ASCO has released a new guideline on the treatment of patients with metastatic breast cancer in resource-constrained settings, where maximal setting–recommended treatments are not available.1 The guideline, designed for clinicians, policymakers, and patients, provides stratified recommendations based on the resources available.
Sana Al Sukhun, MD, MSc, FASCO
Individuals in low- and middle-income regions carry a disproportion burden of breast cancer deaths worldwide. Overall, these patients account for 62% of breast cancer cases and comprise 72% of breast cancer–related deaths.2 Patients in Low and Middle Human Development Index countries also tend to be diagnosed with breast cancer earlier in life, which adds to the social and economic burdens of cancer, said Sana Al Sukhun, MD, MSc, FASCO, of the Al Hyatt Oncology Practice in Amman, Jordan, and Guideline Co-Chair, in a recent ASCO interview.3
Dr. Al Sukhun noted that although many clinicians are aware of the importance of clinical practice guidelines for improving outcomes for patients with cancer, these guidelines are typically developed in high-resource regions or settings. “Their applicability in countries with low resources . . . is definitely limited, because they cannot really adopt and adapt to those guidelines,” she said, highlighting the importance of developing resource-stratified guidelines.
Adapting Guidelines for Resource-Constrained Settings
To develop the guideline, ASCO convened a multinational, multidisciplinary Expert Panel that also included patient representatives and an ASCO Guidelines staff member with expertise in health research methodology. The Expert Panel reviewed and adapted existing maximal setting, ASCO-published guidelines, incorporating clinical experience in resource-constrained settings. Recommendations were validated through formal consensus.
The guideline frames its recommendations using a four-tier resource setting approach, which was originally developed by the Breast Health Global Initiative.2 In this framework, settings are categorized as basic, limited, enhanced, and maximal, according to the allocation of resources toward improving clinical outcomes. Decisions should be guided based on the highest stratum of resources available.1
Banu K. Arun, MD, of The University of Texas MD Anderson Cancer Center, and Guideline Co-Chair, noted in the same interview that there is variability in resources not only across countries but also within individual countries, such as between rural and urban areas, where disparities in resources can exist.
Focusing on Available Resources, Clinician Responsibility
The guideline provides recommendations for the treatment of metastatic breast cancer across lines of treatment based on the status of hormone receptors, HER2, other biomarkers, and menopausal status. They noted that treatment recommendations should be made based on the availability of quality pathologic and biomarker results.1
Banu K. Arun, MD
The guideline also addresses the treatment of patients in settings where accurate diagnostics are not available. “There are some basic settings where, unfortunately, immunohistochemistry for estrogen receptor or progesterone receptor and HER2 determination is not available,” Dr. Arun said. “In these cases, clinicians may presume hormone receptor positivity and offer tamoxifen, in most cases. It is expected that immunohistochemistry would be available in limited and, of course, enhanced settings.”
Dr. Arun noted that as clinicians consider these recommendations, they should also be familiar with key publications and subgroup analyses and understand that treatment must be individualized for each patient. “Ultimately,” she said, “it’s the clinician’s responsibility to find the best available therapy for the patient, and sometimes that includes no treatment and supportive care.”
Echoing this sentiment, Dr. Al Sukhun emphasized that the guidelines are there to support the clinician’s decision. “After all,” she said, “the clinician is the one . . . who can evaluate the patient from all aspects—social, physical, tumor—so it’s not just about the tumor, it’s about the patient and the environment where the clinician is treating the patient.”
The overarching goal of the guideline, Dr. Al Sukhun said, is to improve outcomes for patients worldwide by empowering clinicians to optimize care, advocate for improved outcomes through strategic resource allocation, and identify areas for research. She added that the guidelines are also there to help inform policymakers in implementing strategies that can efficiently improve outcomes. Hopefully, the combination of research, advocacy, health policy, and treatment guidance will help improve outcomes for individuals diagnosed with breast cancer “and ultimately reduce mortality, particularly in less fortunate, limited-resource settings, for patients everywhere,” Dr. Al Sukhun concluded.
REFERENCES
2. 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 12(suppl 1):S3-S15, 2006.
3. Heer E, Harper A, Escandor N, et al: Global burden and trends in premenopausal and postmenopausal breast cancer: A population-based study. Lancet Glob Health 2020;8:e1027-e1037, 2020.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, January 11, 2024. All rights reserved.
