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Treatment guidelines for patients with metastatic breast cancer often recommend tests, drugs, and procedures that are not available in lower-income countries. New recommendations from ASCO address this issue.

"This clinical practice guideline addresses the following overarching clinical question: What is the optimal treatment for patients diagnosed with metastatic breast cancer in resource-constrained settings?" Sana Al Sukhun, MD, MSc, of the Al Hyatt Oncology Practice in Amman, Jordan, and other members of the expert panel wrote in the document in

Al Sukhun, who is guideline co-chair with Banu K. Arun, MD, of the University of Texas MD Anderson Cancer Center in Houston, discussed the recommendations in the following interview.

One reason these guidelines were developed is the higher proportion of deaths from breast cancer in lower- and middle-income countries. What are some of the reasons for this?

Al Sukhun: The disparity in outcomes is mainly driven by inferior access to care. In 2014, the World Health Organization (WHO) recognized that access to cancer care is instrumental to the efforts to control noncommunicable diseases and adopted the as a priority of the global health agenda in 2017 at the WHO 70th World Health Assembly -- thus further highlighting the importance of the contribution of cancer control to world health.

Another factor is advanced presentation due to the challenge of early detection -- mainly related to a deficiency in public health education and breast cancer awareness. Of course, access to resource-appropriate multidisciplinary care must be in place once diagnosis is established for early detection to improve outcomes.

Indeed, many women avoid seeking care in early-stage disease despite their awareness because of challenges related to ineffective referral pathways, inadequate care packages, geographic dispersion, and fear of financial toxicity and inability to work, which are often disruptive to meager family finances.

The concept of resource limitation used in these guidelines takes more than the income of a country or region into account. Can you tell us more about this? What other factors were considered?

Al Sukhun: Not only is it about financial income, but more about medical infrastructure, as it relates to the availability of equipment, hospital/clinic setup, and expertise -- medical, surgical, pathology services, radiation therapy, and ancillary supportive services -- in addition to the available medical, surgical, and radiotherapy options. Money by itself cannot provide the above without proper allocation of resources to develop those services.

This guideline identifies four categories of resource settings: basic, limited, enhanced, and maximal. How do clinicians determine which setting they are in?

Al Sukhun: Those definitions are not absolute; they are there to support the decision of the clinician when unable to deliver what they know is optimal due to resource challenges.

In addition, they are flexible for the decision to change depending on what's available. Therefore, clinicians can properly offer the next best if the best is not available. The strict definition is more for policy makers to prioritize resource allocation to improve their infrastructure to graduate through the levels with the goal of getting to optimal level.

The guideline says patients may need to be made aware that lack of access to high-end treatments should not be associated with lack of benefit. Can you explain this?

Al Sukhun: More than half of accelerated approval drugs showed no clinical benefit in confirmatory trials, according to a study presented at the American Association for Cancer Research 2024 annual meeting. The study found that of the 46 cancer drugs granted accelerated approval by the FDA between 2013 and 2017, 63% were converted to regular approval even though only 43% demonstrated a clinical benefit in confirmatory trials after more than 5 years of follow-up.

Physicians and patients must learn to address the pros and cons of each therapy, including but not limited to financial toxicity. They must have realistic expectations based on data. Most of the time, patients associate expensive medication with dramatic benefit, even if the scientific evidence does not support these expectations.

If patients cannot afford those expensive medications, they decline treatment or shy away from seeking healthcare. Awareness campaigns must address such expectations and educate patients on the benefit they may experience from affordable medications.

Read the guideline here and expert commentary about it here.