Implementation Research Key to Solving Global Cancer Care Puzzle

Benjamin O. Anderson, MD

Health investment is failing to match the challenge presented by a growing cancer burden in countries at all economic levels, enhancing the need for new approaches that help optimize the delivery of care, according to Benjamin O. Anderson, MD, during a keynote lecture at the 2017 Lynn Sage Breast Cancer Symposium.

Breast cancer is the most common cancer among women around the world, and those in low- and middle-income countries experience the most deaths from the disease, said Anderson, a surgical oncologist at the Seattle Cancer Care Alliance. This reality calls for the creation of resource-stratified guidelines to provide a framework for prioritizing healthcare strategies, which will require further implementation research.

"The new area of research that is relevant to low- and middle-income countries is called implementation research," said Anderson. "The idea is that it is beneficial to study implementation within an existing environment. Rather than having the purified data results that we receive from standard randomized trials, we are conducting an implementation and then discovering what happens with the difficulties of a real-world environment. This implementation research is about what is working with the constraints that the environment imposes."

Anderson gave the Connie Moskow Memorial Lecture at the Lynn Sage symposium. In an interview with OncLive, he discussed the challenges and unmet needs facing global breast cancer care, specifically in low- and middle-income countries.

OncLive: Can you highlight some of the implementation research happening globally?

Anderson: Implementation research is an evolving area but it started in the United States to investigate our own healthcare systems in high-income countries. The initial implementation research had very little to do with cancer, however, now we’re carrying this into the global health community and recognizing that it is a fundamental way to go.

It's also relevant to the modern issues that we're having with healthcare delivery in the United States, because we have 18% of our Gross National Product that is being spent on healthcare. The next country is at 11% and we do not have the same delivery that is taking place in Western Europe.

We do need to study what works and not just from a drug perspective but from a systems perspective.

What do you believe is the biggest global unmet need that should to be addressed for those with breast cancer?

The biggest need is to address the system’s obstacles. Clearly in countries with fewer resources, financial constraints are a big issue that needs to be managed. However, an even more significant problem is the systematic disorganization that is common in limited resource environments. For example, in sub-Saharan Africa there are multiple ongoing problems, but the healthcare system has not been set up well for managing cancer.

This is a problem because prior to 2011, infectious diseases were thought to be the primary health issue in low- and middle-income countries. What is happening globally is that this is being overtaken by non-communicable diseases (NCDs), meaning heart disease, lung disease, diabetes, and cancer. The World Health Organization (WHO) has been tasked by the United Nations to address the NCDs.

The reason that this is different in certain countries is that the hospitals were set up for managing infections or trauma. Those are single event healthcare issues. For example, if the patient has a car accident, they go to the hospital, receive treatment, and eventually leave. There is no continuity. With the NCDs, there is continuity, meaning that it is not just one operation or one drug treatment. It is establishing a protocol.

This is not unique to cancer. It's the same problem with managing cardiovascular disease and diabetes. The issue is how to make systems that will manage patients in a longitudinal way and will use the resources that are available in ways that are optimal.

What are the most important aspects of global breast cancer care?

I would like there to be an improvement in our overall care and not limiting ourselves. The reason we got started with this work in the late 90's and early 2000's was because the majority of people that we interfaced with in high-income countries believed that the problem wasn’t solvable. It is possible to make progress but we need to begin by getting over this idea that it's not a problem or that we can't solve it. We make incremental improvements in everything else we do in medicine, there is no reason to stop here.

We also shouldn't forget that while we talk about the wonders of medicine in the United States, we fail to recognize that we often don't deliver it. In many underserved communities, they are not getting the care that is possible in other areas of the United States.

Where do you see the future of global breast cancer research heading?

Breast cancer is the most common cancer among women around the world. The majority of cases and deaths are now occurring in low- and middle-income countries, which was not what people used to believe, partly because of misinformation. I believe that we're making significant progress by looking at the problem from a more holistic systems-based approach.

There are two areas that one needs to focus on, the first being early diagnosis and the second being effective therapy. It is important to find a cancer within a reasonable period of time. We now have publications coming out about what is the nature of delays in early diagnosis, which could have to do with the patient participation and what they understand, but also the healthcare system. It's unfortunately very common that patients will present with a problem and it is not recognized.

The other area that needs to be focused on is effective therapy. The question with therapy is how can we apply the treatments in ways that are reasonable, recognizing that some of the things we do are very expensive. Many of our targeted therapies cost an unfathomable amount in limited resource environments but other treatments are quite affordable. For example, if a surgeon can do trauma surgery, they could be trained to do a modified radical mastectomy. Between early diagnosis and treatment, we're going to see more system building that is going to make progress.

In our group, we're focused on an area called phased implementation, which is about breaking it down into pieces so that progress can be made.

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