to central
services, document management infrastructure, equipment and administrative
areas. Depending on the type of research, core treatment facilities include:
specialized calibrated equipment; surgical areas including an intensive care unit;
blood, biomarker and other sample collection and processing; and monitoring
65
and specialized nursing areas. Access to central services, such as specialized
laboratory, pathology, imaging or pharmacy services, including aseptic
preparation facilities, together with the skilled personnel, is essential to the
conducting of clinical research.
Source documentation management infrastructure and equipment is
necessary for compliance with GCP. All clinical trial information must be
recorded, handled and saved for precise reporting and interpretation. This
principle applies to all records, regardless of media type used. Filing and
archiving the trial master file is a mandatory requirement for two main reasons:
adequate reporting, interpretation and verification (including the tracking of all
events); and for ensuring the protection of the participating individuals.
Some basic support infrastructure is also needed. This includes meeting
and working areas; access to libraries (including licences for e‑libraries) and
archives; computers and internet access (including videoconferencing) and data
storage (either physical or cloud space); interview equipment (especially for
community based research); office space and equipment; and publishing and
printing equipment.
11.2.6. Quality assurance and safety
Any research programme requires an integrated and comprehensive

system to ensure quality and safety. These are related concepts, safety being a
consequence of a strong approach to quality management. A quality management
system (QMS) includes all activities of the overall management of the
programme that determine the quality policy, objectives, and responsibilities and
their implementation.
Quality management is a transversal activity in a cancer centre that has to be
managed in an integrated and comprehensive way through a QMS that includes
a research component. Depending on the complexity of the cancer centre and the
research programme, it may be worth creating, implementing and maintaining a
subsystem for the research programme, connected to the main QMS.
The QMS applies to all activities related to the research programme. It
also defines the responsibility, authority and interrelationships of personnel who
manage and perform research projects. The QMS also informs institutional policy
making to pursue excellence in the execution of research projects.
Depending on the criteria used for setting it up, the main components of the
QMS are the policy statement (level 1), the pyramid of documentation (level 2,
procedures; level 3, SOPs and work instructions; level 4, records), the control
and monitoring system, the quality audit system and the quality committee.
The level of research complexity will vary by the size of the cancer centre.
For example, a small hospital based centre may limit research to retrospective
66
studies of patient charts to evaluate outcomes, while a large comprehensive
cancer centre can have a wider variety of research capabilities, from basic
research to phase I–III studies.
12. GOVERNANCE,
ADMINISTRATION AND FINANCING
12.1. GOVERNANCE
Hospital governance is defined by the oversight structure of the organization

put in place to oversee and hold the hospital management accountable in its
objective to maximize stakeholder value. Governance begins at the top with the
establishment of the Board. The Board, with its appointed Board of Directors,
as custodian of stakeholder interests, is expected to provide stewardship and
direction, as well as an evaluation of the management’s performance.
Boards are expected to review the risk management and internal control
systems with a view to determining that they remain appropriate and are
functioning effectively. The Board acts as the trustees to the property and
welfare of the organization. It defines the vision, mission, values, objectives and
policies of the organization, which form the basis for defining the strategy and its
implementation.
Boards are also expected to oversee the design of the organizational
structure and select the top executives and key personnel. They review financial
performance and give financial approval for various projects, reserves, distribution
of profit, loan repayment, etc. Boards are a vital link between the cancer centre
and external entities such as the government or economic institutions.
Both governance and control depend on the size and complexity of the
organization and the nature of risk profiles and challenges. The chief executive or
the head of the hospital management team reports to the Board.
Public sector cancer centres are overseen by the national government.
A high level governance mechanism with representation from health, finance,
education and other sectors of government can guide the work and take policy
decisions. An operational committee with multidisciplinary team of technical
officers and administrators is needed.
67
12.2. ADMINISTRATION
It is essential to balance all facets of care, quality and operations to ensure a

sustainable, expandable and collaborative service model. This section provides a
guiding structure for the various roles and responsibilities that need to be assigned
while setting up and managing a cancer centre. This structure can be scaled
down to suit smaller centres, whose focus may be prevention, health education,
initial diagnosis, referral to a higher centre, provision of basic follow‑up care
and palliative services. This structure can further link a state or national level
programme that aligns with their goals and specialty focus.
12.3. FINANCIAL MANAGEMENT
Oncology care requires capital, operational and staff investment for

