Cancer Control Knowledge into Action WHO Guide for Effective Programmes ppt

Diagnosis and
Treatment
Knowledge into Action
Cancer Control
WHO Guide for Effective Programmes

Diagnosis and
Treatment
Knowledge into Action
Cancer Control
WHO Guide for Effective Programmes
WHO Library Cataloguing-in-Publication Data
Diagnosis and Treatment.
(Cancer control : knowledge into action : WHO guide for effective programmes ; module 4.)
1. Neoplasms – diagnosis. 2. Neoplasms – therapy. 3. Early detection. 4. National health programs. 5. Guidelines. I.World Health Organization. II.Series.
ISBN 978 92 4 154740 6 (NLM classification: QZ 241)
© World Health Organization 2008
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Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization
in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial
capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is
being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no
event shall the World Health Organization be liable for damages arising from its use.
The Cancer Control – Diagnosis and Treatment module was produced under the direction of Catherine Le Galès-Camus (Former Assistant Director-General, Noncommunicable
Diseases and Mental Health), Serge Resnikoff (Coordinator, Chronic Diseases Prevention and Management) and Cecilia Sepúlveda (Chronic Diseases Prevention and

Management, coordinator of the overall series of modules).
Twalib Ngoma was the coordinator for this module and Cecilia Sepúlveda provided extensive editorial input.
Editorial support was provided by Anthony Miller (scientific editor), Inés Salas (technical adviser) and Angela Haden (technical writer and editor). Proofreading was done
by Ann Morgan.
The production of the module was coordinated by Maria Villanueva and Neeta Kumar.
Core contributions for the module were received from the following experts:
Baffour Awuah, Komfo Anokye Teaching Hospital, Ghana
Yasmin Bhurgri, Karachi Cancer Registry and Aga Khan University Karachi, Pakistan
Ian Magrath, International Network for Cancer Treatment and Research, Belgium
Luiz Figueiredo Mathias, National Cancer Institute, Brazil
M. Krishnan Nair, Regional Cancer Centre, India
Twalib A. Ngoma, Ocean Road Cancer Institute, United Republic of Tanzania
Eduardo Rosenblatt, International Atomic Energy Agency, Austria
The above contributors have signed a declaration indicating they have no conflicts of interest.
Valuable input, help and advice were received from a number of people in WHO headquarters throughout the production of the module: Caroline Allsopp, David Bramley,
Raphaël Crettaz and Maryvonne Grisetti.
Cancer experts worldwide, as well as technical staff in WHO headquarters and in WHO regional and country offices, also provided valuable input by making contributions
and reviewing the module, and are listed in the Acknowledgements.
Design and layout: L’IV Com Sàrl, Morges, Switzerland, based on a style developed by Reda Sadki, Paris, France.
Printed in Switzerland
More information about this publication can be obtained from:
Department of Chronic Diseases and Health Promotion
World Health Organization
CH-1211 Geneva 27, Switzerland
The production of this publication was made possible through the generous financial support of the National Cancer Institute (NCI), USA,
and the National Cancer Institute (INCa), France. We would also like to thank the Public Health Agency of Canada (PHAC), the National
Cancer Center (NCC) of the Republic of Korea, the International Atomic Energy Agency (IAEA), and the International Union Against Cancer
(UICC) for their financial support.
Cancer is a leading cause of death globally. The World Health Organization
estimates that 7.6 million people died of cancer in 2005 and 84 million people

will die in the next 10 years if action is not taken. More than 70% of all cancer
deaths occur in low- and middle-income countries, where resources available for
prevention, diagnosis and treatment of cancer are limited or nonexistent.
But because of the wealth of available knowledge, all countries can, at some
useful level, implement the four basic components of cancer control – prevention,
early detection, diagnosis and treatment, and palliative care – and thus avoid
and cure many cancers, as well as palliating the suffering.
Cancer control: knowledge into action, WHO guide for effective programmes is
a series of six modules that provides practical advice for programme managers
and policy-makers on how to advocate, plan and implement effective cancer
control programmes, particularly in low- and middle-income countries.
Cancer is to a large extent avoidable. Many cancers
can be prevented. Others can be detected early in their
development, treated and cured. Even with late stage
cancer, the pain can be reduced, the progression of the
cancer slowed, and patients and their families helped
to cope.
iii
Cancer Control Series
Introduction to the
Series overview
6
Prevention
Knowledge into Action
Cancer Control
WHO Guide for Effective Programmes
PREVENTION
A practical guide for programme
managers on how to implement
effective cancer prevention by

