Cost-effective interventions for breast cancer, cervical cancer, and colorectal cancer : new results from WHO-CHOICE

Background: Following the adoption of the Global Action Plan for the Prevention and Control of NCDs 2013-2020, an update to the Appendix 3 of the action plan was requested by Member States in 2016, endorsed by the Seventieth World Health Assembly in May 2017 and provides a list of recommended NCD interventions. The main contribution of this paper is to present results of analyses identifying how decision makers can achieve maximum health gain using the cancer interventions listed in the Appendix 3. We also present methods used to calculate new WHO-CHOICE cost-effectiveness results for breast cancer, cervical cancer, and colorectal cancer in Southeast Asia and eastern sub-Saharan Africa. Methods: We used "Generalized Cost-Effectiveness Analysis" for our analysis which uses a hypothetical null reference case, where the impacts of all current interventions are removed, in order to identify the optimal package of interventions. All health system costs, regardless of payer, were included. Health outcomes are reported as the gain in healthy life years due to a specific intervention scenario and were estimated using a deterministic state-transition cohort simulation (Markov model). Results: Vaccination against human papillomavirus (two doses) for 9-13-year-old girls (in eastern sub-Saharan Africa) and HPV vaccination combined with prevention of cervical cancer by screening of women aged 30-49 years through visual inspection with acetic acid linked with timely treatment of pre-cancerous lesions (in Southeast Asia) were found to be the most cost effective interventions. For breast cancer, in both regions the treatment of breast cancer, stages I and II, with surgery ± systemic therapy, at 95% coverage, was found to be the most cost-effective intervention. For colorectal cancer, treatment of colorectal cancer, stages I and II, with surgery ± chemotherapy and radiotherapy, at 95% coverage, was found to be the most cost-effective intervention. Conclusion: The results demonstrate that cancer prevention and control interventions are cost-effective and can be implemented through a step-wise approach to achieve maximum health benefits. As the global community moves toward universal health coverage, this analysis can support decision makers in identifying a core package of cancer services, ensuring treatment and palliative care for all

Analysis of mammography screening schedules under varying resource constraints for planning breast cancer control programs in low- and middle-income countries : a mathematical study

Background. Low-and-middle-income countries (LMICs) have higher mortality-to-incidence ratio for breast cancer compared to high-income countries (HICs) because of late-stage diagnosis. Mammography screening is recommended for early diagnosis, however, the infrastructure capacity in LMICs are far below that needed for adopting current screening guidelines. Current guidelines are extrapolations from HICs, as limited data had restricted model development specific to LMICs, and thus, economic analysis of screening schedules specific to infrastructure capacities are unavailable. Methods. We applied a new Markov process method for developing cancer progression models and a Markov decision process model to identify optimal screening schedules under a varying number of lifetime screenings per person, a proxy for infrastructure capacity. We modeled Peru, a middle-income country, as a case study and the United States, an HIC, for validation. Results. Implementing 2, 5, 10, and 15 lifetime screens would require about 55, 135, 280, and 405 mammography machines, respectively, and would save 31, 62, 95, and 112 life-years per 1000 women, respectively. Current guidelines recommend 15 lifetime screens, but Peru has only 55 mammography machines nationally. With this capacity, the best strategy is 2 lifetime screenings at age 50 and 56 years. As infrastructure is scaled up to accommodate 5 and 10 lifetime screens, screening between the ages of 44-61 and 41-64 years, respectively, would have the best impact. Our results for the United States are consistent with other models and current guidelines. Limitations. The scope of our model is limited to analysis of national-level guidelines. We did not model heterogeneity across the country. Conclusions. Country-specific optimal screening schedules under varying infrastructure capacities can systematically guide development of cancer control programs and planning of health investments

Prioritising systemic cancer therapies applying ESMO's tools and other resources to assist in improving cancer care globally:the Kazakh experience

BACKGROUND: In Kazakhstan, cancer is the second leading cause of death with a major public health and economic burden. In the last decade, cancer care and cancer medicine costs have significantly increased. To improve the efficiency and efficacy of cancer care expenditure and planning, the Kazakhstan Ministry of Health requested assistance from the World Health Organization (WHO) and the European Society for Medical Oncology (ESMO) to review its systemic cancer treatment protocols and essential medicines list and identify high-impact, effective regimens. MATERIALS AND METHODS: ESMO developed a four-phase approach to review Kazakhstan cancer treatment protocols: (i) perform a systematic analysis of the country’s cancer medicines and treatment protocols; (ii) cross-reference the country’s cancer protocols with the WHO Model List of Essential Medicines, the ESMO-Magnitude of Clinical Benefit Scale and the European Medicines Agency’s medicine availability and indications database; (iii) extract treatment recommendations from the ESMO Clinical Practice Guidelines; (iv) expert review for all cancer medicines not on the WHO Model List of Essential Medicines and the country treatment protocols. RESULTS: This ESMO four-phase approach led to the update of the Kazakhstan national essential cancer medicines list and the list of cancer treatment protocols. This review has led to the withdrawal of several low-value or non-evidence-based medicines and a budget increase for cancer care to include all essential and highly effective medicines and treatment options. CONCLUSION: When applied effectively, this four-phase approach can improve access to medicines, efficiency of expenditure and sustainability of cancer systems. The WHO–ESMO collaboration illustrated how, by sharing best practices, tools and resources, we can address access to cancer medicines and positively impact patient care