quality care delivery, and to meet the specialized needs of adults and children
with cancer [122]. Financing of a cancer centre can be challenging, with overall
costs increasing in line with the complexity and costs of products and equipment
and the number of people seeking care at cancer facilities. Once capitalization
is initiated, finance departments play a crucial role in ensuring that there are
resources available for meeting the comprehensive cancer centre’s objectives,
and that fiduciary responsibilities are upheld. It is imperative to have a strong
finance team from the conception stage, so that cash flows are estimated at every
juncture of the journey in order to be able to make funds available [123].
This can only be achieved through strategic decisions and capital
investments that bear in mind the cancer centre’s vision and mission, and needs
not only to have enough resources to set up the centre, but also to ensure that
there is funding available for operations until the centre breaks even [124]. There
should be a detailed budgeting exercise followed by a cash flow mechanism to
ensure a viable project, including inputs from clinical planning, medical and
non‑medical equipment, design and the building contractor.
Sustainability requires a thorough analysis and adequate calculation for
funds to pay salaries, purchase consumables, maintain and replace equipment in
due time, maintain and expand the existing infrastructure, and train the current
and new workforce. It is important to carry out a feasibility study upfront and
estimate the gaps and the cost. Some important features include:
— Planning to be efficient. This involves answering questions such as how

many beds, ICUs and OTs are required? What is the current bed occupancy
rate and anticipated increase in volume? What technology will be used?
How can facility guidelines be used to facilitate the planning and efficient
68
use of resources? It is important to both avoid unnecessary expenditures and
assess the most cost effective purchases.
— Innovative financing mechanism/identifying multiple donors. It is
the responsibility of the organization setting up the cancer centre
(governmental/NGO/private) to make financial resources available and
form partnerships, and there are several ways this can be done:
● Vendor financing. This includes various modes of partnership with
equipment manufacturers, including mechanisms such as:
○ Deferred payment over 8–10 years.
○ Vendor financed complementary equipment, where the vendor
lends certain expensive equipment to a hospital, which purchases
their inventory of services or consumables; for example,
laboratory reagents and scans.
● Lease finance. This can be adopted in cases where vendor financing
is not possible. Cancer centres can reach out to finance companies to
help them lease equipment. This permits the use of equipment by the
centre without giving them ownership rights.
● Maximizing cost efficiency and revenues.
○ Empanelment with government insurance schemes.
○ Staggered recruitment of human resources based on occupancy.
○ Bulk procurement for drugs and consumables.
○ Policy and advocacy.
● Philanthropic support. Many cancer centres seek and receive
philanthropic support, which has the potential to transform the future
of cancer care and comprehensive cancer centres. The centre may
work with donors and/or foundations to generate funds for strategic
investments.
Lastly, financial systems should be able to record base data for analysis
such as consumption subcategories, risk categorization of patients, and norms.
The finance team should have capabilities in analytics to provide insights on
deviations for ensuring timely measures for sustainability.
69
13. ADVOCACY, COMMUNITY
ENGAGEMENT AND PARTNERSHIPS
13.1. ADVOCACY
Advocacy is a critical component to enhance all areas of cancer control.

Cancer centres are best placed to provide the science and evidence for advocacy
and to be the advocate for cancer control. As providers of cancer care in the
community, cancer centres enjoy better credibility in communications.
13.2. COMMUNITY ENGAGEMENT AND PARTNERSHIPS
The cancer centre has an important role in forging connections with civil
society organizations to facilitate access to important services and support
throughout the care trajectory. Formalized partnerships at the local, national
and international levels can allow the cancer centre to work with external
organizations to resolve unmet patient needs and advocate for patient services
and support that are outside the scope of the cancer centre, or best delivered in
the community. Partnerships with foundations and industry are also important.
Civil society organizations, sometimes named the ‘third sector’ after
government and commerce, refer to the private and family sphere and encompass
a wide array of bodies, which include NGOs, society groups, indigenous groups,
labour unions, charitable organizations, faith based organizations, professional
associations, and foundations aiming for collective action around shared interests,
purposes and values. When mobilized, civil society, as a non‑State actor, has the
power to influence the actions of elected policy makers and businesses and play
crucial and diverse roles in societal development.
Civil society organizations can be engaged to:
— Support a cancer centre in ensuring that patient experience and outcomes

