The Anglo-Indian author Rudyard Kipling is widely known for The Jungle Book, a tale that has been repeated and adapted in written word, illustration, and animation since it was published as a series of stories in the late 19th century. A prolific writer, Kipling had a global career and inspired authors ranging from the Argentinean Jorge Luis Borges to Americans such as Randal Jarrell and Poul Anderson. A political conservative, Kipling has often been seen as a product of the time and civilization in which he was born and lived. We will likely continue to debate his role and that of the British Empire and their legacy around the world, but he was spot on when he said:
“Small miseries, like small debts, hit us in so many places, and meet us at so many turns and corners, that what they want in weight, they make up in number, and render it less hazardous to stand the fire of one cannon ball, than a volley composed of such a shower of bullets.”
Low- and middle-income countries (LMICs) are facing a volley of challenges, big and small, related to non-communicable diseases in general and to cancer in particular. The demographic transition that brought most of the world’s population into cities in the last 50 years has exposed billions to risk factors that are making cancer incidence rise at an unprecedented pace around the globe. With limited resources, LMICs share a disproportionate burden of the disease. According to the GLOBOCAN data from the International Agency for Research on Cancer, there were 14.1 million cases and 8.2 million cancer deaths globally in 2012. The number of cases is expected to reach 23.6 million in 2030, and most of these will occur in LMICs.1,2
There are major disparities in cancer control across the world. The ratio between cancer deaths and the total number of cases is 47% in high-income countries and 66% in LMICs, which invest but a fraction of what high-income countries do in cancer prevention and management. For example, the economic burden from cancer in the United States, United Kingdom, and Japan is $183 to $460 per patient, but in South America, India, and China, the economic burden is $0.54 to $7.92 per patient. Overall, high-income regions spend five to 10 times more per capita than LMICs.3 In addition to a lack of resources, these differences exist because cancer is not always regarded as an important public health issue in LMICs.
LMICs must invest in cancer control in a cost-effective, stepwise fashion to achieve the best results in the shortest amount of time with the most rational allocation of resources. This means clinicians may be forced to provide less-than-ideal care to patients when diagnostic and/or treatment resources are lacking, despite knowing the optimal management strategy based on guidelines developed in wealthier countries. For this reason, it is important to prioritize treatment best practices that will most effectively fill the health care needs in limited-resource regions, where patients commonly present with more advanced disease at diagnosis, and to provide resource-allocation guidance in order to maximize outcomes in a systematic fashion.
Several groups, such as the Breast Health Global Initiative (BHGI), the Asian Oncology Summit, and ASCO, have taken the initiative to develop resource-stratified guidelines in an attempt to help fill this gap. By collecting and interpreting evidence and categorizing them by resource availability, these guidelines provide recommendations for countries on how to improve their situation and advise physicians on how to provide the best care possible within limited resources. This editorial will describe the original experience from BHGI, the Asian Oncology Summit guidelines, and ASCO’s ongoing efforts in resource-stratified cervical cancer guidelines.
The Breast Health Global Initiative
Breast cancer is increasingly common in LMICs, and treatment can significantly improve survival. Established in 2002, BHGI created an international health alliance to develop evidence-based guidelines for countries with limited resources in order to improve outcomes. BHGI serves as a program for international guideline development and as a hub for linkage among clinicians, governmental health agencies, and advocacy groups to translate guidelines into policy and practice. BHGI collaborated with 12 national and international health organizations, cancer societies, and non-governmental organizations to host BHGI Global Summits. BHGI initially stratified resources in basic, limited, enhanced, and maximal levels, and then went on to develop and update resource-sensitive, culturally appropriate, evidence-based guidelines where available, during the 2002, 2005, and 2007 Global Summits. Guidelines were published in 2003 as a theoretical treatise on international breast health care, and they were expanded into a fully comprehensive and flexible framework to permit incremental improvements in health care delivery, based on outcomes, cost, cost-effectiveness, and use of health care services in 2006.
