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Cancer care in countries in the South Asian Association for Regional Cooperation (SAARC) is hindered by many challenges, including inadequate infrastructure, a shortage of skilled health-care professionals, and economic constraints. These factors contribute to disparities in timely diagnosis and treatment, leading to poorer health outcomes. Health-care systems within the region vary considerably, ranging from free public health care in Sri Lanka to predominantly out-of-pocket expenses in Bangladesh, highlighting inequities in financial access and service delivery for patients within this region. The absence of comprehensive national health insurance systems imposes substantial financial burdens on patients with cancer and their families, often resulting in catastrophic health-care costs. Paediatric oncology services reflect these disparities with greater clarity. Although Bangladesh has developed multiple treatment centres, issues such as delayed diagnoses and financial barriers persist. By contrast, countries such as Afghanistan and the Maldives have few specialised paediatric oncology services, necessitating costly referrals abroad that place large strains on families. Geriatric oncology remains underdeveloped across most SAARC nations, with few dedicated services and guidelines. Despite progress in India and Sri Lanka, gaps in specialised training and holistic care for older patients remain. Addressing these disparities requires coordinated efforts, including improving health-care infrastructure, expanding insurance coverage, and fostering regional collaborations. Implementing comprehensive national cancer control programmes across SAARC nations, leveraging intercountry networks, and ensuring political commitment are essential to achieving equitable cancer care and advancing Sustainable Development Goals in the region.

South Asian Association for Regional Collaboration (SAARC) countries, home to 24% of the world's population, are facing the double burden of disease (ie, where a population experiences both an increasing incidence of cancers typically associated with affluence and a sustained or rising burden of cancers linked to infections and poverty) with non-communicable diseases (NCDs) attributing to 47% of the global burden of disease and to about 60% of all deaths. In 2022, cancer in this region accounted for approximately 9·3% of incidence worldwide and 12% of global mortality. Cancer is one of the major NCDs affecting South Asia, accounting for a large proportion of disability-adjusted life-years lost in this region. The most common cancers are lung, head and neck, and gastrointestinal cancers in both sexes, and cervix and breast cancers in females. The cancer burden is high in SAARC countries, although there are differences among countries and within urban and rural regions of each country, depending on the level of available resources, development, and epidemiological shift. Here we discuss various cancer care issues and challenges throughout the cancer care continuum in the SAARC region. We make an urgent call for regional collaboration to develop, modify, and implement a holistic cancer control plan and formulate a systematic approach directed to address the growing burden of cancer in this region. It is crucial to establish strong political will and commitment to take forward the recommended actions outlined in this Series to overcome and address the cancer crisis in the SAARC region, aligning with Sustainable Development Goal 2030 targets.

The education and training of the oncological health-care workforce is vital for building effective health-care systems that deliver optimal care to patients with cancer. In the South Asian Association for Regional Cooperation (SAARC) nations, there is a notable shortage of both physician and non-physician oncology professionals, including oncologists, medical physicists, radiotherapy technologists, and oncology nurses. This shortage is primarily caused by inadequate education and training programmes. Oncology professionals across SAARC countries face several challenges, including a scarcity of trained personnel, poor health-care infrastructure (including resources and equipment), and insufficient educational opportunities. This Series paper examines the current state of oncology education and training programmes within the SAARC region, identifies the challenges faced by oncology professionals, and offers recommendations for improvement. Short-term strategies focus on developing a skilled, multidisciplinary oncology workforce and enhancing existing training programmes. In the long term, the goals are to establish self-sufficient cancer care systems, promote regional collaboration, and strengthen research infrastructure. Achieving these objectives will require comprehensive approaches, increased financial resources, advanced cancer care infrastructure, and innovative educational models. Regional and international collaborations are essential to raise awareness of cancer as a major public health concern, advance prevention and early detection efforts, and bolster research initiatives.

