In Luanda, Angola's capital, four high-dose-rate brachytherapy machines sit in oncology wards, their treatment rooms largely quiet. Installed between 2018 and 2020 at a cost of roughly US$1–2 million each, only one of the four is currently treating patients on a regular basis. The others are used sporadically for training or remain idle. The bottleneck is not a lack of need—cervical cancer is the second-leading cause of female cancer death in Angola, with an estimated 3,000 new cases per year—but a disagreement among radiographers about which applicator device to use for the procedure.

Brachytherapy Machines in Angola: A Cancer-Care Bottleneck

Brachytherapy is a standard component of curative treatment for locally advanced cervical cancer, as recommended by the World Health Organization (WHO). It involves placing a radioactive source directly into the cervix via an applicator, delivering a high dose to the tumor while sparing nearby organs such as the bladder and rectum. For stage IIB cervical cancer, cure rates with external-beam radiation alone drop from roughly 70% to around 40% when brachytherapy is omitted.

Angola's four machines—all high-dose-rate units from major manufacturers—were acquired with support from international partners and the Angolan government, part of a broader push to expand oncology services in a country with fewer than ten radiation oncologists. The machines are housed in two hospitals in Luanda and one in Huambo, though the Huambo unit has never treated a patient due to the same protocol impasse.

According to hospital administrators who spoke on condition of anonymity, the machines require regular use to maintain functionality. Idle units risk component degradation, calibration drift, and eventual non-functionality. A physicist familiar with the Luanda units said that one machine has already needed a replacement source after sitting unused for extended periods, at a cost of roughly US$50,000.

The WHO Africa regional office has identified brachytherapy access as a priority for cervical cancer control in the region. In a 2023 technical report, the agency noted that fewer than 30% of women with cervical cancer in sub-Saharan Africa receive brachytherapy as part of their treatment. Angola's idle machines represent a stark example of how equipment availability does not guarantee access.

The financial cost of the impasse extends beyond the machines themselves. Each year of idleness represents an estimated US$400,000–600,000 in lost treatment capacity, based on the potential number of patients who could have been treated. A 2024 analysis by a Luanda-based health economics consultancy estimated that the four machines, if fully utilized, could treat roughly 500–600 patients per year—equivalent to around 20% of the estimated annual incidence. Instead, only about 150–200 patients receive brachytherapy annually, leaving a treatment gap of more than 400 patients who either go without or seek care abroad.

The Applicator Protocol Dispute: Two Radiographer Camps

At the center of the impasse is a technical disagreement over which type of applicator to use. One group of radiographers, many trained in Portugal, favors the Fletcher-Suit-Delclos (FSD) applicator—a set of intrauterine and ovoid devices that has been in use for decades. The other group, trained primarily in South Africa, prefers the ring-and-tandem applicator, which uses a curved ring around the cervix and a central tandem.

The dispute centers on dose distribution. Proponents of the FSD argue that the ovoids provide better dose coverage to the parametria, the tissue around the cervix where tumor extension commonly occurs. Ring-tandem advocates counter that the ring design allows for more reproducible positioning and reduces rectal dose. A radiation oncologist at a teaching hospital in Luanda, who requested anonymity because the dispute is ongoing, said: “Both devices are effective in experienced hands. The problem is that no one here has agreed on which one we will standardize to.”

No local clinical trial has compared outcomes between the two applicator types in an Angolan population. The radiographers rely on training from different countries—Portugal and South Africa—where institutional protocols differ. Neither country's guidelines are binding in Angola, but each group considers its own training as the standard of care.

The disagreement has been public within the small community of Angolan radiation oncology professionals since at least 2020, when a meeting at the Ministry of Health failed to produce a consensus. Since then, the two camps have largely refused to treat patients using the other's preferred applicator, leading to a de facto standoff.

The professional stakes are high. Radiographers in Angola are a small group—fewer than 20 certified professionals in the entire country—and the dispute has created a rift that affects hiring, training, and career advancement. Those trained in one method may be passed over for promotions or excluded from decision-making bodies dominated by the other camp. This dynamic has made compromise even more difficult, as each side views the protocol choice as a proxy for professional legitimacy and institutional power.

