Evaluation of a National Comprehensive Cancer Network Guidelines-Based Decision Support Tool in Patients With Non-Small Cell Lung Cancer: A Nonrandomized Clinical Trial

Abstract

Importance: The association of guideline-based decision support with the quality of care in patients with non-small cell lung cancer (NSCLC) is not known.

Objective: To evaluate the association of exposure to the National Comprehensive Cancer Center (NCCN) guidelines with guideline-concordant care and patients' decisional conflict.

Design, setting, and participants: A nonrandomized clinical trial, conducted at a tertiary care academic institution, enrolled patients from February 23, 2015, to September 28, 2017. Data analysis was conducted from July 19, 2019, to April 22, 2020. A cohort of 76 patients with NSCLC seen at diagnosis or disease progression and a retrospective cohort of 157 patients treated before the trial were included. Adherence to 6 NCCN recommendations were evaluated: (1) smoking cessation counseling, (2) adjuvant chemotherapy for patients with stage IB to IIB NSCLC after surgery, (3) pathologic mediastinal staging in patients with stage III NSCLC before surgery, (4) pathologic mediastinal staging in patients with stage III NSCLC before nonsurgical treatment, (5) definitive chemoradiotherapy for patients with stage III NSCLC not having surgery, and (6) molecular testing for epidermal growth factor receptor and anaplastic lymphoma kinase alterations for patients with stage IV NSCLC. Subgroup analysis was conducted to compare the rates of guideline concordance between the prospective and retrospective cohorts. Secondary end points included decisional conflict and satisfaction.

Interventions: An online tool customizing the NCCN guidelines to patients' clinical and pathologic features was used during consultation, facilitated by a trained coordinator.

Main outcomes and measures: Concordance of practice with 6 NCCN treatment recommendations on NSCLC and patients' decisional conflict.

Results: Of the 76 patients with NSCLC, 44 were men (57.9%), median age at diagnosis was 68 years (interquartile range [IQR], 41-87 years), and 59 patients (77.6%) had adenocarcinoma. In the retrospective cohort, 91 of 157 patients (58.0%) were men, median age at diagnosis was 66 years (IQR, 61-65 years), and 105 patients (66.9%) had adenocarcinoma. After the intervention, patients received more smoking cessation counseling (4 of 5 [80.0%] vs 1 of 24 [4.2%], P < .001) and less adjuvant chemotherapy (0 of 7 vs 7 of 11 [63.6%]; P = .012). There was no significant change in mutation testing of non-squamous cell stage IV disease (20 of 20 [100%] vs 48 of 57 [84.2%]; P = .10). There was no significant change in pathologic mediastinal staging or initial chemoradiotherapy for patients with stage III disease. After consultation with the tool, decisional conflict scores improved by a median of 20 points (IQR, 3-34; P < .001).

Conclusions and relevance: The findings of this study suggest that exposure to the NCCN guidelines is associated with increased guideline-concordant care for 2 of 6 preselected recommendations and improvement in decisional conflict.

Trial registration: ClinicalTrials.gov Identifier: NCT03982459.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Gubens reported receiving personal fees from Novartis, AstraZeneca, Mersana, Genentech/Roche, Bristol-Myers Squibb, Heron, Boehringer Ingelheim, Takeda, BeyondSpring, and Inivata outside the submitted work. Dr Blakely reported receiving grants from Novartis, AstraZeneca, Mirati, Ignyta, MedImmune, Takeda, Spectrum, and Roche and personal fees from Revolution Medicines, Amgen, and Foundation Medicine outside the submitted work. Dr Jablons reported having a patent to Multigene Assay for Lung Cancer pending, licensed, and with royalties paid. Dr Jahan reported receiving grants from AstraZeneca, Aduro Pharmaceuticals, Bristol-Myers Squibb, Bayer, Alerta Pharmaceuticals, Eli Lilly and Company, Epizyme Pharmaceuticals, Kadmon Pharmaceuticals, Polaris Pharmaceuticals, Springworks Therapeutics, and Trizell Ltd outside the submitted work. Dr Wang reported grants from the US Department of Defense, Damon Runyon Foundation, Conquer Cancer Foundation, and Lung Cancer Research Foundation outside the submitted work. Ms Dunbar reported employment at Gilead Sciences Inc. Dr Wong reported receiving research support from Genentech/Roche outside the submitted work. Dr Yom reported receiving grants from Genentech, Merck, Bristol-Myers Squibb, and BioMimetix outside the submitted work and royalties for book chapters from UpToDate and Springer. No other disclosures were reported.

Figures

Figure 1.. Example of the Web-Based Tool Interface for a Patient With a T2aN2 Tumor Resected With Negative Margins

The patient (or research coordinator) inputs clinical variables in the left panel. Based on that information, treatment options consistent with National Comprehensive Cancer Center (NCCN) guidelines and the timeline representation of the overall treatment course are generated. UCSF indicates University of California, San Francisco.

Figure 2.. Waterfall Plot Showing Changes in Decisional Conflict Scale (DCS) Scores

A negative change suggests decreased decisional conflict. Seven patients experienced an increase in their DCS score after consultation with the web-based tool, while 3 patients experienced no change in DCS score.