Should Resource Constraints Guide Global Guidelines?
Authors: Benjamin O. Anderson
Journal: Journal of the National Comprehensive Cancer Network (2007)

Should Resource Constraints Guide Global Guidelines?Comprehensive efforts to improve global health must address cancer, which kills 4.4 million people each year in low-and medium-income countries (LMCs), more than respiratory infections (3.5 million), respiratory diseases (3 million), HIV/AIDS (2.7 million), diarrheal diseases (1.8 million), and tuberculosis (1.5 million). 1Worsened cancer survival in LMCs is largely due to late stage presentation, which, when coupled with limited diagnosis and treatment capacity, leads to particularly poor outcome. 2 In addition, health care experts in LMCs may not have yet identified cancer as a priority health issue, because infectious diseases drive morbidity and mortality in these countries.However, as the control of communicable diseases improves and life expectancy rises, cancer will become an increasingly obvious public health issue in LMCs. 3 In anticipation, the World Health Organization (WHO) adopted the first Cancer Prevention and Control Resolution (WHA58.22) in May 2005 at the 58 th World Health Assembly.The Resolution calls on member states to collaborate in developing comprehensive cancer control programs "aimed at reducing cancer incidence and mortality and improving the quality of life of cancer patients and their families, specifically through the systematic, stepwise, and equitable implementation of evidencebased strategies for prevention, early detection, diagnosis, treatment, rehabilitation, and palliative care." 4 Clinicians in LMCs are forced to provide suboptimal patient care when diagnostic and/or treatment resources are lacking.Therefore, knowing which resources most effectively fill health care needs is especially important in limited-resource regions, where patients present with more advanced disease and clinicians must provide guidance on how new resources should be allocated to maximize improved outcome.Evidence-based guidelines from high-income countries, such as the NCCN Clinical Practice Guidelines in Oncology, outline optimal approaches to cancer detection, diagnosis, and treatment. 5,6However, the WHO notes that cancer guidelines defining ideal practice have limited utility in LMCs, where resources are absent, inadequate, or dysfunctional. 7In response, experts in some LMCs have attempted to develop cancer treatment guidelines based on the available resources. 8 Sponsored by Susan G. Komen For the Cure and the Fred Hutchinson Cancer Research Center, the Breast Health Global Initiative (BHGI) has published resourcesensitive guidelines, 9 using an NCCN-like evidence-based, expert consensus approach to define comprehensive pathways for evolving LMC breast health care delivery programs addressing early detection, 10 diagnosis, 11 treatment, 12 and health care systems. 13 The BHGI guidelines stratify resources into 4 levels (basic, limited, enhanced, and maximal), making the guidelines simultaneously applicable to countries of differing economic capacities. 14In their report, "Cancer Control Opportunities in Low-and Middle-Income Countries," the Institute of Medicine identifies the BHGI approach as a model for developing resource-sensitive guidelines that could be applied to other cancers or chronic diseases for which effective treatments are available. 15 This begs the question: Is the time ripe to address the need for resource-sensitive cancer care guidelines in America?I believe so.With rising health care costs, dwindling Medicare funding, and a growing uninsured population, the United States will find it increasingly difficult to deliver cancer care.Therapies are added to guidelines based on data regarding efficacy without consideration for cost, when we lack the infrastructure to realistically provide complete cancer care to the underinsured and working poor.The language of economists is foreign to the medical community and has yet to be adopted into cancer care guidelines.The NCCN has provided critical direction in describing evidence-based guidelines for optimal cancer care.Now I believe that the next generation of NCCN guidelines needs to address cost-benefit analysis in ways