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New Cancer Treatment Guideline


On August 8, 2013, the Health Evidence Review Commission (HERC) unanimously approved revisions to the guideline that assists patients, doctors, and health plans in the care of OHP patients with advanced stage cancer. The changes are effective October 1, 2013.

What does the new guideline do?

With a focus on the efficacy of care, rather than life expectancy, the revised guideline makes more services available for people who have been diagnosed with advanced stage cancer. The new guideline enables patients to work with their doctors to discuss the goals, prognoses, side effects, and effectiveness of treatment.

Why did HERC revise was the old guideline?  
HERC’s goal is to ensure the most effective care for patients with very advanced cancers who are on the Oregon Health Plan (OHP).  The commission revised the guideline to help doctors and health plans decide when to offer treatment aimed at curing cancer to patients. 


The history of cancer care coverage by OHP:

1)    When the Oregon Health Plan began, early versions of the Prioritized List of Health Services did not allow payment for ANY care of cancer for patients who had less than a 5% 5-year expected survival due to their cancer. 

2)    In 2009, Guideline Note 12 was adopted to allow payment for more treatment of more cancers for more patients.  It outlined restrictions in care for those patients with a life expectancy of 24 months or less.

3)    Hearing from cancer doctors, patients, and health plans that the guideline still restricted care too much, HERC initiated the revision process for Guideline Note 12 in May 2013. 


What process did HERC use to revise Guideline Note 12?

1)    The Value-based Benefits Subcommittee (VbBS) of HERC heard from various doctors, patients and health plans that the current guideline was not working.

2)    The VbBS convened a workgroup that held two public meetings. The workgroup was made up of oncologists (doctors who care for cancer patients), a nurse who works with cancer patients, a doctor who provides palliative care, an attorney who specialized in healthcare law, and a health plan administrator. A patient member was not able to attend the meetings, but had the opportunity to participate in email discussions. The public meetings were very well attended, and testimony was heard from patient advocates, doctors, and others. Other stakeholders were able to provide input via discussions with HERC staff.

3)    The subcommittee members discussed the new guideline and testimony they heard. VbBS voted unanimously to recommend that HERC adopt the revised version of Guideline Note 12 as proposed by the workgroup.

4)    The entire HERC, which has members from all types of areas in health care (doctors, nurses, chiropractic, patients, health plan administrators, and more) then heard additional verbal testimony and discussed the VbBS recommendation. HERC approved the proposed version of the guideline unanimously. The new guideline will start assisting patients, doctors, and health plans in the care of OHP patients with advanced stage cancer effective October 1, 2013.


What does the new guideline say?

1)    The new guideline allows payment for curative treatment for nearly all cancer patients. Those patients with very serious, metastatic cancer who have such severe health issues (such as kidney failure or heart failure) that curative chemotherapy would be too toxic for them should not have this type of treatment. Patients who have been given many types of current curative chemotherapy but continue to decline in health and have a very limited ability to care for themselves, should also not have more curative chemotherapy.

2)    The new guideline REQUIRES patients and doctors to have a frank and open discussion about the patient’s goals of care and what can really be expected from various care options, including chemotherapy. This conversation needs to cover the harms and side effects of treatments, and allow the patient to make choices about what treatments he or she wants based on his or her values, in shared decision making with his or her doctor. This type of discussion has been shown in scientific studies to improve cancer patients’ lives and allows these patients to spend more time with their families instead of in hospitals.

3)    Cancer care is required to be provided following evidence-based pathways of care devised by leading national cancer expert groups. This ensures that OHP cancer patients receive the type of care that has been shown to have the best results with the fewest side effects and other problems.


What else does OHP do for cancer patients?

OHP provides all types of palliative care for cancer patients, to make sure that they live the most pain-free, highest quality life with their cancer. Patients have access to medicines for nausea and pain, acupuncture, home health care, wheelchairs, surgery to relieve a blockage in the gut, radiation to shrink painful tumors in bones, and all other types of palliative care. This palliative care will continue to be provided to all OHP cancer patients.

New Guideline Effectuve October 1, 2013

Guideline 12 Cancer Care WITH LITTLE OR NO BENEFIT

Cancer is a complex group of diseases with treatments that vary depending on the specific subtype of cancer and the patient’s unique medical and social situation. Goals of appropriate cancer therapy can vary from intent to cure, disease burden reduction, disease stabilization and control of symptoms.  Cancer care must always take place in the context of the patient’s support systems, overall heath, and core values.  Patients should have access to appropriate peer-reviewed clinical trials of cancer therapies.  A comprehensive multidisciplinary approach to treatment should be offered including palliative care services (see Statement of Intent 1, Palliative Care).

 Treatment with intent to prolong survival is not a covered service for patients who have progressive metastatic cancer with

1)    severe co-morbidities unrelated to the cancer that result in significant impairment in two or more major organ systems which would affect efficacy and/or toxicity of therapy; OR

2)    a continued decline in spite of best available therapy with a non reversible Karnofsky Performance Status or Palliative Performance score of <50% with ECOG performance status of 3 or higher which are not due to a pre-existing disability.

Treatment with intent to relieve symptoms or improve quality of life is a covered service as outlined in Statement of Intent 1, Palliative Care. 

To qualify for treatment coverage, the cancer patient must have a documented discussion about treatment goals, treatment prognosis and the side effects, and knowledge of the realistic expectations of treatment efficacy. This discussion may take place with the patient’s oncologist, primary care provider, or other health care provider, but preferably in a collaborative interdisciplinary care coordination discussion.  Treatment must be provided via evidence-driven pathways (such as NCCN, ASCO, ASH, ASBMT, or NIH Guidelines) when available.

Previous Guideline That Was Replaced


Lines 102,103,123-125,144,159,165,166,170,181,197,198,207,208,218,220, 221,228,229,231, 243,249,252,275-278,280,287,292,310-312,320,339-341,356,459,586,622

This guideline only applies to patients with advanced cancer who have less than 24 months median survival with treatment.

All patients receiving end of life care, either with the intent to prolong survival or with the intent to palliate symptoms, should have/be engaged with palliative care providers (for example, have a palliative care consult or be enrolled in a palliative care program).

Treatment with intent to prolong survival is not a covered service for patients with any of the following:

·  Median survival of less than 6 months with or without treatment, as supported by the best available published evidence

·  Median survival with treatment of 6-12 months when the treatment is expected to improve median survival by less than 50%, as supported by the best available published evidence

·  Median survival with treatment of more than 12 months when the treatment is expected to improve median survival by less than 30%, as supported by the best available published evidence

·  Poor prognosis with treatment, due to limited physical reserve or the ability to withstand treatment regimen, as indicated by low performance status.

Unpublished evidence may be taken into consideration in the case of rare cancers which are universally fatal within six months without treatment.

The Health Evidence Review Commission is reluctant to place a strict $/QALY (quality adjusted life-year) or $/LYS (life-year saved) requirement on end-of-life treatments, as such measurements are only approximations and cannot take into account all of the merits of an individual case. However, cost must be taken into consideration when considering treatment options near the end of life. For example, in no instance can it be justified to spend $100,000 in public resources to increase an individual’s expected survival by three months when hundreds of thousands of Oregonians are without any form of health insurance.

Treatment with the goal to palliate is addressed in Statement of Intent 1, Palliative Care.