diagnosis and treatment

Planning step 3
How do we get there?
What can be done with available resources? Having identified
objectives for the diagnosis and treatment programme, the
next step is to formulate an action plan to achieve them.
A template for developing a detailed action plan is provided at
[Link] i
www

When developing a diagnosis and treatment plan, it is important to consider

the relationship with early detection and palliative care activities. To be
effective, a diagnosis and treatment programme that primarily targets
people with curable cancers will need to be linked to early detection
activities. At the same time, treatment services need to be linked to those
for palliative care when the disease is advanced and there are no longer
chances of cure. Treatment services must also raise awareness among
cancer patients, cancer survivors, family and community members about
cancer risk factors and the need for preventive measures to avoid cancer.
(See also the Prevention, Early detection and Palliative care modules.)

The process of translating a diagnosis and treatment plan into action

requires strong leadership and competent management. It also requires
a participatory approach to identify what actions are needed and in
what order. The actions that are feasible and sustainable will need to
be implemented gradually in order to bridge the gaps identified during
planning step 2.

22
 Planning step 3

Bridge the gaps

It is important to evaluate the actions to bridge the gaps in service provision from the
perspective of those who support and will eventually implement those actions, as well as
from the perspective of any potential opponents. Next, there is a need to identify the key
person (or group) with the power to decide on the plan, and then see how that person (or
group) can be activated to make the planned changes.

Table 6 provides examples of actions to bridge gaps in cancer control that would be
appropriate in a low-income country. In this particular case, the decision has been made to
prioritize early diagnosis (i.e. increase awareness of early signs and symptoms) of breast
and cervical cancers, and the diagnosis and treatment of all patients identified by the early
detection activities, as well as all children presenting with acute lymphatic leukaemia. The
country has chosen to implement activities gradually, both in terms of the location of the
target population (i.e. activities will initially target patients identified through the formal
health system before widening contact through community outreach schemes) and their
geographical scope (i.e. if successful in a demonstration area, programme activities will be
expanded to other areas, and ultimately to the whole country).

RAISE THE NECESSARY RESOURCES

A diagnosis and treatment programme should be accompanied by a resource plan. The
resource plan should list existing resources and outline possible strategies for acquiring
needed resources from both governmental and nongovernmental sources.

Starting or reinforcing diagnostic and treatment services as part of a national cancer

control plan is a costly and complex undertaking. For example, in the case of radiotherapy,
it involves much more than simply procuring the necessary facilities and equipment. It also
comprises organizing staffing, provision of supplies, preventive maintenance and repairs,
source replacement, an adequate stock of spare parts, and safety measures for patients and
health-care providers.

To make sure that the necessary human, physical and financial resources are available to
implement the diagnosis and treatment programme, the following questions need to be
answered:
p What resources are currently dedicated to cancer control?
p What resources are specifically allocated to diagnosis and treatment?
p How can current resources be reallocated or shared to achieve the objectives of the
diagnosis and treatment programme?
p Besides resources currently being expended for diagnosis and treatment, what else is
needed to achieve the objectives of the diagnosis and treatment programme?
p What potential sources (internal and external) of funding or other resources are available
to meet these needs?
p How can partners work together to raise funds from government or the private
sector?
23
diagnosis and treatment

Table 6. Examples of actions to bridge identified gaps in cancer

control in a low-resource country
Who has the
Level of Key actions in a selected geographical area power to decide How could they be
Health situation interventions served by the regional cancer centre on key actions? activated to decide?
CORE
GAPS
(difference between With existing For the selected cancer types, elaborate and The local health By providing relevant information
resources disseminate standards for early diagnosis, referral, authorities together on the problem and its possible
OBSERVED and DESIRED follow-up and clinical management, including with the leading solutions through personal
status) psychosocial support, pain relief and palliative care health-care interactions and meetings with
professionals of the relevant stakeholders, using
Identify the specific target groups, estimate the demand relevant sectors, the testimonies of patients and
OBSERVED STATUS for services, and reorient referral mechanisms and supported by the health-care providers
High mortality from breast diagnostic, treatment and palliative care services to national authorities
and cervical cancer ensure timeliness and quality of actions

Include palliative care medication, as well as the

Over 80% of breast and chemotherapy drugs and antibiotics used for treating
cervical cancer patients paediatric acute lymphatic leukaemia, in the national
are diagnosed in very late essential medicines list
stages
Establish outpatient clinics for ambulatory treatment
Less than 20% of children and follow-up
with acute lymphatic Include early detection, diagnostic, treatment and
leukaemia have access palliative care packages in the health insurance scheme
to full treatment and over
80% die within 5 years Ensure full coverage of diagnosis and treatment for
patients from underprivileged communities