Cardiac tumours in children

Cardiac tumours are benign or malignant neoplasms arising primarily in the inner lining, muscle layer, or the surrounding pericardium of the heart. They can be primary or metastatic. Primary cardiac tumours are rare in paediatric practice with a prevalence of 0.0017 to 0.28 in autopsy series. In contrast, the incidence of cardiac tumours during foetal life has been reported to be approximately 0.14%. The vast majority of primary cardiac tumours in children are benign, whilst approximately 10% are malignant. Secondary malignant tumours are 10–20 times more prevalent than primary malignant tumours. Rhabdomyoma is the most common cardiac tumour during foetal life and childhood. It accounts for more than 60% of all primary cardiac tumours. The frequency and type of cardiac tumours in adults differ from those in children with 75% being benign and 25% being malignant. Myxomas are the most common primary tumours in adults constituting 40% of benign tumours. Sarcomas make up 75% of malignant cardiac masses. Echocardiography, Computing Tomography (CT) and Magnetic Resonance Imaging (MRI) of the heart are the main non-invasive diagnostic tools. Cardiac catheterisation is seldom necessary. Tumour biopsy with histological assessment remains the gold standard for confirmation of the diagnosis. Surgical resection of primary cardiac tumours should be considered to relieve symptoms and mechanical obstruction to blood flow. The outcome of surgical resection in symptomatic, non-myxomatous benign cardiac tumours is favourable. Patients with primary cardiac malignancies may benefit from palliative surgery but this approach should not be recommended for patients with metastatic cardiac tumours. Surgery, chemotherapy and radiotherapy may prolong survival. The prognosis for malignant primary cardiac tumours is generally extremely poor

Repaired tetralogy of Fallot: the roles of cardiovascular magnetic resonance in evaluating pathophysiology and for pulmonary valve replacement decision support

Surgical management of tetralogy of Fallot (TOF) results in anatomic and functional abnormalities in the majority of patients. Although right ventricular volume load due to severe pulmonary regurgitation can be tolerated for many years, there is now evidence that the compensatory mechanisms of the right ventricular myocardium ultimately fail and that if the volume load is not eliminated or reduced by pulmonary valve replacement the dysfunction might be irreversible. Cardiovascular magnetic resonance (CMR) has evolved during the last 2 decades as the reference standard imaging modality to assess the anatomic and functional sequelae in patients with repaired TOF. This article reviews the pathophysiology of chronic right ventricular volume load after TOF repair and the risks and benefits of pulmonary valve replacement. The CMR techniques used to comprehensively evaluate the patient with repaired TOF are reviewed and the role of CMR in supporting clinical decisions regarding pulmonary valve replacement is discussed

Technical modifications that might improve long-term outcome of the ross procedure in children

BACKGROUND: Failure of the pulmonary autograft (PVA) following the Ross procedure (RP) has discouraged its widespread use and led to modifications or alternatives to the procedure. We sought to analyze whether certain technical modifications could improve results of the RP in children. METHODS: Sixty-nine patients (median age 12 years, range 0.25 to 17.9) underwent the RP between 01/1996 and 12/2018. Concomitant Konno procedure was performed on 20/69 (29%). Prior interventions included balloon valvuloplasty in 30/69 (44%), and/or surgical valvuloplasty in 39/69 (57%). Technical modifications included utilizing the native aortic root for external annuloplasty, implanting the autograft using uniplanar horizontal sutures through the aortic wall, normalizing the sinotubular junction and wrapping the native root remnant around the PVA. RESULTS: Operative mortality was 1/69 (1.5%), with no late death. No patient had neoaortic valvar stenosis and 7/68 (10%) had mild regurgitation on discharge echocardiogram. At latest follow-up (median 9.4 years, range 0.4 - 21.3) there was no significant change in the latest follow up Z scores of annulus, sinus or sinotubular junction diameters when compared to those at discharge. Three patients (4.4%) required late autograft replacement, two PVA repair, and two resection of pseudoaneurysm. Actuarial freedom from PVA replacement was 87% at 20 yrs. Freedom from right ventricular outflow tract catheter reintervention or reoperation was 83% and 80% respectively. CONCLUSIONS: Technical modifications of the RP used in this cohort might successfully prolong the life of the PVA without compromising its growth, an important advantage in pediatric patients