The NCCN Guidelines Program and Opportunities for Quality Improvement

Author: Stephen B. Edge MD
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Clear evidence is available regarding the wide variation in the quality of cancer care delivered in the United States. These findings led the Institute of Medicine (IOM) in 1999 to call for major changes in cancer care delivery to improve quality and enhance the patient experience.1 Key domains for the recommendations included steps to define appropriate quality care, identify appropriate measures of care, establish mechanisms to collect and analyze cancer treatment information, and assure that care addresses overall needs of patients beyond the core processes of treatment. Despite major changes in medicine, and with the continued and rapid increase in the cost of cancer care, the IOM reiterated their findings in 2013, stating that there exists a crisis in quality, appropriateness, and access to cancer care.2

One of the key efforts in the United States to address quality of care has been the development of comprehensive guidelines for oncology practice by NCCN.3 First published in 1996, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) cover virtually all types and stages of cancer and cover many areas of supportive care. The guidelines are updated at least annually, and more rapidly when key new findings are evident. NCCN Guidelines are widely used as a benchmark of the best standard of care in the United States, and have been adapted for use around the world.4-10

NCCN Guidelines and the NCCN Oncology Outcomes Database Program

In 1996, NCCN leaders recognized that the NCCN Member Institutions should use these guidelines to examine the care they provide to assure and continually improve the quality of that care. This led NCCN to establish a system for collecting information to determine if the care was consistent or “concordant” with the relevant portion of the guidelines. They founded the NCCN Oncology Outcomes Database in 1997 to examine breast cancer care at 5 centers.11,12 Over the ensuing years, the NCCN Oncology Outcomes Database expanded to other centers and to include non-Hodgkin’s lymphoma and lung, ovarian, and colorectal cancers.

The database was initially used to evaluate the quality of cancer care, defined by concordance of treatment for each key phase of care (eg, surgery, radiation, systemic therapy) with the guidelines. Starting in 1999, each participating institution was provided an annual report of concordance for all patients. The NCCN Oncology Outcomes Database has also been used extensively for reporting on patterns and quality of care at NCCN centers and to examine factors influencing treatment choice and outcome, with numerous high-impact publications.13-17

NCCN did not initially set specific standards or levels of required concordance or require specific actions to be taken based on these reports. Concordance findings were provided to each center annually, but the center was left to use the data as they saw fit. No collective review or coordinated action was taken to address the findings. Indeed, no determination was made regarding what level of guideline-concordant care was considered “high-quality” care. Guideline concordance is not expected to be 100%, because any clinical situation may involve circumstances (eg, coexisting illnesses, patient choice) that result in selection of nonconcordant therapy.

Several institutions conducted a detailed review of all nonconcordant care and showed that about half of the instances of “nonconcordant” care was due to clearly documented medical circumstances and half to patient choice; relatively few cases were related to missed or inappropriate care.18,19 However, beyond treatment concordance, the database revealed substantial variation in care among institutions, especially in situations for which no high-level (eg, randomized trial) evidence or conflicting evidence exists. In many studies of practice patterns at NCCN centers, care varied widely among institutions. For example, the rate of breast-conserving surgery among NCCN Member Institutions for stage I breast cancer ranged from 40% to 85%. The use of chemotherapy for hormone receptor-positive breast cancer varied widely, as did use of radiation after mastectomy.13,17,20

The degree of variation in care among centers suggested that opportunities existed to reduce variation, examine key internal processes, and improve the care provided at NCCN centers. Therefore, in 2009, under the leadership of Dr. Jane Weeks, representatives of the institutions participating in the NCCN Oncology Outcomes Database for Breast Cancer met and reviewed in detail the findings from each institution. The group specifically discussed areas with a wide variation in care and agreed that a coordinated effort to address the variation in care among NCCN centers was warranted.