controlling major avoidable cancer
risk factors.
Early Detection
Knowledge into Action
Cancer Control
WHO Guide for Effective Programmes
EARLY DETECTION
A practical guide for programme
managers on how to implement
effective early detection of major
types of cancer that are amenable
to early diagnosis and screening.
Diagnosis and
Treatment
Knowledge into Action
Cancer Control
WHO Guide for Effective Programmes
DIAGNOSIS AND TREATMENT
A practical guide for programme
managers on how to implement
effective cancer diagnosis and
treatment, particularly linked to
early detection programmes or
curable cancers.
Palliative Care
Knowledge into Action
Cancer Control
WHO Guide for Effective Programmes
PALLIATIVE CARE
A practical guide for programme

managers on how to implement
effective palliative care for
cancer, with a particular focus on
community-based care.
Policy and
Advocacy
Knowledge into Action
Cancer Control
WHO Guide for Effective Programmes
POLICY AND ADVOCACY
A practical guide for medium level
decision-makers and programme
managers on how to advocate for
policy development and effective
programme implementation for
cancer control.
The WHO guide is a response to the World Health Assembly
resolution on cancer prevention and control (WHA58.22), adopted
in May 2005, which calls on Member States to intensify action
against cancer by developing and reinforcing cancer control
programmes. It builds on National cancer control programmes:
policies and managerial guidelines and Preventing chronic
diseases: a vital investment, as well as on the various WHO
policies that have influenced efforts to control cancer.
Cancer control aims to reduce the incidence, morbidity and mortality
of cancer and to improve the quality of life of cancer patients in
a defined population, through the systematic implementation
of evidence-based interventions for prevention, early detection,
diagnosis, treatment, and palliative care. Comprehensive cancer
control addresses the whole population, while seeking to respond

to the needs of the different subgroups at risk.
Components of CanCer
Control
Prevention of cancer, especially when integrated with the
prevention of chronic diseases and other related problems (such
as reproductive health, hepatitis B immunization, HIV/AIDS,
occupational and environmental health), offers the greatest
public health potential and the most cost-effective long-term
method of cancer control. We now have sufficient knowledge to
prevent around 40% of all cancers. Most cancers are linked to
tobacco use, unhealthy diet, or infectious agents (see Prevention
module).
Early detection detects (or diagnoses) the disease at an
early stage, when it has a high potential for cure (e.g. cervical
or breast cancer). Interventions are available which permit the
early detection and effective treatment of around one third of
cases (see Early Detection module).
There are two strategies for early detection:
• early diagnosis, often involving the patient’s awareness of
early signs and symptoms, leading to a consultation with
a health provider – who then promptly refers the patient
for confirmation of diagnosis and treatment;
• national or regional screening of asymptomatic and
apparently healthy individuals to detect pre-cancerous
lesions or an early stage of cancer, and to arrange referral
for diagnosis and treatment.
iv
Planning
Knowledge into Action
Cancer Control

WHO Guide for Effective Programmes
PLANNING
A practical guide for programme
managers on how to plan overall
cancer control effectively,
according to available resources
and integrating cancer control
with programmes for other chronic
diseases and related problems.
A series of six modules
Treatment aims to cure disease, prolong life, and improve
the quality of remaining life after the diagnosis of cancer is
confirmed by the appropriate available procedures. The most
effective and efficient treatment is linked to early detection
programmes and follows evidence-based standards of care.
Patients can benefit either by cure or by prolonged life, in cases
of cancers that although disseminated are highly responsive
to treatment, including acute leukaemia and lymphoma. This
component also addresses rehabilitation aimed at improving the
quality of life of patients with impairments due to cancer (see
Diagnosis and Treatment module).
Palliative care meets the needs of all patients requiring relief
from symptoms, and the needs of patients and their families for
psychosocial and supportive care. This is particularly true when
patients are in advanced stages and have a very low chance of
being cured, or when they are facing the terminal phase of the
disease. Because of the emotional, spiritual, social and economic
consequences of cancer and its management, palliative care
services addressing the needs of patients and their families, from
the time of diagnosis, can improve quality of life and the ability

to cope effectively (see Palliative Care module).
Despite cancer being a global public health problem, many
governments have not yet included cancer control in their
health agendas. There are competing health problems, and
interventions may be chosen in response to the demands of
interest groups, rather than in response to population needs or
on the basis of cost-effectiveness and affordability.
Low-income and disadvantaged groups are generally more
exposed to avoidable cancer risk factors, such as environmental
carcinogens, tobacco use, alcohol abuse and infectious agents.
These groups have less political influence, less access to health
services, and lack education that can empower them to make
decisions to protect and improve their own health.
v
BASIC PRINCIPLES OF CANCER CONTROL
• Leadership to create clarity and unity of
purpose, and to encourage team building,
broad participation, ownership of the
process, continuous learning and mutual
recognition of efforts made.
• Involvement of stakeholders of all
related sectors, and at all levels of the
decision-making process, to enable active
participation and commitment of key
players for the benefit of the programme.
• Creation of partnerships to enhance
effectiveness through mutually beneficial
relationships, and build upon trust and
complementary capacities of partners
from different disciplines and sectors.

