Clinical Practice Guidelines in B.C: and the

Strategy for Cancer Control Recommendations

Susan O’Reilly

Head, Division of Medical Oncology

B.C. Cancer Agency &

University of British Columbia.

Provincial Systemic Program Leader,

B.C. Cancer Agency

BCCA Provincial Guidelines Development

Provincial Tumour Groups

• Multidisciplinary groups - site specific e.g. breast, lung, GI– Medical/Radiation/Surgical Oncologists– Pharmacists– Variable participation of other disciplines

Con’t• 20 year history

• Review new scientific data presented at international meetings

– Abstracts

– Peer reviewed papers

– Local (BC) outcomes/experience

– Propose new guidelines for surgical, radiation and systemic therapy/symptom management

– Promulgate and practice according to guidelines

– Cancer Management Manual

Priorities and Evaluation Committee, BCCA

• Broad-based representation of various programs/processes statistical expertise,

• Expert panels (curative/chronic/preventative)

• Rank new program/guideline proposals according to scientific merit

• Scientific review based on 5 levels of evidence

• e.g: level 1 - Scientifically, well-designed, phase III randomized study with sufficient numbers of patients accrued and adequate length of follow-up to determine statistically relevant difference between two or more alternative treatment strategies.

Con’t• Reasonable assessment of early data when

“Level 1” may not have been achieved yet. e.g. large phase II studies or rare cancer diagnoses

• Assessment of cost/benefit

• New programs - new drugs/combinations

• Emerging role in evaluating merit of existing programs

Provincial Systemic Therapy Program

Responsible for:

• BCCA Provincial Oncology Budget

• BCCA operating budget for Systemic (medical oncology programs) in BCCA and community centers

• Interactive treatment and educational information on website www.bccancer.bc.ca

Con’t

• Standards

• Policies

• Guidelines

• Protocols on line (180)

Planning/Approval/

Costing/Implementation

• Outcomes evaluation (with tumor groups)

• Education “

• Research “

• Strategic and financial planning

• Pharmacoeconomics

Professional Treatment Guidelines

• American Society of Clinical Oncology

• Canadian Medical Association

• Various national/international professional societies

Canadian (National) Guidelines• Well-developed adjuvant breast cancer guidelines• Strengths:

– Expert/multidisciplinary/multiprovincial unifying standard

• Weakness:– Protracted consultation process

– Difficulty to be timely when patients/doctors anxious for access

– Provincial Ministries of Health require early budget advice

Provincial Guidelines

• Cancer Care Ontario– Sophisticated guideline process

– Centrally coordinated and lead (Dr. George Browman)

– Clearly defined process

• Various levels of guideline development in other provinces– Labour intensive

but– Good local “buy in”

CANADIAN GUIDELINE DEVELOPMENT

An evolving process:

• Canadian Association of Provincial Cancer Agencies (CAPCA)

• Various CAPCA Advisory Committees

• Interprovincial Drug Strategies and Guidelines Working Group (IDSGWG)

• IDSGWG Extranet: Provincial formularies, guidelines

• Canadian Strategy for Cancer Control (Health Canada/CAPCA/CCS/NCIC)

CANADIAN STRATEGY FOR CANCER CONTROL/CAPCA/CCS/NCIC

Guideline Development Project

• Leader - Dr. G. Browman

• Workshop September 2002, Ottawa

• Broad Scope:– Prevention

– Screening

– Therapy

– Supportive care

– Palliative Care

• Agreement to strike expert working groups

• National coordinating infrastructure proposed

• Respectful of existing initiatives

• Build capacity/methodologies

• Set priorities

• Conduct inventory

• Facilitate patient/public versions

Con’t

• Dissemination/implementation/

evaluation/updating/after care

• Research

• Education for primary health care providers

Do We Need National Consensus?

Therapy Guidelines

Provinces are more similar than different

BUT

Major differences exist in several areas

Con’t• Access to:

– First line Gleevec (imatinab) for chronic myeloid leukemia

– CHOP + Rituximab for first line aggressive lymphomas

– Bisphosphonates– Oxaliplatin for colon cancer– Variable funding policies for “take-home”

drugs• Will some problems be solved by Kirby or

Romanow Report?

• Lack of symptom management/palliative guidelines

• Psychosocial support guidelines not clearly understood or developed (confusion re: “funding” versus “guidelines”)

• Will Canadian guidelines be timely and feasible?

• Enhance consistency?

• Improve outcomes?

• Improve access?

• Improve cost effectiveness?

• Support implementation?

Questions• Are Canadian clinical practice guidelines a

positive or negative influence on standards of care and access to care?

• Will Canadian guidelines be achievable in a timely fashion and be responsive to new evidence?