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.
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.
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
history of cancer care coverage by OHP:
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.
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.
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
did HERC use to revise Guideline Note 12?
Benefits Subcommittee (VbBS) of HERC heard from various doctors, patients and
health plans that the current guideline was not working.
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.
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.
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.
the new guideline say?
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.
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.
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.
does OHP do for cancer patients?
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
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,
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
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
12, TREATMENT OF CANCER WITH LITTLE OR NO BENEFIT PROVIDED NEAR THE END OF LIFE
guideline only applies to patients with advanced cancer who have less than 24
months median survival with treatment.
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).
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
· 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
· Poor prognosis
with treatment, due to limited physical reserve or the ability to withstand
treatment regimen, as indicated by low performance status.
evidence may be taken into consideration in the case of rare cancers which are
universally fatal within six months without treatment.
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
with the goal to palliate is addressed in Statement of Intent 1, Palliative