DESIRED STATUS Train health-care professionals at all levels of care and

introduce adequate referral mechanisms
Reduction in breast and
cervical cancer mortality Train family caregivers and promote the formation of
parents/patients support groups
Not more than 20% of
breast and cervical cancer Create a basic information system to monitor and
cases diagnosed in late evaluate related activities at different levels of care
stages
expanded
Over 70% of children with
acute lymphatic leukaemia With a projected Identify partners in the community and develop joint Local authorities from By disseminating the results of
have access to full increase in, or educational strategies for early detection of breast political, health and the evaluation of previous (core)
reallocation of, and cervical cancers aimed at the target women educational sectors, activities
treatment and over 60% resources supported by the
survive for 5 years Adjust the primary health-care services and the national authorities By advocating to reach more
specialized clinical services to meet the estimated women in the target age
increase in demand for breast and cervical cancer Health-care and group attached to community
care community leaders, organizations
STRENGTHS traditional healers
Existence of specialized Correct weaknesses identified through the monitoring
and evaluation system
diagnostic and treatment
facilities, strong primary Improve quality and coverage of diagnostic, treatment
health care network and and palliative care services for acute lymphatic
community health leukaemia in children, and mobilize further social
initiatives in some support for patients and their families
geographical areas
Desirable
Health insurance system
under development When more Develop educational strategies and low-cost media National and local By disseminating the results of
resources campaigns for early detection of breast and cervical leaders in the the evaluation of previous (core
A ward for treating become cancer aimed at all women political, health and and expanded) activities
available educational sectors
children with acute Develop special strategies for increasing the By advocating to reach all
lymphatic leukaemia adherence to treatment of children with acute Health-care and women in the target age
recently inaugurated lymphatic leukaemia community leaders group in the whole selected
community via community
Monitor the activities and evaluate the results Leaders of national outreach
and local associations
If the evaluation in the target areas is satisfactory, By advocating to expand
start mobilizing resources to expand activities to the activities to the rest of the
rest of the country using a similar stepwise approach country

24
 Planning step 3

A major policy issue is how to ensure adequate and equitable resource mobilization for health
care. Different forms of health system financing exist, which vary in terms of how resources
are generated, pooled and used.

Information on the key policy issues related to health financing,

along with relevant policy tools to aid decision-making, can be
accessed at the WHO web site
i
[Link] www

The diagnosis and treatment component of a national cancer control plan should be accessible
to a large majority of people with cancers that are curable or treatable but not curable. Also,
services should be delivered in an equitable manner. In a low-income country, if diagnosis
and treatment activities are too ambitious – involving costly interventions and sophisticated
technologies – it will not be possible to implement the plan even if there is political will and
commitment. For example, the scarce resources of low-income countries are often dedicated
to ineffective treatment of advanced cancer patients, even though many of the cancers would
have been amenable to early detection. If, instead, advanced cancer patients were to receive
good quality and low-cost palliative care, a significant amount of resources could be reallocated
to early detection, diagnosis and treatment of people with curable cancers. This in itself would
eventually reduce the numbers of people with advanced cancers.

“Despite the billions of dollars spent each year on an ever-

increasing array of medical devices and equipment, the majority of
countries still regard the management of devices as a procurement
issue, rather than an integral part of public health policy. Around
95% of medical technology in developing countries is imported,
much of which does not meet the needs of national health care
systems” (WHO Department of Essential Health Technologies).
i
www
For information on WHO’s strategies and tools to assist national
health authorities in the selection, procurement, use and disposal
of high-quality medical devices, go to
[Link]

25
diagnosis and treatment

ORGANIZE DIAGNOSTIC AND TREATMENT

SERVICES
The development of efficient, equitable and patient-centred diagnostic and treatment services,
within a national cancer control plan, requires the following sequence of actions:
p working with networks to establish a team approach;
p making a realistic estimate of the demand for services in the target population of patients
with cancers that are curable or treatable but not curable (see planning step 2);
p drawing up clear referral guidelines and establishing referral mechanisms for all cases
detected with abnormalities indicative of cancer;
p developing national diagnosis, treatment and follow-up guidelines for the targeted
cancers, including minimum standards of care and quality control mechanisms;
p developing an essential list of medicines for treating the targeted cancers;
p ensuring that diagnosis, treatment and follow-up services are organized and managed
across all levels of care, in accordance with the national guidelines;
p ensuring access, quality, safety and continuity of care within communities, including
self-management training and support for patients;
p ensuring that palliative care services are available for all patients with advanced cancer
when treatment is no longer effective or cannot be provided;
p establishing a well-functioning system for health information and patient records;
p ensuring the availability of adequately trained staff who are capable of working with the
right medicines and equipment, in the right facilities and with adequate financing;
p creating an organizational environment that provides continuous training and incentives
to providers and users.

The above list of actions, which is based on WHO’s health system building blocks, involves
processes of different levels of complexity. WHO recommends a stepwise implementation,
based on the availability of resources and adapted to the particular conditions in the
country.

For further information on WHO’s framework for strengthening health systems, go to

[Link] i
www

26
 Planning step 3

Working with networks to establish a team

approach
Following the development of a cancer diagnosis and treatment plan, it is important for
countries to create optimal conditions for implementation of the programme. These conditions
include continuous political, social and financial support, adequate leadership, sufficient
numbers of trained health-care practitioners working in multidisciplinary teams with clearly
defined roles and functions at the different levels of care, as well as effective national and
international collaborative networks for sharing knowledge and experience.

In recent years, the number of countries participating in international collaborative projects

has steadily increased. In paediatric oncology, in particular, there are now several examples
of highly successful “twinning programmes” which have forged links between paediatric
oncology centres in developed countries and units in countries with limited resources to the
mutual benefit of both parties (Barr et al., 2002; Bonilla, Ribeiro, Wilimas, 2006). Nicaragua’s
experience is described on page 28.

WHO has developed a tool for team building, go to

[Link] i
www

ESTIMATING THE DEMAND FOR SERVICES

When estimating the demand for different diagnostic and treatment services it is important to
consider the prevalence of patients with cancer types that have been prioritized in the plan,
including advanced cancers. It is also important to take into account the clinical protocols
and the technologies used for management and follow-up of these patients, as well as the
support and rehabilitation measures needed for patients and their families.