are of central focus in the design and daily services of the centre.
— Help drive the vision of the first cancer centre in its role beyond that of a
stand‑alone treatment clinic to that of a ‘reference cancer centre’ for the
country and community.
— Participate in realizing that vision in a multifaceted approach, holding
institutions accountable and promoting transparency, raising awareness of
consumer and societal issues, delivering services to meet public information,
education and health needs, bringing experience and knowledge of experts to
70
shape policy and strategy, giving power to the marginalized and supporting
citizen engagement.
— Promote the formation of community based groups, such as local cancer
councils, which play important roles in engaging the target population to
seek available services. Working hand in hand with the cancer centre, these
groups can both shape and implement population based cancer management
tailored in creative ways to the local context. Vehicles for community
outreach and engagement, including the survey and linkage of disease rates
to geographical areas, can enhance actions to reduce loco‑regional health
care disparities. They can also identify barriers to access, such as lack of
transport. Without such grassroots collaboration and awareness campaigns,
much of the marginalized target population may remain out of reach.
— Develop their expertise to support institutions and services, when requested
by the Ministry of Health or the cancer centre, critical to the monitoring,
evaluation and improvement of clinical outcomes, as well as providing
trusted sources of information for the public, such as the national cancer
control strategy through the development and publication of a national
cancer control plan; cancer registry; national cancer research institute; cancer
society; national cancer patient network and professional organizations
involved in the disciplines of cancer care.
71
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and Standardization for Clinical Use, IAEA Human Health Series No. 5, IAEA, Vienna (2015).
INTERNATIONAL ATOMIC ENERGY AGENCY, Standard Operating Procedures for

PET/CT: A Practical Approach for Use in Adult Oncology, IAEA Human Health Series No. 26,
Radiotherapy
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Practices: A Tool for Quality Improvement, IAEA, Vienna (2007).
84
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and Concept Design Considerations, IAEA Human Health Reports No. 10,
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INTERNATIONAL ATOMIC ENERGY AGENCY, Staffing in Radiotherapy: An Activity

Based Approach, IAEA Human Health Reports No. 13, IAEA, Vienna (2015) CD-ROM.
INTERNATIONAL ATOMIC ENERGY AGENCY, The Importance of Having an Adequate

National Legal Framework for the Safe, Secure and Peaceful Use of Nuclear Technology
WORLD HEALTH ORGANIZATION, INTERNATIONAL ATOMIC ENERGY AGENCY,

Technical Specifications of Radiotherapy Equipment for Cancer Treatment,
WHO, Geneva (2021).
Safety and security
INTERNATIONAL ATOMIC ENERGY AGENCY, Code of Conduct on the Safety and

Security of Radioactive Sources, IAEA/CODEOC/2004, IAEA, Vienna (2004).
INTERNATIONAL ATOMIC ENERGY AGENCY, Establishing the Infrastructure for

Radiation Safety, IAEA Safety Standards Series No. SSG-44, IAEA, Vienna (2018).
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Framework for Safety, IAEA Safety Standards Series No. GSR Part 1 (Rev. 1),
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85
Annex
CASE STUDY: A DISTRIBUTED CANCER CARE

MODEL FOR PATIENT ACCESS BY TATA TRUSTS
AND THE GOVERNMENT OF ASSAM, INDIA
A–1. TATA TRUSTS MODEL OF CANCER CARE
In India, there is a need to increase the allocation of trained personnel

resources, coordinate multisectoral policy interventions, and enhance the
engagement of the health system in activities related to cancer prevention and
control [A–1]. The Tata Trusts model of cancer care aims to set up a dynamic,
interdependent, cross‑flowing, technology driven tiered model of care. While
the tier definitions are described differently than those recommended in this
publication, with level one being the highest level of service, the model can be
considered as one example of a cancer centre set‑up which enables the following:
(1) Access through disaggregation. This model features different levels of care
with specific components (see Fig. A–1). Awareness, community screening
and home based palliative care are presented in level 4, while the 3rd
level (L3), situated adjacent to the District/Civil hospital, offers diagnostic
Oncology Allied
A tiered service delivery model to ensure availability
of cancer care at every level
Nuclear Lab Research/ Community
Radiation Medical Surgical
medicine services academics outreach
      