Opportunities for Improvement

Based on this meeting, NCCN initiated the Opportunities for Improvement (OFI) project. Centers participating in the breast outcomes database were invited to participate in this project, in which they would identify and address quality issues in breast cancer treatment within their centers. Each center was provided data on guideline concordance and information on time to treatment based on information from the outcomes database. A project team at each center reviewed these findings and established a program “charter” that outlined a specific plan to address quality issues within their breast cancer treatment system. Periodic teleconference meetings and written progress reports assured progress on stated goals and new areas of focus that developed from the review.

This supplement to JNCCN includes the final reports from each of the NCCN centers participating in the OFI project. The reports illustrate the range of opportunities for quality improvement in large multidisciplinary practices. Athough the charter and objectives of each group were unique to each institution, clear themes are evident.

Institutions were expected to focus on mechanisms to improve concordance with the NCCN Guidelines for Breast Cancer in areas reflecting a low level of concordance. Several institutions addressed specific areas of guideline concordance, such as initiation of endocrine therapy after the recommended time frame following radiation because of barriers to patient flow inside the institution, and the use of bisphosphonates among patients with metastatic breast cancer. However, most of the centers determined that much of the care that was not concordant with the guidelines recommendation was due to physician judgment or patient choice. Therefore, most centers focused on other quality issues.

Several institutions focused on barriers to efficient and timely patient care. The work groups developed under the OFI charter provided a multidisciplinary platform to engage patients and caregivers at all levels to identify and address these barriers. To measure the impact of their efforts, most centers used the time between different components of treatment, such as time from initial diagnosis to consultation or initial surgery, or time from surgery to adjuvant therapies, as defined by the NCCN Oncology Outcomes Database.21,22

Time to treatment may be an important measure of the performance of a cancer program. Delays in treatment, and disparities in delay have clearly been described in hospital and population cohort studies.23-25 In these studies, most individuals receive treatment within time frames generally believed to have no impact on overall cancer outcome. However, delays compounded by repeated delays with successive provider specialties over the course of the typical sequential referral of cancer treatment could have potential negative consequences on outcome.26 Furthermore, delays in treatment may have a significant impact on patient satisfaction and well-being.27 Addressing these delays may have an impact on these outcomes, the patient experience, and the market-competitive performance of a cancer program.

Concern regarding delays in treatment is not new or limited to the United States. Delays may be caused by patient, primary care diagnostic, or cancer care system issues, with delays within the care system being a significant issue in United States and United Kingdom.28 Delays in treatment became so significant in the United Kingdom that the National Health Service set standards for time from diagnosis to initial consultation.29,30 The standards call for consultation regarding suspicious breast findings within 14 days, a maximum 1-month wait from diagnosis to treatment, and maximum 2-month wait from urgent general practitioner referral to treatment for all cancers.30 Hospital compliance rates with these standards are provided to the public.

The articles in this supplement provide insights into the collective wisdom at the participating NCCN centers regarding the best target areas for improving care and the patient experience. These efforts may help other programs define targets for practice evaluation and continuous quality improvement. These key efforts are necessary to improve cancer outcomes and experiences, and will be necessary in the coming era of public quality reporting and value-based reimbursement.31

References

  • 1.

    Hewitt M, Simone JV. Ensuring Quality Cancer Care. Washington, DC: National Academy Press; 1999.

  • 2.

    Levit L, Balogh E, Nass S, Ganz PA, eds. Delivering High Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press; 2013.

    • Search Google Scholar
    • Export Citation
  • 3.

    Gradishar WJ, Anderson BO, Blair SL. NCCN Clinical Practice Guidelines in Oncology for Breast Cancer. Version 1.2014. Available at: NCCN.org. Accessed November 27, 2013.

    • Search Google Scholar
    • Export Citation
  • 4.

    Boland GM, Chang GJ, Haynes AB. Association between adherence to National Comprehensive Cancer Network treatment guidelines and improved survival in patients with colon cancer. Cancer 2013;119:15931601.

    • Search Google Scholar
    • Export Citation
  • 5.

