ASCO has released a new guideline for clinicians and policymakers in resource-constrained settings on treating patients with late-stage colorectal cancer.1
Mary D. Chamberlin, MD
“Around the world, there is a huge variation in resources, and what is available to clinicians may change week to week,” said Mary D. Chamberlin, MD, of Dartmouth-Hitchcock Medical Center and Guideline Co-Chair. “Guidelines need to be flexible, based on what is available at the time the clinician is making decisions about patient care.”
This variation in resources may occur, not only between countries, but also within countries, from region to region or even city to city. To address this variation, ASCO adopted a framework for the guideline from the four-tier resource setting approach developed by the Breast Health Global Initiative. This framework classifies resource settings as follows:
- Basic: Core resources or fundamental services that are absolutely necessary for any cancer health-care system to function;
- Limited: Second-tier resources or services that are intended to produce major improvements in outcomes and are attainable with limited financial means and a modest infrastructure;
- Enhanced: Third-tier resources or services that are optional, but important, and should produce further improvements in outcomes and increase the number and quality of options as well as patient choice;
- Maximal: High-level/state-of-the-art resources or services.
Previous Global Guidelines Taken Into Account
The guideline expert panel took into account previously published guidelines from around the world, including guidelines from the National Comprehensive Cancer Network, European Society for Medical Oncology, Cancer Council Australia, Singapore Cancer Network, Japanese Society for Cancer of the Colon and Rectum, and the United Kingdom’s National Institute for Health and Care Excellence.
“These guidelines each address the best means of diagnosing and treating advanced colorectal cancer, emphasizing the most essential services needed in [lower-resource] countries and/or regions and settings, but guiding [based] on important options available in more resource-rich settings,” explained E. Gabriela Chiorean, MD, of the University of Washington, Fred Hutchinson Cancer Research Center, and Guideline Co-Chair.
“The guideline can also help determine what resource investments may be valuable to increase the quality of life and survivorship of [patients with] advanced colorectal cancer.”— E. Gabriela Chiorean, MD
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Clinical Questions and Patient Discussions
For each of the seven clinical questions posed in the guideline, ASCO’s multidisciplinary, international panel had to decide the optimal management for patients with late-stage colorectal cancer from initial diagnosis to follow-up based on available resources.
One clinical question, for example, asked: What are optimal treatments for patients with late-stage colorectal cancer, specifically related to the approach of the primary tumor? According to the guideline, in basic and limited settings, if there is a high risk of obstruction, significant bleeding, perforation, or tumor-related symptoms, treatment should be resection of the primary tumor or diverting ostomy. However, in enhanced and maximal settings, there is the added option of colon or rectal stenting or systemic chemotherapy for local and distant disease control.
Another key question asked: What systemic therapies should be used in the first-line treatment of advanced colorectal cancer? Often, in basic settings, no chemotherapy option exists, so patients should be referred, when possible, to centers with more advanced resources. Limited settings typically have access to only single-agent fluoropyrimidine chemotherapy. Enhanced settings have access to doublet or triplet chemotherapy combinations, and, in maximal settings, patients should also have access to the addition of molecularly targeted therapies and immunotherapies, depending on their genetic or molecular tumor profile.
When chemotherapy is available in limited- and sometimes basic-resource settings, careful risk-benefit discussions are recommended, so patients truly understand the relative and absolute benefits of treatment. Such conversations must take into account the many risks involved from missing treatments due to a lack of transportation or costs to the family due to a loss of income from family members missing work to transport or care for a family member with cancer. Data on absolute improvement in overall survival from systemic therapy in limited- or basic-resource settings are extremely limited and desperately needed to guide these difficult conversations.
Additional clinical questions addressed in the guideline include diagnosis; symptom management; staging; optimal first-, second-, and third-line treatments; and on-treatment surveillance and follow-up strategies.
Raising Global Awareness
The most important part about resource-stratified guidelines, according to Dr. Chamberlin, is to raise awareness of the challenge of treating cancer in any setting around the world. “As clinicians and researchers, we need to make sure our research is going to be applicable to other populations because the global burden of cancer is rising exponentially in areas with the least resources to manage it,” she said. “Those of us who are trained in oncology using maximal resources need to be able to interpret evidence and make recommendations to those clinicians treating the bulk of the most challenging [cases].”
The new recommendations were designed to aid not only clinicians, but also policymakers in various countries, Dr. Chiorean said. “These [recommendations] will provide local physicians, health ministries, and medical boards with the guidance and strategies on the best means of diagnosing and treating late-stage colorectal cancer in their country and each of their communities,” she commented. “The guideline can also help determine what resource investments may be valuable to increase the quality of life and survivorship of [patients with] advanced colorectal cancer.”
Drs. Chamberlin and Chiorean said they hope that readers of the guideline will take advantage of the corresponding author e-mail and write in with their thoughts and insights (guidelines@asco.org). As the landscape of cancer treatment and resources evolves, ASCO will regularly update its guidelines. Input from clinicians in various resource settings could help further inform these potential future modifications.
DISCLOSURE: For full disclosures of the panelists, visit jco.ascopubs.org.
REFERENCE
1. Chiorean EG, Nandakumar G, Fadelu T, et al: Treatment of patients with late-stage colorectal cancer: ASCO resource-stratified guideline. JCO Glob Oncol 6:414-438, 2020.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, March 11, 2020. All rights reserved.