• Responding to the needs of people
at risk of developing cancer or already
presenting with the disease, in order to
meet their physical, psychosocial and
spiritual needs across the full continuum
of care.
• Decision-making based on evidence,
social values and efficient and cost-
effective use of resources that benefit the
target population in a sustainable and
equitable way.
• Application of a systemic approach
by implementing a comprehensive
programme with interrelated key
components sharing the same goals and
integrated with other related programmes
and to the health system.
• Seeking continuous improvement,
innovation and creativity to maximize
performance and to address social and
cultural diversity, as well as the needs
and challenges presented by a changing
environment.
• Adoption of a stepwise approach
to planning and implementing
interventions, based on local
considerations and needs (see next
page for WHO stepwise framework for
chronic diseases prevention and control,
as applied to cancer control).

Series overview
6
PLANNING STEP 1
Where are we now?
1
Investigate the present state of the
cancer problem, and cancer control
services or programmes.
WHO stepwise framework
vi
6
PLANNING STEP 2
Where do we want to be?
2
Formulate and adopt policy. This includes
defining the target population, setting
goals and objectives, and deciding on
priority interventions across the cancer
continuum.
6
PLANNING STEP 3
How do we get there?
3
Identify the steps needed to implement
the policy.
The planning phase is followed by the policy implementation phase.
Implementation step 1
CORE
Implement interventions in the policy that are
feasible now, with existing resources.

Implementation step 2
EXPANDED
Implement interventions in the policy that are
feasible in the medium term, with a realistically
projected increase in, or reallocation of, resources.
Implementation step 3
DESIRABLE
Implement interventions in the policy that are
beyond the reach of current resources, if and when
such resources become available.
Series overview
1
6
KEY MESSAGES 2
PRE-PLANNING 6
Is a new cancer diagnosis and treatment plan needed? 6
PLANNING STEP 1: WHERE ARE WE NOW? 8
Assess the number of cancer patients in need of diagnosis and treatment 8
Assess the existing diagnosis and treatment plan and ongoing activities 10
Assess the social context 14
Self-assessment by countries 15
PLANNING STEP 2: WHERE DO WE WANT TO BE? 16
Define the target population for diagnosis and treatment 16
Identify gaps in diagnostic and treatment services 17
Set objectives for diagnostic and treatment services 17
Assess the feasibility of diagnostic and treatment interventions 17
Address ethical aspects 19
Set priorities for diagnostic and treatment services 20
PLANNING STEP 3: HOW DO WE GET THERE? 22
Bridge the gaps 23

Raise the necessary resources 23
Organize diagnostic and treatment services 26
Implement quality control 36
Establish registration and coordination systems 37
Build in monitoring and evaluation 37
CONCLUSION 39
REFERENCES 40
ACKNOWLEDGEMENTS 41
DIAGNOSIS AND TREATMENT MODULE CONTENTS
6
6
1
Contents
DIAGNOSIS AND TREATMENT
2
KEY MESSAGES
The first module in the Cancer Control series, Planning,
provides a template for cancer control planning and
progamme implementation. The recommended framework
draws on earlier WHO work in this field, the principles of
which are set out in National cancer control programmes,
policies and managerial guidelines (WHO, 2002), and
various WHO policies that have influenced cancer control
in the recent past.
This module discusses how to plan and implement an
effective diagnosis and treatment programme using a
public health approach, within the context of a national
cancer control programme. It will be updated within the
next 5 years as it is intended to evolve in response to new
knowledge, evidence- based information, national needs

and experience.
DIAGNOSIS AND TREATMENT
3
The key messages for people involved in planning cancer
diagnosis and treatment services are as follows:
p
The main goals of a diagnosis and treatment programme are to cure
or considerably prolong the life of cancer patients and to ensure the
best possible quality of life to cancer survivors.
p
Diagnosis and treatment services should initially target all patients
presenting with curable tumours. If more resources are available, the
programme should be extended to include patients with the common
cancers that are treatable but not curable.
p
Effective diagnostic and treatment services use a multidisciplinary
approach and are integrated into the existing health system. Services
are usually best developed at the secondary and tertiary levels as
they are often costly, requiring specialized staff, infrastructure and
procedures.
p
Treatment involves not only managing all aspects of the cancer itself,
but also the psychosocial and rehabilitation needs of the patients and
their families. Psychosocial support is particularly important because,
in many countries, cancer is greatly feared and stigmatized.
p
Although the basic principles of cancer treatment are the same
throughout the world, the specific treatment approaches adopted in
each country should take into account cost-effectiveness, affordability,
and social and ethical aspects. Services should, however, always be

