Download Interpreting the Latest National Comprehensive Cancer Network

Interpreting the Latest
National Comprehensive Cancer Network (NCCN) Guidelines
Devon Webster, MD
Board Certified in Internal Medicine and Medical Oncology
gy
Associate Medical Director
Ann Correa, RN, OCN
Training & Special Projects Lead
AllMed Healthcare Management
© AllMed Healthcare Management, Inc.
Overview
• About the NCCN
• Updates to the Guidelines
–
–
–
–
Breast Cancer
Colon Cancer
Lung Cancer
Th id C
Thyroid
Cancer
• New Guidelines for Survivorship
• Determining
D t
i i medical
di l necessity
it ffor
cancer care
The NCCN: A Not-for-Profit Alliance of
th World’s
the
W ld’ 23 L
Leading
di C
Cancer C
Centers
t
New Members in 2013:
•
UC San Diego Moores
Cancer Center
•
University of Colorado
Cancer Center
“Our mission,
“O
i i
as an alliance
lli
off lleading
di cancer centers
t
d
devoted
t d
to patient care, research, and education, is to improve the
quality, effectiveness, and efficiency of cancer care so that
patients can lead better lives.
lives ”
The NCCN Clinical Practice Guidelines
i O
in
Oncology
l
• 58 guidelines with 149 algorithms
–
–
–
Sequential management decisions and interventions for
97% of malignant cancers
C
Consensus
recommendations
d ti
b
based
d on th
the b
bestt evidence
id
available at the time they are derived
Continuously updated and revised to reflect new data and
new clinical information
• Used as the standard for clinical policy in oncology by
many clinicians and payers
• Sign-in: www.nccn.org
Classification of Recommendations in
th NCCN Guidelines
the
G id li
• Category 1
–
Based upon high-level evidence, there is uniform NCCN
consensus that the intervention is appropriate
• Category
g y 2A*
–
Based upon lower-level evidence, there is uniform NCCN
consensus that the intervention is appropriate
• Category 2B
–
Based upon lower-level evidence, there is NCCN consensus that
the intervention is appropriate
• Category
C
3
–
Based upon any level of evidence, there is major NCCN
disagreement that the intervention is appropriate
* All recommendations are category 2A unless otherwise noted.
2013 Updates: Breast Cancer
Workup
Breastt MRI optional;
B
ti
l consider
id ffor
mammographically occult tumors
Metastatic Disease
• Ado-trasutuzumab emtansine
(Herceptin DM1) is preferred for
treatment of HER2+
HER2 disease with
prior exposure to Herceptin
Adjuvant Chemotherapy
• TAC is
i no longer
l
preferred
f
d
• Dose dense AC followed by weekly
Taxol now preferred
•
NCCN Guidelines. Breast Cancer. Version 2.2013.
2013 Updates: Colon Cancer
Lynch syndrome testing
•
MMR protein
t i ttesting
ti iis now
recommended for any patient under age
50 with colon cancer or with stage II
colon
l cancer
Metastatic disease
•
•
•
Bevacizumab is now recommended in
the second-line setting
Ziv-aflibercept in combination with
FOLFIRI or irinotecan as second-line
second line
therapy for irinotecan naïve patients
Regorafenib as late-line therapy for
patients refractory to all options
NCCN Guidelines. Colon Cancer. Version 2.2013.
2013 Updates: Non
Non-small
small cell Lung Cancer
Screening
•
Screening with low-dose CT is recommended in high-risk
smokers and former smokers (See NCCN Guidelines for lung
cancer screening)
Workup
•
Mediastinoscopy and/or EBUS replaced by “Pathologic
mediastinal lymph node evaluation” which can include CTCT
biopsy
Adjuvant chemotherapy
•
Patients likely to receive chemotherapy may receive
induction chemotherapy (preoperative) as an alternative
NCCN Guidelines. Non small cell . Version 2.2013.
Updates for Thyroid Carcinoma:
N d l Evaluation
Nodule
E l
i
• Follicular or Hürthle cell
neoplasm
–
Consider molecular
diagnostics
• Follicular lesion of
undetermined
d t
i d significance
i ifi
–
Consider molecular
diagnostics
g
NCCN Guidelines. Thyroid Carcinoma. Version 2.2013.