Since 2007, the initiative has focused on the implementation of the guidelines with pilot educational projects in Asia, Latin America, and Africa, known as learning laboratories. The 2010 Global Summit focused on optimizing the delivery of health care, and the 2012 Global Summit focused on palliative care and survivorship. As of 2014, authors associated with BHGI have published more than 200 related articles, and more than 500 papers from non-BHGI authors have cited the guidelines and the initiative.4
BHGI presented recommendations based on a four-tiered, resource-stratified system: basic, limited, enhanced, and maximum levels. Basic level indicates fundamental or core services that are absolutely necessary for any cancer system to function (e.g., mastectomy). Limited level includes second-tier services that intend to produce major improvements in outcomes and are achievable with scant financial means and modest infrastructure (e.g., tamoxifen as adjuvant therapy). Enhanced level includes third-tier services that are optional in a resource-constrained setting but are important and should produce further improvements in outcome and increase the number and quality of therapeutic options and choices for patients (e.g., aromatase inhibitors). Maximum level represents services that might be used in settings with many resources or that might be recommended in cancer guidelines that do not account for resource constraints but that should be judged lower priority than resources or services listed in the basic, limited, or enhanced categories, on the basis of their great cost or impracticality for broad use in a resource-limited environment (e.g., colony-stimulating factors in adjuvant therapy). To be useful, resources at the maximum level always depend on the existence and functionality of all lower-level resources.5-10
Resource-Stratified Guidelines and Consensuses in Asia
Using the four-tiered, resource-based approach pioneered by BHGI, the Asian Oncology Summit, under the auspices of Lancet Oncology, lead the development of a series of consensuses that, although based in and created for Asia, serve as an added model for use in both LMICs and high-income countries around the world. These consensuses, which range from non–small cell lung cancer and breast cancer to nasopharyngeal and gastric carcinomas to screening and palliative care, were created with preparatory work before and meetings during the Asian Oncology Summit sessions between 2009 and 2013. Like the BHGI before them, these guidelines give individual clinicians a practical framework for treating patients and give policymakers insight into how to plan resource-appropriate cancer control. One of the innovative aspects—of the colon cancer guidelines, in particular—was the formal use, review, and development (when none were available) of health-economics evaluations and their incorporation into consensus development using World Health Organization cost-effectiveness criteria for the inclusion of diagnostic and treatment technologies at each resource level. A full list of the Asian Oncology Summit guidelines is included in the Table.
ASCO’s Resource-Stratified Guidelines: Cervical Cancer
Building on these experiences and on its own track record in guideline development, ASCO is currently working on resource-stratified recommendations for cervical cancer. This unified effort will cover the whole spectrum of the disease, divided in three areas: primary prevention, secondary prevention/screening, and work-up and treatment, which will also include survivorship, supportive care, and palliative care. Under the leadership of a Guidelines Advisory Committee, ASCO has already convened three expert panels and plans to have the work completed as soon as possible and to expand this experience into a planned series of resource-stratified guidelines.
Resource-stratified guidelines are an important tool in our fight for global cancer control. We hope that this editorial will whet your appetite to learn more about the efforts of ASCO’s International Affairs Committee and the Society in general. Join the fight. Get involved as a volunteer.
Adapted from the 2015 ASCO Daily News.
- Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136:E359-86.
- Bray F, Ren JS, Masuyer E, et al. Global estimates of cancer prevalence for 27 sites in the adult population in 2008. Int J Cancer. 2013;132:1133-45.
- Lopes G de L, de Souza JA, Barrios C. Access to cancer medications in low- and middle-income countries. Nat Rev Clin Oncol. 2013;10:314-22.
- Echavarria MI, Anderson BO, Duggan C, et al. Global uptake of BHGI guidelines for breast cancer. Lancet Oncol. 2014;15:1421-3.
- Anderson BO, Distelhorst SR. Guidelines for International Breast Health and Cancer Control—Implementation: Introduction. Cancer. 2008;113 (suppl 8):2215-6.
- Carlson RW, Anderson BO, Chopra R, et al. Treatment of breast cancer in countries with limited resources. Breast J. 2003;9 (suppl 2):S67-74.
- Anderson BO, Shyyan R, Eniu A, et al. Breast cancer in limited-resource countries: an overview of the Breast Health Global Initiative 2005 guidelines. Breast J. 2006;12 (suppl 1):S3-15.
- Anderson BO, Yip CH, Smith RA, et al. Guideline implementation for breast healthcare in low-income and middle-income countries: overview of the Breast Health Global Initiative Global Summit 2007. Cancer. 2008;113:2221-43.
- Yip CH, Cazap E, Anderson BO, et al. Breast cancer management in middle-resource countries (MRCs): consensus statement from the Breast Health Global Initiative. Breast. 2011;20 (suppl 2):S12-9.
- El Saghir NS, Adebamowo CA, Anderson BO, et al. Breast cancer management in low resource countries (LRCs): consensus statement from the Breast Health Global Initiative. Breast. 2011;20 (suppl 2):S3-11.
- Asian resource-stratified guidelines. The Lancet. Accessed February 18, 2015.