Window on Reality

 

Window On Reality:

This project was funded by an Educational Grant from Fresenius Kabi:

The global disparities in cancer care are stark. Lack of resources and basic infrastructure mean that most low to middle income countries (LMIC) have no access to cancer screening, early diagnosis, treatment or palliative care. Consequently a diagnosis of cancer leads, in most cases, to a painful and distressing death.
 
However, over one third of cancer deaths are due to preventable causes such as viral infection, poor nutrition and widespread tobacco use. Another third of cases are treatable if detected early – but governments and institutions face a wide range of serious health problems and cancer is often not a priority in limited resource settings.
 
By 2030 there are expected to be 22 million new cases of cancer every year, 60% of which will be in LMIC’s where governments are least prepared to address the growing cancer burden and where survival rates are often less than half those of more developed countries. The majority of cancer patients present with advanced or metastatic disease, and while more must be done to promote earlier disease detection, it is important to  understand what treatment options might be available for these patients.
 
There are very few data on uptake and utilisation of modern anticancer medicines and whether internationally developed treatment guidelines are  at all relevant  in LMICs. There is no doubt that cancer treatment guidelines can help to improve the outcomes of patients who present with treatable cancer, however, there is a growing consensus that the treatment guidelines currently available are aimed at high income countries therefore are not fit for purpose in LMIC’s. There is a recent trend towards the introduction of resource stratified cancer specific guidelines to support cancer care in LMICs.
 
Project:
We have received an educational grant to explore in detail what breast and lung cancer regimes are used by oncologists in Thailand, Philippines, Malaysia, Vietnam, Indonesia, India, China, Argentina, Brazil, Chile and Mexico.   We also explored whether they use national and/or international guidelines, and if not, is there a role for a group of internationally well respected oncologists to work together to develop practically useful management guidelines?
 
Key Opinion Leaders (KOL’s):
AfrOx identified KOL’s in India, China and South America to help us contact their local Medical Oncology Societies to distribute the survey who also helped to develop and refine the survey: 
  • India; Prof Gouri Shankar Bhattacharyya, Past President: Indian Society of Medical &Paediatric Oncology.
  • China: Prof Yuan- Kai Shi, Prof of Medical Oncology, Vice President, Chinese Society of medical Oncology.
  • South America: Prof Gilberto Lopes: Chief Medical and Scientific Officer, Oncoclinicas do Brasil.
 
Survey:
We developed the survey with help of our KOL’s and faculty at Oxford University especially Prof D Kerr. This survey was then digitised by DBM Wissenschafft, a company with an excellent track record of developing and collating data from medical surveys. The survey asked for general information on the clinical guidelines Oncologists in these countries used and more specific information on the regimes used to manage Breast and Lung Cancer.
 
Summary Analysis of Survey:
We have approached oncologists throughout; India, China, Thailand, Philippines, Malaysia, Vietnam, Indonesia, Argentina, Brazil, Chile and Mexico. 139 (3%) oncologist responded to the survey. 
The majority of participants who did respond were Consultants (44%), or Heads of the Oncology department (31%). The majority of respondents were from University Hospitals ([48%] which in LMIC’s are likely to see the majority of cancer patients) and private hospitals (35%), the other participants were from community hospitals or medical practices  This therefore represents a senior and influential group of oncologists, who are likely to be considered Key Opinion Leaders in their own countries.
 
Of the 139 responses collated 80 (58%) of them always use guidelines to support their clinical decisions. The guidelines used by the participants vary, as well with some referring to more than one set of guidelines; 128 (92%) use NCCN guidelines, 76 (55%) ASCO Guidelines, 76 (55%) use ESMO Guidelines and 40% refer to National Guidelines.  Asked which guidelines the participants mainly rely on, all of them stated that NCCN guidelines were most widely used..
However, these guidelines are used predominantly for private and self- pay patients as national healthcare systems and insurance cover in the countries involved in the survey are not sufficiently well funded to support these particular treatment protocols.
 
Of the respondents who use national guidelines, their stated reason for not relying on the international guidelines is that the treatments that are specified in them are not easily accessible within their countries. 
When international guidelines are used 75% of the participants have to modify the guidelines to treat their patients, in contrast to this only 53% of those who answered the question said they were rarely required to do this with national guidelines.
80% of the respondents agreed that national guidelines set by their National Oncology society would be useful as these would have been adapted to suit the population of patients whom they serve. 
 
 Detailed Responses
The following sections summarise the raw data collected in the survey.
 
Breast Cancer:
 
For Neoadjuvant treatment for Breast cancer the respondents use (Fig1):
 
Which of the following regimes are your preferred choices for use in neoadjuvant treatment of breast Cancer?

