Breast Cancer Diagnosis and Treatment in Low- and Mid-Resource Settings: the Role of Resource-Stratified Clinical Practice Guidelines

Abstract

One of the most important recent advances in the management of cancer patients have become the development of guidelines. Guidelines are usually evidence-based or international consensus guidelines. Those guidelines may not be applicable worldwide, especially where resources are limited. This prompted initiatives for the development of resource-stratified guidelines so that health care providers and authorities can do the best they can with the resources they have, while working on improving their resources. We will describe the process of development of those guidelines and briefly review recommendations for awareness, screening, diagnosis, and treatment of breast cancer, focusing on countries and special populations with limited resources. The World Health Organization (WHO) described three resource scenarios (low-resource, middle-resource, and high-resource scenarios) in order to facilitate the establishment of national cancer control plans. The Breast Health Global Initiative (BHGI), as an initiative group with goals to improve the care of patients with breast cancer in low- and mid-resource settings, identified four levels of resource availability (basic, limited, enhanced, and maximal) with comprehensive sets of recommendations for each. BHGI published resource-stratified breast cancer guidelines starting in 2006, and later on updated them and focused on implementation and health systems. The National Comprehensive Cancer Network (NCCN) initiated a program, building upon the BHGI experience to resource stratify cancer treatment guidelines across multiple cancer types and published NCCN Framework for resource stratification in breast cancer in 2016. Subsequently, the NCCN has published multiple additional resource stratification frameworks that use slightly different definitions of resource level than use by the BHGI. The American Society of Clinical Oncology (ASCO) has also assembled a Guidelines Advisory Group for Resource Stratification for different cancers, and published its first comprehensive resource-stratified guidelines for cancer of the cervix. International efforts to improve management and reduce disparities in the outcome of breast cancer patients’ worldwide focus on recommendations for better allocation of available resources in different countries. The WHO, BHGI, NCCN, ASCO, and other international initiatives issued various resource-stratified guidelines (RSG) based on levels of resources in different countries. We shed the light on the development of these guidelines and discuss awareness, prevention of advanced disease at presentation, and management. Future research is needed to update and improve dissemination and implementation of RSG, as well as building infrastructure, reforming of health systems, and better allocating resources.