Level 1: Advanced
Apex
centres
Level 2:
Dedicated unit, 
annexed to     High end
ᵡ 
GMC/MSH
Level 3:
Diagnostics and day care   ᵡ ᵡ  ᵡ 
Basic
unit annexed to DH
Level 4:
Awareness, community screening, ᵡ ᵡ ᵡ ᵡ ᵡ ᵡ 
home based palliative care
FIG. A–1. Model of cancer care with different levels of care offering specific components.
87
services (radiology and pathology) along with protocol driven day care
management of chemotherapy and radiation. These centres will ease the
burden of routine care currently managed by the few apex centres. The 2nd
level (L2), located at a Government Medical College, offers comprehensive
cancer services except highly technical procedures such as bone marrow
transplantation, neurosurgery and complex surgical resections or
reconstructive work, as well as advanced diagnostics (molecular, genomics
and proteomic). The apex level (L1), which is where the supply is currently
concentrated, will focus on complex care, education and research.
(2) Technology driven integration. Radiology, pathology and nuclear medicine
reporting, as well as treatment planning, are enabled virtually and remotely
in a location where oncology specialists are available (see Fig. A–2). This
helps overcome the biggest bottleneck, namely insufficient specialized
manpower at the delivery centres [A–2]. The central station will manage:
— Patient navigation and information dissemination through a
multilingual call centre for patient queries, reminders and counselling.
— Collaboration between clinicians through virtual tumour boards,
treatment planning, reporting and asset management and utilization.
— Standardization and down streaming of pathways using a ‘maker and
checker’ mechanism for diagnostics, chemotherapy and radiation.
This will support the ‘upskilling’ of posted resources.
FIG. A–2. Relationship between the service centres and the central command.
88
— Tracking use of assets and movement of personnel in terms of
bed utilization, emergency care, billing, quality assurance, shift
management and leave support.
(3) Standardization of care delivery. Use of standardized clinical protocols
in adherence to guidelines issued by the national cancer grid, operational
hospital processes and aspects of patient experience [A–2]. Uniform
infrastructure and facilities across all centres available close to home will
eventually reduce the number of patients seeking large city based hospitals
for their clinical reputation.
(4) Patient care financing. Financial barriers are often quoted as the reason for
patients choosing to not access treatment or dropping out mid‑treatment.
Each centre is being equipped to educate and assist patients to take
advantage of appropriate insurance schemes, such as Ayushman Bharat
(Central Government scheme) or Atal Amrit Abhiyan (insurance scheme
floated by the Government of Assam), etc. [A–3, A–4]. Other instruments
under consideration to ease this problem are patent loans and subscriptions
to the provider centres.
(5) Personnel and training. The staffing in these facilities will pilot a unique
model well established in developed countries but in its nascent stage in
India. A team of specialists and nurses are being developed through bespoke
fellowship courses in oncology of three months and six months duration,
respectively. The intent is to shift tasks that can be provided by specialist
Dibrugarh
Lakhimpur
Jorhat
Tezpur
Kokrajhar
Darrang
Barpeta Diphu
Guwahati
L1 – Apex centre
Silchar L2 – Comprehensive cancer hospital
L3 – Day care centre
FIG. A–3. Map of Assam showing proposed locations for cancer centres.
89
medical personnel with adequate training away from oncologists, thereby
addressing the requirement of capable human resources in a limited supply
scenario. Such models have already been tried elsewhere across the world
and in India [A–5 to A–9].
(6) Early detection. The proposed model adopts a ‘catchment’ approach going
beyond infrastructure creation using the following vehicles:
— Conducting screening camps. Population based screening for common
cancers (oral, breast, cervix) based on Government of India guidelines
for early detection of cancer and management of referral systems.
— Community awareness about risk factors of cancer and prevention
measures. Training of frontline health workers, such as the auxiliary
nurse‑midwife, Anganwadi worker, accredited social health activist,
medical social workers and training of women’s self‑help groups.
— Tobacco control. Outreach programme for students covering
National Service Scheme students and teachers from colleges, school
(class 8–10) students and teachers, nursing college students and
teachers, Cigarettes and Other Tobacco Products Act sensitization
workshop for district law enforcement and district education officers,
working with the Education Department for the enforcement of
tobacco free educational institutions.
— Training of private practitioners for timely referrals (general
practitioners (GPs), dentists, etc.), training allopathic practitioners
(GPs, dentists, gynaecologists, etc.).
— Cancer registry. Making cancer notifiable/reportable in every state,
implementation of a hospital based cancer registry, implementation of
a population based cancer registry in the relevant area.
— Palliative care. Providing home based palliative care services to the
community in the relevant area. Holding sensitization workshops
with government departments to ensure availability of opioids in
institutions.
— Patient affordability. Spreading awareness among the population of
government insurance schemes.
(7) Research programmes. In addition to clinical and training activities, an
ambitious research programme was started which has attracted significant
grant funding. These are in the areas of public health, cancer therapeutics
and low cost technology. Management of collaboration with researchers in
India from an interdisciplinary background, international organizations such
as King’s College London, the US National Cancer Institute and Harvard
University, as well as industry partners in biotechnology and therapeutics
around the world.
90
Group CEO Roles and responsibilities
Central/ • Strategic direction

