Should There Be International Standards for Cancer Care?

Should There Be International Standards for Cancer Care?

George W. Sledge, MD, FASCO

Mar 14, 2011

Discussions of cancer care begin with science and end with economics and politics. This is true within countries, but is particularly the case when we cross borders. While there is much about cancer that is common everywhere — smoking-induced lung cancer has pretty much the same biology in Beijing and Boston — the treatment of cancers is defined as much by the infrastructure of health care systems as it is by the results of Phase III trials presented at ASCO. This infrastructure, in turn, is the product of economic, social, and political forces that have little to do with science.

Doctors are responsible for the care of individual patients. Health care systems are responsible for maximizing the health of general populations. Health care systems all make decisions, and all ration care (though they ration care in very different ways). Some rationing occurs at a very basic level: a local regulatory refusal to approve a new agent, or a simple lack of appropriate technology or a lack of the money required to pay for a new agent. All of this is understood by those studying international health care.

This leads us to a simple question: should there be international standards for cancer care? Are there cancer therapies so basic that they should be the birthright of all the people of this world? This is more than a philosophical question, though philosophical question it certainly is. It is an important, basic, and practical question. Such standards, once established, represent the bar over which all governments should jump if they are to deserve the consent of the governed.

But how do we establish such standards? This is a question that requires our serious attention, but it is far from simple to answer. First, because every health care system faces different challenges with different resources, and must make decisions that are often painful even to contemplate. Secondly, advances in cancer care render such standards a constantly moving target. And finally, cancer is an exceptionally complex subject about which it is easy for reasonable people to disagree.

Do we have any models for the development of such standards? Ben Anderson and his colleagues in the Breast Health Global Initiative have developed a tiered set of therapeutic standards that takes into account available resources while attempting to maximize clinical benefits. This seems as reasonable a way forward as any. It does not, and should not, imply that some deserve better care than others. An optimum standard of care (however difficult to define with precision) exists and should ultimately be available to all. But in many low- and middle-income countries even the most basic standards of care are lacking, and the BHGI approach offers a way forward. ASCO has endorsed these standards.

What is ASCO’s role in the creation of such standards? As medical societies go, we are a relatively prosperous one, but our annual budget still represents only a rounding error in the global health care budget. We cannot solve all of the world’s problems. But we are good at bringing people together. We have an immensely talented pool of volunteers from all over the planet. We have the credibility, I hope, that comes from a consistent pattern of caring for those in need and developing new approaches to treatment. We have expertise in standard setting from our longstanding guideline development and quality assessment efforts. We have an active and engaged International Affairs Committee, a great staff interested in the problem, and good relations with international cancer societies. These are real assets in approaching this issue, and they support the possibility of partnering with others to help develop such standards.

There is a temptation to give in to despair in contemplating the fate of cancer patients in the poorer parts of the world, where the Hobbesian nature of society dooms all too many to premature and often painful deaths. When HIV/AIDS is epidemic, and malaria all too common, and poverty renders the fruits of modern science unimaginable to all but the fortunate few, why even bother thinking about HER2-targeted therapy for breast cancer or imatinib for CML?

The utilitarian answer is that poverty need not be permanent, and that the rising economic tide of the past fifty years has put cancer care in reach of increasing numbers even as the cancer problem has grown. Many simple and relatively inexpensive answers, appropriately applied, could save enormous numbers of lives and decrease human suffering to an immense degree.

But there is, I think, an additional answer as why we should create international standards. Abraham Lincoln, the greatest of American presidents, once spoke of the American Declaration of Independence, with its proud proclamation that all men are created equal, and that they were endowed with the inalienable rights of life, liberty, and the pursuit of happiness. I quote from his thoughts on the Declaration and its authors:

“They did not mean to assert the obvious untruth, that all were then actually enjoying that equality, nor yet, that that they were about to confer it immediately upon them. In fact they had no such power to confer such a boon. They meant simply to declare the right, so that the enforcement of it might follow as fast as circumstances should permit. They meant simply to set up a standard maxim for free society, which should be familiar to all, and revered by all; constantly looked to, constantly labored for, and even though never perfectly attained, constantly approximated, and therefore constantly spreading and deepening its influence, and augmenting the happiness and value of life to all people of all colors everywhere.”

I certainly couldn’t say it any better.


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