The majority of advanced cancer patients will need simple diagnostic procedures (microscopic
verification or imaging) and approximately 20% may benefit from palliative surgery,
radiotherapy, chemotherapy or other procedures which can improve their quality of life to a
certain extent (Sausville, Longo, 2005). Table 7 provides examples of the uses of palliative
surgery, radiotherapy and chemotherapy in advanced cancer patients.

27
diagnosis and treatment

nicaragua
Model programme for cancer treatment in a low-income country
The decision to organize the Diagnosis and Care Programme A new project was launched in 2007 to decentralize and
for Children with Cancer in Nicaragua, the second poorest coordinate haemato-oncology care in other departments of
country in Latin America, was taken over 20 years ago, during the hospital. This project aims to decrease delays in diagnosis,
a period of great political and social instability. The decision continue to reduce abandonment of treatment, improve
was based on the principle that Nicaraguan children have the treatment compliance, and care for terminally ill patients. Each
same right as those from developed countries to be cured type of cancer is treated according to international evidence-
of diseases – not only diseases of poverty, but also other based protocols, adapted to the local context. From the
diseases, such as cancer. The right to health care cannot be beginning, the multidisciplinary teams that provide care have
denied. It is a basic human right, as fundamental as the right adopted a holistic and psychosocial approach.
to life.
Because the role of the nursing staff is of vital importance in
The Diagnosis and Care Programme for Children with Cancer caring for children with cancer, two specific programmes have
was planned to provide long-term services. Although the been developed, one on quality of nursing, the other on nursing
initial focus was on acute lymphoblastic leukaemia, a leadership. These programmes have helped to motivate nurses
frequently curable and relatively common childhood cancer, and have facilitated their training.
provision was made to eventually include the full range of
childhood cancers in the programme. A strategic alliance has been formed between the health
professionals, CONANCA and the Association of Parents of
A twinning arrangement was agreed between an oncology Children with Cancer. This alliance has sensitized health
centre in Monza, Italy, and the children’s hospital, La Mascota, authorities, as well as governmental and nongovernmental
in Nicaragua. This has proved to be a rewarding experience organizations to the importance of diagnosing and treating
for health-care teams in both Italy and Nicaragua. Initially, cancer. The alliance has also contributed to mobilizing
seven paediatricians were trained in haemato-oncology at resources for the programme.
the Haemato-oncology Centre of San Gerardo Hospital in
Monza. Training was also provided – at different centres – for The programme at La Mascota has provided a model for the
a surgical oncologist, two pathologists and seven nurses, as development of other services within Nicaragua and beyond.
well as laboratory and pathology technicians. Subsequently, Programme sustainability allowed for the creation of Monza’s
facilities to provide care to children with cancer were set up International School of Paediatric Haemato-oncology (MISPHO)
in Nicaragua. in 1996, with the participation of 14 Latin American countries, to
promote twinning programmes similar to the one in Nicaragua
Various sources of funding were identified, both at the and assist in the training of the participating doctors. Following
national and international levels, to ensure the financial the subsequent founding of the Central American Association
independence and long-term sustainability of the programme. of Paediatric Haemato-oncology (AHOPCA), there has been a
At present, there are 32 beds, an operating room, a day real interaction between the haemato-oncology centres in the
hospital for outpatients, a haematology laboratory and a participating countries.
hostel that provides accommodation for patients who live far
Sources: Masera G et al. (2006). Twinning between pediatric
from the centre. Antineoplastic drugs and support therapy hematology-oncology centres in low-and high income countries:
are provided by the Nicaraguan Committee for Supporting 20 years of collaboration between Italy and Latin America. Educational
Children with Cancer (CONANCA). All patients are treated free Book. Congress of American Society of Clinical Oncology, USA.
of charge. Additional information supplied by Dr Fulgencio Baez, Department of
Haematology-oncology, Children’s Hospital La Mascota, Nicaragua.

28
 Planning step 3

Table 7. Examples of uses of surgery, radiotherapy and

chemotherapy to palliate symptoms in advanced cancer patients
Chemotherapy or hormone
Surgery Radiotherapy therapy
• Ostomy and bypass to correct • To control profuse bleeding from • To shrink a tumour
obstructions of urinary and a tumour • To relieve pain or distress
digestive tract • To relieve compression of the in advanced cancer, such
• Locoregional control of disease superior vena cava as oropharyngeal cancer,
in appropriately selected patients • To relieve pain secondary to nasopharyngeal cancer or
(e.g. breast cancer) bone metastasis prostate cancer
• “Toilet” surgery, to control • To relieve symptoms caused
fungating cancers or recurrence by spinal cord compression or
and progression of disease, to cerebral metastasis
control pain, to relieve spinal • To relieve severe dysphagia
cord compression or airways from oesophageal obstruction
obstruction
• Debulking of disease (e.g.
ovarian cancer)
• Resection of metastatic disease
with curative intent

IMPLEMENTING DIAGNOSIS AND TREATMENT

SERVICES
Figure 1 shows how cancer diagnostic and treatment services, including rehabilitation,
psychosocial support and patient education programmes, might be distributed across
the levels of care and within the community. Each country needs to elaborate its own
organizational model taking into consideration the targeted cancers; the physical, emotional,
social and spiritual needs of patients and their families; and the complexity, cost-effectiveness
and affordability of interventions.

WHO recommends that the less complex diagnosis and treatment services are located in
places that are easily accessible to the target groups at the district level. The more complex
and specialized services can be centralized at the regional or national level, where the
expertise and more sophisticated technologies are concentrated and can be provided in a
sustainable manner. Collaborative networks of professionals, working in diagnosis, treatment,
rehabilitation and psychosocial support within and across levels of care, as well as in the
community, are necessary to ensure the best results.