Cancer is a major global health threat, with 35 million new cases projected by 2050, predominantly in low-income and middle-income-countries. Within South Asian Association for Regional Cooperation (SAARC) countries, a notable gap in cancer research investment and output compared with high-income countries highlights the need to strengthen research capacity. The rising cancer incidence across SAARC countries is not being matched by local research, particularly in clinical trials in molecular biology, targeted therapy, immunotherapy, and cancer vaccines. This paucity of research is problematic as guidelines and therapies developed in high-income countries might not be directly applicable to low-income and middle-income countries due to distinct regional sociocultural, genetic, and environmental factors and are often impractical in these countries due to cost and implementation challenges. This Series paper examines the cancer research landscape within SAARC countries, focusing on Bangladesh, Nepal, Sri Lanka, India, Pakistan, Afghanistan, Bhutan, and Maldives. We analyse PubMed publication rates and examine available infrastructure, current research (including clinical trials), and limitations and disparities among SAARC countries in terms of cancer research. Key challenges include disparities in health-care access, cultural and economic barriers, and little funding and infrastructure. Strengthening cancer research in SAARC countries requires building collaborative networks, improving research facilities and training, focusing on local epidemiological studies, and developing affordable technologies and treatments. Effective policy and stakeholder engagement could greatly advance cancer care in the region.

Aims This review aims to synthesize the existing literature on palliative radiotherapy (RT) delivered in two daily fractions for patients with advanced cancer, focusing on its impact on symptom alleviation, treatment tolerance, and the implications for clinical practice and future research. Methods An international team conducted this narrative review, adhering to SANRA guidelines. Studies published in English on palliative RT delivered in two daily fractions were selected without date restrictions. The literature search, using a combination of specific key terms, led to a comprehensive examination of relevant studies. Data on study objectives, treatment approaches, palliative effectiveness, and toxicity were extracted and qualitatively analyzed. Results The review included 29 publications, showing consistent efficacy in symptom reduction (63.0%–100% palliative response rate) and general tolerability across various cancer types. These studies highlighted the potential radiobiological advantages and practicality of accelerated multi-fractionated regimens, which provide rapid tumor response with reduced late toxicity risks. Furthermore, the logistical benefits of such treatments, including shorter hospital stays and minimized travel requirements, were noted as particularly valuable during challenging times such as recent pandemics. Conclusions The evidence supports the integration of evidence-based, accelerated-hypofractionated RT into palliative care strategies, ensuring effective symptom management with minimal patient burden. Future research should focus on comparative studies on single versus multiple-cycle treatments, optimal intervals between treatment cycles, and the integration of advanced RT techniques.

Metastases with soft tissues invasion, impending fractures or spinal cord compression (complicated bone metastases) represent a common clinical problem in advanced cancers and frequently lead to deterioration of patients’ quality of life (QoL). A phase I–II study was planned to define the maximum tolerated dose (MTD) of a short-course radiotherapy (RT) and its efficacy in palliation of complicated bone metastases. A phase I trial was designed with three dose-escalation steps: 16, 18, and 20 Gy. Total dose at each level was delivered in 2 days, twice daily. Eligibility criteria were painful complicated bone metastases and ECOG performance status ≤ 3. The presence of acute toxicity ≥ Grade 3 (RTOG scale) was considered the dose limiting toxicity. The MTD was used to plan a phase II trial with pain response as the primary outcome. Pain was recorded using a Visual Analogic Scale (VAS), and QoL using CLAS scales. Forty-five patients were enrolled in this trial. In phase I no Grade ≥ 2 acute toxicities were recorded. Thus 20 Gy was established as MTD. In phase II, with a median follow-up of 4 months, rates of complete symptom remission, partial response, no symptomatic change, and symptoms progression were 32.0%, 52.0%, 8.0%, and 8.0%, respectively. This RT protocol tested in our study is effective and tolerable with comparable results to traditional RT treatments delivered in 5–10 daily fractions.