provided in an equitable and sustainable manner.
p
Health professionals caring for cancer patients need to be prepared to
decide, in consultation with the patient, when therapeutic measures to
cure or prolong life are no longer likely to be beneficial to the patient
and to institute palliative care instead (see Palliative care module).
Key messages
4
DIAGNOSIS AND TREATMENT
Cancer diagnosis comprises the various techniques and procedures
used to detect or confirm the presence of cancer. Diagnosis typically
involves evaluation of the patient’s history, clinical examinations, review of
laboratory test results and radiological data, and microscopic examination
of tissue samples obtained by biopsy or fine-needle aspiration.
Cancer staging is the grouping of cases into broad categories based on the
extent of disease, that is, how far the cancer has spread from the organ or
site of origin (the primary site). Knowing the extent of disease (or stage) helps
the physician determine the most appropriate treatment to either effect a
cure, decrease the tumour burden, or relieve symptoms. “Early cancer”
refers to stages I and II. “Advanced cancer” refers to stages III and IV. Stage
of disease at diagnosis is generally the most important factor determining
the survival of cancer patients. The duration of survival is widely used as a
measure of the effectiveness of the treatment of cancer.
Cancer treatment is the series of interventions, including psychosocial
support, surgery, radiotherapy, chemotherapy and hormone therapy, that
is aimed at curing the disease or prolonging the patient’s life considerably
(for several years) while improving the patient’s quality of life.
Cancer management involves cancer staging and treatment. Cancer
management starts from the moment the patient’s diagnosis of cancer
is confirmed.

key denitions
5
Cancer survivors are those patients who having had cancer are, following
treatment, now cured of the disease. Cure is defined as the attainment of
normal life expectancy and has three important components:
p
recovery from all evidence of disease (complete remission);
p
attainment of a stage of minimal or no risk of recurrence or
relapse;
p
restoration of functional health (physical, developmental and
psychosocial).
Curable cancers are cancers for which treatment can give patients a
high potential for being disease free in the 10 years following cessation of
treatment, such that the patient may eventually die of another condition.
Curable cancers include:
p
cancers that can be detected early and effectively treated;
p
cancers that although disseminated or not amenable to early
detection methods, have a high potential for being cured with
appropriate treatment.
Cancers that are treatable but not curable are cancers for which
treatment can prolong life considerably (for several years) by temporarily
stopping or slowing down the progression of the disease.
Key messages
PRE-PLANNING
It is estimated that, worldwide, there are millions of cancer
patients with curable cancers. With early detection, timely

diagnosis and adequate treatment, carried out within the
context of a comprehensive cancer control plan, the lives
of a significant number of cancer patients can be saved or
prolonged considerably.
6
DIAGNOSIS AND TREATMENT
IS A NEW CANCER DIAGNOSIS AND
TREATMENT PLAN NEEDED?
There is no country in the world where cancer does not occur. Curative treatment exists for
about one third of all cancer cases, but particularly breast, cervical and oral cancers, provided
they are detected early. Some cancers, such as metastatic seminoma, and acute leukaemia and
lymphomas in children, although disseminated or not amenable to early detection methods, have
high potential for being cured. Patients suffering from these types of cancers can be diagnosed
and treated with interventions that are affordable, even in low-income countries.
Unfortunately, in many countries, particularly low-income countries, diagnostic and treatment
services are not planned rationally. Treatment technologies and infrastructure are not linked
to early detection strategies, and there is usually an excessive reliance on costly procedures
that serve mainly the wealthy who can afford them. Consequently, a high proportion of patients
having cancers that are curable if detected early are diagnosed in advanced stages, at which
point a small number receive costly, but ineffective and incomplete treatment. In such settings,
the same resources would be better employed, and would benefit a greater number of patients,
if they were to be used to fund low-cost palliative care (see Early detection and Palliative care
modules).
The development of good quality diagnostic and treatment services to address curable cancers
is therefore imperative, especially in the great majority of low-income countries. This would help
to save lives, avoid unnecessary suffering and make more efficient use of limited resources.

her story
DIAGNOSED WITH ACUTE
LYMPHOBLASTIC LEUKAEMIA

AT THE AGE OF 12 YEARS,
LALITA IS NOW DISEASE FREE
AND LOOKS TO THE FUTURE
WITH OPTIMISM AND HOPE
7
Eulalia Maria Vásquez Rivera (Lalita) is originally from
Tegucigalpa, Honduras, and is the fourth daughter in a
low-income family. She has six brothers and sisters.
Lalita was experiencing bone pain, permanent fever,
weight loss and bleeding gums. She remembers what
happened during hurricane Mitch, when her parents
took her to Escuela Hospital, the main teaching
hospital in the public health system. At 12 years of
age, in the Paediatric Haemato-oncology Unit, she was
diagnosed with acute lymphoblastic leukaemia.

