Network Readies Its Practice Guidelines

Last January, 13 of the nation's foremost cancer centers formedthe Na-
tional Comprehensive Cancer Network (NCCN), an alliance that spansthe nation geographically, with the goal of providing high-qualitycost-effective medical services to cancer patients across thecountry.

The means to achieve that goal include the development by eachmember institution of regional networks so that patients can betreated where they live, the formation of practice guidelinesto standardize care, and the collection of outcomes data to assessthe effectiveness of treatment.

ONCOLOGY NEWS INTERNATIONAL interviewed physicians involved inthe NCCN for a perspective on practice guidelines and an updateon how the network is proceeding in meeting its goals.

"As oncology care begins to consolidate and become more uniform,there are advantages to having expert centers come together todevelop mutually acceptable ways of approaching cancer patients,"said Rodger Winn, MD, of M.D. Anderson Cancer Center.

Steven Rosen, MD, director, Northwestern University Lurie CancerCenter, and member of the NCCN executive committee, said thatby working together to develop guidelines and collect outcomesdata, the alliance can help insurers and third-party payers geta handle on the cost of care for specific cancer diagnoses.

"In addition to establishing the most appropriate way totreat a disease, guidelines give you for the first time an opportunityto reasonably assess what it costs to provide care for patients,"Dr. Rosen said.

He noted that the endeavor represents a departure for institutionswith traditional academic ties such as the Lurie Cancer Center."External influences are making us revisit how we do business.To attract patients to our institutions, we must make sure thatpatients have the support of their insurance carriers, and toget that support we must provide cost-effective treatment,"he said.

Dr. Winn emphasized that the guidelines under development allowphysicians flexibility in their treatment approaches. "Anyguideline is just that, a set of recommendations that probablyapply to the majority of patients," he said.

For example, in a certain disease, there may be general agreementamong NCCN members to use multimodality therapy (chemotherapy,surgery, and radiation), but the precise way of putting togetherthe three elements or the exact drug regimens used may vary frominstitution to institution.

Guidelines Panels

The guidelines panels are multidisci-plinary, including surgeons,radiation oncologists, and medical oncologists from various NCCNsites who are recognized experts in the field. Each panel consistsof five to eight members.

The NCCN staff prepares a basic outline or flowchart as a startingpoint for the panel to consider at its meeting (an evening andall-day conference). The panel's goal is to revise the initialdocument to reflect what they consider to be the general NCCNapproach. From there, the document goes to each of the 13 memberinstitutions for revisions and comments.

The revisions from each institution are returned to the expertpanel for collation, and if a large disparity is found betweenthe panel's recommendations and members' practice, the panel reconvenesfor more discussion.

Why would any busy physician want to sit on yet another committee?According to Dr. Winn, "most panel members say that it'sfun, and there's very little fun left in medicine today. Theyenjoy coming together with their colleagues for a day when thephone doesn't ring just to discuss and debate issues in theirfield."

Assessing the Guidelines

Four categories of acceptance are provided for each element ofthe guidelines, to allow physicians to assess how they are tobe used, based on the strength of the recommendation.

• Category 1 elements are areas of treatment where there isgeneral agreement among most oncologists.
• Category 2 elements represent the NCCN consensus while recognizingthat alternative treatments are available.
• Category 3 elements are temporary guidelines concerning anarea of treatment where the data are not clear and more intensiveanalysis is needed.
• Category 4 elements represent areas in which there is disagreementbetween NCCN institutions about the preferred treatment. Physiciansmust use their own clinical judgment as to treatment; enrollmentin clinical trials is encouraged.

"The guidelines are built on the premise that it is alwaysappropriate to put a patient on a sound clinical trial,"Dr. Winn said. "They never preempt clinical trials, but theonly time this is actually mentioned is in areas where there doesnot appear to be any other real option."

He added that for categories 2, 3, and 4, the guidelines willbe annotated so that physicians will know the thinking behindthem.

Level of Complexity

Because panel members are expert subspecialists, the NCCN guidelinesare reaching a level of complexity beyond that of most such efforts,Dr. Winn said.

He used small-cell lung cancer as an example. In their preliminarydeliberations the panel working on the guidelines for this diseaseagreed that radiation therapy should be considered after chemotherapy,but they also went into such details as to when to irradiate andwhether to irradiate to a field the size of the original tumoror to narrow the field to encompass only the remaining tumor.

He noted that guidelines for cancer prevention will come later,after the treatment guidelines are completed.

Catherine Harvey, Dr.PH, chief operating officer for the NCCN,told ONCOLOGY NEWS INTERNATIONAL that currently six clinical guidelinesfor the common cancers have been through expert panel and anotherfour are expected to be finished in the next few months. By earlynext year, she expects that the first NCCN guidelines will bein testing at all member institutions.

She noted that guidelines will be updated on a regular schedule,but will also be revised any time new clinical data become available.

Dr. Harvey referred to the NCCN clinical guidelines as "fullcourse of care guidelines that go from diagnosis to death or cure.It's a way for our member institutions to assure that the cancerpatients who are not eligible for clinical trials receive thebest possible standard therapy available."

Outcomes Data Collection

Appropriate outcome measures are needed to allow the quality ofcare of NCCN members to be assessed and compared "among ourselvesand to any other national benchmarks," Dr. Winn said.

Such measures, currently under development by NCCN committees,will include "process measures," he said. "Forexample, what percentage of our stage II breast cancer patientsreceive adjuvant chemotherapy? We know from national figures itmay be as low as 65% or 70%. We need to know if our own figureswithin the NCCN are higher." Another example would be thepercentage of breast cancer patients in the network who receivebreast-conserving surgery.

The outcomes study that is furthest along, Dr. Winn said, askswhat percentage of NCCN's T3 and T4 larynx cancer patients undergolarynx preservation.

NCCN Participants