I was asked to give a presentation on resource-stratified guidelines. This is an approach to cancer management guidelines that my prior group, the Breast Health Global Initiative, based at the Fred Hutchinson Cancer Research Center developed over the past twenty years.

What are the resource-stratified guidelines?

When we started doing our global work out of Seattle, we went to Ukraine to help develop programmes. It became apparent during that work that the high-income country guidelines that we would help develop such as the National Comprehensive Cancer Network guidelines, NCCN guidelines, or ASCO guidelines or ESMO guidelines, it became apparent to us that they really didn’t apply or work in that limited-resource setting of Ukraine. That led to the question if the standard high-income country guidelines don’t work, what would work in that setting? 

The problem with the high-income country guidelines is that they assume you have all of the tools in place and it asks an important scientific question which is, ‘How do you put this together in the best way to minimise the chances of cancer coming back?’ The problem is that it doesn't help you if you don’t have all of the resources. There’s no prioritisation scheme to help you decide how you would implement this. That’s what led to our development of the research-stratified guideline approach.

How beneficial are they for research in LMICs?

So it’s important to understand that research-stratified guidelines is an approach rather than a specific guideline. The concept is that within an evidence-based guideline framework you examine all of the resources that are required in that complete setting and then you take those resources and you put them in an order. You segregate them based upon their relative necessity, because there are some resources that are mandatory – if you don’t have these resources, you really can’t begin. We call those basic level resources. We learned about this in Ghana because we learned that in the major cancer centres that it might take six months to generate a pathology report because that really was not a well-resourced area pathology-wise at that time. So, that’s a basic level resource – if you don’t have that you really can’t effectively administer treatment.

The next level up was limited level resources or core level resources. Those are those resources that are going to make a major difference in outcome, such as survival. So many of the drug therapies that we do, we have very high level evidence that they will make people live longer when they’re administered therapeutically. 

The next level we call enhanced level resources. Those are ones that might not improve survival but would make major differences in some other factors. So, for example, in breast cancer, breast conservation therapy – being able to do a lumpectomy with radiation rather than a mastectomy. Doing the smaller surgery with radiation does not save more lives but it makes it more acceptable and therefore more people will potentially participate.

Then the top level resource, we determined, those were resources you don’t focus on because there are some tools that are very expensive, complicated, and they are not going to make that major difference. One of the unfortunate aspects is that, in the high-income countries, that’s what we tend to talk about the most when, in fact, that’s not what is necessary to create a system. So the resource-stratified guideline approach is how do we build a system with the resources that we have and, equally important, if there are gaps, what are those gaps and what resources do we need to fill these. These are being applied; now, we started it but now NCCN and ASCO both have adopted a resource-stratification framework for what they do, and in fact WHO has adopted this as well. 

There are some special guideline approaches such as harmonised guidelines that are adapted specifically to a region. NCCN has done harmonised guidelines together with colleagues from Sub-Saharan Africa for the Sub-Saharan Africa region.

Anything else you’d like to add?

I think that we talk a lot about guidelines and it’s absolutely an important place to start. There’s a misconception that there is the perfect guideline and somehow that makes it better; actually different guidelines tend to do different things. So you want a guideline that’s appropriate for the environment that you have. But perhaps more important than the guideline, whether it is resource-stratified or not, is are you able to follow the guideline? Because even if you have a guideline, if you can only administer the therapies that are described in that guideline in a small percentage of patients, then it’s really not achieving the outcome. So, the ability to apply the guideline may be more important than the guideline selection itself.