Resource-Stratified Diagnostics in India: Current Practices and Aspirations for a National Standard

Purpose As international health systems set goals to improve and expand access to cancer care services, the global health community has applied evidence-based principles to develop resource-stratified pathways for cancer detection, diagnosis, and treatment. The Breast Health Global Initiative (BHGI) defines four detailed sets of infrastructure at the levels of basic, limited, enhanced, and maximal. Operationalizing these pathways to improve and expand breast cancer care requires an assessment of current resource availability and use, as well as an understanding of how clinical stakeholders value and prioritize various modalities. This study adapted the BHGI framework for breast cancer diagnostics to characterize the natural state of health system capabilities in India. This work aims to contribute to the validation of the resource stratification schema while collecting implicit practitioner impressions of an aspirational resource level, as would be codified by a national standard. Methods We interviewed oncologists at public and private hospitals in six urban areas throughout India with a multisection survey tool about the effects of cancer care infrastructure on patient care. In this section, respondents filled out a grid representation of 30 BHGI 2.5 diagnostic modalities divided into clinical tools, imaging and laboratory tests, and pathology. Respondents indicated whether they currently used each modality, and whether they would recommend that this should be included in a national standard of breast cancer care for India. Results At least three fourths of respondents indicated that they personally use 21 of the diagnostic modalities (n = 52), but only recommended 15 modalities for the national standard (n = 50). The top 11 modalities currently used included six basic, three limited, and two enhanced, whereas the top 11 modalities recommended for the national standard included four basic, one limited, three enhanced, and three maximal. Conclusion Diagnostic modalities consistently used by urban oncologists are not fully congruent with the group’s collective vision for a national standard of care, nor do the oncologists recommend a consistently more basic or limited national approach compared with urban practice. These heterogeneous results indicate that expanding breast cancer care in India will likely require dynamic recalibration of goal resource level definitions across the nodes of each regional referral network. AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. 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/jco/site/ifc . No COIs for the author.