Cancer Control Opportunities in Low- and Middle-Income Countries (2007) / Chapter Skim
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4 Defining Resource-Level-Appropriate Cancer Control
4 Defining Resource-Level-Appropriate Cancer Control
Pages 106-137
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From page 106... ...
, in its 1992 report on guidelines and policies for National Cancer Control Programmes, gave prominence to the idea of tailoring interventions to three scenarios: low, medium, and high resource levels, in a very general sense (WHO, 2002) (Table 4-1)
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From page 107... ...
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From page 108... ...
08 :CoiranecS secruoseRfoleveLhgiH evisneherpmocnehtgnertS htlaehdesab-ecnedive dnanoitomorp smargorpnoitneverp ediwnoitanerusnedna ninoitatnemelpmi rehtohtiwnoitaroballoc srotces enituorhsilbatsE teloivartlufognirotinom ksirehtfislevelnoitaidar hgihsirecnacniksfo · · :BoiranecS foleveL muide M secruoseR detargetnipoleveD evitneverplacinilc gnilesnuocrofsecivres nisrotcafksirno erachtlaehyramirp dna,sloohcs,sgnittes secalpkrow ledompoleveD smargorpytinummoc detargetninarof noitneverpothcaorppa elbacinummocnonfo sesaesid · · :AoiranecS secruoseRfoleveL woL erehterehwsaeranosucoF laitnetopdnasdeentaergera sseccusrof ytiroirptahterusnE eraseigetartsnoitneverp spuorgesohtotdetegrat nacdnalaitneuflnierataht ,.g.e(ssecorpehtdaehraeps ) srehcaetdnasrekamycilop revilrofcimednesaeranI sititapehetargetni,recnac rehtohtiweniccavsuriv B smargorpnoitaniccav · · · deunitnoC 1-4 seirtnuoCllA htlaehdetargetnitnemelpmI noitneverpdnanoitomorp elbacinummocnonrofseigetarts /evitalsigeledulcnitahtsesaesid latnemnorivnednayrotaluger noitacudesallewsaserusaem detegrat,cilbuplarenegehtrof slaudividnidna,seitinummoc sserddadna,esuoccabotlortnoC ,teidyhtlaehnu,esulohocla dnalauxesdna,ytivitcalacisyhp srotcafevitcudorper eziminimotycilopetomorP dnasrecnacdetaler-lanoitapucco snegonicraclatnemnorivnenwonk yrassecennufoecnadiovaetomorP ksir-hgihnithgilnusoterusopxe snoitalupop · · · · ELBAT tcepsA noitneverP
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From page 109... ...
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From page 110... ...
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From page 111... ...
The example of how this objective may begin to be achieved (described in detail in this chapter) is the Breast Health Global Initiative (BHGI)
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From page 112... ...
Even where there are choices to be made, however, the number of options in most cases is likely to be limited, making decisions manageable. Basic factors that may affect decisions about appropriate services include: · The monetary cost of the intervention To patients To governments or other payers · Characteristics of patients and their cancers presenting for treatment Prevalent cancer types Stage distribution of cancers Common co-morbidities and nutritional status Availability of social support for patients during and following treatment · Characteristics of effective interventions Time course, including total inpatient and outpatient requirements, and follow-up Acute toxicity Long-term effects, including permanent disability, disfigurement, and effect on quality of life Need for and availability of rehabilitation · Institutional requirements General infrastructure Specific equipment and drugs Infection control measures, including isolation facilities Medical, nursing, technician, and psychosocial personnel needs This chapter draws on the BHGI experience specifically related to guideline development which, at this writing, remains the only available model.
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From page 113... ...
Benjamin Anderson, a breast surgeon at the Fred Hutchinson Cancer Center in Seattle, who has led the effort since the beginning. The first BHGI Global Summit Consensus Conference on International Breast Health Care was held in October 2002 in Seattle (the conference is hereafter referred to as the 2002 Global Summit)
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From page 114... ...
The next sections of this chapter discuss issues that were important in creating an appropriate context for the guideline effort, and then describe the refined and improved procedures, used in the second summit and to revise the guidelines. GUIDELINE DEVELOPMENT FOR LIMITED-RESOURCE SETTINGS: SPECIAL CONSIDERATIONS REGARDING BREAST CANCER To be applicable and effective, practice guidelines must go beyond summarizing the available evidence and prescribing interventions using strictly
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From page 115... ...
These observations from the first Global Summit served as the basis of the 2005 BHGI Global Summit Consensus Conference on International Breast Health Care (hereafter referred to as the 2005 Global Summit) , where specific recommendations were addressed.
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From page 116... ...