Figure 2 provides a map of a typical patient’s pathway. This pathway should be considered
when planning and organizing referral mechanisms, and when coordinating services within
and across levels of care. Patients’ journeys need to be monitored and evaluated in order to
ensure delivery of timely and good quality services.

29
diagnosis and treatment

Figure 1. Distribution of cancer diagnostic and treatment services

across the levels of care in a typical middle-income country

Tertiary care level

(national or regional hospital)
Diagnosis
Imaging: X-ray, ultrasonography, mammography, computerized tomography (CT) scan, endoscopy
Laboratory: Cytology, haematology, histopathology, prognostic markers, immunochemistry
Treatment
Radiotherapy, complex surgery and chemotherapy, rehabilitation, psychosocial support,
self-help groups, patient education programmes

Secondary care level

(district hospital)
Diagnosis
Imaging: X-ray, ultrasonography, mammography, endoscopy
Laboratory: Cytology including fine-needle aspiration, haematology, biopsy, routine histopathology
Treatment
Moderately complex surgery and chemotherapy (mainly outpatient clinics), rehabilitation, psychosocial support,
self-help groups, patient education programmes

Primary care level

Early referral of suspicious cases, simple surgical procedures (e.g. cryotherapy of pre-cancerous lesions of the cervix),
retrieval of patients who abandon treatment, patient support groups, patient education and rehabilitation,
education and training of community caregivers including traditional healers

In organizing cancer diagnostic and treatment services it is also important to take into
account that people around the world are every day making improvements in health as a
direct benefit of innovative approaches using information and communication technologies,
such as telemedicine. Telemedicine provides rapid access to shared and remote medical
expertise and may prove to be a feasible solution for increasing access to specialty cancer
diagnostic and treatment services throughout a country or across countries. For example,
telepathology was employed to achieve teleconsultation between a tertiary cancer referral
centre, Tata Memorial Centre in Mumbai, India, and a rural hospital. The evaluation showed
that it was possible to have good pathology consultation in 99% cases (Desai et al., 2004).

For more information on the use of telemedicine in oncology in

developing countries, go to i
[Link] www

30
 Planning step 3

Figure 2. A patient’s pathway

Key points in the cancer journey

goes to

Family doctor or Routine

health centre screening

Local hospital or cancer

centre to undergo tests
Cancer not
diagnosed

Diagnosis of cancer

Treatments Palliative care

Continuing treatment
End of treatment

Long-term monitoring Relapse

Terminal care
and follow-up

Long-term survival
Cure

Source: Fitch M (2003). Supportive care: rebalancing efforts. In: Sullivan T et al., eds. Strengthening the quality of cancer services in
Ontario. Ottawa, CHA Press: 141–163.

DIAGNOStic SERVICES
Diagnostic services within a national cancer control plan aim to provide timely clinical and
histopathological confirmation of cancer in all suspected cases. Diagnostic services are
also required for staging of the disease, monitoring treatment and response and follow-up
investigations. Physical examination, imaging procedures, laboratory tests and pathology
reports which include detailed examination of surgical specimen not only allow cancer to be
confirmed but also provide information to determine the stage of the cancer (Longo, 2005;
Sausville, Longo, 2005). Cancer staging helps the doctor plan a person’s treatment and
estimate prognosis (see key definitions, page 4).

Figure 1 illustrates a rational distribution of diagnostic services, where more complex and
costly procedures are concentrated at the tertiary level.

31
diagnosis and treatment

It is the responsibility of the treating physician and the respective diagnostic laboratories to
work in close collaboration to ensure quality of diagnostic and staging procedures, facilitate
prompt referral of patients to treatment or palliative care, as well as to communicate and
discuss about difficult cases. Regarding histopathological evaluation it is important to ensure
that the specimen is adequately obtained, fixed, labeled and transported. As explained above,
telemedicine may play an important role in providing distant and timely consultation within
services or across services.

For more information on cancer staging, go to

[Link]
i
For information on the TNM classification system for cancer staging, go to
www
[Link]

treatment SERVICES
Treatment services within the context of a national cancer control plan aim to cure the disease
or prolong life considerably, while ensuring a good quality of life.

Cancer treatment is highly specialized and requires the involvement of various disciplines. The
main treatments used alone or in combination are surgery, radiotherapy and chemotherapy.
These can be carried out only where there are adequate diagnostic and therapeutic facilities,
staffed by trained medical professionals.

Cancer patients and their families need person-centred care. When cancer strikes, it has more
than a physical impact. Cancer (and its treatment) also has emotional, social, psychological
and spiritual consequences for both the patient and their family members. Whether or not
individuals have timely access to adequate psychosocial support and rehabilitation, when
needed, will greatly influence their quality of life and their ability to cope.

Multidisciplinary teams of health-care professionals at the tertiary and secondary levels

of care should evaluate the patient early in the treatment process, and guide subsequent
treatment and follow-up. The team members are responsible for implementing clinical
management protocols in accordance with national guidelines. All relevant health-care
professions should be represented in the team, including radiation oncologists, surgeons,
medical oncologists, paediatric oncologists, gynaecologists, pathologists, haematologists,
radiologists and oncology nurses, as well as psychosocial and rehabilitation staff.

The decision as to which of the targeted cancers are treated at which of the levels of care
will depend on the particular cancer, the stage at diagnosis, the type of treatment required
and the availability of suitable infrastructure, as well as the availability of well-trained and
experienced professionals (see Figure 1).