    Chagpar R, Xing Y, Chiang YJ. Adherence to stage-specific treatment guidelines for patients with colon cancer. J Clin Oncol 2012;30:972979.

  • 6.

    Ellis SD, Blackard B, Carpenter WR. Receipt of National Comprehensive Cancer Network guideline-concordant prostate cancer care among African American and Caucasian American men in North Carolina. Cancer 2013;119:22822290.

    • Search Google Scholar
    • Export Citation
  • 7.

    Jackson GL, Zullig LL, Zafar SY. Using NCCN clinical practice guidelines in oncology to measure the quality of colorectal cancer care in the veterans health administration. J Natl Compr Canc Netw 2013;11:431441.

    • Search Google Scholar
    • Export Citation
  • 8.

    Korman H, Lanni T Jr, Shah C. Impact of a prostate multidisciplinary clinic program on patient treatment decisions and on adherence to NCCN guidelines: the William Beaumont Hospital experience. Am J Clin Oncol 2013;36:121125.

    • Search Google Scholar
    • Export Citation
  • 9.

    Visser BC, Ma Y, Zak Y. Failure to comply with NCCN guidelines for the management of pancreatic cancer compromises outcomes. HPB (Oxford) 2012;14:539547.

    • Search Google Scholar
    • Export Citation
  • 10.

    Abulkhair O, Saghir N, Sedky L. Modification and implementation of NCCN guidelines on breast cancer in the Middle East and North Africa region. J Natl Compr Canc Netw 2010;8(Suppl 3):S815.

    • Search Google Scholar
    • Export Citation
  • 11.

    Niland JC. NCCN Internet-based data system for the conduct of outcomes research. Oncology 1998;12:142146.

  • 12.

    Weeks J. Outcomes assessment in the NCCN: 1998 update. Oncology 1999;13:6971.

  • 13.

    Christian CK, Niland J, Edge SB. A multi-institutional analysis of the socioeconomic determinants of breast reconstruction: a study of the National Comprehensive Cancer Network. Ann Surg 2006;243:241249.

    • Search Google Scholar
    • Export Citation
  • 14.

    Brewster AM, Etzel C, Zhou R. The impact of obesity on receipt of adjuvant chemotherapy for breast cancer in the National Comprehensive Cancer Network (NCCN) centers. Breast Canc Res Treat 2011;130:897904.

    • Search Google Scholar
    • Export Citation
  • 15.

    Buchholz TA, Theriault RL, Niland JC. The use of radiation as a component of breast conservation therapy in National Comprehensive Cancer Network Centers. J Clin Oncol 2006;24:361369.

    • Search Google Scholar
    • Export Citation
  • 16.

    LaCasce AS, Kho ME, Friedberg JW. Comparison of referring and final pathology for patients with non-Hodgkin’s lymphoma in the National Comprehensive Cancer Network. J Clin Oncol 2008;26:51075112.

    • Search Google Scholar
    • Export Citation
  • 17.

    Punglia RS, Hughes ME, Edge SB. Factors associated with guideline-concordant use of radiotherapy after mastectomy in the national comprehensive cancer network. Int J Radiat Oncol Biol Phys 2008;72:14341440.

    • Search Google Scholar
    • Export Citation
  • 18.

    Romanus D, Weiser MR, Skibber JM. Concordance with NCCN Colorectal Cancer Guidelines and ASCO/NCCN quality measures: an NCCN institutional analysis. J Natl Compr Canc Netw 2009;7:895904.

    • Search Google Scholar
    • Export Citation
  • 19.

    Francescutti V, Watroba NL, Edge SB. Concordance with NCCN practice guidelines for local therapies as a measure of quality of care: review of practice and identification of quality gaps [abstract]. J Clin Oncol 2011;29(Suppl):Abstract 6019.

    • Search Google Scholar
    • Export Citation
  • 20.

    Hassett MJ, Hughes ME, Niland JC. Chemotherapy use for hormone receptor-positive, lymph node-negative breast cancer. J Clin Oncol 2008;26:55535560.

