
==== Front
JCO Glob Oncol
JCO Glob Oncol
go
GO
JCO Global Oncology
2687-8941
Wolters Kluwer Health

39236284
GO-24-00310
10.1200/GO-24-00310
00185
SPECIAL ARTICLES
Medical Education and Practice
ASCO Global Guidelines: Methods and Opportunities
https://orcid.org/0000-0001-5032-4503
Aziz Zeba MD 1
https://orcid.org/0000-0002-1834-0551
Temin Sarah MSPH 2
https://orcid.org/0009-0009-8472-2986
Bachmann Sarah 2
Lopes Gilberto MD, MBA 3
https://orcid.org/0000-0002-1323-4119
Fadelu Temidayo MD 4
1 Hameed Latif Hospital, Lahore, Pakistan
2 American Society of Clinical Oncology, Alexandria, VA
3 Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
4 Dana-Farber Cancer Institute MGH, Boston, MA
American Society of Clinical Oncology; e-mail: guidelines@asco.org.
2024
5 9 2024
5 9 2024
10 e24003101 7 2024
1 8 2024
© 2024 by American Society of Clinical Oncology
2024
American Society of Clinical Oncology
https://creativecommons.org/licenses/by-nc-nd/4.0/ Creative Commons Attribution Non-Commercial No Derivatives 4.0 License: http://creativecommons.org/licenses/by-nc-nd/4.0/

OPEN-ACCESSTRUE
==== Body
pmcThe objectives of this article are to describe updates to the ASCO Global Guidelines methods and to provide background of the motivations for Global Guidelines that are responsive to varying access to cancer prevention and treatment resources, which are embedded in the broader context of ASCO's efforts on evidence-based clinical practice guidelines.

INTRODUCTION

Global Cancer Burden

Cancer is one of the leading causes of morbidity and mortality worldwide, with a disproportionately rising burden in low– and medium–Human Development Index regions (HDIs), where 61% of the world's total cases of patients newly diagnosed with cancer are diagnosed annually and 71%-75% of cancer deaths.1,2 Worldwide, 74%-75% of the annual total deaths are caused by noncommunicable diseases, principally from cardiovascular disease and cancer second.3 In 2019, 77% of all deaths from noncommunicable diseases occurred in low- and medium-HDI regions.3 Globally, the economic toll from cancer is 19% higher than that from cardiovascular disease, not considering direct medical costs and total number of years lost with a subsequent impact on productivity. The latter makes cancer the largest single burden on total economy when compared with HIV and other infectious diseases.4,5 Cancer is expected to increase especially in low-HDI countries.

Experience With ASCO Guidelines

According to WHO, comprehensive cancer treatment is only available in 15% of low-income countries.2 Comprehensive cancer care and treatment include multidisciplinary teams often with specialists in medical oncology, radiation, diagnostic specialties such as radiology and pathology, supportive care, palliative care, and other complementary services. Many oncology clinical care guidelines often presume the availability of an extensive care infrastructure. ASCO has long-standing experience with developing evidence-based clinical practice guidelines, with a current portfolio of 216 (as of this writing: guidelines, with 13 de novo guidelines, one living guideline, and 16 guideline updates in development). ASCO started developing guidelines in 1993.6 Those guidelines provide detailed and medically sound compilations of updates, insights, advice, and recommendations in the areas of greatest clinical need and uncertainty to ensure that patients get the best-quality medical care. However, ASCO guidelines often presume the availability of maximal resources, which may limit their global applicability and contextual relevance within settings with more limited resources.

ASCO Global Engagement

Health authorities, clinicians, policymakers, patients, and families in resource-constrained settings often experience a lack of expert guidance and may struggle to access learning resources relevant to their settings. ASCO, with nearly 50,000 members in 170 countries, is well poised to fill this gap and to provide tailored and relevant guidance responsive to available resources. ASCO established a Center for Global Impact (CGI) that partners with oncology communities worldwide to integrate global perspectives into ASCO strategies and operations and to catalyze and advance ASCO's global impact goals as directed by the Society's mission, vision, and strategic plans. ASCO's international programs focus on improving the quality of cancer care around the world, accelerating research and innovation to improve care tomorrow, and supporting the professional development of oncology leaders who will guide this work.

