Treatment decision-making for oncologists and their patients may become simpler through the use of graphic NCCN Evidence Blocks™, which were unveiled at the NCCN 10th Annual Congress: Hematologic Malignancies™ sponsored by the National Comprehensive Cancer Network® (NCCN¨). The first of the NCCN Evidence Blocks are published within new versions of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Chronic Myelogenous Leukemia and Multiple Myeloma.
“In an age of visual information, the NCCN Evidence Blocks are a time-saving tool for efficient scanning and interpretation of multiple therapy options in an efficient format,” said Robert W. Carlson, MD, Chief Executive Officer of the NCCN. The NCCN Evidence Blocks are part of NCCN’s decision to include “value” in its Guidelines and to enhance shared decision-making.
According to Dr. Carlson, clinicians have wanted more rationale for NCCN Guidelines’ recommendations. Patients have requested information to enhance their decision-making. And, in response to the rising cost of cancer care, payers have wanted affordability to be added to the standard criteria of efficacy, toxicity, and level of evidence. “To address these issues, NCCN developed a novel system,” he said.
Customizing Treatment Decisions
The NCCN Evidence Blocks, he noted, will enhance treatment choices based on individual perspectives of value. Physician and patient together can consider the attributes and drawbacks of possible therapies and select the most acceptable treatment for that patient.
“A 35-year-old breast cancer patient with young children, for example, will almost exclusively focus on effectiveness and be less concerned about toxicity and affordability,” said Dr. Carlson, a breast cancer specialist. “In contrast, an 80-year-old with identical breast cancer is more likely to focus on quality of life, and perhaps affordability.”
“We believe both perspectives are important and valid. We needed a system that will accommodate both those and others,” he added. “The NCCN Evidence Blocks provide information so the patient can create her own value equation and apply this framework in selecting treatment.”
Dr. Carlson emphasized that the graphics will be “merely a starting point for discussion” and should not be perceived as directives. “They do not replace the categories of evidence that we use.”
Specifics of the Blocks
The NCCN Evidence Blocks are published in new versions of the NCCN Guidelines (at this point, only for chronic myelogenous leukemia and multiple myeloma) and are a visual representation of five key value measures that are part of specific NCCN Guidelines’ recommendations: efficacy of the regimen, safety of the regimen, quality and quantity of evidence in support of the regimen, consistency of evidence, and affordability of the regimen.
The scoring system is simple: Shading of only one block indicates “least favorable,” whereas five shaded blocks indicate “most favorable.” The more shading the block has, the better the regimen in all components. With such a graphic, NCCN figured clinicians and patients alike could quickly appreciate the relative merits of the treatment options.
Demystifying the Cost of Care
The new component of this list is affordability, which has never been a factor in NCCN recommendations of specific treatments. It is time, Dr. Carlson said, to “demystify” the cost of care and, at the very least, enhance the financial discussion.
“There’s been a conspiracy of silence” on this issue, he said. “Patients are embarrassed to bring up cost. Physicians hesitate to bring it up, because there’s the implication that maybe if you can’t afford it, you won’t get the most effective treatment. The result is that patients leave with a prescription they won’t fill, because they can’t pay for it.”
By being an equal factor in the NCCN Evidence Blocks, affordability enters the discussion. “If patients are concerned about expense, and they see a therapy listed as very expensive, this is a signal to the patients and providers that it’s time to understand the magnitude of the financial risk,” he said.
The affordability measurement represents an estimate of overall total cost to society of a therapy, including but not limited to acquisition, administration, in-patient and out-patient care, supportive care (antiemetics, growth factors, etc), infusions, toxicity monitoring, and so forth.
The Development Process
To develop the graphics, NCCN panel members were asked to score each of the five key measures for each systemic treatment recommendation. The scores from all members were averaged and rounded to the nearest integer.
NCCN staff developed a survey instrument that included the five key measures for each treatment recommendation with the Guidelines. Individual panel members, in isolation (not collaboration), then scored each of the regimens. Responses were collated, and an average was generated and rounded to the nearest integer. Results were translated into the graphic and placed within the Guidelines.
Dr. Carlson predicted that, for some panels, this will be “a mammoth task.” For example, there are about a dozen regimens for metastatic non–small cell lung cancer, used across five lines of treatment.
For the affordability estimates, panelists were not provided specific dollar amounts for each regimen, since cost figures can be unreliable and vary by institution, insurance coverage, and other factors. Instead, they used their expertise as “subsubspecialists” in a disease state to rank regimens (total cost of care) on a 5-point affordability scale, from “very inexpensive” to “very expensive,” Dr. Carlson explained.
“Panelists may not be able to give you the exact cost of a regimen, but they can tell you whether it is hundreds of thousands of dollars a year, $50,000, or $10,000. The estimate will not be what the patient will pay, but it will signal, ‘This is very expensive, and if the price tag is important, you need additional information,’” he said. “There was remarkable agreement in terms of which buckets this ‘affordability’ fell into.”
Moving Forward
By the end of 2015, NCCN expects to publish NCCN Evidence Blocks for systemic therapies (not surgery or radiation therapy) for breast, colon, non–small cell lung, and rectal cancers. NCCN Evidence Blocks for systemic therapies are expected to be contained within the complete library of NCCN Guidelines by the end of 2016.
In the near term, NCCN will continue to publish two sets of NCCN Guidelines: those including NCCN Evidence Blocks and those published without them. The NCCN Evidence Blocks are not currently published in the NCCN Guidelines for Patients® and are intended for use in the United States only.
For more information on the NCCN Evidence Blocks, visit www.nccn.org/EvidenceBlocks/. ■
Disclosure: Dr. Carlson reported no potential conflicts of interest.