    • Search Google Scholar
    • Export Citation
  • 21.

    Vandergrift JL, Niland JC, Theriault RL. Time to adjuvant chemotherapy for breast cancer in National Comprehensive Cancer Network institutions. J Natl Cancer Inst 2013;105:104112.

    • Search Google Scholar
    • Export Citation
  • 22.

    Partridge AH, Hughes ME, Ottesen RA. The effect of age on delay in diagnosis and stage of breast cancer. Oncologist 2012;17:775782.

  • 23.

    Fedewa SA, Edge SB, Stewart AK. Race and ethnicity are associated with delays in breast cancer treatment (2003-2006). J Health Care Poor Underserved 2011;22:128141.

    • Search Google Scholar
    • Export Citation
  • 24.

    Fedewa SA, Ward EM, Stewart AK, Edge SB. Delays in adjuvant chemotherapy treatment among patients with breast cancer are more likely in African American and Hispanic populations: a national cohort study 2004-2006. J Clin Oncol 2010;28:41354141.

    • Search Google Scholar
    • Export Citation
  • 25.

    Bleicher RJ, Ruth K, Sigurdson ER. Preoperative delays in the US Medicare population with breast cancer. J Clin Oncol 2012;30:44854492.

  • 26.

    Shin DW, Cho J, Kim SY. Delay to curative surgery greater than 12 weeks is associated with increased mortality in patients with colorectal and breast cancer but not lung or thyroid cancer. Ann Surg Oncol 2013;20:24682476.

    • Search Google Scholar
    • Export Citation
  • 27.

    Mazor KM, Roblin DW, Greene SM. Toward patient-centered cancer care: patient perceptions of problematic events, impact, and response. J Clin Oncol 2012;30:17841790.

    • Search Google Scholar
    • Export Citation
  • 28.

    Hansen RP, Vedsted P, Sokolowski I. Time intervals from first symptom to treatment of cancer: a cohort study of 2,212 newly diagnosed cancer patients. BMC Health Serv Res 2011;11:284.

    • Search Google Scholar
    • Export Citation
  • 29.

    Lyratzopoulos G, Abel GA, McPhail S. Measures of promptness of cancer diagnosis in primary care: secondary analysis of national audit data on patients with 18 common and rarer cancers. Br J Canc 2013;108:686690.

    • Search Google Scholar
    • Export Citation
  • 30.

    NHS Cancer Plan: A plan for investment, A plan for reform. 2000. Available at: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4014513.pdf. Accessed November 27, 2013.

    • Search Google Scholar
    • Export Citation
  • 31.

    Patel KK, Morin AJ, Nadel JL, McClellan MB. Meaningful physician payment reform in oncology. J Oncol Pract 2013;9:49a53a.

If the inline PDF is not rendering correctly, you can download the PDF file here.

Stephen B. Edge, MD, is the Cancer Center Director of the Baptist Cancer Center at the Baptist Memorial Health Care System based in Memphis, Tennessee. Prior to this, he held the Alfiero Foundation Endowed Chair in Breast Oncology and was Chief of Breast Surgery at Roswell Park Cancer Institute in Buffalo, New York. Dr. Edge served on the NCCN Board of Directors for over 10 years and on the NCCN Executive Committee for the past 8 years. In addition, he was a founding member of the NCCN Oncology Outcomes Database program and served on the NCCN Guidelines Panel for Breast Cancer for 16 years.

Dr. Edge served as Chair of the Commission on Cancer of the American College of Surgeons from 2008-2012 and as Chair of the American Joint Committee on Cancer. He is the editor of the 7th Edition of the AJCC Cancer Staging Manual. He has served in numerous capacities for ASCO and was elected as a Fellow of ASCO in 2010. Dr. Edge’s primary clinical interest is breast cancer diagnosis and treatment. His research focuses on evaluation and improvement of community-wide quality of cancer care. He has published over 180 papers in peer-reviewed journals.

