Guideline-Directed Cancer Care Can Help Reduce Disparities, NCCN’s Schatz Says

Note: A previous version of this article appeared with our meeting coverage.

Guideline-directed cancer care, with help from a clinical support tool, can close disparities while reducing costs more efficiently than other means, such as prior authorization. Following clinical guidelines leads to better outcomes in cancer care and can reduce disparities between White patients and patients of color, Alyssa Schatz, MSW, said while opening the 2022 Patient-Centered Oncology Care® meeting, held November 9-10, 2022, in Nashville, Tennessee. Schatz is the senior director of policy and advocacy for the National Comprehensive Cancer Network (NCCN).

Schatz said the root causes of disparities in cancer care are multifactorial, as studies show patients of color with cancer can receive suboptimal care regardless of insurance status. In her talk, “Advancing Equitable Care Through Guidelines Adherence,” Schatz said following guideline-directed care can close these gaps while reducing costs more efficiently than other means, such as prior authorization.

“We know there are deep, longstanding, and ongoing inequities and injustices in who does and does not get access to the highest standard of care possible,” Schatz said. “As a nation, we have a long history of structural and interpersonal racism. And that history impacts the systems we have in place today.”

Health care systems, she said, do not yet deliver care in a fully equitable way, and this is especially true when it comes to who receives guideline-directed cancer care. “There are stark racial disparities between patients who do and do not receive optimal guideline-inherent care. Patients who are Black are dramatically less likely to receive guideline-inherent care than patients who are White.”

Disparities occur for multiple reasons, Schatz said, including the shortage of doctors and nurses of color who work in oncology and the underrepresentation of minority populations in clinical trials. Following NCCN guidelines can reduce the likelihood that factors, such as implicit or explicit bias or social determinants of health (SDOH), can drive poor cancer outcomes, Schatz said. In the past, some studies did not even report the results by race, she said.

NCCN guideline development
Schatz walked the audience through the guideline development process, explaining how scientists from NCCN’s 32 member institutions participate in 61 panels that produce 84 guidelines, covering 97% of cancers. More than 1700 volunteers develop the guidelines throughout the year, providing updates to each at least once a year. In reality, Schatz said, guidelines are developed continuously; important trial results or FDA approvals are quickly incorporated.

The NCCN has strict rules to prevent outside interference in its processes, Schatz said, and the result is a high level of confidence in the guidelines it produces. More than 13 million downloads of the guidelines took place in 2021, she said.

Impact on care
The result is that guideline-directed care offers better outcomes and decreases costs, according to Schatz. A study conducted in 2015 between UnitedHealthcare and NCCN compared following guidelines with prior authorization. “When comparing drug costs [with] their trends nationwide, United found that adherence to guidelines reduced chemotherapy drug cost trends by 20%,” she said. The pilot saved $5.3 million, and 95% of prescriptions were approved within 24 hours.¹

A separate study published by the NCCN found that patients with metastatic breast cancer had $1841 more in out-of-pocket costs when their care failed to follow guidelines compared with care that did follow guidelines. “Thousands of dollars may be the difference between being able to afford treatment and being able to afford rent,” Schatz said. “This is a really meaningful impact.”

Now, she said, “studies are increasingly indicating that [the guidelines] may also be a tool to reduce inequities in care outcomes.”

A study in ovarian cancer found that Black patients were less likely to receive guideline-recommended care than White patients. “Non–guideline recommended care was associated with inferior care outcomes,” Schatz said.²

A study in triple-negative breast cancer found that non-Hispanic Black patients and Hispanic patients were less likely to receive care, according to guidelines, than White patients. Further, patients who did not receive guideline-adherent care had worse disease-specific survival compared with patients who did receive care per NCCN guidelines.³ In lung cancer, a study showed non-Hispanic Black patients were less likely than non-Hispanic White patients to receive NCCN guideline–adherent care.⁴

What can be done?
Schatz emphasized that delivering guideline-adherent care by itself will not eliminate all disparities in cancer care. “I want to be really careful that I’m not saying that guideline adherence and clinical decision support mechanisms are going to solve all the inequities in our care system, because we all know that is not the case. It is not a panacea,” she said. Instead, a multipronged approach to tackling inequities would feature a way to measure how well health systems or community providers are doing in addressing health equity.

Schatz highlighted work by the Elevating Cancer Equity Working Group to develop the Equity Report Card, which she said is a tool that can help providers, payers, and accreditation entities advance racially equitable practices in cancer care. The report card includes 17 practices where providers and health systems can be measured in the areas of community engagement, accessibility of care, and SDOH, addressing bias in care delivery and quality and comprehensive care. However, Schatz said, the academic centers that developed the tool recognize that most care occurs in community practices; the working group plans to convene a second group to develop a pilot for community-based care. “We are hoping to launch that pilot in 2023,” she said. 

References
1. Newcomer LN, Weininger R, Carlson RW. Transforming prior authorization to decision support. J Oncol Pract. 2017;13(1):e57-e61. doi:10.1200/JOP.2016.015198.
2. Bristow RE, Powell MA, Al-Hammadi N, et al. Disparities in ovarian cancer care quality and survival according to race and socioeconomic status. J Natl Cancer Inst. 2013;105(11):823-832. doi:10.1093/jnci/djt065
3. Ubbaonu C, Chang J, Ziogas A, et al. Disparities in the receipt of the National Comprehensive Cancer Network (NCCN) guideline adherent care in triple-negative breast cancer (TNBC) by race/ethnicity, socioeconomic status, and insurance type. J Clin Oncol. 2020;38(suppl 15):1080. doi:10.1200/JCO.2020.38.15_suppl.1080
4. Blom EF, Ten Haaf K, Arenberg DA, de Koning HJ. Disparities in receiving guideline-concordant treatment for lung cancer in the United States. Ann Am Thorac Soc. 2020;17(2):186-194. doi:10.1513/AnnalsATS.201901-094OC