3D image-guided brachytherapy (3D-IGBT) has become a standard therapy for cervical cancer. However, the use of 3D-IGBT is limited in East and Southeast Asia. This study aimed to clarify the current usage patterns of 3D-IGBT for cervical cancer in East and Southeast Asia. A questionnaire-based survey was performed in 11 countries within the framework of the Forum for Nuclear Cooperation in Asia. The questionnaire collected the treatment information of patients with cervical cancer who underwent 3D-IGBT. The cumulative external beam radiotherapy and 3D-IGBT doses were summarized and normalized to a biological equivalent dose of 2 Gy per fraction (EQD2) using a linear-quadratic model. Of the 11 institutions representing the participating countries, six (55%) responded to the questionnaire. Overall, data of 36 patients were collected from the six institutions. Twenty-one patients underwent whole-pelvic irradiation and 15 underwent whole-pelvic irradiation with central shielding. Patients received a median of four treatment sessions of 3D-IGBT (range, 2–6). All 3D-IGBT sessions were computed tomography (CT)-based and not magnetic resonance image-based. The median doses to the high-risk clinical target volume D90, bladder D2cc, rectum D2cc and sigmoid colon D2cc were 80.9 Gy EQD2 (range, 58.9–105.9), 77.7 Gy EQD2 (range, 56.9–99.1), 68.0 Gy EQD2 (range, 48.6–90.7) and 62.0 Gy EQD2 (range, 39.6–83.7), respectively. This study elucidated the current patterns of 3D-IGBT for the treatment of cervical cancer in East and Southeast Asia. The results indicate the feasibility of observational studies of CT-based 3D-IGBT for cervical cancer in these countries.

Previous trials showed the tolerability and efficacy of a palliative radiotherapy (RT) regimen (SHARON) based on the 4 fractions delivered in 2 days in different oncological settings. In order to identify possible predictors of symptomatic response, the purpose of this study is to perform a pooled analysis of previous trials. We analyzed the impact on symptomatic response of the following parameters: tumor site, histological type, performance status (ECOG), dominant symptom, and RT dose using the Chi-square test and Fisher’s exact test. One-hundred-eighty patients were analyzed. Median RT dose was 20 Gy (range: 14–20 Gy). The overall response rate was 88.8% (95% CI 83.3–92.7%) while pre- and post-treatment mean VAS was 5.3 (± 7.7) and 2.2 (± 2.2), respectively ( p  < 0.001). The overall response rate of pain, dyspnea, bleeding, dysphagia, and other symptoms was 86.2%, 90.9%, 100%, 87.5%, and 100%, respectively. Comparing the symptomatic effect based on the analyzed parameters no significant differences were recorded. However, patients with locally advanced disease showed a higher rate of symptomatic responses than metastatic ones (97.3% vs 83.0%; p  = 0.021). Finally, the complete pain response rate was more than double in patients with mild to moderate (VAS: 4–7) compared to those with severe (VAS > 7) pain (36.0% vs 14.3%; p  = 0.028). This pooled analysis showed high efficacy of the SHARON regimen in the relief of several cancer-related symptoms. The markedly and significantly higher complete pain response rate, in patients with mild-moderate pain, suggests early referral to palliative RT for patients with cancer-related pain.

The main clinical goal for patients with advanced or metastatic thoracic cancer is palliation of tumor-related symptoms and improvement of quality of life. The aim of this phase I–II trial was to define the maximum tolerated dose (MTD) of a short-course of palliative radiotherapy (RT) and to evaluate its efficacy in terms of palliative response. A phase I trial was planned with escalating dose increments. Total doses ranged from 16 to 20 Gy delivered (BID) in two consecutive days. Dose limiting toxicity was defined as any acute grade ≥ 3 toxicity based on the RTOG scale. MTD was used in the phase II trial to evaluate the efficacy of this regimen using a two stage Simon’s design. Fifty-four patients were enrolled. The upper dose level of 20 Gy was defined as the MTD. In patients treated with this dose, the overall palliative response rate was 96.5% (CI 0.95: 81.3–99.9%). Complete pain relief rate was 50.0%. Median survival without symptomatic progression was 3 months. The tested short course accelerated regimen was well tolerated and effective in the palliative setting of metastatic or locally advanced chest cancer. A phase III trial is ongoing to validate this RT schedule.Trial registration: NCT03465553.

To determine the maximum tolerated dose (MTD) of a short-course accelerated radiotherapy and its feasibility for symptomatic palliation of advanced head and neck cancer or head and neck metastases from any primary site. A phase I trial in four dose-escalation steps was planned: total dose ranged between 14 and 20 Gy in a total of four fractions administered twice a day. The dose-limiting toxicity (DLT) was determined as grade 3 or more toxicity occurring during treatment. The MTD obtained was used to plan a phase II trial. A total of 48 patients were treated. In the phase I trial, the 20 Gy dose level was determined to be the MTD. In the phase II trial, the palliative response rate was 82.7%, with a median duration of palliation of 3 months. Short-course accelerated radiotherapy was well tolerated and effective for palliation. These findings may help design future prospective randomized studies.