ASTROnews: The Radium Saga, Belgium and the Bomb, Radiotherapy in the Belgian Healthcare System

By Vincent Gregoire, M.D., Ph.D., and Karin Haustermans, M.D., Ph.D. – Special correspondents

This article is a follow-up to the Summer 2009 “News from the Old World” column by ASTROnews Editorial Board member Dirk Rades, M.D. You can find that article at www.astro.org/astronews.

The radium saga
It is not by chance that Brussels, Belgium, became the seat not only of ESTRO, ASTRO’s European counterpart, but also of EORTC, the European Organization for Research and Treatment of Cancer (the European RTOG) and of ECCO, the European Cancer Conference (European ASCO). Of course, Brussels is Europe’s capital city, but Belgian radiotherapy had a much more potent asset than the proximity of the European Commission: Emmanuel van der Schueren (1944-1998).

After completing a research period at Stanford and working for five years at the Netherlands Cancer Institute in Amsterdam with ESTRO’s founder Klaas Breur, Dr. van der Schueren came back to Belgium to head the radiotherapy department of Leuven University. From this position, he injected a galvanizing amount of energy both in building the Belgian and European radiotherapy and oncology societies and clinical research infrastructures to position radiotherapy solidly at the heart of European cancer care.

Probably less known is the fact that Belgium was an early adopter of radiotherapy – the first RT treatment took place there as early as 1903 – and has supplied clinical and research departments worldwide, and also in the U.S., with 50 percent of all the radium ever produced. An International Atomic Energy Association (IAEA) document grosses the total amount of radium ever produced at 4.5 kilograms! Until the 1920s, radium was an extremely rare element. It was produced in Czechoslovakia in minute quantities mainly destined for scientific research. To produce 1 gram of radium, 500 tons of ore were required as well as 10,000 tons of chemicals, 1,000 tons of coal and 100,000 tons of water. No wonder radium fetched a price 330,000 times higher than that of gold!

That was until 1915 when a mining engineer at the Belgian company Union Minière du Haut Katanga prospecting for Copper in then Belgian Congo’s Katanga, struck gold. He discovered huge pitchblende deposits with a uranium oxide content of 50 percent, 30 times higher than anything discovered thus far. Due to wartime pressures, radium production could start only in 1922. A first cargo of very high-grade ore arrived in the port of Antwerp in December 1921. Within one year, already 12 grams of radium were produced in Olen, Belgium, reportedly with technical advice of Marie Curie. It took “only” 10 tons of the Katanga ore to produce 1 gram of radium. Until then, radiation therapy treatments with radium had only been available in two privately owned Belgian “hospices” catering exclusively to rich cancer patients.

That changed in January 1923 when the Union Minière offered 8 grams of radium on loan to the Belgian University Foundation, destined for Belgian Universities: Gent, Brussels, Leuven and Liège. Of the 2 grams each university received, 1.75 grams was to be used for patient treatment and 0.25 grams for research. Also, the Marie Curie Foundation in Paris was provided with radium.

Belgium dominated the world market for radium until the mid-1930s when comparable high-grade ore was discovered along the shores of the Great Bear Lake in Northwestern Canada. Henceforth and until the 1960s when particle accelerators and nuclear reactors could efficiently produce cheaper radionuclides, the Belgians (60 percent) and the Canadians (40 percent) shared the world market. Belgium remains, together with Canada, one of the main providers of radionuclides for brachytherapy.

Belgium and the bomb
Since 1939, the “Union Minière” had been selling uranium ore to the United States and Canada mainly for the production of radium for medical applications, and the U.S. tried to convince the Belgians to sell to them the Katanga uranium reserves. Reportedly, Albert Einstein intervened at some point with Belgium’s Queen Elisabeth, a good friend of his with a keen interest in science and music, pleading for support for his new fatherland. In 1938, two German physicists were successful in fissioning uranium atoms. In 1942, the Manhattan project for the production of the atom bomb was born. Already in the same year, a secret agreement was signed between the Union Minière and the U.S. without the prior knowledge of the Belgian government. By 1944 (Belgium was by then occupied by the Germans), the U.S. had already bought 30,000 tons of uranium ore. In that year, another secret agreement was signed, this time between the U.S. and the United Kingdom on one side and the Belgian government in exile in London on the other, turning over the total Katanga uranium ore production to the U.S. and the U.K. for a period of 10 years in exchange for knowledge sharing.

