Analysis of Resource-Stratified Guidelines May Inform Future Treatment Recommendations in Breast Cancer Globally


Research on NCCN resource-stratified guidelines for treating breast cancer could lead to overtreating patients in lower-middle and upper-middle income countries, while low-income populations could receive undertreatment.

The delivery of care based on National Comprehensive Cancer Network (NCCN) resource-stratified guidelines for the treatment of breast cancer could result in overtreating patients in lower-middle and upper-middle income countries as well as undertreating low-income populations, according to research published in JCO Clinical Oncology.

Resource-stratified guidelines from the NCCN were developed to further refine treatment recommendations based on the patient’s area of origin, with the level of economic development being an additional factor in therapy selection along with categories of scientific evidence.

Lower-middle income populations were categorized as the “Core” group, upper-middle income was categorized as “Enhanced,” and low-income was categorized as “Basic.” The research found that the Basic guidelines do not recommend chemotherapy for any patient, while Core and Enhanced guidelines suggest that 87% and 86% of patients, respectively, have an indication for 1 line of chemotherapy at minimum based on category 1 evidence.

When additional variables were introduced, including grade, age, and patient preference, chemotherapy need fell to 70% for Core and 75% for Enhanced guidelines–treated patients. After incorporating multigene signatures, the need for chemotherapy fell to 50% for patients in the Maximal setting, which was defined as populations with the highest income.

“Based on NCCN resource-stratified guidelines, the global resource-stratified need for breast cancer chemotherapy in 2018 is 1.4 million people, the need for HER2 treatments is 183,943 people, and the need for first-course endocrine therapy is 1.6 million people,” the investigators wrote.

The investigators developed decision trees focusing on first-course systemic therapy to quantify the needs and costs of breast cancer treatments if these NCCN resource-stratified guidelines are adopted globally.

A 17-fold increase in the cost for chemotherapy, HER2, or immunotherapy was seen by applying Maximal ($22,313 Australian dollars [AUD]) vs Core ($1,278 AUD) guidelines, with an 8-fold increase observed from Basic to Maximal guidelines for endocrine therapy ($1,236 vs $9,809 AUD, respectively).

The use of Maximal resource-stratified guidelines for treating patients with breast cancer would result in a 28% decline in the need of chemotherapy. On the other hand, first-course treatment cost would rise by 1.8-fold ($21 to $37 billion AUD) due to use of more costly therapies.

The investigative team made assumptions to generate the current model, including population attributes, drug costs, stage distribution, and global resource availability. The team assigned each of the countries included to a resource group to Basic, Core, Enhanced, or Maximal treatment guidelines.

Breast cancer incidence rates were taken from each country in 2018 and modeled out to 2040 based on linear population growth from the Global Cancer Observatory (GLOBOCAN). Three sensitivity analyses were performed focusing on the change in chemotherapy needs for estrogen receptor–positive, HER2-negative, and node-negative breast cancers.

The research team explained that these findings have the potential to inform planning for health services for high-, middle-, and low-income countries. The data will also inform how future resource-stratified guidelines for breast cancer evolve moving forward.

“The absence of chemotherapy in Basic settings should be reconsidered to allow equitable resource allocation across tumor types,” the investigators wrote. “This model is flexible and can estimate the need and cost of implementing NCCN breast cancer resource-stratified guidelines for any system based on their unique resource mix, drug costs, and population attributes.”


Wilson BE, Jacob S, Do V, et al. Are NCCN Resource-Stratified Guidelines for breast cancer systemic therapy achievable? A population-based study of global need and economic impact. JCO Glob Oncol. Published June 2021. doi:10.1200/GO.21.00028

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