Clinical • Standardization
country HQ Quality and
services and Support Partner- • High level networking/
service HR SCM Finance Legal IT
command services ships arrangements with other hospitals
excellence
centre • Programme development
COO/CEO
• Resource management
• Monitoring of outcomes at units
Regional HQ • Quality assurance
Quality and service • Smooth operations
Finance and Legal
Clinical services excellence/support HR
SCM
services
Facility Head
Unit level • Operations and implementation
(L1, L2, L3)
Clinical Quality and service Support
SCM Finance HR
services excellence services
FIG. A–4. Organizational structure for a level 3 comprehensive cancer centre.
The model described above is being piloted in the State of Assam by

Tata Trusts, in collaboration with the State Government, through a special
purpose vehicle, the Assam Cancer Care Foundation, to set up a network of ten
hospitals across the three levels initially. These hospitals are in different stages
of construction and will be commissioned in a phased manner starting from the
year 2021 after which care outcomes will be measured.
The locations of ten upcoming hospitals in this distributed network are
mentioned below and shown in Fig. A–3, with the map of Assam. The State
Cancer Institute at Guwahati is being strengthened to an L1 centre. A total of
To be considered for
Full-time
outsourcing
Executive Assistant Facility Head
Lead: Clinical Lead: Quality and Lead: Supply chain Lead: Support
Lead: Nursing Lead: Finance Lead: HR
services service excellence management services
Onco Nurses Doctors Engineering and

Medical quality Accounts and Procurement
Recruitment, L&D maintenance
taxation
Gen Nursing Food and
Residents Service excellence Stores
Payables cafeteria
OT and CSSD Operations
MRD ICN Billing (includes Pharmacy Security and fire

OPD and
Diagnostics cashier, insurance)
Nutrition Housekeeping
Palliative
Receivables
Stoma Biomedical Front office
engineering Planning and MIS
Preventive Paramedics/ IT
Technicians
Infection control
Diagnostics
ICU and HDU
Coordinators/
Nursing Gen, Duty Docs
Superintendent/
Admin
FIG. A–5. Organizational structure for a level 3 comprehensive cancer centre.
91
four L2 centres are being established adjacent to Government Medical Colleges
at Dibrugarh, Barpeta, Silchar and Diphu. A total of five L3 centres are being
set up, with four adjacent to Government Medical Colleges (existing and
upcoming) at Tezpur, Jorhat, Lakhimpur and Kokrajhar, and one adjacent to
the District Hospital in Darrang (see the organizational structure in Figs A–4
and A–5). Accommodation will be provided for staff at all facilities and for
patients near L2 facilities. This network will reduce travel times to access cancer
services to less than 2.5 h for every person in Assam (see Table A–1).
TABLE A–1. BROAD FACILITY CONFIGURATION LEVELS AND