ASCO Global Guidelines Formation

ASCO's international volunteer programs include professional development, education, training, quality improvement, and support for and dissemination of research in low- and middle-income countries (LMICs) and regions.7,8

ASCO considered the reality of the challenges of implementing ASCO guidelines, including global variation in resources, and thus began publishing resource-adapted Global Guidelines (previously called Resource-Stratified Guidelines) in 2016. The initial framework of the ASCO Global Guidelines was based on the foundational work by the Breast Health Global Initiative (BHGI), which developed evidence-based, economically feasible, and culturally appropriate guidelines for nations with limited health care resources to improve breast cancer outcomes9 and is described in a previous 2018 ASCO publication.10 ASCO has adapted BHGI's four-tier resource stratification levels and now uses three when guidelines from high-resourced settings are available (Basic, Limited, and Enhanced; Table 1). In addition, the guidelines are intended to complement—but not replace—local guidelines because local guidelines can better reflect local situations. This guideline process uses ASCO's Evidence-Based Medicine Committee high-quality guideline methods with the goal of creating flexible, resource-stratified methods to practice guidelines, where clinicians and health authorities can identify how existing resources can be optimally applied to improve cancer outcomes. Table 2 outlines the Global Guidelines that have been published and are upcoming. This article aims to provide an update of the Global Guidelines process including a review of the background, methods of development, and dissemination of ASCO's Global Guidelines.

TABLE 1 Framework of Resource Stratification

Setting	Definition	
Basic	Core resources or fundamental services that are absolutely necessary for any public health/primary health care system to function; basic-level services are typically applied in a single clinical interaction. Vaccination is feasible for highest-need populations	
Limited	Second-tier resources or services that are intended to produce major improvements in outcomes such as incidence and cost-effectiveness and are attainable with limited financial means and modest infrastructure; limited-level services may involve single or multiple interactions. Universal public health interventions are feasible for greater percentage of population than the primary target group	
Enhanced	Third-tier resources or services that are optional but important; enhanced-level resources should produce further improvements in outcome and increase the number and quality of options and individual choice (perhaps ability to track patients and links to registries)	
Maximal	May use high-resource settings' guidelines
High-tier resources or services that may be used/available in some high-resource countries and/or may be recommended by high-resource setting guidelines that do not adapt to resource constraints but that nonetheless should be considered a lower priority than those resources or services listed in the other categories on the basis of extreme cost and/or impracticality for broad use in a resource-limited environment	
NOTE. Data adapted.9,11

TABLE 2 ASCO Global Guidelines Publications

Disease Site	Guideline	
Breast cancer	Systemic Treatment of Patients With Metastatic Breast Cancer (2024)12	
GI cancer	Early Detection for Colorectal Cancer (2019)13
Treatment of Patients with Early-Stage Colorectal Cancer (2019)14
Treatment of Patients with Late-Stage Colorectal Cancer (2020)15	
Gynecological cancer	Primary Prevention of Cervical Cancer (2017)16
Secondary Prevention of Cervical Cancer (2022)17,18
Management and Care of Women with Invasive Cervical Cancer (2022)19,20
Assessment of Adult Women with Ovarian Masses and Treatment of Epithelial Ovarian Cancer (2021)21	
Supportive care	Palliative Care in the Global Setting (2018)22	
In development	Global Adaptation of Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Systemic Cancer Therapy23,24	

METHODS

The target audiences for the guidelines are clinicians, program planners, public health providers, health and public health authorities, policymakers, patients, and caregivers. The ASCO Global Guidelines program uses methods adapted from other established methodologies, including ASCO's systematic review techniques and consensus methodology, and the ADAPTE methodology, which has been previously described.6,7 A central goal for the ASCO development of these Global Guidelines is to provide expert guidance for situations in which maximal resources are not available.