Only after the explosion of the bombs in Nagasaki and Hiroshima though would the Union Minière Company and the Belgian government realize that their uranium deliveries to the U.S. had served for the production of the atom bombs for military purposes (according to the documents “for the protection of civilization”). The sludge of the ore was returned to Belgium for the extraction of radium.

Radiotherapy in the Belgian healthcare system
Belgium has a universal healthcare system covering all Belgian citizens. The total cost of healthcare amounts to about 10 percent of the gross national product. The system is financed by compulsory contributions of employers and employees, based on the principle of solidarity. Unlike the U.K., the system is not free. Patients pay part of the costs for drugs, physician visits and hospitalization.

However, once the total bill for a patient exceeds 1,000 € (about $1,470 by current exchange rate), the government steps in to pay the bills irrespective of the patient’s income. Even dental prostheses are covered. That means that while the breaks are put on overconsumption through co-responsibility for the bill, patients are shielded against the worst financial consequences. The collection of contributions and reimbursements are managed by competing nonprofit health insurance non-government organizations, some with vague links to political parties. They operate at an overhead cost not exceeding 7 percent.

Doctors’ fees and reimbursement levels for patients and hospitals are negotiated between the parties involved and the government. Doctors can choose to opt out of the system negotiated by their professional organizations and charge higher fees, but the supplemental charges are not reimbursed. Only a small minority of physicians go for this option. The government tries to cap expenses within a manageable level, e.g., by negotiations with pharmaceutical companies and healthcare providers and endorsement of all evidence-based treatments.

There is no real rationing and there are no capacity problems or waiting lists for surgery or radiation therapy, while patients have total freedom to choose their GP or specialist as well as the hospital. Thanks to a dialogue with the government to provide them with up-to-date information, appropriate reimbursement levels for radiation therapy could be negotiated in the past with each treatment also paying into a savings account for the replacement of equipment.

Thanks to the Belgian radiation therapy society and particularly to the positive engagement of recently retired Past President Prof. Walter van den Bogaert with the Health Care Authorities, radiation therapy is no longer the poor brother in the Belgian oncology departments. Unfortunately, progressive escalating costs have since been outpacing and eroding the provisions both for the replacement of equipment and for the reimbursement of high-tech treatments.

Organization of radiotherapy services in Belgium, quality assurance and specialist education
The majority of hospitals in Belgium are private nonprofit entities, but there are also public facilities and private for-profit clinics. As a result, Belgium ended up in the late 1980s with 25 radiation oncology departments for about 11 million inhabitants. They are all equipped with state of the art infrastructure (reportedly Belgium has the highest density of PET facilities per inhabitant worldwide) and have access to the latest developments. Adequate staffing levels and built-in standards integrated in the organization and operating procedures are enforced by regulation. Radiation oncologists also have a college which ensures peer-reviewed quality assurance and serves as a government liaison. Also worth mentioning is that the level of radiation physics is exceptionally high in Belgium. Finally, radiation oncology has a professional organization that watches over the professional interests of the radiation therapy community.

Specialist education
Belgian radiation therapy is a challenging education program for trainees. Each year, residents attend two to three full weekends of nationally organized educational symposia staffed and supported by the joint academic staff of all the university hospitals, two society meetings and 10 Saturday morning teaching sessions. In addition, they are encouraged to attend ESTRO courses. A systematic examination is administered after two years of training followed by a national board examination at the end of the fourth year of residency. Those who fail are given a second chance at the end of year five.

Thank you to Mrs. Germaine Heeren, Dr. Yolande Lievens and Dr. Walter Van den Bogaert for their input in the text. They are all affiliated with the Department of Radiation Oncology, University Hospitals of Leuven.

Dr. Gregoire practices at the Université Catholique de Louvain St-Luc University Hospital in Brussels, Belgium. Dr. Haustermans practices at UH Gasthuisberg in Leuven, Belgium.

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