Guideline for Treatment of Cancer Near the End of Life

What are we trying to do? We are trying to ensure the most effective care for patients with very advanced cancers who are on the Oregon Health Plan (OHP). We currently have a guideline which helps doctors and health plans decide when to offer treatment aimed at curing cancer to patients. The HERC has heard concerns from cancer doctors, patients, and health plans that the current guideline (Guideline Note 12) restricts care too much. The history of cancer care coverage by OHP: 1) Early versions of the Prioritized List 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) The current Guideline Note 12 was adopted in 2009 to allow payment for more treatment of more cancers for more patients. It outlines restrictions in care for those patients who have a life expectancy of 24 months or less. What has been done so far to update Guideline Note 12? 1) The Value Based Benefits Subcommittee (VBBS) of the Health Evidence Review Commission (HERC) heard from various doctors, patients and health plans that the current guideline was not working. 2) The VBBS convened a workgroup that held 2 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. What does the proposed 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 get 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 get more curative chemotherapy. 2) The new guideline REQUIRES patients and doctors to have a frank and open discussion about the patients 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

Guideline for Treatment of Cancer Near the End of Life

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 Oregon 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? 1) 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 Oregon cancer patients. What happens now? 1) The VBBS will hear testimony from patients, doctors, pharmaceutical companies, and any other interested member of the public today. 2) The committee members will discuss the new guideline and the testimony they hear. They may choose to re-work some or all of the guideline, or they may adopt is as it is written. 3) If the guideline is adopted, it will be reviewed by the entire HERC, which has members from all types of areas in medicine (doctors, nurses, chiropractic, patients, health plan administrators, and more). The HERC may make changes or accept it as the VBBS has approved. 4) If approved, the guideline will start assisting patients, doctors, and health plans in the care of patients with advanced stage cancer beginning in October 2013.

Guideline for Treatment of Cancer Near the End of Life

Proposed New Guideline

GUIDELINE 12 CANCER CARE NEAR THE END OF LIFE Cancer is a complex group of diseases with treatments that vary depending on the specific subtype of cancer and the patients 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 patients support systems, overall heath, and core values. Patients should have access to appropriate peerreviewed 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 patients 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.

Guideline for Treatment of Cancer Near the End of Life

Current Guideline To Be Replaced

GUIDELINE NOTE 12, TREATMENT OF CANCER WITH LITTLE OR NO BENEFIT PROVIDED NEAR THE END OF LIFE 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 individuals 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.