Overview

ASCO sets a high priority on assembling multidisciplinary Expert Panels with members from multiple resource settings. Some of the members come from ASCO's recently established Regional Councils which provide guidance on member needs and opportunities in their regions of the world and facilitate the engagement of members of their regions in ASCO.8 Regional Councils currently exist in Asia Pacific, Latin America, Sub-Saharan Africa, and Central and Eastern Europe. ASCO Regional Councils are composed of oncologists with a diverse balance of individuals by career stage (senior and early career), sex, discipline (radiologists, surgeons, and palliative care physicians, etc), geographic region, and income setting. Members of Expert Panels also represent diverse dimensions including geographic, northern/southern hemisphere, sex, and discipline; many members are from (or have extensive experience in) basic- and limited-resource settings. All Expert Panels include patient advocates and/or patients. ASCO has long-established guideline development procedures, including formal consensus using a modified Delphi strategy, and now uses these and other validated methods to develop Global Guidelines. These methods include a modified ADAPTE method and, because of the paucity of evidence from some of these settings, formal consensus.25

Selection of Topics

Under the leadership of a Global Guidelines Advisory Group (AG), ASCO has expanded its suite of products into a series of guidelines. The topics were suggested by ASCO members and the AG and were prioritized by the Guidelines AG and Evidence-Based Medicine Committee, which includes members from many continents and practice environments, representing members from all resource settings. To increase efficiency by lessening the need to systematically review and formerly assess non-ASCO guidelines before adapting them for resource-constrained settings, the AG is now selecting topics which already have ASCO resource-agnostic systematic review-based guidelines.

Systematic Review

All Maximal setting ASCO guidelines begin with a systematic review of the evidence, including a literature search with prespecified elements.

Modified ADAPTE Process

Although some of the guidelines published since 2018 were based on non-ASCO guidelines, more recently, they are based on existing ASCO guidelines. Rather than searching for, assessing, and adapting the existing non-ASCO guidelines, we now identify ASCO guidelines to adapt.

Expert Panels review the ASCO Maximal setting recommendations and assess the availability of the recommended interventions in more resource-constrained settings through various methods such as conducting literature searches for publications that assess the availability of the interventions and collating other vetted publicly available databases. For example, the International Atomic Energy Agency maintains a updated directory of radiotherapy centers around the world, which has been a very useful resource.26

Recommendation Development

The methods for developing recommendations for resource-constrained settings are largely the same as previously described in 2018. Briefly, the Expert Panel cochairs and/or Steering Group initially develop recommendations and then share them with the full Expert Panel or, alternatively, the subgroups of the full Expert Panel draft recommendations. Recommendation development uses standard ASCO guideline recommendation syntax crafted to help Guideline Expert Panels systematically develop clear, translatable, and implementable recommendations (ASCO Guidelines Methodology Manual).27

Formal Consensus

The formal consensus methods also remain the same. Briefly, when the Expert Panel deems the available literature insufficient to inform an evidence-based recommendation to guide clinical practice, a formal consensus process is used to develop recommendations, which are considered the best current guidance for practice.25 The Expert Panel is then supplemented by additional experts (ie, a Consensus Rating Panel) to independently rate levels of agreement with the recommendations. The levels of agreement must collectively meet a prespecified threshold (eg, ≥75%) that the experts must have rated agree or strongly agree for each recommendation. The results are reported either in the guideline or its supplement. More details on ASCO methodologies are available in the ASCO Guidelines Methodology Manual.

ASCO also conducts an Open Comment process by making draft recommendations available online to potential reviewers to make nonbinding advisory comments. Guideline Expert Panels review all these advisory comments and, at their discretion, may or may not modify recommendations.

DISSEMINATION AND IMPLEMENTATION

ASCO submits each Global Guideline in the open access journal, the Journal of Clinical Oncology: Global Oncology (JCO GO) and a companion to the guideline in Journal of Clinical Oncology: Oncology Practice (JCO OP). Global Guidelines are also freely available through the ASCO website and in the ASCO guidelines app (available for download in the Apple App Store and Google Play Store). ASCO leverages its social media and other communication mechanisms (such as Pocket Cards) to disseminate the guidelines. ASCO also provides summaries of the Global Guidelines in French and Spanish languages.

