Rapid advances in the oncology field over the past 2 decades has provided a better understanding of cancer biology, which has led to the development of many new and more effective therapeutic options. Better disease characterization fostered the evolution of precision oncology. Nevertheless, unless biomedical advances are accompanied by a parallel improvement in healthcare delivery, many patients will not fully benefit from them. Translational research bridges the gap between bench and bedside by creating an evidence base. However, translational research does not address the range of real-world patients, disease states, and resource availability, nor does it leverage knowledge gained from other sources. Furthermore, translational research does not monitor real-world activities. Therefore, a chasm can exist between how patients do in clinical trials and the real-world experience of patients outside of trials.
Implementation science can bridge the gap between available best evidence and actual patient care.1 Implementation science ensures that providers can apply evidence consistently and efficiently and can monitor adherence to recommended interventions. It is the last and most critical step in adopting evidence-based practice. Implementation science begins with developing or adapting guidelines that synthesize the evidence and use it to make recommendations for patient management.2 Best practices incorporate evidence generated from classic studies with pragmatic research and the clinical experience of expert clinicians (Figure 1).
For more than 2 decades, NCCN has created a variety of resources to assist healthcare professionals provide better care to patients with cancer. NCCN has developed evidence-based, consensus-driven guidelines (available at NCCN.org) used both in the United States and around the world to outline step-by-step clinical decision-making, from risk assessment and screening through palliation and end-of-life care.3
To create the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines), multidisciplinary panels of experts selected from the 27 NCCN Member Institutions evaluate the data at each point in disease management and reach evidence-based consensus on appropriate interventions. To keep pace with rapidly evolving data, the NCCN Guidelines are updated continuously. Strong emerging experience suggests thatpatients treated in accordance with the NCCN Guidelines have better outcomes in several cancer types.4–10 Further, NCCN has a variety of tools to help clinicians implement the guidelines in clinical practice, including compendia enumerating recommended uses of imaging, biomarker testing, and drugs and biologics; chemotherapy order templates; and patient versions of the NCCN Guidelines.
NCCN Guidelines have also been adapted to various regions to meet the regulatory environments, medical expertise, and patient characteristics in those regions.11,12 Finally, to facilitate use of the NCCN Guidelines by practitioners in middle and lower resource settings and provide treatment recommendations applicable to different levels of healthcare resources, NCCN developed Frameworks for Resource Stratification.13
The frameworks preserve the context of the full NCCN Guidelines, yet provide a strategy for providing the highest quality healthcare in resource-limited environments to efficiently improve patient outcomes (Figure 2). The frameworks, which use a modification of the model developed by the Breast Health Global Initiative, stratify recommendations for care into 4 resource levels: Basic Resources, Core Resources, Enhanced Resources, and NCCN Guidelines. Resource stratification can help build an incremental, step-by-step roadmap from a basic level of care to more comprehensive care, through a set of rational improvements in applying resources.
These levels were originally designed to be used for regional allocation of resources; however, as different regions have considered adoption, a variety of additional models are being considered. In many lower resource countries, advanced medical facilities equipped with complex medical equipment and expert clinicians are centralized to a small number of tertiary care centers. Geographically dispersed, smaller regional centers provide less-specialized care, and a local clinical system provides basic care. The frameworks might be used to identify the types of interventions that should be available at each of these care sites.
In other cases, an individual setting or region might have access to interventions that are stratified at different levels, and may wish to develop a mosaic to match the resources available. For example, an otherwise low-resource setting might have radiation therapy capability but limited access to pharmaceuticals. In that case, a care model might be envisioned that includes elements of both basic and core resources.
Additionally, NCCN Evidence Blocks help users of the NCCN Guidelines prioritize recommendations. Given increasing interest in the escalating cost of cancer treatment,NCCN decided to add an affordability measure that takes into account the total medical costs of providing a regimen, including cost of the drug, administration, supportive care, management of expected toxicities, and likelihood of hospitalization. The information provided by the NCCN Evidence Blocks allows comparison of regimens across these 5 domains based on the values of the individual clinician and patient. They can also be used in concert with the frameworks by users of the NCCN Guidelines to help prioritize which agents and combinations to select. The goal is to provide clinicians and patients the opportunity to make decisions based on the patient's values through shared decision-making models (Figure 3).14
All of these resources provide guidance in deciding what should be available in a particular setting, but recommendations must be tailored to individual circumstances to be maximally helpful in implementing high-quality care. Developing an implementation model will help translate this abundant knowledge into action and improve delivery of evidence-based medicine in a variety of resource settings.
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Carlson RW, Scavone JL, Koh WJ. NCCN Framework for Resource Stratification: a framework for providing and improving global quality oncology care. J Natl Compr Canc Netw 2016;14:961–969.