Lalita started chemotherapy treatment in November
2001 and successfully completed it at the end of
August 2004. She has been free of the disease for
3 years. She is now 17 years old and very happy.
One of her dreams used to be to become an interior
decorator, but now she would like to become a nurse.
Lalita says, “Suffering from cancer has taught me
to enjoy life immensely. Whatever I undertake, I will
achieve through faith in God and in myself.”
Lalita is but one of the 500 children who have been
diagnosed and treated for acute lymphoblastic
leukaemia in the past 7 years at the Paediatric
Haemato-oncology Unit of the Escuela Hospital. The
Unit is open to all children who suffer from leukaemia

or other types of cancer. For patients from low-income
families, the cost of treatment is covered by the public
health system, with the assistance of the Honduran
Foundation for Children with Cancer. Assistance
from the latter is generally in the form of provision
of chemotherapy drugs, special laboratory tests, and
psychosocial support for patients and their families.
Honduras is a low-income country facing numerous
economic and social challenges. However,
thanks to a well-organized programme for the
treatment of childhood cancer, great progress
has been made. Today, around 60% of children
with acute lymphoblastic leukaemia can be cured
using standardized protocols for treatment and
comprehensive care.
Source: Information provided by Dr Ligia Fu Carrasco, Paediatric
Haemato-oncology Unit, Escuela Hospital, Tegucigalpa, Honduras.
Further information on the work that has been done to fight childhood
cancer in Honduras, including the efforts of the civil community, can be
found at .
Pre-planning
8
DIAGNOSIS AND TREATMENT
PLANNING STEP 1
Where are we now?
The Planning module provides an overview of what to
assess in relation to the overall cancer needs in the general
population, the groups particularly at risk, and the existing
plan and services for responding to those needs. This
Diagnosis and treatment module provides more detailed

information on how to assess the number of people in need
of diagnosis and treatment, and the existing diagnostic and
treatment policies and services.
ASSESS THE NUMBER OF CANCER PATIENTS IN
NEED OF DIAGNOSIS AND TREATMENT
By assessing the number of people with curable cancers or cancers that are treatable but
not curable, it is possible to estimate the number of patients who could benefit most from
timely and adequate diagnostic and treatment services.

Performing such an assessment will provide responses to the following key questions:
p
Which are the most common cancer types that have high potential for being detected
early and cured?
p
Which are the most frequent cancer types that, although disseminated or not amenable
to early detection, have a high potential for being cured?
p
Which are the most frequent cancer types that are treatable but not curable?
p
What proportion of all paediatric cancers are curable?
p
What proportion of all paediatric cancers are treatable but not curable?
p
What proportion of all adult cancers are curable?
p
What proportion of all adult cancers are treatable but not curable?
9
Table 1. The burden of curable cancers and cancers that are
treatable but not curable: what to assess
Cancer type/site Incidence

Stage at
diagnosis Survival Mortality Disparities
Cancers that are curable when detected early
Breast
Cervix
Colon and rectum
Oral cavity
Nasopharynx
Larynx
Stomach
Skin melanoma
Other skin cancers
Urinary bladder
Prostate
Retinoblastoma
a
Testis
Cancers that are disseminated or not amenable to early detection but potentially curable
Metastatic seminoma
Acute lymphatic leukaemia
a
Hodgkin lymphoma
a
Non-Hodgkin lymphoma
a
Osteosarcoma
a
All curable cancers
Cancers that are treatable but not curable
Advanced breast cancer

Advanced cutaneous melanoma
Advanced Hodgkin lymphoma
Advanced non-Hodgkin lymphoma
For each common cancer type with a high potential for cure or for which treatment may
prolong the patient’s life considerably (for several years), it is important to determine the age,
sex and geographical disparities in incidence, stage distribution, mortality and survival.
Table 1 provides a template for organizing the data obtained by the disease burden assessment
and thereby identifying the most common types of curable cancers and cancers that are
treatable but not curable. The necessary data can be derived according to the approaches
described in the Planning module (see planning step 1, pages 14–15).
Planning step 1
a
High cure rates in children.
10
DIAGNOSIS AND TREATMENT
ASSESS THE EXISTING DIAGNOSIS AND
TREATMENT PLAN AND ONGOING ACTIVITIES
In assessing the existing diagnosis and treatment plan and ongoing activities, it is important
to recognize that diagnosis and treatment together constitute a complex component of
overall cancer control which, in an ideal scenario at least, is closely allied to early detection
and palliative care activities. Cancer diagnosis and treatment services are mainly available
at the secondary and tertiary levels, and are usually provided by professionals from a great
variety of disciplines and specialties.
Table 2 shows what to assess regarding the existing cancer diagnosis and treatment plan
and ongoing activities. These aspects are discussed in more detail in the Planning module.
The initial focus should be on the gap between what is needed to provide services to the
population with curable cancers, and what is currently available.
Table 2. The diagnosis and treatment plan and related activities:
what to assess
Plan and activities What to assess

