Dr Derek Raghavan: Evidence-Based Guidelines Will Improve Cancer Outcomes, Reduce Costs

The purpose of evidence-based guidelines is to reduce the level of variation, improve outcomes, and reduce costs, said Derek Raghavan, MD, PhD, FACP, FRACP, president, Carolinas HealthCare System's Levine Cancer Institute.

With studies finding large variation and price differences in how care is delivered, what is the importance of putting in place evidence-based guidelines and ensuring they are followed?
One of the really important things about having evidence-based guidelines is, it’s stops the unnecessary variation. It basically gives what I have to describe as a “cookbook” approach to treatment. It’s predicated on level 1 evidence, which means randomized clinical trials, very carefully structured patient populations, so the stringency of assessment, the level of attention to detail of what population of patients with a set of drugs will get what results. That will reduce the level of variation that we have, and it becomes very important if you’re trying to get your arms around the cost of treatment.

If every physician wants to use every new drug, they’re almost always very expensive, you’ll have wide levels of variation of outcome, side effects, and cost. Increasingly, we move to the value proposition: what is the outcome for the unit cost? So, developing guidelines, that are predicated on expert opinions—so, you have a bunch of experts getting together and agreeing that their guidelines will be based on level 1 evidence from randomized trials or very well-structured trials. What’s happened in the past is, patterns of practice are sometimes from a bunch of good ol’ boys who get together and say, “I do this, what do you do? Oh, you do the same thing. Well, let’s say that’s the way to do it.” Now, we’re actually looking at the domain of evidence that’s out there, that’s published, that’s been peer-reviewed, and that’s true, and we then take into account the level of genetic variation, the level of population variation.

The Lancet Oncology commission recently published a statement that I think was terribly important: If every patient with cancer in the United States was able to have the results achieved by a college-educated white male, the death rate by cancer would drop by 25%. That’s a tremendously important statement. What it says is that in United States—and this actually isn’t restricted just to the United States—the people who have educated and resources get better results than the people who don’t. If you look in the field of disparities of care there are some less-educated African Americans and Hispanics, there are people that don’t speak the language from other groups, the elderly, the isolated poor, poverty itself will impede the ability to get great results. We’ve published data to show that patients on Medicaid and Medicare have worse results than people with private insurance.

By developing guidelines that take into account the variation of the populations that we’re treating, we should be able to improve the cancer treatment results in terms of cure rates and length of remissions, reduce the side effects, and, importantly, bring down the costs. If the medical profession doesn’t do this and doesn’t take leadership, then government functionaries will do it, and it will be predicated on misunderstanding of very complex data. So, we have to get this right and we have to do it as a profession.
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