The guidelines have also been disseminated through the ASCO CGI, including through the ASCO International Cancer Corps program and in collaboration with Health Volunteers Overseas.28 ASCO is assisting health care organizations in LMICs to improve the quality of care provided to patients with cancer, and the guidelines have been incorporated into those collaborations. The ASCO/Conquer Cancer International Development and Education Award (IDEA) and IDEA Palliative Care Awards assist early-career oncologists in LMICs, and today, there are more than 450 recipients of this award in more than 73 countries.29 The guidelines have been disseminated to the IDEA network for further promotion and adoption in their practice settings.

DISCUSSION

The rising toll of cancer in LMICs mandates effective interventions at all levels of cancer care. Considering the rising costs of cancer care globally, optimal use of resources to optimize outcomes becomes essential. ASCO guidelines offer trustworthy and effective recommended care options that can be used to help plan treatment and management. However, the guidelines do not replace clinician judgment; their use and implementation need to be based on individual circumstances. Global Guidelines can provide individual clinicians and health systems with a practical framework for management of each patient, on the basis of the level of health care resources available in the country, region, or practice area where care is being given. Global Guidelines also give policymakers insight into how to plan resource-appropriate cancer control. Importantly, the guidelines can provide objective criteria for aspirational goals of improving the level of care; the criteria can be used to lobby for, or otherwise implement, new resources to elevate care and prevention options to reach the next resource stratum.

LIMITATIONS

A major limitation of developing Global Guidelines is that the vast complexity and variety of existing health settings make it challenging to provide uniform and meaningful recommendations for all possible resource levels. The reality of cancer care in many LMICs involves dynamic availability of resources; for example, a specific test or medication may be available some of the time but not always. Hence, the guidelines are intended to provide objectives to help local teams to customize care and planners reach the next stratum of services while working within the settings of local health situations.

The development of Global Guidelines is also sometimes challenged by limited evidence from the settings where the guidelines are intended to be applied. The limited evidence is partially attributed to a lack of resources needed to conduct research although this may be changing. Through Conquer Cancer, The ASCO Foundation, ASCO offers International Innovation Grants, which fund research in innovative cancer control solutions for low-resource practice environments. Fifty-two grants have been awarded since 2014. Research topics include the use of telehealth and mobile apps, screening and education for general practitioners, palliative care, and cervical cancer.30 Conquer Cancer also offers the Global Oncology Young Investigator Award, which funds research by early-career investigators to encourage and promote quality research in global oncology and to develop next-generation researchers to address global health needs. Thirty-four grants have been awarded since 2018. Research topics are wide-ranging and include studies of barriers to care, pediatric cancer care, improving guideline adherence, and implementation research. The need for contextually relevant research and real-world data from limited-resource settings cannot be overemphasized.

There is also limited research to date on the reach, adoption, and implementation outcomes of the developed Global Guidelines. Moreover, the guideline development process can also help to identify gaps in research. Each guideline contains specific suggestions for future research (such as setting-specific research on a given intervention). Defining and assessing implementation outcomes of the Global Guidelines is essential, and there are emerging studies that can serve as a guide.31 Rigorous research on Global Guidelines by clinicians in resource-constrained settings can identify best practices, and when combined with efforts to increase the affordability of cancer treatment, our proposed approaches can better enable patients and their families to benefit from cancer treatments without suffering potentially avoidable financial hardship. Implementation methods may include audit and feedback strategies, creating measures, and working with key opinion leaders. Therefore, ASCO will develop an implementation framework for the purposes of knowledge transfer while continuing its environmental scoping of other such guidelines.

OPPORTUNITIES

Given ASCO's truly global reach, across 170 countries, there are tremendous opportunities for ASCO to help elevate oncology care standards globally. The ASCO CGI organizes live, in-country training courses in LMICs on a range of cancer control topics, and the relevant guidelines are incorporated into faculty talks and disseminated to the audience. ASCO also supports the City Cancer Challenge, an initiative that aims to improve access to care in participating cities.32 As part of this initiative, local technical teams may adapt treatment guidelines, including ASCO and other guidelines, into city- or country-specific oncology guidelines tailored to the resources available in that location. ASCO will continue to develop Global Guidelines as it deepens relationships with its international membership and other stakeholders in standing against cancer worldwide. It is the view of ASCO that health care providers and health care system decisionmakers should be guided by the recommendations for the highest stratum of resources available.