32
 Planning step 3

Surgery for common cancers, such as breast and cervical cancers, should be available at
the secondary and tertiary health care levels. In contrast, surgery for less common and more
complex diseases, such as cancer of the colon, stomach, oesophagus and larynx, should
be done at regional or national reference centres where the appropriate expertise is more
likely to be located.

In some settings, less complex surgery could be performed at district hospitals by

In some settings, less complex surgery could be performed at district hospitals by well-
trained professionals. Other simple procedures, such as cryotherapy for the treatment of
pre-cancerous lesions of the cervix, can be done at the primary health care level by well-
trained professionals (WHO, 2006). This presupposes that an early detection programme is
in place in an area where there is a high incidence of cervical cancer.

Cancer surgery is a highly specialized and complex discipline and cancer surgeons need
lengthy training. The surgeon who treats cancer must be familiar with the natural history of
individual cancers and with the principles and potential roles of surgery, radiation therapy,
chemotherapy, immunotherapy and other new treatment modalities.

It is important to recognize that surgical competence alone, without the back up of suitable
infrastructure and a highly-qualified and competent supporting team, does not guarantee
excellent results. In this context, it is interesting to note that anaesthesia-related mortality has
decreased in the past four decades largely because of the development of new techniques
and new anaesthetics, stricter practice standards, better infrastructure, and improved
intra-operative monitoring techniques.

The WHO manual Surgical care at the district hospital, which provides
guidance on the organization and management of district surgical
services, can be accessed via the WHO web site, go to i
[Link] www

Radiotherapy requires costly equipment and facilities, and specialized expertise. Radiotherapy
should, therefore, only be provided by regional or national cancer centres or tertiary level
hospitals where the necessary infrastructure and expertise is concentrated and can be made
available on a sustainable basis.

A radiotherapy unit needs highly specialized professionals and support staff, such as radiation
oncologists, radiation therapy technologists, medical radiation physicists, physical therapists,
psychologists, electronics technicians and maintenance engineers.

33
diagnosis and treatment

Before initiating construction of a radiotherapy facility, approval by the national regulatory

authority must be obtained. The International Atomic Energy Agency (IAEA) requires the
presence of a national regulatory body, as well as a legislative and statutory framework to
regulate the safety of facilities and radiation-related activities (IAEA, 1996). Although the initial
capital outlay is significant, both in terms of equipment costs and staffing requirements, the
running costs of radiotherapy services are relatively low.

A patient requiring radiotherapy may be treated using two broad groups of techniques:
teletherapy and brachytherapy. External beam radiation therapy or teletherapy is usually
administered in a tertiary hospital on an ambulatory basis. The treatment takes place in an
enclosed shielded room (bunker) and no anaesthesia is needed for adult patients. It may be
administered by cobalt machines or by medical linear accelerators. For the majority of patients
with curable cancers or cancers that are treatable but not curable, cobalt machines are the
more cost-effective option in low- and middle-income countries (WHO, 2002; Barton et al.
2006). This is not simply because the capital and maintenance costs of a cobalt machine
are much lower than those for a linear accelerator, but also because a linear accelerator is
easily damaged by an unstable electric supply, a common hazard in low-income countries
(Van der Giessen, 2002).

For certain cancers, brachytherapy is usually administered in addition to teletherapy. For

example, invasive cervical cancer requires intracavitary brachytherapy if the intent is to cure
the disease. Brachytherapy may be administered in high dose rate or low dose rate depending
upon the availability of expertise and infrastructure (WHO, 2006).

In addition to the teletherapy and brachytherapy equipment, high-quality treatment by

radiotherapy requires certain quality assurance devices and tools, such as an imaging device
(a fluoroscopic or computerized tomography simulator), immobilization devices, shielding
devices, a treatment planning computer system and dosimetry tools.

The Programme of Action for Cancer Therapy (PACT) was created

by the International Atomic Energy Agency (IAEA) in 2004 to help
fight the developing world’s growing cancer crisis. Building on
the IAEA’s expertise in radiotherapy, PACT is uniquely placed to
promote the transfer of technology, experience and skills to those
most in need. It aims to build partnerships with other cancer i
organizations to fight the disease on a broad, comprehensive and www
multidisciplinary front.

For further information, go to

[Link]

34
 Planning step 3

Chemotherapy is usually very expensive, may have severe side-effects and often requires
patients to undergo a prolonged period of treatment. In low-resource settings, the initial
focus for services should be the treatment of the most common curable cancers for which
there is significant evidence that chemotherapy alone or in combination with other treatment
modalities is effective.

A chemotherapy unit needs highly specialized professionals and support staff, such as
medical oncologists, paediatric oncologists, haematologists, oncology nurses, pharmacists
and psychologists. As most chemotherapy can be given on an outpatient basis, large-scale
inpatient facilities are not required.

It is generally recommended that chemotherapy units be attached to district or general

hospitals at the secondary level. This makes chemotherapy more accessible to patients and
reduces the likelihood of abandonment of treatment. For example, the paediatric cancer
programme in Honduras has recently established six satellite chemotherapy units in different
provinces. These units provide ambulatory treatment, in accordance with national protocols,
to patients diagnosed at the tertiary level referral centre. The units also provide follow-up
of all the paediatric cancer patients in their respective geographical areas. They coordinate
closely with the referral centre for training, monitoring, evaluation and research purposes.

More complex chemotherapy should be provided at the tertiary level in oncology departments,
or in regional or national cancer centres, where the best diagnosis and treatment facilities
and expertise are concentrated.

Having established national treatment protocols for the prioritized cancers, the necessary
chemotherapeutic agents and other important medicines should be included in a country’s
list of essential medicines. The essential drugs list and the treatment protocols will guide the
practice of chemotherapy nationwide, in both private and public institutions.