MULTIDISCIPLINARY CARE SERVICES
Department L1 L2 L3
Diagnostic
X ray/fluoroscopy 1 1 0
X ray 2 1 1
Ultrasound 3 2 1
Mammography 1 1 1
CT 1 1 1
MRI 1 1 1
Interventional radiology
(digital subtraction 1 0 0
angiography, DSA)
Endoscopy 2 2 0
Audiometry and brainstem

evoked response audiometry 1 0 0
(BERA)
OPD
Consulting rooms 30 20 10
92
MULTIDISCIPLINARY CARE SERVICES (cont.)
Department L1 L2 L3
Day care
Chemotherapy chairs 20 20 15
Chemotherapy beds 20 20 12
Day care beds 10 4 10
Total 50 44 37
Treatment
Linear accelerator 4 2 2
CT simulator 1 1 1
Brachytherapy 1 1 1
Minor OT 2 2 1
PET–CT 1 1 0
Gamma camera/SPECT 1 1 0
Cell irradiator 1 0 0
Preparation room in radiation

therapy and radiology for 1 0 0
paediatric sedation
Surgery and in-patient
Operating theatres 8 3 0
SICU/HDU/ICU beds 40 21 0
93
Department L1 L2 L3
Ward beds and palliative care

160 48 0
beds
Bone marrow transplantation

8 0 0
beds
Radioactive iodine beds 3 0 0
Pre-/post-op 18 7 0
Endoscopy, minor OT
13 8 0
recovery and DSA
ER 8 4 0
Total beds 250 88 0
Other services
Procedure and treatment

rooms: OPD/chemo, wards 7 4 2
and ICU
Dialysis/CRRT 2 1 0
TMT/ECG/Echo rooms Yes One each One each
Telemedicine Yes Yes Yes
Blood bank, complete Yes Yes No
Blood bank, storage space Yes Yes Yes
Tumour board Yes Yes Yes
Home care orientation area Yes Yes Yes
94
Department L1 L2 L3
Laboratory, basic —
collection, haematology and Yes Yes Yes
biochemistry
Laboratory, advanced — Yes, with

Yes No
immunology/histopathology flowcytometry
Central sterile services

Yes Yes Yes
department
Physiotherapy Yes Home care Home care
Mortuary Yes Yes No
Mandatory inclusions in all facilities
• Preventive oncology, tumour board room, measurable residual disease, cancer

registry, pharmacy and training facilities.
• Medical gas pipeline system, central monitoring system, nurse call bell system,
modular OTs, biomedical waste disposal system. kitchen, laundry, café, dining, stores
and administration.
• Heating, ventilation and air conditioning system, uninterrupted power supply and
diesel generator sets, sewage treatment plants, water treatment plant and reverse
osmosis plant, closed circuit television (CCTV) and public address system, access
control system, power backup, fire detection and alarm system and detailed building
signage plan.
• Patient centric design.
• Compliant with building standards and national clinical requirements.
• Energy efficient green building design.
• Indian context design.
• Digital nerve centre and central command centre.
95
REFERENCES TO THE ANNEX
[A–1] SRINATH REDDY, K., SHAH, B., VARGHESE, C., RAMADOSS, A., Responding
to the threat of chronic diseases in India, Lancet 366 (2005) 1744.
[A–2] PRAMESH, C.S., BADWE, R.A., SINHA, R.K., The national cancer grid of India,
Ind. J. Med. Paed. Oncol. 35 (2014) 226.
[A–3] AYUSHMAN BHARAT, www.pmjay.gov.in
[A–4] ATAL AMRIT ABHIYAN, A Pioneering State Wide Health Insurance Scheme,
atalamritabhiyaan.aaas-assam.in/
[A–5] COOMBS, L.A., HUNT, L., CATALDO, J., A scoping review of the nurse
practitioner workforce in oncology, Cancer Med. 5 (2016) 1908.
[A–6] WEN, J., SCHULMAN, K.A., Can team-based care improve patient satisfaction? A
systematic review of randomized controlled trials, PloS One 9 (2014) e100603.
[A–7] CONIGLIO, D., Collaborative practice models and team-based care in oncology, J.
Oncol. Prac. 9 (2013) 99.
[A–8] KELVIN, J.F., et al., Non-physician practitioners in radiation oncology: Advanced
practice nurses and physician assistants, Int. J. Radiat. Oncol. Biol.
Phys. 45 (1999) 255.
[A–9] ERIKSON, C., SALSBERG, E., FORTE, G., BRUINOOGE, S., GOLDSTEIN, M.,
Future supply and demand for oncologists: Challenges to assuring access to oncology
services, J. Oncol. Prac. 3 (2007) 79.
97
ABBREVIATIONS
CT computed tomography
eP electronic prescribing
HBCR hospital based cancer registries
HIS hospital information systems
ICU intensive care unit
MDT multidisciplinary team
MNT medical nutrition therapy
MRI magnetic resonance imaging
OT operating theatre
PCR polymerase chain reaction
QA quality assurance
QMS quality management system
SACT systemic anticancer therapy
99
CONTRIBUTORS TO DRAFTING AND REVIEW
Abdelaziz, F.R. International Atomic Energy Agency
Abdel‑Wahab, M. International Atomic Energy Agency
Anderson, O.B. World Health Organization
Badwe, R. Tata Memorial Centre, India
Barton-Burke, M. Memorial Sloan Kettering Cancer Center, United

