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Guideline for Treatment of Cancer Near the End of Life

Guideline for Treatment of Cancer Near the End of Life

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Published by Statesman Journal
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).
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).

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Published by: Statesman Journal on Aug 09, 2013
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08/23/2013

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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 veryadvanced cancers who are on the Oregon Health Plan (OHP). We currently have a guidelinewhich 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 thecurrent 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 treatmentof more cancers for more patients. It outlines restrictions in care for those patients whohave 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 ReviewCommission (HERC) heard from various doctors, patients and health plans that thecurrent guideline was not working.2)
 
The VBBS convened a workgroup that held 2 public meetings. The workgroup wasmade up of oncologists (doctors who care for cancer patients), a nurse who works withcancer patients, a doctor who provides palliative care, an attorney who specialized inhealthcare 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 publicmeetings were very well attended, and testimony was heard from patient advocates,doctors, and others. Other stakeholders were able to provide input via discussions withHERC 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 discussionabout the patient’s goals of care and what can really be expected from various careoptions, including chemotherapy. This conversation needs to cover the harms and sideeffects 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’
1
 
 
Guideline for Treatment of Cancer Near the End of Life
lives and allows these patients to spend more time with their families instead of inhospitals.3)
 
Cancer care is required to be provided following evidence-based pathways of caredevised 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 thefewest 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 livethe most pain-free, highest quality life with their cancer. Patients have access tomedicines for nausea and pain, acupuncture, home health care, wheelchairs, surgery torelieve 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 Oregoncancer 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 iswritten.3)
 
If the guideline is adopted, it will be reviewed by the entire HERC, which has membersfrom all types of areas in medicine (doctors, nurses, chiropractic, patients, health planadministrators, and more). The HERC may make changes or accept it as the VBBS hasapproved.4)
 
If approved, the guideline will start assisting patients, doctors, and health plans in thecare of patients with advanced stage cancer beginning in October 2013.
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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 specificsubtype of cancer and the patient’s unique medical and social situation. Goals of appropriatecancer 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 patient’s supportsystems, overall heath, and core values. Patients should have access to appropriate peer-reviewed clinical trials of cancer therapies. A comprehensive multidisciplinary approach totreatment 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 twoor 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 KarnofskyPerformance Status or Palliative Performance score of <50% with ECOG performancestatus 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 asoutlined in Statement of Intent 1, Palliative Care.To qualify for treatment coverage, the cancer patient must have a documented discussion abouttreatment goals, treatment prognosis and the side effects, and knowledge of the realisticexpectations of treatment efficacy. This discussion may take place with the patient’s oncologist, primary care provider, or other health care provider, but preferably in a collaborativeinterdisciplinary care coordination discussion. Treatment must be provided via evidence-driven pathways (such as NCCN, ASCO, ASH, ASBMT, or NIH Guidelines) when available.
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