WHO’s model list of essential medicines (WHO, 2007), which includes a range of chemotherapy
drugs on which countries can base their own essential medicine lists, is updated every
2 years.

The current WHO model list of essential medicines can be

obtained from the WHO web site, go to i
[Link] www

Access to essential drugs has improved in most low-income countries with the production
of generic versions of proprietary drugs. Generic drugs are frequently as effective as, but
much cheaper than, brand-name drugs and are available locally.

35
diagnosis and treatment

Psychosocial support should be an integral part of treatment services. Cancer programmes

need to ensure that psychosocial support is available in addition to surgical, chemotherapy
and hormone therapy, radiation and symptom management interventions. This requires
collaborative partnerships among a range of institutionally-based and community-based
health-care providers, as well as the involvement of professional and volunteer bodies.

Basic psychosocial care must be integral to the practice of all health-care professionals
dealing with cancer patients. Psychosocial care is demonstrated in actions such as:
p offering patients and their families emotional support and information;
p communicating in a person-centred and sensitive manner;
p referring patients to peer support (such as other cancer patients or cancer survivor
groups) and volunteer-led initiatives that help patients meet their psychosocial needs;
p referring patients requiring additional assistance to psychosocial experts, such as social
workers, psychologists, chaplains, trained nurses and therapists.

Individuals who receive appropriate emotional or psychosocial care during the period of
diagnosis and treatment tend to experience less anxiety and depression, and are more
likely to be able to return to a productive life. Both patients and families report a significant
improvement in quality of life (Blake-Mortimer et al., 1999; Coates, 1997), and better
adherence to therapy has been observed (Fawzy, 1999).

IMPLEMENT QUALITY CONTROL

For a diagnosis and treatment programme to be effective, it needs competent management
and a quality control system that ensures that services are provided in accordance with
quality standards.

Key elements in a quality control system for a diagnosis and treatment programme are:
p continuous training of health-care providers at the different levels of care;
p monitoring of management processes and results;
p provision of clinical services by competent health professionals, in accordance with
established clinical guidelines;
p maintaining the required quality and safety standards for laboratory and treatment
equipment, infrastructure and materials (including drugs).

In the case of chemotherapy, the quality control system should ensure that drugs are:
p obtained from reliable manufacturers;
p stored, used and discarded according to prescribed conditions;
p periodically analysed for bioactivity in a national laboratory;
p prescribed only by adequately trained physicians.

36
 Planning step 3

In the case of radiation therapy, the quality control system should ensure that:
p processes and procedures are designed to confirm that radiotherapy is administered
appropriately and safely, and documented properly;
p a hospital radiation safety committee is established for the prevention of radiation
accidents, as well as to ensure adherence to optimal medical practice and compliance
with the International Basic Safety Standards for Protection against Ionizing Radiation
and for the Safety of Radiation Sources (IAEA,1996).

ESTABLISH REGISTRATION AND COORDINATION

SYSTEMS
Hospital-based cancer registries and coordination systems are important tools for ensuring
adequate follow-up of all cancer patients in a given target group. They are also important for
quality control, and monitoring and evaluation purposes (Jensen et al., 1991).

Useful tools for developing hospital-based cancer registries can be accessed through the
web site of the United States Centers for Disease Control and Prevention, go to i
[Link] www

BUILD IN MONITORING AND EVALUATION

Both the development and the implementation of a cancer diagnosis and treatment
programme need to be monitored and evaluated periodically in order to ensure that the
objectives of the programme are being achieved. Evaluation requires careful design and
planning. This should start early on in the planning phase of the activities.

Mention has already been made of the application of a quality improvement framework to the
evaluation of the performance of diagnosis and treatment programmes (see planning step 2).
Table 8 provides examples of structure, process and outcome indicators and their standards,
which can be used to evaluate a diagnosis and treatment programme targeting common curable
cancers. National cancer control programmes: policies and managerial guidelines (WHO,
2002) provides further guidance on monitoring and evaluating cancer control programmes,
including diagnosis and treatment programmes, using both the quality improvement and the
system model frameworks.

No matter which framework is used, the evaluation plan needs to define clearly:
p who will do the evaluation;
p what will be evaluated;
p which core indicators (measures) and standards (values set by stakeholders) will be used;
p how the evaluation will be designed and carried out to ensure credibility;
p how the results of the evaluation will be used to improve programme performance.
37
diagnosis and treatment