ACKNOWLEDGMENT

We thank all the Expert Panel cochairs, members, and other ASCO volunteers and staff who have contributed to the publication and dissemination of ASCO Global Guidelines.

AUTHOR CONTRIBUTIONS

Conception and design: Gilberto Lopes

Administrative support: Sarah Temin, Sarah Bachmann

Collection and assembly of data: All authors

Data analysis and interpretation: All authors

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/go/authors/author-center.

Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

Gilberto Lopes

This author is a member of the JCO Global Oncology Editorial Board. Journal policy recused the author from having any role in the peer review of this manuscript.

Stock and Other Ownership Interests: Lucence Diagnostics, Xilis, Biomab, Morphometrix, CDR-Life

Honoraria: Boehringer Ingelheim, Blueprint Medicines, AstraZeneca, Merck, Janssen

Consulting or Advisory Role: Pfizer, AstraZeneca

Research Funding: Merck Sharp & Dohme (Inst), EMD Serono (Inst), AstraZeneca (Inst), AstraZeneca, Blueprint Medicines (Inst), Tesaro (Inst), Bavarian Nordic (Inst), NOVARTIS (Inst), G1 Therapeutics (Inst), Adaptimmune (Inst), BMS (Inst), GlaxoSmithKline (Inst), AbbVie (Inst), Rgenix (Inst), Pfizer (Inst), Roche (Inst), Genentech (Inst), Lilly (Inst), Janssen (Inst), Lucence, Xilis, E.R. Squibb Sons, LLC

Travel, Accommodations, Expenses: Boehringer Ingelheim, Pfizer, E.R. Squibb Sons, LLC, Janssen, Seagen, Celgene, Ipsen, Pharmacyclics, Merck, AstraZeneca

Other Relationship: Mirati Therapeutics

Temidayo Fadelu

Research Funding: Celgene (Inst), Cepheid (Inst)

