Supporting cities deliver quality cancer care is at the core of C/Can’s mission, and it’s a task that requires coordination and tailored solutions even when oncology medicines and technologies are available. This article illustrates how C/Can is assisting cities in low- and middle-income countries (LMICs) to overcome two key challenges in delivering equitable access to quality cancer care: lack of a multidisciplinary approach to cancer care; and an absence of patient management guidelines. What’s more, C/Can is the first organization working in this field that has taken such a city-led approach.
There is mounting evidence that patients’ survival and quality of life can be improved and achieved for certain cancers by adopting a multidisciplinary approach. At the same time, it has been shown that lapses in communication between the various care providers can result in delayed treatment planning, reduced therapy effectiveness, unnecessary duplication of tests, misallocation of resources and incomplete follow-up.
The results of the needs assessment conducted in C/Can cities by the Technical Committees show that one of the main barriers to increasing access to quality cancer care is the lack of multidisciplinary teams (MDT) and a multidisciplinary cancer management (MCM) approach in most cancer services – which means cancer care specialists (diagnostic, treatment and supportive care), working together to decide on the best treatment option for each patient . The lack of guidelines on how best to incorporate this approach into the cancer care continuum of a particular city and/or country is also an issue. Most of the time, international guidelines cannot be implemented in LMICs because they lack the resources.
Dr Rolando Camacho, C/Can’s Global Special Advisor for Technical Assistance, explains that overcoming these challenges is a complex task that requires careful coordination between multiple healthcare professionals and all those involved, as well as the exchange of technical information and regular communication. That said, he notes, thanks to advances in the different disciplines involved, there has been an increase in precision diagnostics and multimodality therapy that can be optimized by increased contact between specialists treating a single cancer patient:
“C/Can is coordinating partners to provide tailored training on Multidisciplinary Care Management (MCM), as well as how best to implement this approach, and also on developing cancer management guidelines adapted to the local cancer burden,” adds Dr Camacho.
The response in Cali, Asunción and Yangon
After joining C/Can, Cali, Asuncion and Yangon conducted a comprehensive assessment of cancer care capacity and needs in the public and private sectors. As expected, among the main challenges the technical groups there identified were the lack of a multidisciplinary approach and the absence of clinical management guidelines adapted to the available resources.
In response, technical groups in each city designed a project to adapt guidelines for management of the most common and curable cancers (starting with cervix and breast). They also set up multidisciplinary teams to manage patients with those cancers.
As Diogo Neves, C/Can’s Technical Assistance and Partnerships Manager, explains:
“By promoting this approach, C/Can is contributing to the reduction of variability in access to the best achievable care by the patients and, thus, supporting improved access to equitable quality cancer care.”
The technical groups created in Asuncion, Cali and Yangon to address these tasks reviewed the literature and relevant national and international guidelines and prepared a draft that was discussed with a large number of peers from each city. C/Can, with the assistance and close collaboration of international partners such as the American Society of Clinical Oncology (ASCO), the Oncology Nursing Society / the International Society of Nurses in Cancer Care (ONS/ISNCC), and the American Society for Clinical Pathology (ASCP), among others, facilitated consultation with international experts to provide these cities with support to reach consensus and formally present the authorities with consolidated guidelines and protocols for managing patients with invasive cancer (breast and cervix), as well as a draft resolution to implement MDT and guidelines in all centres treating cervical and breast cancer patients.
Based on the recommendations of external expert panels, the City Teams in Cali and Asunción worked on drafts to create a final document that was submitted to, and approved by, the City Executive Committee. This was then referred to the respective ministries of health for endorsement as a requirement for Multidisciplinary Team Care Practice for cancer patients, with the aim of incorporating it into national guidelines.
In the case of Yangon, the documents are yet to be sent to and approved by the City Executive Committee and referral to the Ministry of Health and Sports for endorsement as requirements for Multidisciplinary Team Care Practice and guidelines for cancer patients.
C/Can will continue to provide a range of initiatives to help its network of cities create sustainable cancer care
As part of C/Can’s commitment to improve equitable access to quality cancer care, we regularly organize activities to support cities in making a lasting and sustainable impact to benefit patients. These include promoting interactive peer-review processes (city consultations) and international consultations to support the adaptation of international cancer care guidelines to local contexts. (with support from C/Can partners).
In this regard, C/Can works with ASCO to support our cities to adapt international quality standards and best practices to the reality on the ground, which means adjusting international guidelines to the resources available there. This has already been completed in Cali, Asuncion and Yangon, to be followed in April by Kumasi, and Porto Alegre and Tbilisi in the last quarter of this year.
Vanessa Eaton, Director of International Education at ASCO’s Department of International Affairs, explains:
“ASCO is keen to work with City Cancer Challenge and other organizations to hold Multidisciplinary Cancer Management Courses in support of the development of city-wide treatment guidelines and the adoption of multidisciplinary care as standard practice.”
In conjunction with the ASCO ECHO program, Cali and Asuncion now have ongoing one-hour-monthly-session on cervical cancer. These will be followed by similar sessions on breast cancer. Yangon will start this year.
Similarly, C/Can has arranged and supported scientific visits to the breast and cervical cancer units at Barcelona’s Hospital del Mar and the Catalan Institute of Oncology (ICO) in November 2019 for teams from Cali and Asuncion. Teams from Yangon will visit the Tata Memorial Hospital in Mumbai in the third quarter of 2020, while others from Kumasi will do so in April, from Porto Alegre and Tbilisi in the last quarter of this year.
 20-25 local professionals representing cancer care providers across the city, and patients’ organizations, with expertise in the four technical work streams: 1) Management of Oncological Care Services; 2) Core Diagnostic and Clinical Services; 3) Quality of Cancer Care; 4) Community Access and Integrated Care and supported by around 200 health professionals from all cancer care services in the city.