States of America
Borrás, J. Instituto Catalán de Oncología, Spain
Bray, F. International Agency for Research on Cancer
Buchpiguel, C. Hospital das Clínicas da Universidade de São Paulo,

Brazil
Chandy, M. Tata Medical Centre, India
Cracknell, N. Ramsay Health Care, United Kingdom
Dalby, M. Barts Health NHS Trust, United Kingdom
El‑Haj, N. International Atomic Energy Agency
El‑Metnawy, W. Centre of Clinical Oncology and Nuclear Medicine,

Egypt
Ferdous, L. Bangabandhu Sheikh Mujib Medical University,

Bangladesh
Fidarova, E. World Health Organization
Fitch, M. University of Toronto, Canada
Foreman, E. The Royal Marsden NHS Foundation Trust, United

Kingdom
Gauvreau, C. International Agency for Research on Cancer
Ghoz, H. Clatterbridge Cancer Centre, United Kingdom
Giammarile, F. International Atomic Energy Agency
101
Gospodarowicz, M. Princess Margaret Cancer Centre, Canada
Greiss, H. Fertility & Cryogenics Lab, United States of America
Grewal, A. Tata Trusts, India
Grover, S. University of Pennsylvania, United States of America
Holmberg, O. International Atomic Energy Agency
Ilbawi, A. World Health Organization
Kassick, M. International Atomic Energy Agency
Lam, C. St. Jude Children’s Research Hospital, United States

of America
Liao, Z. University of Texas MD Anderson Cancer Centre,

United States of America
Loreti, G. International Atomic Energy Agency
Luna‑Fineman, S. World Health Organization
Mandane, B. Guy’s and St Thomas’ NHS Foundation Trust, United

Kingdom
Maree, L. University of the Witwatersrand, South Africa
McQuestion, M. Princess Margaret Cancer Centre, Canada
Mikhail, M. International Atomic Energy Agency
Milner, D. American Society for Clinical Pathology, United

States of America
Murphy‑Alford, A. International Atomic Energy Agency
Mushani, T. Aga Khan University School of Nursing and

Midwifery, Kenya
Nabhani‑Gebara, S. Kingston University London, United Kingdom
Narasimhamurthy, S.M. Pennsylvania Hospital, United States of America
Ortiz, R. World Health Organization
102
Otoe Ohene Oti, N. National Centre for Radiotherapy and Nuclear
Medicine, Ghana
Paez, D. International Atomic Energy Agency
Pandit, M. Tata Trusts, India
Patel, A. The Christie NHS Foundation Trust, United Kingdom
Pineros, M. International Agency for Research on Cancer
Polo, A. International Atomic Energy Agency
Pramesh, C.S. Tata Memorial Centre, India
Prasad, R.R. State Cancer Institute, India
Purushotham, A. King’s College London, United Kingdom
Ranganathan, P. Tata Memorial Centre, India
Roitberg, F. World Health Organization
Sebastian, P. Cancer Care Initiative, Tata Trusts, India
Sethuraman, L. Tata Trusts, India
Sheldon, L. Oncology Nursing Society, United States of America
Siderov, J. Olivia Newton‑John Cancer Wellness and Research