No other potential conflicts of interest were reported.
==== Refs
REFERENCES

1. National Cancer Institute: Understanding Cancer. Cancer Statistics. 2024. https://www.cancer.gov/about-cancer/understanding/statistics
2. World Health Organization: WHO Cancer Fact Sheet. 2022. https://www.who.int/en/news-room/fact-sheets/detail/cancer
3. World Health Organization: Noncommunicable diseases fact sheet. 2023. https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases
4. Chen S , Cao Z , Prettner K , et al : Estimates and projections of the global economic cost of 29 cancers in 204 countries and territories from 2020 to 2050. JAMA Oncol 9 :465-472, 2023 36821107
5. Society AC: The Global Cancer Burden. American Cancer Society. https://www.cancer.org/about-us/our-global-health-work/global-cancer-burden.html
6. Somerfield MR , Bohlke K , Browman GP , et al : Innovations in American Society of Clinical Oncology practice guideline development. J Clin Oncol 34 :3213-3220, 2016 27382097
7. The ADAPTE Collaboration: The ADAPTE Process: Resource Toolkit for Guideline Adaptation. Version 2.0. 2009. http://g-i-n.net
8. ASCO: ASCO Regional Councils. https://society.asco.org/get-involved/volunteering-committees/regional-councils
9. Anderson BO , Shyyan R , Eniu A , et al : Breast cancer in limited-resource countries: An overview of the breast health global initiative 2005 guidelines. Breast J 12 :S3-S15, 2006 16430397
10. Al-Sukhun S , Temin S , Chavez-MacGregor M , et al : ASCO resource-stratified guidelines: Methods and opportunities. JCO Glob Oncol 10.1200/JGO.18.00113
11. Horton S , Gauvreau CL : Cancer in low- and middle-income countries: An economic overview, in Gelband H , Jha P , Sankaranarayanan R , et al (eds): Cancer: Disease Control Priorities (Volume 3) (ed 3). Washington, DC, The International Bank for Reconstruction and Development/The World Bank, 2015
12. Al Sukhun S , Temin S , Barrios CH , et al : Systemic treatment of patients with metastatic breast cancer: ASCO resource–stratified guideline. JCO Glob Oncol 10.1200/GO.23.00285
13. Lopes G , Stern MC , Temin S , et al : Early detection for colorectal cancer: ASCO resource-stratified guideline. JCO Glob Oncol 10.1200/JGO.18.00213
14. Costas-Chavarri A , Nandakumar G , Temin S , et al : Treatment of patients with early-stage colorectal cancer: ASCO resource-stratified guideline. JCO Glob Oncol 10.1200/JGO.18.00214
15. Chiorean EG , Nandakumar G , Fadelu T , et al : Treatment of patients with late-stage colorectal cancer: ASCO resource-stratified guideline. JCO Glob Oncol 10.1200/JGO.19.00367
16. Arrossi S , Temin S , Garland S , et al : Primary prevention of cervical cancer: American Society of clinical oncology resource-stratified guideline. JCO Glob Oncol 10.1200/JGO.2016.008151
17. Jeronimo J , Castle PE , Temin S , et al : Secondary prevention of cervical cancer: ASCO resource-stratified clinical practice guideline. JCO Glob Oncol 10.1200/JGO.2016.006577
18. Shastri SS , Temin S , Almonte M , et al : Secondary prevention of cervical cancer: ASCO resource-stratified guideline update. JCO Glob Oncol 10.1200/GO.22.00217
19. Chuang LT , Temin S , Camacho R , et al : Management and care of women with invasive cervical cancer: American Society of clinical oncology resource-stratified clinical practice guideline. JCO Glob Oncol 10.1200/JGO.2016.003954
20. Chuang LT , Temin S , Berek JS , et al : Management and care of patients with invasive cervical cancer: ASCO resource-stratified guideline rapid recommendation update. JCO Glob Oncol 10.1200/GO.22.00027
21. Vanderpuye VD , Clemenceau JRV , Temin S , et al : Assessment of adult women with ovarian masses and treatment of epithelial ovarian cancer: ASCO resource-stratified guideline. JCO Glob Oncol 10.1200/GO.21.00085
22. Osman H , Shrestha S , Temin S , et al : Palliative care in the global setting: ASCO resource-stratified practice guideline. JCO Glob Oncol 10.1200/JGO.18.00026
23. Mohile SG , Dale W , Somerfield MR , et al : Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. J Clin Oncol 36 :2326-2347, 2018 29782209
24. Dale W , Klepin HD , Williams GR , et al : Practical assessment and management of vulnerabilities in older patients receiving systemic cancer therapy: ASCO guideline update. J Clin Oncol 41 :4293-4312, 2023 37459573
25. Loblaw DA , Prestrud AA , Somerfield MR , et al : American Society of Clinical Oncology clinical practice guidelines: Formal systematic review-based consensus methodology. J Clin Oncol 30 :3136-3140, 2012 22778311
26. IAEA: IAEA DIrectory of RAdiotherapy Centres (DIRAC). https://dirac.iaea.org/
27. ASCO: ASCO Guidelines Methodology Manual. Alexandria, VA, American Society of Clinical Oncology, 2022. https://society.asco.org/practice-patients/guidelines/guideline-methodology
28. ASCO: International Cancer Corps. https://society.asco.org/get-involved/volunteering-committees/international-cancer-corps
29. ASCO: International Development & Education Award. 2024. https://society.asco.org/career-development/grants-awards/funding-opportunities/international-development-education-award
30. ASCO: Grants & Awards: View All Recipients. https://society.asco.org/career-development/grants-awards/grant-award-recipients
31. DeBoer RJ , Ndumbalo J , Meena S , et al : Development of a theory-driven implementation strategy for cancer management guidelines in sub-Saharan Africa. Implement Sci Commun 1 :24, 2020 32885183
32. (C/Can) CCC: City Cancer Challenge. https://citycancerchallenge.org/