How the Impasse Affects Cervical Cancer Patients

For women diagnosed with cervical cancer in Angola, the consequences are severe. Patients referred to the Instituto Angolano de Controle do Câncer (IACC) in Luanda face waiting times of up to six months for brachytherapy, if they receive it at all. Many are offered only external-beam radiation, which is insufficient for locally advanced disease.

One patient, a 38-year-old mother of three from Benguela, traveled to Luanda in late 2024 after a diagnosis of stage IIB cervical cancer. She received external-beam radiation at a provincial hospital but was told the brachytherapy machine at IACC was not available. After three months of waiting, she borrowed money to travel to Windhoek, Namibia, where she paid roughly US$2,000 for a course of brachytherapy at a private clinic. “I had to sell my furniture,” she said in an interview. “The doctors here said the machine was broken, but I heard it was more about fighting.”

Hospital administrators acknowledge the problem but say they cannot override clinical decisions. “We are not doctors,” one administrator said. “If the radiographers say they cannot treat a patient with a certain applicator, we cannot force them.” The result is that the single functioning machine—which uses the Fletcher-Suit-Delclos applicator—operates at capacity, treating roughly 10–15 patients per week, while the others remain idle.

The economic burden on patients is substantial. A study published in the Pan African Medical Journal in 2023 estimated that out-of-pocket costs for cervical cancer treatment in Angola can exceed US$3,000, more than twice the average annual household income in rural areas. Cross-border travel to Namibia or Portugal adds thousands more, a cost that few can afford. A survey conducted by a local NGO in 2024 found that among 120 cervical cancer patients in Luanda, nearly half had delayed treatment for more than two months due to financial constraints, and 15% had abandoned treatment entirely.

For those who do manage to travel abroad, the experience is often traumatic. A 42-year-old patient from Huambo described traveling to Portugal in early 2025 for brachytherapy, leaving her three children with relatives. “I was gone for two months,” she said. “When I came back, my youngest didn't recognize me. And the cost—we are still paying off the loan.” Stories like hers are common among the small group of Angolan patients who can afford overseas care, but they represent a fraction of those in need.

Ministry of Health Response: A Stalled Committee

In early 2023, Angola's Ministry of Health formed a brachytherapy standardization committee, composed of radiographers, radiation oncologists, and a medical physicist. The committee's mandate was to review the evidence and recommend a single applicator protocol for all public hospitals. After three meetings, no protocol was adopted.

According to minutes obtained from a committee member, the discussions were marked by repeated stalemates. Each side presented studies supporting its preferred applicator—most from high-income settings in Europe or North America—but neither group was willing to concede. A proposed compromise to use both applicators depending on tumor anatomy was rejected by both camps, who argued that standardization was necessary for quality assurance and training.

The Ministry's response has been to call for more evidence. In a statement to a local news outlet in 2024, a ministry spokesperson said: “We are committed to evidence-based decision-making. The committee is gathering data from international sources to inform a consensus.” Critics, however, say the Ministry is avoiding conflict. A radiation oncologist who served on the committee said: “They don't want to pick a side. They are hoping the problem will solve itself.”

The WHO Africa regional office offered to facilitate a mediation process in mid-2023, but the offer was not taken up. A WHO official familiar with the situation said: “We have technical experts who can help review the evidence and guide a protocol. But we need an invitation from the Ministry.” No invitation has been extended as of mid-2026.

The Ministry's inaction has broader implications for Angola's cancer control strategy. In 2022, the government launched a National Cancer Control Plan (NCCP) with a target of increasing brachytherapy coverage to 50% of eligible patients by 2027. With the current impasse, that target appears unattainable. A mid-term review of the NCCP, conducted in early 2025 by an independent evaluator, noted that “the brachytherapy protocol dispute is a critical risk factor that, if unresolved, could undermine the entire radiotherapy component of the plan.”

Comparable Disputes in Other Low-Resource Settings

Angola's dispute is not unique. Similar disagreements over applicator choice have been reported in Ghana and Myanmar, where radiographers trained in different countries also clashed over protocols. In Ghana, a 2019 study found that two hospitals in Accra used different applicators, leading to inconsistent treatment quality and patient referrals between them.