Diagnosis and treatment
plan
• Endorsement of the plan and its scope (geographical area and cancer types included)
• Whether or not part of a comprehensive cancer control plan
• Timeliness (updated/outdated)
• Accessibility to the written plan
• Stakeholders’ involvement in plan development
• Inclusion of critical sections of the plan (assessments, goals and objectives, strategies,
timetable, responsible persons, resources, monitoring and evaluation)
• Priorities (objectives and actions related to diagnosis and treatment of curable cancers)
• Integration with the plan for noncommunicable diseases and other related problems
• Utility of the plan (used to guide programme implementation)
Ongoing diagnosis and
treatment services
• Number and coverage of diagnosis and treatment interventions and related services
offered (including patient education, psychosocial support, symptom management, home
care, etc.)
• Quality of ongoing diagnosis and treatment activities
• Integration with ongoing services for noncommunicable diseases and other related
problems
• Evaluation of outcomes, output and process indicators, and trends
Resources of ongoing
diagnosis and treatment
services
• Information systems (cancer registries, surveillance of diagnosis and treatment
interventions)
• Protocols, guidelines, manuals, educational materials, etc.
• Physical resources (infrastructure, technologies, essential list of chemotherapy drugs)
• Human resources (leaders, councils, committees, health-care networks, health-care
providers, partners, traditional healers)

• Financial resources
• Regulations and legislation
Context of the diagnosis
and treatment plan and
activities
• SWOT analysis: strengths, weaknesses, opportunities and threats concerning the
performance of the cancer diagnosis and treatment programme
11
Ask the following questions to assess the existing diagnosis and treatment service
provision:
WHAT DIAGNOSIS AND TREATMENT SERVICES ARE AVAILABLE?
p
Are there diagnosis and treatment services for curable tumours? How are they
organized?
p
Are the diagnosis and treatment services linked to early detection programmes?
p
Are the diagnosis and treatment services linked to palliative care?
p
What is the target population for the diagnosis and treatment programme? Does it
explicitly include adults and children?
p
What diagnostic tests are recommended to confirm the diagnosis of specific types of
curable cancers and of other common cancers that are treatable but not curable?
p
Are there clinical guidelines for the treatment of the curable cancers?
p
Are there clinical guidelines for the treatment of the cancers that are treatable but not
curable?
p

Are there guidelines for the provision of patient information and support?
p
Are there guidelines for organizing treatment services for curable tumours?
p
Are there guidelines for organizing treatment services for the cancers that are treatable
but not curable?
p
Do the organizational guidelines define the roles and functions of health-care providers
at the different levels of care?
p
Are there systems to ensure regular monitoring and evaluation?
p
Do the monitoring and evaluation systems include adequate quality control of the
diagnostic, treatment and follow-up methods?
HOW WELL ARE DIAGNOSIS AND TREATMENT PROGRAMMES DOING? HAVE
MEASURES OF SERVICE DELIVERY QUALITY BEEN IDENTIFIED AND ARE THEY
MONITORED REGULARLY?
Quality can either be assessed through a system model of inputs, processes, outputs and
outcomes (short-, medium- and long-term) or by adopting a continuous quality improvement
framework, composed of a number of quality dimensions that can be explored through
questions such as the ones listed below:
p
Are all the diagnostic and treatment services accessible (ensuring coverage and
timeliness) to the target population?
p
Are the services acceptable (ensuring providers’ and patients’ satisfaction) and
appropriate (based on established standards) for the target groups?
p
Are the competencies (knowledge and skills) of the providers appropriate for the
services needed?

p
Is there continuity (integration, coordination and ease of navigation) in the activities of
the diagnosis and treatment programme?
p
Are the diagnostic and treatment services safe for providers, patients and the
environment?
p
Are the diagnostic and treatment services effective (in terms of cure or improved
survival) and efficient (providing the best results at the lowest cost)?
Planning step 1
12
DIAGNOSIS AND TREATMENT
ASSESSING THE EFFECTIVENESS OF DIAGNOSTIC AND
TREATMENT SERVICES
In the medium and long term, an effective diagnosis and treatment programme, with good
coverage of the target groups, should result in:
p
improvement in 5- and 10-year survival and cure rates for patients with the targeted
cancers;
p
improved quality of life for cancer survivors;
p
decreased mortality among patients with the targeted cancer types.
ASSESSING THE EFFICIENCY OF DIAGNOSIS AND
TREATMENT PROGRAMMES
Diagnosis and treatment programmes can achieve very different results with the same level
of resources. Programmes are particularly efficient if they target curable cancers.
It is unfortunately not rare, in low-resource settings, to see a local government investing
in hugely expensive cancer treatments, such as bone marrow transplant units. Only a few
very high-income patients will be able to afford such costly treatment, and their chances of