Updates for Thyroid Carcinoma:
M d ll
Medullary
Th
Thyroid
id Carcinoma
C i
• Recurrent or p
persistent disease
–
–
Cabozantinib (category 1) added as an option to consider
Vandetanib changed from category 2A to category 1 recommendation
• New to algorithm
–
Increasing tumor markers, in the absence of structural disease
progression, are not an indication for treatment with vandetanib or
cabozantinib
• Revised
–
While not FDA approved for treatment of thyroid cancer, other
commerciallyy available small molecular kinase inhibitors ((such as
sorafenib or sunitinib) can be considered if clinical trials,
vandetanib, or cabozantinib are not available or appropriate, or if
the patient progresses on vandetanib or cabozantinib
NCCN Guidelines. Thyroid Carcinoma. Version 2.2013.
Updates for Thyroid Carcinoma:
A
Anaplastic
l i Thyroid
Th
id Carcinoma
C i
New section provides systemic
therapy options
– Concurrent chemoradiation
regimens: paclitaxel/carboplatin,
paclitaxel, cisplatin, doxorubicin
– Chemotherapy regimens:
paclitaxel/carboplatin,
paclitaxel, doxorubicin
NCCN Guidelines. Thyroid Carcinoma. Version 2.2013.
Need for Guidelines for Survivorship
Estimated Number of Cancer Survivors in the United
States From 1975 to 2012
• According to National Cancer
Institute (NCI),
(NCI) there are >13
million American cancer
survivors as of January 2012
• Individual is considered a
cancer survivor from the
g
moment of diagnosis
• Recognizing and managing the
healthcare needs of cancer
survivors
i
h
has b
become a
significant responsibility of
oncologists and primary care
providers
NCI. Survivorship-related statistics and graphs. Available at: http://dccps.nci.nih.gov/ocs/prevalence/.
First-Ever NCCN Guidelines for
S
Survivorship
i
hi
• 8 distinct areas of care
–
–
–
–
–
–
–
–
Anxiety and depression
Cognitive function
Exercise
Fatigue
Immunizations and infections
Pain
Sexual function
Sleep disorders
• Sample assessment tool with 2-3
questions on each of the 8 key
criteria
NCCN Guidelines. Survivorship. Version 1.2013.
Determining Medical Necessity for Cancer Care:
H
How
H
Health
lth Plans
Pl
Use
U the
th NCCN G
Guidelines
id li
• When making reimbursement
decisions about different cancer
treatments
• Coverage
C
off off-label
ff l b l use off d
drugs
and biologics for cancer treatment
–
–
If indicated in the guidelines in
place at the time of treatment
with category 1, 2A, or 2B level of
evidence
Unless plan language explicitly
prohibits off-label use of drugs
Independent Medical Review:
F ilit t D
Facilitates
Determination
t
i ti off M
Medical
di l N
Necessity
it
• Medical necessity must be supported by thorough clinical
d
documentation
t ti
• Independent medical review looks at whether a specific
procedure/treatment was medically necessary
• Provides specialty match to allow healthcare plans to ensure that
the requested treatment falls under the medical necessity
requirements before approving a course of treatment
• Reviewers stay on top of treatments as they are studied more
extensively and potentially accepted into clinical guidelines
• Avoids conflicts of interest, which can relate to economics, lack of
specialists to review cases, or having the same doctor who denied a
case review an appeal
Conclusions
• NCCN promotes continuous quality improvement in
cancer care
–
Creates/updates clinical practice guidelines used by patients,
clinicians, and other healthcare decision-makers
• Many health plans have adopted NCCN guidelines for
making coverage decisions for patients with cancer, who
often require complex therapies
• Diagnostic
Di
i testing
i and
d therapies
h
i ffor cancer continue
i
to
evolve rapidly
–
Clinicians and health p
plans face the challenge
g of ensuring
g that
all patients receive preventive, diagnostic, treatment, and
supportive services that are most likely to lead to optimal
outcomes
Questions &
Answers
All participants will receive a free copy of our latest publication via
email:“Interpreting the Latest NCCN Guidelines”
Keep an eye out for our next webinar invitation for the May webinar
“Bariatric Surgery: When is it Medically Necessary?” which we are
please to announce, has been approved for CEU credits by the CCMC!
For more information, contact us:
AllMed Healthcare Management,
g
, Inc..
(800) 400-9916
[email protected]
www.allmedmd.com
Follow us on Twitter: @allmedmd
Join our LinkedIn Group: Clinical Decision Makers