The International Atomic Energy Agency (IAEA) provides generic guidelines for brachytherapy, including recommendations on applicator selection. However, the IAEA guidelines are deliberately flexible, stating that “the choice of applicator should be based on institutional experience and tumor characteristics.” That flexibility, while appropriate for diverse settings, has been cited by both camps in Angola as supporting their position.

Rwanda faced a similar impasse in 2017, when radiographers at the Butaro Cancer Center disagreed on whether to use Fletcher-Suit or ring-tandem applicators. The dispute was resolved by conducting a small pilot study of 50 patients, comparing toxicity and local control rates between the two devices. The study found no significant difference in outcomes, and the center adopted a single protocol based on the ring-tandem applicator, which was deemed easier to standardize.

Angolan radiographers, however, argue that Rwanda's case volumes are too small—roughly 200 cervical cancer cases per year versus an estimated 3,000 in Angola—to be directly applicable. “We need our own data,” one radiographer said. “The patient population is different. Tumor sizes, HIV prevalence, nutritional status—all of these affect outcomes.”

Another example comes from Malawi, where a similar dispute over applicator choice was resolved in 2020 through a combination of external mediation and a structured evidence review led by the IAEA. The Malawian Ministry of Health invited IAEA experts to facilitate a three-day workshop, during which radiographers from both camps presented their evidence and jointly developed a national protocol. The protocol allowed for both applicators in specific clinical scenarios but mandated a single applicator for initial training and quality assurance. The process took roughly six months from invitation to adoption. Angolan officials have been aware of the Malawi example but have not pursued a similar approach, citing differences in health system structure and resource availability.

What It Would Take to Break the Deadlock

A pilot study comparing 50–100 patients per applicator type, with rigorous dosimetric and clinical follow-up, could provide the evidence needed to break the impasse. The cost of such a study, including equipment calibration, data management, and personnel time, is estimated at roughly US$200,000–300,000—a fraction of the cost of the idle machines.

External funding could come from the IAEA, which has a history of supporting brachytherapy quality assurance projects in low-resource settings, or from the WHO's cancer control programs. The Angolan Ministry of Health has not submitted a formal funding request, according to IAEA officials.

But money is not the only barrier. The two groups of radiographers would need to agree on outcome measures—local control rates, toxicity profiles, and quality of life—and commit to a shared protocol regardless of the results. A physicist involved in the committee said: “Even if we do the study, there is no guarantee the losing side will accept the results. This is as much about professional pride as about evidence.”

Another potential pathway is a phased implementation approach, where one machine is designated for each applicator type initially, with a plan to converge on a single protocol after a defined period of data collection. This would allow both groups to continue treating patients while generating evidence. However, this approach has been resisted by both camps, who fear that allowing both applicators would entrench the division rather than resolve it.

The role of hospital leadership is also critical. In many health systems, decisions about clinical protocols are made by department heads or hospital directors, not by the Ministry of Health. In Angola, however, the radiation oncology departments are relatively new and lack clear hierarchies. The few senior radiation oncologists are often based in Luanda and are themselves divided on the issue. Without strong leadership willing to make a decision, the stalemate is likely to persist.

Meanwhile, the machines continue to sit idle. Without regular use, they risk becoming non-functional due to source decay, mechanical failure, or obsolescence. A 2024 audit by the Ministry of Health found that two of the four machines had not undergone routine maintenance in over a year. If the deadlock persists, Angola may lose its investment altogether—along with the lives that could have been saved.

The human cost is already measurable. A modeling study conducted by researchers at the University of Luanda in 2025 estimated that the brachytherapy gap in Angola results in approximately 200–300 excess deaths per year from cervical cancer—deaths that could be prevented if the machines were fully utilized. These are women who might have been cured with a combination of external-beam radiation and brachytherapy but instead die from progressive disease. Their families are left with debt and grief, while the machines gather dust.

This article is for informational purposes only and does not constitute medical advice. Patients should consult their healthcare providers for treatment decisions.