Research Agenda
Knowledge about the feasibility, effectiveness, and cost-effectiveness of cancer control interventions by health services in developing countries is extremely limited, partly because of the relative paucity of active research in this area. Work in the area of descriptive epidemiology, especially work based on cancer registry data, dominates the research literature on cancer in developing countries. A second body of literature consists of comparative epidemiology and case-control studies designed to assess the importance of various risk factors for cancer.
Although information from such studies is an essential first step for characterizing the nature and extent of the cancer burden and for monitoring the ultimate effect of cancer control interventions, it does not provide a sufficient knowledge base for designing and implementing cancer control programs. For progress to be made for developing countries, much more work is needed in the following areas:
-
Clinical evaluation studies of cancer control interventions in developing countries. Clinical evaluation studies of preventive, screening, and treatment interventions that are specifically tailored to the needs and conditions of developing countries would be useful, including controlled clinical trials where possible.
-
Health services research in developing countries. Health services research designed to characterize the amount, distribution, and organizational structure of health sector resources in developing countries would be helpful, along with research to fill the gaps between current resource endowments and the amount of funding that would be needed to implement the minimally acceptable level of effective cancer control. In developing countries, shortages of the equipment and personnel needed to administer radiotherapy for cancer, for example, have been well documented (Levin, Meghzifene, and Tatsuzaki 2001). However, no systematic analyses are available outside developed countries (Owen, Coia, and Hanks 1997) that project radiotherapy resource needs in terms of clinically effective applications of radiotherapy, both by cancer site and by the known effectiveness of radiotherapy for primary treatment, adjuvant therapy, and palliative care. Similarly, even though researchers have carried out patterns of care studies that characterize the dissemination of radiation, chemotherapy, and hormonal therapy in many developed countries, comparable information for developing countries is generally unavailable. Health services research studies could also contribute important information about the current structure and organization of primary, secondary, and tertiary care in specific developing countries, with the ultimate aim of modeling and implementing cancer control delivery systems that either are integrated with or supplement existing care delivery systems. Studies of this type are needed to ensure that there is a balance, for example, between resources devoted to screening and those devoted to diagnostic follow-up and treatment. The disappointing performance of cervical cancer screening programs in many developing countries has been due in part to the lack of effective diagnostic follow-up and treatment following screening.
-
Country-specific economic evaluation studies. Country-specific studies need to be done that assess resource requirements, economic costs, effectiveness, and ultimately cost-effectiveness of cancer control interventions adapted or tailored to the needs and requirements of low-and middle-income settings. Heuristic extrapolation is a first analytical step in this direction, but such studies can indicate only whether more direct and realistic studies are needed.
-
Studies of innovative health care information and communications technology. More research is needed to determine if technological advances, such as computerized image reading or long-distance consultation by oncology specialists, facilitated by telemedicine communications technology, might alter the cost-effectiveness equation by raising quality, by lowering costs, or both. For remote localities or small, low-income developing countries, training and employing local expertise or advanced equipment for every aspect of cancer control may not be necessary if advanced communication and information technology could be used to facilitate virtual collaboration.