Fig 1: Regimes used for neoadjuvant treatment of breast cancer. More than one answer was possible. Other (all answers): AC followed by paclitaxel (every 3 weeks); EP(epirubicin+ paclitaxel ); clinical trail; AT; TA(paclitaxel+epirubicin); doxorubicin plus taxol; Paclitaxel and trastuzumab; Weekly Pacli + trastuzumab; AC followed by Paclitaxel; 1) AC Q 3 wk 4 cycles followed by Docetaxel Q 3 wk 4 cycles 2) Docetaxel + Doxorubicin (or Epirubicin) Q 3 wk 6 cycles; ; Weekly paclitaxel; NA; ADR and Docetaxel; AC followed by docetaxel; AC followed by Docetaxel; AC followed by T; AC followed by docetaxel (not dose dense); AC followed by paclitaxel; Ac followed by docetaxel; AC followed by paclitaxel; AC followed by Docetaxel; AC followed by Taxotere; AC-T; AC followed by weekly T; AC followed docetaxel; AC followed by Docetaxel; AC followed by Taxen (weekly Paclitaxel or 3 week docetaxel; DA (docetaxel + doxorubicin), DE (docetaxel + epirubicin); AC/ Docetaxel; paclitaxel; I refer patients to the medical and radiation oncologists


Fig 1: Regimes used for neoadjuvant treatment of breast cancer. More than one answer was possible. Other (all answers): AC followed by paclitaxel (every 3 weeks); EP(epirubicin+ paclitaxel ); clinical trail; AT; TA(paclitaxel+epirubicin); doxorubicin plus taxol; Paclitaxel and trastuzumab; Weekly Pacli  + trastuzumab; AC followed by Paclitaxel; 1) AC Q 3 wk 4 cycles followed by Docetaxel Q 3 wk 4 cycles 2) Docetaxel + Doxorubicin (or Epirubicin) Q 3 wk 6 cycles; ; Weekly paclitaxel; NA; ADR and Docetaxel; AC followed by docetaxel; AC followed by Docetaxel; AC followed by T; AC followed by docetaxel (not dose dense); AC followed by paclitaxel; Ac followed by docetaxel; AC followed by paclitaxel; AC followed by Docetaxel; AC followed by Taxotere; AC-T; AC followed by weekly T; AC followed docetaxel; AC followed by Docetaxel; AC followed by Taxen (weekly Paclitaxel or 3 week docetaxel; DA (docetaxel + doxorubicin), DE (docetaxel + epirubicin); AC/ Docetaxel; paclitaxel; I refer patients to the medical and radiation oncologists
 
The neo- adjuvant regimes mentioned most frequently as not being available for our respondents are (Fig2):
Breast 2
Fig 2: Neoadjuvant treatments for breast cancer that are not available. More than one answer was possible.
 

Adjuvant treatment most preferred for Breast Cancer (fig3):

Breast 3

Figure 3: Regimes for adjuvant treatment of breast cancer. More than one answer was possible. Other: AC followed by paclitaxel (every 3 weeks); TA(paclitaxel+epirubicin); Docetaxel/Carboplatin and EC FOLLOWED by Docetaxel; AC followed by docetaxel or AC followed by weekly paclitaxel; AC followed by paclitaxel 3 weekly; EC followed by Docetaxel; followed by Paclitaxel if indicated; 1) AC Q 3 wk 4 cycles followed by Docetaxel Q 3 wk; AC followed by docetaxel; NA; AC and weekly paclitaxel; AC followed by taxane (docetaxel or weekly paclitaxel); AC followed by Docetaxel; AC followed by T; AC (not dose dense) followed by weekly paclitaxel; AC followed by paclitaxel; AC followed by Taxotere; AC-T; AC followed by weekly T; AC - T; AC followed by weekly paclitaxel; AC followed by paclitaxel (not dose dense); paclitaxel; Refer to medical oncology

Adjuvant Chemotherapy not available in participants countries (Fig 4):

Breast 4

Fig 4: Adjuvant treatments for breast cancer that are not available. More than one answer was possible.

Which regimes our participants use in combination with trasuzumab in HER2 positive disease (Fig 5):

Breast 5

Figure 5: Combination with trasuzumab in HER2 +ve disease. More than 1 answer was possible. Other: EC followed by Docetaxel and Tras; NA; FEC3 FOLLOWED BY 3T and Herceptin; Refer to medical oncologists

The Number of participants whom use full dose Chemotherapy as described by guidelines:

Breast 6

Which anti hormonal agents our participants have regular access to:
 B1
The combination of drugs used by our participants for treating metastatic Breast Cancer are:

B2
 
How often our participants use single agent chemotherapy:

B3

 Which Single agents our participants use:

B4
 
How many lines of chemotherapy our participants offer their patients with metastatic breast cancer:

B5

 What assays our participants use to guide their therapy:

B6

 

 

Non Small Lung Cell Lung Cancer:

Which regimes our participants use for neoadjuvant treatment of NSCLC:

NSCLC 1

Which regimes our participants use for adjuvant treatment of NSCLC:

NSCLC 2

What our participants use in treatment advanced NSCLC (Fig 1):

NSCLC 3+


  Fig ;1 treatment of advanced NSCLC. More than one answer was possible., Other: Erlotinib; Cisplatin and pemetrexed; Not applicable; Pemetrexed/cisplatin, Gemcitabine/cisplatin


How many of our participants uses full dose chemotherapy recommended by the guidelines for treatment of NSCLC:

NSCLC 4+
 
Use of single agent chemotherapy by our participants in treatment of NSCLC:

NSCLC 5+
 
The drugs our participants use for single agent chemotherapy:

NSCLC 6+
 
Treatment lines used on average by our participants treating patients with NSCLC:

NSCLC 7+
 
Tests used by our participants to monitor NSCLC:

NSCLC 8+

Small Cell Lung Cancer:

Following regimes used by participants in treatment of SCLC:

SCLC 1
 
Number of participants using full dose chemotherapy for SCLC according to guidelines:

SCLC 2

Number of lines of Chemotherapy used by our participants in treatment of SCLC treatment:

SCLC3

AfrOx used the  information from this project to write an article in the Journal of Global Oncology.

Follow this link to read: http://ascopubs.org/doi/full/10.1200/JGO.2016.008250