Centre, Austin Health, Australia
Sullivan, R. King’s College London, United Kingdom
Torode, J. Union for International Cancer Control, Switzerland
Trimble, E. National Cancer Institution, National Institutes of

Health, United States of America
van der Merwe, D. International Atomic Energy Agency
Varghese, C. World Health Organization
Wardell, S. The Christie NHS Foundation Trust, United Kingdom
Wright, D. University Hospital Southampton NHS Foundation

Trust, United Kingdom
103
Yarne, J. National Centre for Radiotherapy and Nuclear
Medicine, Ghana
Zubizarreta, E. International Atomic Energy Agency
Technical Meeting
Vienna, Austria: 13–15 February 2019
104
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22-00059E-T
Cancer centres are a major resource in ensuring a
comprehensive approach to cancer treatment and
its planning. This publication proposes a framework
to develop a cancer centre and/or to strengthen the
provision of services in an existing cancer centre. The
framework provides the features of multidisciplinary
cancer care and details the infrastructure, human
resources and equipment for different services. This
framework is expected to be used as a guide to
developing cancer centres, taking into consideration
the local context and resources.

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Setting Up a Cancer Centre:

AFGHANISTAN GEORGIA OMAN

INTERNATIONAL ATOMIC ENERGY AGENCY

Marketing and Sales Unit, Publishing Section

Printed by the IAEA in Austria

IAEA Library Cataloguing in Publication Data

Cancer is a leading cause of death worldwide, accounting for nearly

2. ESTABLISHING A CANCER CENTRE . . . . . . . . . . . . . . . . . . . . 3

2.1. What is a cancer centre? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

3. PATIENT CARE PATHWAYS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

3.1. Multidisciplinary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

4.1. Buildings and layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

5. DIAGNOSIS AND STAGING: FACILITY REQUIREMENTS . . 18

5.1. Laboratory medicine, pathology and blood bank . . . . . . . . . . 18

6. MULTIDISCIPLINARY AND MULTIMODALITY

6.1. Cancer surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

7.1. Palliative care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

9. PAEDIATRIC CANCER SERVICES . . . . . . . . . . . . . . . . . . . . . . . 54

9.1. Early diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

10. INFORMATION SYSTEMS, MEDICAL RECORDS

11. EDUCATION, TRAINING AND RESEARCH . . . . . . . . . . . . . . . 61

11.1. Training, ongoing education and accreditation . . . . . . . . . . . 61

12. GOVERNANCE, ADMINISTRATION AND FINANCING . . . . 67

ANNEX: CASE STUDY: A DISTRIBUTED CANCER

Cancer is an established public health priority and leading cause of death

The objective of this publication is to propose a framework to develop a

While not losing sight of necessary prioritization and planning of the

This publication describes the essential elements of a cancer centre. After

— Establishing a cancer centre;

2. ESTABLISHING A CANCER CENTRE

2.1. WHAT IS A CANCER CENTRE?

Cancer centres are an important element in the provision of services and

Dedicated cancer care as part of

Cancer care network–distributed

2.1.1. Benefits of a cancer centre

2.1.2. Role of a cancer centre in a cancer control programme

Cancer control programmes are public health programmes that aim to

2.2. FRAMEWORK FOR DEVELOPING A CANCER CENTRE

This guide describes the components of a cancer centre based on service

A patient centred approach is a crucial component of high quality health

& TERTIARY (SH)

Both prevention and screening activities will benefit from an effective

Services coordination and care planning

Diagnosis and treatment Prevention, supervisorship and palliative care

Education, training and research

Advocacy, community engagement and partnership

FIG. 3. Schematic representation of the elements of a cancer centre.

3. PATIENT CARE PATHWAYS

A care pathway is defined as “a complex intervention for the mutual

Long term survival

useful in minimizing diagnostic and treatment delays by scheduling some of the

Cancer services should be oriented towards a patient centric model of

A well-developed and functioning infrastructure is essential for delivering

Infrastructure planning should also take into account the following

— Setting up a stand‑alone cancer centre;

Additionally, when establishing or scaling up diagnostic imaging, nuclear

TABLE 1. ESTIMATING INFRASTRUCTURE REQUIREMENTS

Scope of facility/ Key elements to

Location, size Statistics Population, cancer burden, estimates and projections,