Treatment and Referral Policies
Treatment Policies
Treatment policies need to be formulated by the National Cancer Control program (NCCP) to assure some uniformness of quality of care across the country that is cost-effective within the available resources. This can be done by delivering care within multidisciplinary tumor groups, each of which covers one or more of the major tumor sites (breast, gastrointestinal, lung, hemopoietic, gynecologic, etc.). Pediatrics is traditionally a tumor group, often with links to an international clinical research group for assistance with treatment protocols for rare tumors. In formulating treatment guidelines tumor groups should consider adding members from the practicing community, both for their contribution to policy formulation, and to take advantage of the continuing medical education that that guideline formulation can provide. Depending on available treatment options, each team may include surgeons, radiation and medical oncologists, nurses, psychologists and/or social workers, pathologists, radiologists, volunteers, etc. as appropriate. For each case, both the patient and the family are included in the deliberations to take advantage of the opportunity for education. Treatment plans are formulated during team meetings that some countries call tumor boards. In addition to delivering integrated care, each team meets regularly to develop and maintain current, treatment and referral guidelines for its tumor sites. For purposes of program integration, these tumor groups become subgroups of an overall treatment policy committee under the cancer control advisory group for the NCCP. The larger committees will add other expertise such as pharmacy, epidemiology, and perhaps representatives from the ministry of heath and the administration of the NCCP, so that broader issues such as program evaluation, priority setting in the face of limited resources, and strategic planning can be addressed.
To develop treatment policies, tumor groups require information about the predominant types of cancer by site and by stage in the geographic catchment or region served by the treatment programs. Guidelines for treatment of each stage of each cancer are then formulated based on evidence from the published literature as adapted to local circumstances and modified by priorities that reflect chance of cure and the availability of resources, equipment and facilities. Allocation of resources is given to patients with potentially curable tumors. Other groups are identified, such as those with incurable tumors who require palliative care, and those where treatment may prolong life, but not offer cure, where curative therapy may be attempted depending on the availability of resources and the relative likelihood of cure. Similar teams my be formed among specialty groups for development of their own technical guidelines for delivery of nursing, chemotherapy, radiation therapy, surgery, etc.
In the face of constrained resources, the committees may face some difficult decisions as to what can benefit the most patients. Where two modalities like surgery and radiotherapy are equally effective, the choice of which one to use may be determined by the demands for these modalities by other tumor sites. Even a less effective method may be chosen if it uses resources more effectively for the cure and quality of life of a larger number of patients. Where resources are too short to allow optimal treatment of all of the patients with a particular tumor, it may be necessary to make modifications consistent with the best possible outcomes , such as reducing the number of radiotherapy treatments, simplifying chemotherapy protocols, or even eliminating palliative chemotherapy or other relatively ineffective maneuvers and referring out of the country patients who require complex procedures such as bone marrow transplantation or who have rare but treatable tumors such as in the pediatric population where both experience and high technology are required.
The Contribution of Norms and Standards
Countries often create norms for cancer treatment. They are often very detailed and represent an enormous investment of time and effort to produce. They become rapidly outdated and compliance is often poor and undocumented.
An easier alternative is to have direct computer access to the Medlars system in Washington via the internet to be able to log on to the PDQ (Physician Direct Query) database. One can access PDQ on the Internet via Cancernet using e-mail. Although not marketed as treatment guidelines, this database has this information for most of the major tumors. The material is updated frequently by peer review panels and is evidence-based with extensive bibliographies. Information on clinical trials and research, as well as physician and institutional referral data are available for North America. There is a section for patients. Downloading some of this material as a first step might then make the production of local referral, treatment and follow-up guidelines easier, since they would need only to be adapted to local practice rather than generated from scratch. The U.S. NCI has a program to assist developing countries with acquiring access to this and related cancer databases. The U.S. National Library of Medicine’s Internet Grateful Med Prototype can now also be searched for free over the Internet.
There are more fundamental issues around norms ands guidelines that must be confronted. It takes a great effort to produce them, but it is difficult to get or show compliance to them and they rapidly become outdated. Many areas of oncology are controversial and it can be hard sometimes to get consensus. Norms can be useful, but their formulation does not automatically mean they will be implemented and a quality program guaranteed. Norms have a rigid connotation to them, and hence they are often too detailed and try to cover every possible exigency, while the term "practice guidelines" conveys the more flexible quality that is needed. Where they can fall down is when they are rigidly applied to individuals, often for additional agendas than just patient care, such as economics. It is not sufficiently appreciated that medicine at the level of the individual patient is still largely an art that no set of norms can truly encompass. This is particularly true with patients with advanced cancer. There is always a balance between the art and the science (represented by the guidelines). This is a topical and controversial area in oncology in North America and Europe currently with the development of clinical epidemiological concepts such as evidence-based medicine. The reference cited below summarizes these issues in relationship to practice guidelines in oncology.
Referral Policies
Referral policies are also needed to provide guidance on how patients are to move through the cancer control system quickly and efficiency so that they receive the right treatment by the right people at the right place and time. The cancer system is ultimately constructed at the national level as a "3-2-1" network, that refers to the tertiary, secondary and primary levels of care delivered by an NCCP. Referral policies are one way that coordination within such a complex network is achieved. Clear guidelines for how to refer patients between the various levels of the treatment network are established and promulgated, taking into account the distribution of available resources. It is important to form referral links between early diagnosis and screening programs with treatment programs, and between the latter and palliative care programs so that patients do not "fall between the cracks".
DeVita VT Jr, Hellman S and Rosenberg SA Eds (1997) Cancer. Principles and Practice of
Oncology. Ed 5. Lippincott-Raven, Philadelphia. Contains an article on the PDQ information
system.
MacDonald JS, Haller DG & Mayer RJ (1995) Manual of Oncologic Therapeutics. Ed 3. JB
Lippincott Co.,Philadelphia.
WHO (1995) National Cancer Control Programmes. Policies and Managerial Guidelines. World
Health Organization, Geneva.
Winchester DP (Ed). Tumor Board Case Management. Lippincott-Raven, Hagerstown MD, 1997.
Winn RJ (1995) Current status of practice guidelines in oncology. Oncology 9: 601-605.