Table 8. Examples of structure, process and outcome indicators

and their standards for the evaluation of a diagnosis and
treatment programme for common curable cancers
Core indicators Standards
STRUCTURE
• Policies and regulations include diagnosis and treatment as a key component of the national cancer Official documents, laws, regulations,
control plan guidelines or manuals published,
• Funding and service delivery models established to support the provision of cancer diagnosis and updated and available
treatment for all patients with curable cancers
• List of essential medicines for the complete treatment of curable cancers requiring chemotherapy
agents and other medicines
• Network of health workers across the different levels of care trained to refer patients without delay Accreditation of referral, diagnosis
or to provide good diagnostic and treatment services and treatment services at the
respective levels of care
• Hospital registries for monitoring and follow-up of all cancer patients targeted by the programme, Computerized standardized hospital
linked to the early detection information system as needed registries for targeted cancers
• Educational courses that provide: Undergraduate and postgraduate
– core knowledge and skills to practising health-care professionals across all levels of care courses available, including in-
regarding referral of cancer cases and provision of palliative care; service training for health workers
– expert knowledge and skills to selected health-care professionals on providing diagnosis and across all levels of care
treatment services at the secondary and tertiary levels, as needed
– undergraduate oncology education to health-care professionals (doctors, nurses, pharmacists, Education of patients and family
social workers) focusing on awareness of early signs and symptoms of common detectable members integrated into clinical
cancers services
– education to patients and family caregivers
Patient support groups available
PROCESS
• Number of cases detected early where patients get timely confirmation of diagnosis Within a month of referral date
• Number of curable cancer patients getting timely treatment Within a month of diagnosis
• Number and type of trained health-care professionals at the secondary and tertiary levels of care To be defined according to
qualified to provide diagnosis and treatment for curable cancers according to established standards the patients load and
countries capacity
• Proportion of patients whose cancers are detected early who get timely diagnosis >80% diagnosed within a month
• Proportion of patients with diagnosed curable cancers who get timely treatment >80% initiated treatment within
a month
• Proportion of curable cancer patients who get adequate treatment according to established >80%
guidelines
• Proportion of curable cancer patients who abandon or do not complete treatment, by age, sex and <10%
socioeconomic group
• Proportion of curable cancer patients and their family caregivers who get psychosocial support >80%
throughout the course of the disease
• Proportion of patients and family caregivers receiving relevant education >80%

OUTCOME
Short-term outcomes
• Proportion of curable cancer cases diagnosed in early stages >70%

Medium- and long-term outcomes (5 and 10 years)

• Overall 5-year survival rates for curable cancers >80%
• Overall 10-year survival rates for curable cancers >60%
• Mortality rates for curable cancers <20%

38
 Conclusion

Conclusion
A plan for the diagnosis and treatment of cancer is a key component of any
overall cancer control plan. Its main goal is to cure cancer patients or prolong
their life considerably, ensuring a good quality of life. In order for a diagnosis
and treatment programme to be effective, it must never be developed in
isolation. It needs to be linked to an early detection programme so that cases
are detected at an early stage, when treatment is more effective and there is
a greater chance of cure. It also needs to be integrated with a palliative care
programme, so that patients with advanced cancers, who can no longer benefit
from treatment, will get adequate relief from their physical, psychosocial and
spiritual suffering. Furthermore, programmes should include a awareness-
raising component, to educate patients, family and community members about
the cancer risk factors and the need for taking preventive measures to avoid
developing cancer.

Where resources are limited, diagnosis and treatment services should initially
target all patients presenting with curable cancers, such as breast, cervical
and oral cancers that can be detected early. They could also include childhood
acute lymphatic leukaemia, which has a high potential for cure although
it cannot be detected early. Above all, services need to be provided in an
equitable and sustainable manner. As and when more resources become
available, the programme can be extended to include other curable cancers
as well as cancers for which treatment can prolong survival considerably.

Cancer Control
Knowledge into Action
WHO Guide for Effective Programmes

This module on diagnosis and treatment is intended to

evolve in response to national needs and experience.
WHO welcomes input from countries wishing to share Diagnosis and
Treatment
their successes in diagnosis and treatment. WHO also
welcomes requests from countries for information relevant to their specific
needs. Evidence on the barriers to diagnosis and treatment in country contexts
– and the lessons learned in overcoming them – would be especially welcome
(contact at [Link]
39
diagnosis and treatment

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• Longo DL (2005). Approach to the patient with cancer. In:
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in low-income and middle-income countries. Lancet Oncology, 16th ed. New York, McGraw Hill Medical Publishing Division:
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• Bonilla M, Ribeiro R, Wilimas J (2006). Pediatric oncology in • National Cancer Institute (2003). Common terminology criteria
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Monograph on pediatric oncology. Madrid, Pearson Prentice Department of Health and Human Services, National Institute
Hall: 881–893. of Health ([Link] accessed
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quantity of life among patients with cancer: a review of the • Sausville EA, Longo DL (2005). Principles of cancer treatment.
effectiveness of group psychotherapy. European Journal of In: Kasper DL et al, eds. Harrison’s Principles of Internal
Cancer, 35:1581–1586. Medicine, 16th ed. New York, McGraw-Hill Medical Publishing
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• Coates A (1997). Quality of life and supportive care. Supportive
Care in Cancer, 5:435–438. • Van der Giessen P (2002). Maintenance costs for cobalt
machines and linear accelerators: new machines versus old.
• Desai S, Patil R, Kothari A et al. (2004). Telepathology Radiotherapy and Oncology, 62:349–350.
consultation service between Tata Memorial Centre, Mumbai
and Nargis Dutt Memorial Charitable Hospital, Barshi, Solapur, • WHO (2002). National cancer control programmes: policies
Maharashtra: an analysis of the first 100 cases. Indian Journal and managerial guidelines, 2nd ed. Geneva, World Health
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• Fawzy FI (1999). Psychosocial interventions for patients with • WH0 (2005). World Alliance for Patient Safety: WHO draft
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40
 Acknowledgements