survival will be low. The same level resources could, however, be used to treat hundreds of
children, including those from low-income families, who have acute lymphatic leukaemia,
for which cure rates are potentially over 80%.
Relevant questions to ask in order to assess the efficiency of diagnosis and treatment
programmes are shown in Table 3.
ASSESSING PATIENT SAFETY IN DIAGNOSIS AND
TREATMENT PROGRAMMES
Patient safety is achieved by avoiding, preventing or ameliorating adverse outcomes or injuries
stemming from the processes of health care (WHO, 2005). In the United States of America,
the National Cancer Institute has recommended common terminology for reporting adverse
events, applicable to all oncology clinical trials regardless of chronicity of adverse events or
modality of treatment. This terminology is useful in assessing the safety of all health-care
interventions (National Cancer Institute, 2003).
To assess whether a diagnosis and treatment component is safe in a country or region, it is
useful to pose the following questions:
HOW MANY PATIENTS PER YEAR EXPERIENCE MEDICAL ERRORS OR SUFFER
INJURIES ASSOCIATED WITH THE DELIVERY OF DIAGNOSIS AND TREATMENT
PROCEDURES?
When answering this question, it is instructive to consider any possible complications of
diagnostic tests and treatment, medication errors, side-effects of medications, critical
incidents and psychosocial consequences of treatment, and also any associated quality-
of-life aspects.
13
Table 3. Questions to help assess the efficiency of cancer
diagnosis and treatment programmes
Efficiency measure
Basic
question(s)
Examples of specific questions relating to diagnosis and treatment
programmes: the answer “yes” means that the programme is efficient

Technical efficiency
(using given
resources to
maximum
advantage)
Could we
produce the
same outcome
with fewer
resources?
• Is the treatment programme directed at the right target groups? For example,
is the programme directed at patients with early stages of cancer, rather than
those with advanced cancer?
• Is the amount of over-treatment insignificant? For example, are recommended
conservative procedures, rather than more invasive ones, used to treat cervical
cancer in-situ?
• Are staff adequately trained and do they perform well?
• Is there adequate equipment for optimal diagnosis and treatment?
• Are facilities and supplies being fully used?
• Are we using all available information?
• Are we helping patients to adhere to their treatment and care regimes? For
example, are we educating patients about their disease and treatment, and
empowering them to cope effectively?
Productive efficiency
(choosing different
combinations of
resources to achieve
the maximum health
benefit for a given
cost)

Could we
improve the
health outcome
for a given
cost?
• Have we reallocated the available diagnostic and treatment resources, and
targeted patients with curable cancers, to obtain better outcomes?
• Have we redistributed the diagnostic and treatment resources to underserved
groups within the target population?
• Do we complete the diagnostic, treatment and follow-up protocol in patients
with early symptoms of cancer?
• Do we maintain and develop the performance of health workers?
• Do we maintain a level of workload that is between the minimum and
maximum standards?
• Do we maintain adequate standards of diagnostic and treatment service
provision through quality assurance?
• Do we provide appropriate advice and counselling for patients and their
families to help them cope with their situation?
Could we
reduce costs
for a given
outcome?
Based on the evidence, are we using the most cost-effective:
• early detection tests?
• definitive diagnostic tests?
• treatment options?
• follow-up options?
• health workers?
• strategies to identify those at high risk for emotional distress?
• strategies to empower the target groups to take more responsibility for their

own decisions?
• strategies to reach the target groups?
• strategies to reach patients with abnormal results and refer them for further
investigations?
• strategies to follow up patients who have been treated?
• strategies to improve the performance of health workers?
• strategies for quality control?
Allocative efficiency
(achieving the right
mixture of health-
care programmes to
maximize the health
of society)
Could we
improve the
health of
society by
choosing a
better mix of
programmes?
• Do we choose the most cost-effective and affordable diagnosis and treatment
interventions for the population?
• Do we choose the most cost-effective and affordable cancer prevention and
palliative care interventions for the population?
Planning step 1
14
DIAGNOSIS AND TREATMENT
WHAT ACTIONS ARE BEING TAKEN TO ENSURE PATIENT SAFETY IN RELATION
TO THE DELIVERY OF DIAGNOSIS AND TREATMENT PROCEDURES?
p

Is there a system to identify medical errors and causes of patient injury?
p
Are practices being implemented that eliminate medical errors and systems-related
risks and hazards?
ASSESSING CUSTOMER SATISFACTION WITH
DIAGNOSIS AND TREATMENT SERVICES
Customer satisfaction is the state of mind that customers (patients and their families) have
when their expectations have been met or exceeded. Customer satisfaction is subjective.
To establish whether a diagnosis and treatment programme for cancer is producing customer
satisfaction, it is useful to ask the following questions:
p
Do patients comply with treatment and follow-up?
p
Is customer satisfaction improving over time?
p
How many formal complaints have been received?
p
What are customers’ expectations, preferences, needs and requirements?
p
Are the services designed to meet customers’ expectations, preferences, needs and
requirements?
ASSESS THE SOCIAL CONTEXT
The development of a diagnosis and treatment plan and programme requires a thorough
understanding of the context. The integration of social context with the diagnosis and
treatment plan will considerably enhance acceptance of the plan, both politically and socially.
One way to do this is through an analysis of the strengths, weaknesses, opportunities and
threats (SWOT analysis) of the existing plan and related activities.
During the course of a SWOT analysis, the following questions should be answered:
WHAT ARE THE STRENGTHS AND WEAKNESSES ASSOCIATED WITH PLAN
DEVELOPMENT AND IMPLEMENTATION?

