Page 0038

GLOBAL CANCER POLICY-MAKING

CONTEXT-RELEVANT GUIDELINES IN

CANCER CARE: BREAST CANCER

EARLY DETECTION, DIAGNOSIS

AND TREATMENT IN LOW- AND

MIDDLE-INCOME COUNTRIES

BENJAMIN O ANDERSON, CHAIR AND DIRECTOR, BREAST HEALTH GLOBAL INITIATIVE, JOINT

MEMBER, FRED HUTCHINSON CANCER RESEARCH CENTER AND PROFESSOR OF SURGERY

AND GLOBAL HEALTH MEDICINE, UNIVERSITY OF WASHINGTON, SEATTLE, WASHINGTON, USA

Resource constraints in developing health systems require difficult allocation decisions to optimize

cancer outcomes. Cancer care guidelines developed in high-income countries have limited utility in

developing countries, because many of the resources described in the ideal health care delivery

system are unavailable or unaffordable, making it unclear where to begin in creating a realistic and

sustainable cancer control strategy. New approaches to health care system design require that an

evidence-based approach to resource prioritization be established. Co-founded by Susan G Komen

for the Cure and the Fred Hutchinson Cancer Research Center, the Breast Health Global Initiative

(BHGI) has created resource-stratified guidelines that provide a framework for programme

development and a template for gap analysis to determine how existing resources can be applied in

the most effective way to improve breast cancer outcomes. These approaches can be applied to

other common malignancies that have a significant potential for improved outcome but are hindered

by significant infrastructure limitations.

Resource allocation for developing cancer advanced disease at diagnosis.

programmes Initial attempts at establishing a cancer treatment

Physicians working in low- and middle-income countries programme require treatment approaches that favour simple

(LMIC) may be forced to make decisions contrary to their best and highly efficacious therapies. Key treatment alternatives

medical knowledge. Despite knowing the optimal should be discussed, considering both relative costs of the

management for a given patient based on guidelines interventions, efficacy differences, and the expected

developed in wealthy countries, less-than-optimal solutions availability of resources and personnel to implement

are offered to patients because diagnostic and/or treatment programmatic policies. Flexibility in recommendations is

resources are lacking. The constraint of limited resources important, because heterogeneity exists in social, economic

generates tension for the clinician who is unable to offer “gold and health system barriers to improvement among countries

standard” treatments to any or all of the patients. This tension or even among regions of the same country, making universal

is amplified by the clinicians’ added responsibility of having to recommendations impractical.

manage an inadequate, fixed amount of resources from an

insufficient cancer programme budget. Does a clinician decide The need for cancer care guidelines addressing

to treat 10 patients with an older, less expensive issues in LMIC

chemotherapy regimen, or to treat two patients, with a newer, Early detection and comprehensive cancer treatment play

more efficacious but also more expensive regimen? It is synergistic roles in creating improved breast cancer

important to determine which resources commonly applied in outcomes. In economically developed countries, guidelines

resource-abundant countries are most needed in limited- outlining optimal approaches to early detection, diagnosis and

resource settings, where patients typically present with treatment of breast cancer are defined and have been

36 CANCER CONTROL 2013

Index

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