Acknowledgements
EXTERNAL EXPERT REVIEWERS THE FOLLOWING WHO STAFF Margaret Fitch, International Society of
WHO thanks the following external ALSO REVIEWED DRAFT Nurses in Cancer Care and Sunnybrook
experts for reviewing draft versions of VERSIONS OF THE MODULE Regional Cancer Centre, Canada
the module. Expert reviewers do not Kathleen Foley, Memorial Sloan-Kettering
necessarily endorse the full contents of WHO regional and country offices Cancer Center, USA
the final version. Cherian Varghese, WHO India Country Leslie S. Given, Centres for Disease
Office Control and Prevention, USA
Manzoor Ahmad, College of Pathologists, Nabiha Gueddana, Ministry of Public
Pakistan WHO headquarters Health, Tunisia
A. M. M. Shariful Alam, National Institute Meena Cherian Anton G.J.M. Hanselaar, Dutch Cancer
of Cancer Research and Hospital, Dominique Egger Society, the Netherlands
Bangladesh Suzanne Hill Christoffer Johansen, Danish Institute of
Benjamin Anderson, Breast Health Center, Rania Kawar Cancer Epidemiology, Danish Cancer
University of Washington School of Andreas Reis Society, Denmark
Medicine, USA Cecilia Sepúlveda Ian Magrath, International Network
Luis Fulgencio Baez, Department of for Cancer Treatment and Research,
Haematology-oncology, Children’s Belgium
Hospital La Mascota, Nicaragua WHO CANCER TECHNICAL Anthony Miller, University of Toronto,
Barry D. Bultz, Tom Baker Cancer Centre GROUP Canada
and University of Calgary, Canada The members of the WHO Cancer M. Krishnan Nair, Regional Cancer Centre,
Miriam Campbell, Coordinator National Technical Group and participants in India
Programme on Childhood Cancer, Chile the first and second Cancer Technical Twalib A. Ngoma, Ocean Road Cancer
Luis Casanova, Instituto Nacional de Group Meetings (Geneva 7–9 June and Institute, United Republic of Tanzania
Enfermedades Neoplasicas, Peru Vancouver 27–28 October 2005) provided D. M. Parkin, Clinical Trials Service Unit
Cheryl Cavanagh, Department of Health, valuable technical guidance on the and Epidemiological Studies Unit,
England framework, development, and content England
Eduardo L. Cazap, Latin-American and of the overall publication Cancer control: Julietta Patnick, NHS Cancer Screening
Caribbean Society of Medical Oncology, knowledge into action. Programmes, England
Argentina Paola Pisani, International Agency for
Lea Derio, Cancer Programme, Ministry of Baffour Awuah, Komfo Anokye Teaching Research on Cancer, France
Health, Chile Hospital, Ghana You-Lin Qiao, Cancer Institute, Chinese
Margaret Fitch, International Society of Volker Beck, Deutsche Krebsgesellschaft Academy of Medical Sciences and
Nurses in Cancer Care, and Toronto e.V, Germany Peking Union Medical College, China
Sunnybrook Regional Cancer Centre, Yasmin Bhurgri, Karachi Cancer Registry Eduardo Rosenblatt, International Atomic
Canada and Aga Khan University Karachi, Energy Agency, Austria
Sue Hawkett, Department of Health, Pakistan Michael Rosenthal, International Atomic
England Vladimir N. Bogatyrev, Russian Oncological Energy Agency, Austria
Neeta Kumar, cancer control consultant, Research Centre, Russian Federation Anne Lise Ryel, Norwegian Cancer Society,
Geneva, Switzerland Heather Bryant, Alberta Cancer Board, Norway
Mike Richards, St Thomas’ Hospital, Division of Population Health and Inés Salas, University of Santiago, Chile
England Information, Canada Hélène Sancho-Garnier, Centre Val
Simon Sutcliffe, British Columbia Cancer Robert Burton, WHO China Country Office, d’Aurelle-Paul Lamarque, France
Agency, Canada China Hai-Rim Shin, National Cancer Center,
Bhadrasain Vikram, National Cancer Eduardo L. Cazap, Latin-American and Republic of Korea
Institute, USA Caribbean Society of Medical Oncology, José Gomes Temporão, Ministry of Health,
Argentina Brazil
Mark Clanton, National Cancer Institute,
USA

41
diagnosis and treatment

Other participants Observers Luiz Figueiredo Mathias, National Cancer

Barry D. Bultz, Tom Baker Cancer Centre Benjamin Anderson, Breast Health Center, Institute, Brazil
and University of Calgary, Canada University of Washington School of Les Mery, Public Health Agency of Canada,
Jon F. Kerner, National Cancer Institute, Medicine, USA Canada
USA Maria Stella de Sabata, International Union Kavita Sarwal, Canadian Strategy for
Luiz Antônio Santini Rodrigues da Silva, Against Cancer, Switzerland Cancer Control, Canada
National Cancer Institute, Brazil Joe Harford, National Cancer Institute, USA Nina Solberg, Norwegian Cancer Society,
Jo Kennelly, National Cancer Institute of Norway
Canada, Canada Cynthia Vinson, National Cancer Institute,
USA

42
The World Health Organization estimates that 7.6 million people died of cancer in
2005 and 84 million people will die in the next 10 years if action is not taken.

More than 70% of all cancer deaths occur in low and middle income countries,
where resources available for prevention, diagnosis and treatment of cancer are
limited or nonexistent.

Yet cancer is to a large extent avoidable. Over 40% of all cancers can be prevented.
Some of the most common cancers are curable if detected early and treated. Even with
late cancer, the suffering of patients can be relieved with good palliative care.

Cancer control: knowledge into action: WHO guide for effective

programmes is a series of six modules offering guidance
on all important aspects of effective cancer
control planning and implementation.

Worldwide, millions of cancer patients can be cured or have their lives prolonged considerably if they
have timely access to adequate diagnosis and treatment services.

This module addresses specific aspects of diagnosis and treatment. It is based on the Planning module,
which provides a comprehensive understanding of the overall cancer control planning process and its main
steps. The Diagnosis and treatment module discusses how to develop an effective diagnosis and treatment
programme with a public health approach, within the context of a national cancer control programme.

ISBN 92 4 154740 6