Essential medicines list in national cancer control plans: a secondary analysis from a global study

Policy strategies for capacity building and scale up of the workforce for comprehensive cancer care: a systematic review

BACKGROUND

Patients with cancer in low- and middle-income countries experience worse outcomes as a result of the limited capacity of health systems to deliver comprehensive cancer care. The health workforce is a key component of health systems; however, deep gaps exist in the availability and accessibility of cancer care providers.

MATERIALS AND METHODS

We carried out a systematic review of the literature evaluating the strategies for capacity building of the cancer workforce. We studied how the policy strategies addressed the availability, accessibility, acceptability, and quality (AAAQ) of the workforce. We used a strategic planning framework (SWOT: strengths, weaknesses, opportunities, threats) to identify actionable areas of capacity building. We contextualized our findings based on the WHO 2030 Global Strategy on Human Resources for Health, evaluating how they can ultimately be framed in a labour market approach and inform strategies to improve the capacity of the workforce (PROSPERO: CRD42020109377).

RESULTS

The systematic review of the literature yielded 9617 records, and we selected 45 eligible papers for data extraction. The workforce interventions identified were delivered mostly in the African and American Regions, and in two-thirds of cases, in high-income countries. Many strategies have been shown to increase the number of competent oncology providers. Optimization of the existing workforce through role delegation and digital health interventions was reported as a short- to mid-term solution to optimize cancer care, through quality-oriented, efficiency-improving, and acceptability-enforcing workforce strategies. The increased workload alone was potentially detrimental. The literature on retaining the workforce and reducing brain drain or attrition in underserved areas was commonly limited.

CONCLUSIONS

Workforce capacity building is not only a quantitative problem but can also be addressed through quality-oriented, organizational, and managerial solutions of human resources. The delivery of comprehensive, acceptable, and impact-oriented cancer care requires an available, accessible, and competent workforce for comprehensive cancer care. Efficiency-improving strategies may be instrumental for capacity building in resource-constrained settings.

CILP is a potential pan-cancer marker: combined silico study and in vitro analyses

CILP (Cartilage intermediate layer protein), an ECM (extracellular matrix) glycoprotein, is found to be associated with intervertebral disc degeneration, chronic heart failure, obese and cardiac fibrosis. However, there are few reports on the role of CILP in tumors. Thus, in this study, we mainly explored the function of CILP in the occurrence and development of tumors and whether it could be a potential pan-cancer marker. Pan-cancer data in this study were obtained from UCSC Xena. Single-cell data were obtained from GSE152938. ROC (Receiver operating characteristic) curves were used to evaluate the accuracy of CILP in predicting the occurrence of different tumor types. The Kaplan-Meier plots were used to assess the relationship between CILP expression and survival prognosis in different tumor types by COX regression analysis. Pseudotime analysis and cell communication analysis were used to further explore the function of CILP at Single cell level. The human RCC (renal cell carcinoma) cell lines ACHN and 786-O were used for further experimental verification. Bulk RNA-seq showed differences in CILP expression in several tumors. ROC curves showed that 14 tumors have AUC > 0.7. Kaplan-Meier plots indicated that CILP is a risk factor for patients in 3 kinds of tumors. ScRNA-seq (Single cell RNA sequencing) suggested that CILP might influence tumors through fibroblasts and cell-cell communication. Finally, we verified the function of CILP at the cellular level by using RCC cell lines ACHN and 786-O and found that knockdown of CILP could significantly inhibit migration and invasion. This finding supports that CILP could be a risk factor as well as a pan-cancer predictor for patients.

Impact of Prior Authorization on Patient Access to Cancer Care

Prior authorization (PA) is a type of utilization review that health insurers apply to control service delivery, payments, and reimbursements of health interventions. The original stated intent of PA was to ensure high-quality standards in treatment delivery while encouraging evidence-based and cost-effective therapeutic choices. However, as currently implemented in clinical practice, PA has been shown to affect the health workforce, adding administrative burden to authorize needed health interventions for patients and often requiring time-consuming peer-to-peer reviews to challenge initial denials. PA is presently required for a wide range of interventions, including supportive care medicines and other essential cancer care interventions. Patients who are denied coverage are commonly forced to receive second-choice options, including less effective or less tolerable options, or are exposed to financial toxicity because of substantial out-of-pocket expenditures, affecting patient-centric outcomes. The development of tools informed by national clinical guidelines to identify standard-of-care interventions for patients with specific cancer diagnoses and the implementation of evidence-based clinical pathways as part of quality improvement efforts of cancer centers have improved patient outcomes and may serve to establish new payment models for health insurers, thereby also reducing administrative burden and delays. The definition of a set of essential interventions and guidelines- or pathways-driven decisions could facilitate reimbursement decisions and thus reduce the need for PAs. Structural changes in how PA is applied and implemented, including a redefinition of its real need, are needed to optimize patient-centric outcomes and support high-quality care of patients with cancer.

