Radiotherapy is a cornerstone of cancer treatment, with nearly 50% of patients requiring it at some point during their care [1] . Timely access is critical, as treatment delays are associated with tumor progression, reduced therapeutic efficacy, and increased mortality [1] - [3] . In high-income countries (HICs), efficient infrastructure and strategic workforce planning help minimize waiting times [4] . However, the situation is markedly different in low- and middle-income countries (LMICs), including Bangladesh. Bangladesh faces a rising cancer burden, with approximately 150,000 new cases diagnosed annually [5] . Yet, fewer than 25 operational linear accelerators are available nationwide. According to the World Health Organization (WHO), there should be at least one radiotherapy unit per 250,000 people—a standard that Bangladesh falls far short of meeting [2] . The combination of limited infrastructure and a shortage of trained professionals results in prolonged treatment delays, often lasting several weeks or even months. In contrast, countries such as Canada, the United Kingdom, and Australia report median wait times of 16 - 28 days [1] [6] . The European Society for Radiotherapy and Oncology (ESTRO) recommends initiating radiotherapy within four weeks of diagnosis [1] . In LMICs, delays of six to eight weeks or more are common, primarily due to systemic challenges [4] [7] . In LMICs, delays of six to eight weeks or more are common, primarily due to systemic challenges.

These disparities highlight the urgent need for reform in resource-limited settings. Extended waiting times affect not only physical health but also mental well-being [8] . Patients awaiting radiotherapy often experience anxiety, depression, and a profound sense of uncertainty [9] [10] . Their physical symptoms may worsen, diminishing their overall quality of life. While research frequently focuses on oncologists and hospital administrators, the role of medical physicists—key contributors to the safe and accurate delivery of radiotherapy—remains underexplored [12] . Their dual expertise in clinical and technical domains positions them uniquely to offer insights into operational inefficiencies.

While most studies emphasize clinical outcomes, few investigate the broader impacts of treatment delays, particularly in LMICs. This research aims to fill that gap by examining how prolonged radiotherapy wait times affect both the mental and physical health of patients in Bangladesh, incorporating perspectives from medical physicists to highlight systemic barriers.

Delays in LMICs like Bangladesh impact both patient survival and mental health. Lack of counseling services worsens anxiety and depression [11] [12] . Tumor progression during delays requires new treatment plans, adding to workloads and delays for others [3] . Head, neck, cervical, and lung cancers are particularly vulnerable to delay-related progression [1] [3] . Even one week of delay can reduce local tumor control by 1% - 2% [3] . This discussion focuses on the broad impact of these delays, especially from the perspective of medical physicists. While the roles of oncologists and surgeons are often emphasized, despite their critical role, medical physicists are often excluded from policy and triage decisions, limiting system efficiency [14] . Other countries have responded by expanding automation, teamwork, and infrastructure [12] . Bangladesh should consider similar reforms. Patients who experience long waiting periods often suffer emotional stress. In settings where counseling services are scarce, and communication is inconsistent; this distress is even more pronounced. Worries about cancer progression, financial challenges, and the difficulty of traveling to urban treatment centers all add to their emotional burden. These observations are consistent with trends in other LMICs, where poor communication and limited support systems worsen the mental health effects of treatment delays. From a physical standpoint, delays allow tumors to grow or change in shape, which often requires new CT scans and revised treatment plans. This increases the workload on healthcare teams and further delays treatment for other patients, worsening inefficiencies. Rapidly progressing cancers like those in the head and neck, cervix, and lungs are especially vulnerable. Research suggests that even a one-week delay can reduce the success of local tumor control by 1% - 2%. This study confirms such trends, as nearly 20% of patients who waited over four weeks needed their treatment plans adjusted. Medical physicists face the challenge of delivering accurate treatment while managing these anatomical changes. When too much time passes between a patient’s initial CT scan and their first radiation session, the original plan may no longer be suitable. This could compromise both treatment effectiveness and the safety of surrounding healthy tissues. These challenges underline the need for clear guidelines to reevaluate plans, especially for patients who have been delayed more than three weeks. Despite their key role, physicists are often excluded from decisions about patient scheduling and triage. This exclusion limits the clinical team’s insight, as physicists are responsible for treatment planning and technical delivery. Including them in policy and scheduling decisions could improve quality care, reduce unnecessary replanning, and improve overall system efficiency. Globally, other countries have responded to similar issues by expanding access to radiotherapy, increasing automation, and strengthening teamwork across disciplines. Bangladesh should explore adapting these solutions to fit local needs. Empowering physicists to contribute to both policy and daily operations would be a vital step forward. In conclusion, solving this problem requires a complete system-level response. Investment in infrastructure must be paired with better workforce planning, digital scheduling tools, and clearer patient communication. Furthermore, adding mental health services and community follow-up programs could ease the emotional burden that comes with unavoidable delays in treatment.

This study is subject to several limitations. First, the use of a single-center design may limit the generalizability of the findings to other settings within Bangladesh or other LMICs. Second, patient interviews relied on self-reported experiences, which may introduce recall bias—particularly in emotional and psychological assessments. Third, patients with less than two weeks of delay were excluded from the analysis, potentially skewing the dataset toward more severe delay cases. Additionally, staffing patterns and machine availability may vary across institutions, and this variability was not captured in the analysis. Future studies with larger, multi-center data sets and longitudinal designs are recommended to strengthen the evidence base.

Based on the study findings, the following recommendations are proposed:

The authors thank the participating patients for their contributions. Special appreciation to the medical physicists who shared their professional insights.