NCCN Evidence Blocks Help Frame Value-Based Decisions for Systemic Therapies

May 2016, Vol 7, No 4

The evidence blocks were incorporated into the National Comprehensive Cancer Network (NCCN) clinical practice guidelines late last year and act as a visual representation of 5 key measures related to specific recommendations. The evidence blocks allow an efficient comparison across multiple treatment options and provide “a basis for framing decisions and value considerations,” said NCCN Chief Executive Officer Robert W. Carlson, MD, Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, who presented the evidence blocks at the 2016 NCCN annual conference. With the growing use of value metrics in decision-making in cancer care, stakeholders requested that the NCCN consider a value component in its guidelines. The resulting evidence blocks permit patients to decide what constitutes value based on the following 5 key measures:

  1. Affordability
  2. Efficacy
  3. Safety
  4. Quality and quantity of evidence
  5. Consistency of evidence.

Affordability refers to the overall cost of an intervention, including the drug cost, required supportive care, infusions, toxicity monitoring, the management of toxicity, and the probability of care being delivered in a hospital.Each of the 5 measures is scored using a standardized scale from 1 to 5, with 1 being the least favorable and 5 the most favorable. Individual panel members complete a survey for each systemic therapy regimen across all 5 measures. The scores are then used to build a 5 × 5 graphic table that constitutes the evidence block for a particular intervention. Each measure is represented in a column of the table, and shaded according to the standardized scale; the more shaded a column, the better the measure for a particular systemic therapy.

The Patient’s Perspective of Value Is Key

NCCN panel members are specifically instructed to not consider cost when generating guidelines, but “value has many definitions, and not all definitions of value are based upon cost,” said Dr Carlson. “They may be based on toxicity or larynx preservation, breast preservation, or other aspects or components of cancer care. We thought that the patient perception of value is the single most important perception in the whole project.” The definition of value varies greatly from patient to patient. Dr Carlson used the example of a 25-year-old woman who presents with high-risk breast cancer. “She is going to be interested almost exclusively in efficacy,” he said. “She is not going to want to hear about toxicity; she is not going to be concerned about cost.” Conversely, an 85-year-old woman who presents with an identical breast cancer would most likely focus primarily on quality of life and on not wanting to be a financial burden to her family. “Both perspectives, we believe, are perfectly valid and appropriate to consider in the decision-making process,” Dr Carlson said. “So we wanted a system where we could provide information that allows the patient to create his or her own value formula in a shared decision-­making process.”


Cost was added to the equation (as part of the affordability measure) so that patients, physicians, and others can actively participate in decision-making if cost is an issue for the patient. Cost is not considered in the inclusion of a drug on a guideline, “but cost information should be available to the patient in the decision-making about their choices,” Dr Carlson said.

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