An analysis of survivorship care strategies in national cancer control plans in Africa

PURPOSE

In 2017, the World Health Organization urged member states to develop and implement national cancer control plans (NCCPs) and to anticipate and promote cancer survivor follow-up care, which is a critical yet often overlooked component of NCCPs. This study aims to examine the inclusion of cancer survivorship-related strategies and objectives in NCCPs of African countries.

METHODS

Independent reviewers extracted strategies, objectives, and associated indicators related to survivorship care from 21 current or recently expired NCCPs in African countries. Building on a similar analysis of the US state cancer control plans, reviewers categorized these strategies according to an adapted version of the ten recommendations for comprehensive survivorship care detailed in the 2006 National Academy of Medicine report.

RESULTS

A total of 202 survivorship-related strategies were identified, with all NCCPs including between 1 and 23 references to survivorship. Eighty-three (41%) strategies were linked to measurable indicators, and 128 (63%) of the survivorship-related strategies were explicitly focused on palliative care. The most frequent domains referenced were models of coordinated care (65 strategies), healthcare professional capacity (45), and developing and utilizing evidence-based guidelines (23). The least-referenced domains were survivorship care plans (4) and adequate and affordable health insurance (0).

CONCLUSIONS

The results of this study indicate that survivorship objectives and strategies should extend beyond palliative care to encompass all aspects of survivorship and should include indicators to measure progress.

IMPLICATIONS FOR CANCER SURVIVORS

Stakeholders can use this baseline analysis to identify and address gaps in survivorship care at the national policy level.

Measuring the global response to antimicrobial resistance, 2020-21: a systematic governance analysis of 114 countries

BACKGROUND

Understanding strategic commitments and policy responses to overcome antimicrobial resistance at the national, regional, and global levels is required to evaluate current progress and direct future planning. National action plans (NAPs) are the primary mechanism for guiding national strategy and action for antimicrobial resistance governance. Although several NAPs have been developed, no comprehensive content analysis of these plans exists. Using a governance framework, we aimed to assess all publicly available NAPs on antimicrobial resistance.

METHODS

We systematically reviewed the contents of NAPs on antimicrobial resistance from 114 countries, applying a governance framework containing 18 domains and 54 indicators in three integral areas: policy design, implementation tools, and monitoring and evaluation. As well as manually searching NAPs and doing online and literature searches that were relevant to specific indicators from repository inception to June 1, 2022, several data sources were used to generate scores, including the Tripartite Antimicrobial Resistance Country Self-Assessment Survey, the Global Antimicrobial Resistance and Use Surveillance System, the Global Antimicrobial Resistance Research and Development Hub, and various WHO datasets. NAPs were included if the country had also submitted the NAP to the Tripartite Antimicrobial Resistance Country Self-Assessment Survey 2020-21, if the NAP was retrievable through a publicly accessible database or website, and if the NAP was either published in English or eligible for machine translation. Three researchers independently reviewed each NAP and were initially blinded to the evaluations of other researchers. They generated a score using a quantification system for each of 54 indicators. The Cochrane protocol for ensuring reliability was followed. The three researchers were then unblinded and met to resolve any disagreements in scoring to reach a consensus agreement. In each case of discrepancy, consensus was reached between the researchers. We developed criteria to standardise the process of quantifying each indicator. We also weighted and collated relevant national data from various sources to generate composite scores concordant with the key governance areas. We transformed these data to a scale of 0 (worst) to 100 (best), ranked countries on the basis of their mean scores, and used descriptive statistics to analyse global and regional trends.

FINDINGS

306 NAPs were identified and 114 were eligible for analysis. Between 2020 and 2021, the mean antimicrobial resistance governance score was 51 (SD 14). Norway had the highest governance score (mean 85 [SD 32]), and the Federated States of Micronesia had the lowest governance score (28 [37]). The highest scoring domain was participation (83 [16]), and the lowest scoring domains were accountability (30 [18]) and feedback mechanism (30 [25]). Domains relating to policy design (55 [13]) and implementation tools (54 [17]) scored similarly, whereas monitoring and evaluation (38 [20]) efforts were lower.

INTERPRETATION

International efforts to control antimicrobial resistance varied considerably between countries. Monitoring and evaluation efforts need improving for continuous understanding of national and international progress. International response might not be commensurate with the scale and severity of antimicrobial resistance.

FUNDING

None.

Ten Years of the International Cancer Control Partnership: Promoting National Cancer Control Plans to Shape the Health System Response for Cancer Control

Growing premature mortality because of cancer is an increasing public health concern in all countries. This article reviews 10 years of the International Cancer Control Partnership (ICCP) considering the themes of National Cancer Control Plan (NCCP) support, technical assistance, governance, and the renewed momentum of global calls to action. ICCP has provided key resources for the cancer community by hosting a portal with national cancer control and noncommunicable disease (NCD) plans, strategies, guidelines, and key implementation guides for a growing community of best practices. ICCP partners have responded to the changing needs of country planners, adjusting technical guidance as needs evolve from planning to implementation at the national level with an associated shift to peer-to-peer learning and knowledge exchange. The ICCP offer to assist countries in cancer planning continues to be relevant as countries focus on implementation of global initiatives for breast, cervical, and childhood cancers. These initiatives are important to drive priority actions and a systems approach in the emerging road map on NCDs-a message that will be supported by a second global review of NCCPs in 2023. This is critical for driving national action in all countries on cancer and other NCDs in line with global health commitments made for 2030 and adopted by the United Nations General Assemblies. ICCP sees robust systems and financial planning for implementation, monitoring, and evaluation of NCCPs and protection from cancer-related catastrophic expenditure, as critical to longer-term sustainability and success. ICCP calls for national policymakers to prioritize integration of cancer prevention and control into emerging universal health care approaches, including pandemic preparedness/health system resilience and calls for an equity focus in new NCCPs.