Dr. Edge received his medical degree from Case Western Reserve University School of Medicine, and his postgraduate training in surgery at University Hospitals of Cleveland. In addition, he completed a fellowship in the Surgery Branch of the NCI. He is board certified in surgery.

The ideas and viewpoints expressed in this editorial are those of the author and do not necessarily represent any policy, position, or program of NCCN.

  • 1.

    Hewitt M, Simone JV. Ensuring Quality Cancer Care. Washington, DC: National Academy Press; 1999.

  • 2.

    Levit L, Balogh E, Nass S, Ganz PA, eds. Delivering High Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press; 2013.

    • Search Google Scholar
    • Export Citation
  • 3.

    Gradishar WJ, Anderson BO, Blair SL. NCCN Clinical Practice Guidelines in Oncology for Breast Cancer. Version 1.2014. Available at: NCCN.org. Accessed November 27, 2013.

    • Search Google Scholar
    • Export Citation
  • 4.

    Boland GM, Chang GJ, Haynes AB. Association between adherence to National Comprehensive Cancer Network treatment guidelines and improved survival in patients with colon cancer. Cancer 2013;119:15931601.

    • Search Google Scholar
    • Export Citation
  • 5.

    Chagpar R, Xing Y, Chiang YJ. Adherence to stage-specific treatment guidelines for patients with colon cancer. J Clin Oncol 2012;30:972979.

  • 6.

    Ellis SD, Blackard B, Carpenter WR. Receipt of National Comprehensive Cancer Network guideline-concordant prostate cancer care among African American and Caucasian American men in North Carolina. Cancer 2013;119:22822290.

    • Search Google Scholar
    • Export Citation
  • 7.

    Jackson GL, Zullig LL, Zafar SY. Using NCCN clinical practice guidelines in oncology to measure the quality of colorectal cancer care in the veterans health administration. J Natl Compr Canc Netw 2013;11:431441.

    • Search Google Scholar
    • Export Citation
  • 8.

    Korman H, Lanni T Jr, Shah C. Impact of a prostate multidisciplinary clinic program on patient treatment decisions and on adherence to NCCN guidelines: the William Beaumont Hospital experience. Am J Clin Oncol 2013;36:121125.

    • Search Google Scholar
    • Export Citation
  • 9.

    Visser BC, Ma Y, Zak Y. Failure to comply with NCCN guidelines for the management of pancreatic cancer compromises outcomes. HPB (Oxford) 2012;14:539547.

    • Search Google Scholar
    • Export Citation
  • 10.

    Abulkhair O, Saghir N, Sedky L. Modification and implementation of NCCN guidelines on breast cancer in the Middle East and North Africa region. J Natl Compr Canc Netw 2010;8(Suppl 3):S815.

    • Search Google Scholar
    • Export Citation
  • 11.

    Niland JC. NCCN Internet-based data system for the conduct of outcomes research. Oncology 1998;12:142146.

  • 12.

    Weeks J. Outcomes assessment in the NCCN: 1998 update. Oncology 1999;13:6971.

  • 13.

    Christian CK, Niland J, Edge SB. A multi-institutional analysis of the socioeconomic determinants of breast reconstruction: a study of the National Comprehensive Cancer Network. Ann Surg 2006;243:241249.

    • Search Google Scholar
    • Export Citation
  • 14.

    Brewster AM, Etzel C, Zhou R. The impact of obesity on receipt of adjuvant chemotherapy for breast cancer in the National Comprehensive Cancer Network (NCCN) centers. Breast Canc Res Treat 2011;130:897904.

    • Search Google Scholar
    • Export Citation
  • 15.

    Buchholz TA, Theriault RL, Niland JC. The use of radiation as a component of breast conservation therapy in National Comprehensive Cancer Network Centers. J Clin Oncol 2006;24:361369.

    • Search Google Scholar
    • Export Citation
  • 16.

    LaCasce AS, Kho ME, Friedberg JW. Comparison of referring and final pathology for patients with non-Hodgkin’s lymphoma in the National Comprehensive Cancer Network. J Clin Oncol 2008;26:51075112.

