Should Cost of Care be Considered in a Clinical Practice Guideline?

The global increase in cancer has fueled a large investment into research for more effective treatment strategies.The payoff from this investment has been a knowledge explosion that is overwhelming to the average oncologist.In response, a knowledge-synthesis industry has developed that uses the tools of systematic searches and standardized analytic processes to make sense of the large volume of frequently contradictory literature.Experts review the evidence and provide interpretation in the context of their professional values to guide their colleagues in clinical practice.Typically, guideline developers focus on questions of clinical effectiveness and efficacy, but rarely, if ever, consider the budgetary impacts of implementing the guideline or the cost-effectiveness of a new treatment.This issue of JNCCN focuses on guidelines for small cell and non-small cell lung cancer produced by the NCCN; neither of these guidelines mentions cost.In this commentary, we look at guideline development processes in general and specifically in Ontario, Canada, to consider the question: Is this an important omission or an irrelevancy?For more than a decade, a multidisciplinary Lung Disease Site Group (LDSG) in the province of Ontario, Canada, has developed practice guidelines through Cancer Care Ontario's Program in Evidence-Based Care (PEBC), based at McMaster University.The LDSG has produced 25 clinical practice guidelines (CPGs), including 12 for non-small cell lung cancer and 4 for small cell lung cancer.Guidelines were also developed for each of the 8 new chemotherapeutic agents introduced since 1995 for the treatment of lung cancer, the radiotherapeutic management of lung cancer (10 guidelines), and the management of less common intrathoracic tumours (mesothelioma, thymoma).Guideline development has followed the practice guideline development cycle described by Browman et al. 1 Guideline development begins with a systematic review of the Englishlanguage literature with a focus on randomized clinical trials.The PEBC search strategy purposefully does not include a search for articles on cost or cost-effectiveness.Although a consideration of the cost-effectiveness of new interventions is not part of the formal process of guideline development, members of the LDSG sometimes raise concerns that expensive drugs may not be funded through the provincial drug funding mechanism.The draft guideline goes through a structured process of external review whereby clinicians involved in providing care to patients with lung cancer ensure that no relevant data were overlooked, provide comment on the level of support for the recommendations, and assist in knowledge transfer.2,3 This process asks practitioners to consider barriers to guideline implementation, and cost of the intervention is often a reported concern.The final guideline is submitted as a manuscript for publication and posted on Cancer Care Ontario's Web site (www.cancercare.on.ca).The original intent of the CPGs was to develop a convenient source of highquality information to guide clinicians providing care to patients.However, soon after the program was established, the guidelines became the key clinical data summary for those involved in making funding decisions about new anticancer drugs 224

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