Consensus Process Each panel was asked to stratify the health care interventions relevant to their areas into four levels: 1. "Basic" level -- Core resources absolutely necessary for any breast health care system to function.
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From page 117... ...
For example, a country may have community clinics that provide care at the basic level, regional hospitals that provide care at the limited level, and a national cancer center that provides care at the enhanced or maximal level. Because circumstances vary so widely around the world, decisions about how to plan the overall structure of a national breast program must be made on a country-by-country, region-byregion, and facility-by-facility basis.
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From page 118... ...
2005 Global Summit Guideline Outcome Summary The cumulative work of the four panels results in a matrix guideline spanning the spectrum of breast health care from early detection to treatment and palliation of advanced disease, and considers the full spectrum of available resources (Tables 4-34-7)
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From page 119... ...
. Copyright 2006 by the Breast Health Global Initiative, Fred Hutchinson Cancer Research Center.
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From page 120... ...
. Copyright 2006 by the Breast Health Global Initiative, Fred Hutchinson Cancer Research Center.
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From page 121... ...
. Copyright 2006 by the Breast Health Global Initiative, Fred Hutchinson Cancer Research Center.
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From page 122... ...
. Copyright 2006 by the Breast Health Global Initiative, Fred Hutchinson Cancer Research Center.
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From page 123... ...
. Copyright 2006 by the Breast Health Global Initiative, Fred Hutchinson Cancer Research Center.
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From page 124... ...
. Copyright 2006 by the Breast Health Global Initiative, Fred Hutchinson Cancer Research Center.
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From page 125... ...
. Copyright 2006 by the Breast Health Global Initiative, Fred Hutchinson Cancer Research Center.
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From page 126... ...
A strength of the BHGI guideline development process is its collaborative nature, creating partnerships to improve health care in limitedresource countries (Figure 4-1)
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From page 127... ...
Does a clinician decide to treat 10 patients with an older, less expensive chemotherapy regimen, or to treat 2 patients with a newer, more efficacious, but also more expensive regimen? To establish a cancer treatment program in a limited-resource setting, key treatment alternatives should be considered, weighing costs, efficacy differences, and the expected availability of resources and personnel to implement the program.
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From page 128... ...
The information can be used to plan the future development of a unit by prioritizing the acquisition of missing elements. The guidelines also can support a clinician's request for specific equipment and funding for breast cancer treatment.
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From page 129... ...
The BHGI has built financial support from the first summit through the upcoming 3rd biennial summit, and no new such undertaking will succeed without adequate support. As a benchmark, the budget for the 2007 global summit, which will support 75 participants from around the world and 5 staff members at a 4-day meeting in Budapest, is US $400,000.
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From page 130... ...
Guidelines for palliative care for the common cancers should be developed, and will be applicable to people dying from all types of cancer. A major consideration in decisions about offering treatment for cancers in resource-limited settings are characteristics of the interventions themselves -- the specific types of surgery or drugs, for example -- needed to achieve a good outcome.
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From page 131... ...
For other cancers down the list of the 10 leading causes of cancer death, the overall survival among U.S. cancer patients is much better, and there are substantial differences between the mortality to incidence ratio between less and more developed countries, suggesting that treatment makes a significant difference in survival.
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From page 132... ...
The difference in the mortality to incidence ratio between less and more developed countries would be larger if these statistics were more comparable. Cancers of Children and Young Adults As is the case with cancers of adults, practitioners in LMCs have formally or informally prioritized cancer types of children and young adults for treatment.
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From page 133... ...
100 Surgery, radiotherapy Local/regional 100 Surgery or radiotherapy Hodgkin's lymphoma 85 Chemotherapy, radiotherapy (overall) Local 90 Radiotherapy or chemotherapy Regional 90 Radiotherapy and/or chemotherapy Distant 76 Radiotherapy and chemotherapy SOURCE: National Cancer Institute (2006)
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From page 134... ...
Resource-level-specific guidelines would be useful for all the prioritized tumors. DISCUSSION AND RECOMMENDATION The BHGI guidelines, as well as any other guidelines produced, are tools that can enable progress in cancer control, but their mere existence is unlikely to result in major changes.
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From page 135... ...
2003. Global Summit Consensus Conference on International Breast Health Care: Guidelines for countries with limited resources.
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From page 136... ...
2006a. Breast cancer in limited-resource countries: An overview of the Breast Health Global Initiative 2005 guidelines.
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From page 137... ...
Bethesda, MD: National Cancer Institute, SEER Program. Shyyan R, Masood S, Badwe RA, Errico KM, Liberman L, Ozmen V, Stalsberg H, Vargas H, Vass L, Global Summit Diagnosis and Pathology Panel.
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