    • Search Google Scholar
    • Export Citation
  • 17.

    Punglia RS, Hughes ME, Edge SB. Factors associated with guideline-concordant use of radiotherapy after mastectomy in the national comprehensive cancer network. Int J Radiat Oncol Biol Phys 2008;72:14341440.

    • Search Google Scholar
    • Export Citation
  • 18.

    Romanus D, Weiser MR, Skibber JM. Concordance with NCCN Colorectal Cancer Guidelines and ASCO/NCCN quality measures: an NCCN institutional analysis. J Natl Compr Canc Netw 2009;7:895904.

    • Search Google Scholar
    • Export Citation
  • 19.

    Francescutti V, Watroba NL, Edge SB. Concordance with NCCN practice guidelines for local therapies as a measure of quality of care: review of practice and identification of quality gaps [abstract]. J Clin Oncol 2011;29(Suppl):Abstract 6019.

    • Search Google Scholar
    • Export Citation
  • 20.

    Hassett MJ, Hughes ME, Niland JC. Chemotherapy use for hormone receptor-positive, lymph node-negative breast cancer. J Clin Oncol 2008;26:55535560.

    • Search Google Scholar
    • Export Citation
  • 21.

    Vandergrift JL, Niland JC, Theriault RL. Time to adjuvant chemotherapy for breast cancer in National Comprehensive Cancer Network institutions. J Natl Cancer Inst 2013;105:104112.

    • Search Google Scholar
    • Export Citation
  • 22.

    Partridge AH, Hughes ME, Ottesen RA. The effect of age on delay in diagnosis and stage of breast cancer. Oncologist 2012;17:775782.

  • 23.

    Fedewa SA, Edge SB, Stewart AK. Race and ethnicity are associated with delays in breast cancer treatment (2003-2006). J Health Care Poor Underserved 2011;22:128141.

    • Search Google Scholar
    • Export Citation
  • 24.

    Fedewa SA, Ward EM, Stewart AK, Edge SB. Delays in adjuvant chemotherapy treatment among patients with breast cancer are more likely in African American and Hispanic populations: a national cohort study 2004-2006. J Clin Oncol 2010;28:41354141.

    • Search Google Scholar
    • Export Citation
  • 25.

    Bleicher RJ, Ruth K, Sigurdson ER. Preoperative delays in the US Medicare population with breast cancer. J Clin Oncol 2012;30:44854492.

  • 26.

    Shin DW, Cho J, Kim SY. Delay to curative surgery greater than 12 weeks is associated with increased mortality in patients with colorectal and breast cancer but not lung or thyroid cancer. Ann Surg Oncol 2013;20:24682476.

    • Search Google Scholar
    • Export Citation
  • 27.

    Mazor KM, Roblin DW, Greene SM. Toward patient-centered cancer care: patient perceptions of problematic events, impact, and response. J Clin Oncol 2012;30:17841790.

    • Search Google Scholar
    • Export Citation
  • 28.

    Hansen RP, Vedsted P, Sokolowski I. Time intervals from first symptom to treatment of cancer: a cohort study of 2,212 newly diagnosed cancer patients. BMC Health Serv Res 2011;11:284.

    • Search Google Scholar
    • Export Citation
  • 29.

    Lyratzopoulos G, Abel GA, McPhail S. Measures of promptness of cancer diagnosis in primary care: secondary analysis of national audit data on patients with 18 common and rarer cancers. Br J Canc 2013;108:686690.

    • Search Google Scholar
    • Export Citation
  • 30.

    NHS Cancer Plan: A plan for investment, A plan for reform. 2000. Available at: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4014513.pdf. Accessed November 27, 2013.

    • Search Google Scholar
    • Export Citation
  • 31.

    Patel KK, Morin AJ, Nadel JL, McClellan MB. Meaningful physician payment reform in oncology. J Oncol Pract 2013;9:49a53a.

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