Hyaluronic-Acid-Tagged Cubosomes Deliver Cytotoxics Specifically to CD44-Positive Cancer Cells

Delivery of chemotherapy drugs specifically to cancer cells raises local drug doses in tumors and therefore kills more cancer cells while reducing side effects in other tissues, thereby improving oncological and quality of life outcomes. Cubosomes, liquid crystalline lipid nanoparticles, are potential vehicles for delivery of chemotherapy drugs, presenting the advantages of biocompatibility, stable encapsulation, and high drug loading of hydrophobic or hydrophilic drugs. However, active targeting of drug-loaded cubosomes to cancer cells, as opposed to passive accumulation, remains relatively underexplored. We formulated and characterized cubosomes loaded with potential cancer drug copper acetylacetonate and functionalized their surfaces using click chemistry coupling with hyaluronic acid (HA), the ligand for the cell surface receptor CD44. CD44 is overexpressed in many cancer types including breast and colorectal. HA-tagged, copper-acetylacetonate-loaded cubosomes have an average hydrodynamic diameter of 152 nm, with an internal nanostructure based on the space group Im3m. These cubosomes were efficiently taken up by two CD44-expressing cancer cell lines (MDA-MB-231 and HT29, representing breast and colon cancer) but not by two CD44-negative cell lines (MCF-7 breast cancer and HEK-293 kidney cells). HA-tagged cubosomes caused significantly more cell death than untargeted cubosomes in the CD44-positive cells, demonstrating the value of the targeting. CD44-negative cells were equally relatively resistant to both, demonstrating the specificity of the targeting. Cell death was characterized as apoptotic. Specific targeting and cell death were evident in both 2D culture and 3D spheroids. We conclude that HA-tagged, copper-acetylacetonate-loaded cubosomes show great potential as an effective therapeutic for selective targeting of CD44-expressing tumors.

Implications of Oncology Trial Design and Uncertainties in Efficacy-Safety Data on Health Technology Assessments

Background: Advances in cancer medicines have resulted in tangible health impacts, but the magnitude of benefits of approved cancer medicines could vary greatly. Health Technology Assessment (HTA) is a multidisciplinary process used to inform resource allocation through a systematic value assessment of health technology. This paper reviews the challenges in conducting HTA for cancer medicines arising from oncology trial designs and uncertainties of safety-efficacy data. Methods: Multiple databases (PubMed, Scopus and Google Scholar) and grey literature (public health agencies and governmental reports) were searched to inform this policy narrative review. Results: A lack of robust efficacy-safety data from clinical trials and other relevant sources of evidence has made HTA for cancer medicines challenging. The approval of cancer medicines through expedited pathways has increased in recent years, in which surrogate endpoints or biomarkers for patient selection have been widely used. Using these surrogate endpoints has created uncertainties in translating surrogate measures into patient-centric clinically (survival and quality of life) and economically (cost-effectiveness and budget impact) meaningful outcomes, with potential effects on diverting scarce health resources to low-value or detrimental interventions. Potential solutions include policy harmonization between regulatory and HTA authorities, commitment to generating robust post-marketing efficacy-safety data, managing uncertainties through risk-sharing agreements, and using value frameworks. Conclusion: A lack of robust efficacy-safety data is a central problem for conducting HTA of cancer medicines, potentially resulting in misinformed resource allocation.

Breast Cancer Priorities in Limited-Resource Environments: The Price-Efficacy Dilemma in Cancer Care

Breast cancer has become one of the leading causes of morbidity and mortality in low- and middle-income countries, where 62% of the world's total new cases are diagnosed. Therefore, the productivity loss because of premature death resulting from female breast cancer is also on the rise. The major challenge in low- and middle-income countries is to reduce the proportion of women presenting with advanced-stage disease, a challenge unlikely to be overcome by adoption of expensive national mammography screening programs. Awareness and education campaigns should focus not only on patients and societies but also on policy makers to address and optimize breast cancer care. Adaptation of existing guidelines and prioritization according to local resources are essential to address the unique needs and overcome the unique barriers of each society to facilitate practical implementation and improve outcomes. Emphasis on the principle of a cancer groundshot in addressing value in cancer care is vital to improving access to therapies that are proven to work rather than chasing after new drugs or innovations of doubtful or marginal clinical benefit. Until we have drug-pricing interventions that take into account the local income of each society, we must acknowledge the fact that the delivery of cancer care will never be the same all around the world.