BPI20-023: International Adaptation of the Resource-Stratified NCCN Frameworks for Breast, Cervical and Rectal Cancers in Bolivia

Introduction: Cancer outcomes can improve by up to 30% if accepted standards of care are practiced. Existing guidelines assume the accessibility of costly diagnostic and treatment resources that are often geographically or financially inaccessible in low resource settings. The present collaboration between National Comprehensive Cancer Network (NCCN) and PROMIS-Bolivia adapted the NCCN Frameworks for breast, cervical and rectal cancers to resource and financial constraints across Bolivia to provide evidence-based guidelines for patients and health centers with basic, core, enhanced and maximal resources. Methods: A multidisciplinary panel of 36 Bolivian experts was recruited with equal representation across cancer subspecialties, health sectors and geographic regions. Each expert independently reviewed Spanish-translations of NCCN Frameworks for breast, cervical and rectal cancers, and proposed adaptations to accommodate local resource and access limitations. Proposed adaptations were summarized and reviewed by NCCN. A national adaptation workshop was held April 24, 2019 in La Paz, Bolivia. NCCN Panel Chairs led simultaneous expert panel discussions for breast, cervical and rectal cancers to review proposed modifications and develop a consensus national adaptation of each Framework. Results: Consensus Framework adaptations were successfully developed by each multidisciplinary panel. Minimal adaptations were made to the breast and cervical cancer Frameworks. Rectal cancer staging at basic, core and enhanced resource levels will utilize rigid proctoscopy and pelvic CT due to inaccessibility of MRI and endorectal ultrasound, with abdominal ultrasound and chest radiographs to evaluate metastatic disease at basic and core levels. Treatment algorithms rely heavily on curative and palliative surgery due to unaffordability of chemotherapy at basic levels and radiotherapy at core levels. Post-treatment surveillance is recommended at longer intervals using the above imaging modalities and CEA when available. Conclusions: International adaptations of NCCN Frameworks are needed to ensure evidence-based cancer care in settings where patients cannot access or afford the international standard of care. Implementation of these adapted Frameworks will permit evaluation of their impact on clinical outcomes, financial toxicity and treatment abandonment among patients in Bolivia. Examples of finalized Bolivian Adaptations of the NCCN Frameworks will be illustrated.

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Corresponding Author: Steven J. Schuetz, MD
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