The first pass at the data shows that compliance with the NCCN guidelines is stronger in the treatment of breast than colon or lung cancer, but also that about one-third of breast cancer patients prescribed tamoxifen or an aromatase inhibitor aren’t renewing their prescriptions. “We can bring that information back to the physician, and they can have a discussion with their patient about why they aren’t taking that medicine,” he said.
Feedback from physicians has also identified coding problems for carcinoid tumors of the colon and disagreement over whether bevacizumab (Avastin) is truly contraindicated in patients with lung cancer and brain metastases. UHC shares these concerns, along with the national aggregate data, with the NCCN.
Dr. Eric P. Winer, director of the Breast Oncology Center at the Dana-Farber Cancer Institute in Boston and chief scientific adviser for Susan G. Komen for the Cure, said that of all the guidelines to use, the NCCN guidelines make the most sense, but that oncologists would hear and listen more closely to the message that their practice is out of line if it were delivered by a state or national accreditation program.
“The practicing physician is less likely to trust that the insurer has a clear understanding of what the optimal practice would be,” he said. “It’s just not a credible source in the way that a committee of one’s peers might be.”
Dr. Newcomer said he’d love to see other groups take on the task but has not seen similar published quality data coming out of medical groups. “We are filling a void that’s there,” he said.
Is the Fast Lane Too Broad?
Dr. Ira Klein, clinical head of oncology condition analysis for Aetna Inc., said it doesn’t rely exclusively on the NCCN for the development of guidelines and payment. Aetna has covered drugs for indications in NCCN’s Compendium with a consensus rating of 2b or greater but looks to a variety of sources including top-tier journals and outside opinions when creating guidelines and their clinical practice policy bulletins.
“Relying solely on the NCCN would be like using the Cliff Notes,” he said.
Dr. Klein went on to say that the strength of the NCCN guidelines is that they are evidence based and very good at bringing experts together for consensus-based care when the evidence isn’t particularly strong. Their weakness is that they “could be likened to a 50-lane highway” in cases where multiple treatment options would be appropriate for one disease at one stage, Dr. Klein said.
Dr. Newcomer echoed this sentiment, faulting the NCCN for not assigning a hierarchy to its decisions. He cited the array of recommended chemotherapy regimens for breast cancer, and said, “Where I’d like to see the NCCN guidelines go is to say that of these 14, these 2 are the best.”
Still, both insurers are looking to the NCCN regarding coverage of bevacizumab, following the FDA’s Oncologic Drugs Advisory Committee July vote recommending against its use for the first-line treatment of metastatic breast cancer. Dr. Newcomer said UHC will continue to cover the drug for this indication until the NCCN makes its recommendation following the FDA’s final vote. Dr. Klein said if the FDA removes breast cancer as an indication for bevacizumab, Aetna would consider dropping its existing coverage for the drug and would take the NCCN’s position into consideration in its decision.
The speed at which the NCCN can make such a revision to its guidelines is part of what makes them so unusual. “They are assiduously up to date,” Dr. McGivney said. Staff members track the literature, news of large clinical trials, and FDA filings in order to stay abreast of changes in the evidence, with some 2010 guidelines already in their third or fourth edition.
“We really are in the information age and, of all the areas of medicine, cancer care is probably the most rapidly advancing with respect to the science and research,” he said.
This point was driven home when the American Society of Clinical Oncology (ASCO) published guidelines for stage IV non–small cell lung cancer earlier this year without encompassing emerging data on the importance of epidermal growth factor receptor mutations in treatment response.
“The advantage of systematic review-based guidelines like ASCO uses is that they are more evidence-based, strictly speaking, but take longer to conduct and require methodological expertise,” said Dr. Ethan M. Basch, chair of ASCO’s clinical practice guidelines committee. “The advantage of narrative review with consensus-based guidelines such as used by NCCN is that they can be conducted more rapidly, but are less evidence-based in terms of their degree of systematic approach and hence may be more subject to the biases of panel members.”