These are factors affected by internal forces, such as political support, leadership,
stakeholders’ involvement and resources available. For example, politicians and decision-
makers are usually supportive of treatment services for cancer but they do not prioritize
cost-effective and affordable treatments, and thus often neglect or overlook prevention, early
detection, rehabilitation and palliative care.
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For more information on patient safety, go to
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WHAT ARE THE OPPORTUNITIES AND THREATS ASSOCIATED WITH PLAN
DEVELOPMENT AND IMPLEMENTATION?
These are factors affected by external forces, such as the international cancer control agenda,
the political and economic situation within the country, and the existence of other pressing
health priorities. For example, the fact that WHO and its international partners are promoting
a balanced approach to cancer control interventions – from prevention to end-of-life
care – represents an opportunity to advocate for the development of more effective and
efficient national policies for diagnosis and treatment.
SELF-ASSESSMENT BY COUNTRIES
WHO has developed a set of self-assessment tools for assessing, at different levels of
complexity, the population cancer needs and existing services. A description of the tools can
be found in the Planning module.
Self-assessment tools, which can be adapted to country
circumstances, are available from the WHO web site
/>The WHO web site also provides links to sources
containing more specific tools for assessing the needs
and existing services for diagnosis and treatment of cancer.
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i
For further information, including details of
international organizations working in cancer

diagnosis and treatment, go to
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Planning step 1
16
DIAGNOSIS AND TREATMENT
PLANNING STEP 2
Where do we want to be?
The assessment exercise described in the previous section
( planning step 1) aims to identify the gaps in services,
as well as in data and knowledge, with regard to the burden
of curable cancers and cancers that are treatable but not
curable.
The next step is to consider what could be done, given limited
resources and capacity, in order to answer the question:
Where do we want to be?
DEFINE THE TARGET POPULATION FOR
DIAGNOSIS AND TREATMENT
The selection of the target population for a diagnosis and treatment plan depends on the
burden of curable cancers and cancers that are treatable but not curable.
In the case of curable cancers, the target population will be the following:
p
all patients of a certain age group and sex in which an abnormality indicative of cancer
has been detected through an early detection examination or test, or by chance during
a routine examination;
p
all patients, particularly children, that present with signs and symptoms of a cancer that
has a high potential for being cured.
In the case of cancers that are treatable but not curable, the target population will be all

patients who present with cancers and who could benefit from treatment because they could
have their lives prolonged considerably and their quality of life improved.
17
IDENTIFY GAPS IN DIAGNOSTIC AND
TREATMENT SERVICES
Using the results of the assessment, the gaps in diagnosis and treatment service provision
can be identified (present state versus desired state) and potential corrective interventions
considered. For example, if, as is often the case in resource-constrained countries, the
majority of cervical cancer patients are presenting in advanced stages, the introduction of
a well-organized early detection programme coupled with timely diagnosis and treatment
could eventually have a significant impact on survival rates and thus reduce substantially
the mortality from cervical cancer.
It is important to assess the impact of diagnosis and treatment interventions previously
implemented in the target population, and also of those that have been successfully applied
elsewhere, particularly in similar socioeconomic and cultural settings.
SET OBJECTIVES FOR DIAGNOSTIC AND
TREATMENT SERVICES
The objectives of diagnostic and treatment services should respond to the needs of people
who have curable cancers or cancers that are treatable but not curable. The objectives should
be directly related to the identified gaps in services. For a diagnosis and treatment plan to be
effective, all process and outcome objectives need to promote the common goal of improving
survival and reducing mortality among the targeted population.
Table 4 provides examples of short-, medium- and long-term process and outcome objectives
for diagnosis and treatment, according to the level of resources.
ASSESS THE FEASIBILITY OF DIAGNOSTIC AND
TREATMENT INTERVENTIONS
The feasibility of diagnosis and treatment interventions in a given population depends on the
skills and infrastructure available, the knowledge and attitudes of the target population, and
the motivation of the government and health-care providers.
For a diagnosis and treatment programme to be effective, it should target people with curable

cancers, and it should deliver good quality services (early detection, diagnosis, treatment
and follow-up) equitably – usually for an indefinite duration – to all members of the target
population.
For decades some resource-constrained countries, where a high proportion of patients present
with cancers in advanced stages, have invested in costly and often ineffective treatments
which serve relatively few patients. As a consequence, there has been no improvement
Planning step 2