The National Comprehensive Cancer Network (NCCN) brings together 28 of the leading cancer centers devoted to patient care, research and education. NCCN is the global leader in advancing and setting the standards for high-quality cancer care.
Dr. William Gradishar joins the show to share how Northwestern Medicine plays a critical role in the development of resources that guide cancer care around the world.
Selected Podcast
The role of Northwestern Medicine’s Lurie Cancer Center in Developing NCCN Guidelines
Featured Speaker:
Learn more about William Gradishar, MD
William Gradishar, MD
William Gradishar, MD, is chief of the Division of Hematology and Oncology in the Department of Medicine and the deputy director for the Clinical Network for the Robert H. Lurie Comprehensive Cancer Center at Northwestern University. His clinical research focuses on the development of novel therapies for the treatment of breast cancer.Learn more about William Gradishar, MD
Transcription:
The role of Northwestern Medicine’s Lurie Cancer Center in Developing NCCN Guidelines
Melanie Cole (Host): The National Comprehensive Cancer Network brings together 28 of the leading cancer centers devoted to patient care, research, and education. NCCN is the global leader in advancing and setting the standards for high quality cancer care. Here to tell us about that today is Dr. William Gradishar. He’s the chief in the Division of Hematology and Oncology in the Department of Medicine and the deputy director for the clinical network for the Robert H. Lurie Comprehensive Cancer Center at Northwestern University. Dr. Gradishar, I’m so glad to have you with us today. Tell us a little bit about your role with NCCN, and how Northwestern Medicine as a whole is involved with developing some of these guidelines.
William Gradishar, MD (Guest): Northwestern has been part of NCCN since its inception two decades ago, and we have a number of our faculty who play critical roles in the leadership of the NCCN as well as having leadership roles in each of the individual disease site guidelines—so for lung cancer, for GI cancer, for breast cancer, which I chair, and all the other diseases. So, we’ve had a very significant role in developing the guidelines that physicians not only in the United States, but around the world, principally look to as evidence-based ways of knowing what’s best for their patients, and the other thing that’s evolved from these guidelines is actually payors, insurance companies look to them as well because they’re vetted as evidence-based guidelines for what is the most appropriate and optimal care for any given patient. So, many of the people that I mentioned who are on the faculty serve in these roles, which are voluntary along with representatives from all of the other cancer centers that make up, you know, their part of the consortium, and this is an effort that’s ongoing. It’s a dynamic process. It’s not a one-off. So, we meet in person or by teleconference frequently when new data becomes available so that we can update the guidelines in every discipline. So, they’re really very contemporary, and they represent the best information for doctors and patients.
Host: So, that’s updating. Tell us a little bit about the process for developing the guidelines for NCCN. What makes an NCCN Cancer Center?
Dr. Gradishar: What makes an NCCN Cancer Center is generally these are some of the top cancer centers in the United States. You can predictably sort of recite—among those are places like the M.D. Anderson, Memorial Sloan Kettering, Yale, Hopkins, us, you know, and a variety of other places, and it was a much smaller pool of institutions at the outset, and as I said, we were among the founding members of the NCCN, and each year that goes by, there are applications for other institutions to join, and they try to go slowly, and part of the reason for that is because the guideline process is a very laborious thing. You know, for instance, with my area, breast cancer, we meet physically once a year, and we have representatives from all the disciplines: surgery, medical oncology, radiation oncology, pathology. You name it, anybody who touches breast cancer patients are represented in the room, and each institution has the ability to send one representative. So, we have a large contingent of people that look at the guidelines that currently exist, and interestingly, if you went back to the first year we did this, the guidelines are very simplistic. This is over 20 years ago, and each year and each time we meet, we refine them. So, they’ve become very sophisticated, you know. Instead of a three-page guideline, it’s now 50 pages, and each year we look at what new evidence exists. The process in the room is actually that we create an agenda. We assign faculty members to look at specific areas, and if there’s debate about what is best, the evidence is presented and then the group as a whole votes on whether a change should be implemented to the guidelines, and then the guidelines are updated online and are available to the broader world once that deliberation is completed, and you know, we’re very open about who sits on the guideline committee. We look at who has conflicts so that we don’t run into issues about how the guidelines are generated, and you know, it’s a very open process with respect to how we arrive at our conclusions.
Host: That is so interesting. Thank you for that explanation of the process, and as you are specializing in breast cancer, NCCN recently updated guidelines for breast cancer treatment options including immunotherapy. Explain a little bit about this update and what it means for patient care.
Dr. Gradishar: Immunotherapy has been around now for several years and used in other disease sites where it’s shown to improve patient outcome—things like melanoma, lung cancer, and some other diseases. In breast cancer the utility of immune therapy hasn’t been quite as clear, but there have been recently at least a couple of clinical trials, particularly in patients with metastatic disease, where the use of immune therapy in addition to chemotherapy in a select group of patients with metastatic disease. So, it’s not all patients. They have to have very specific characteristics. May enhance the outcome of patients over what chemotherapy alone can achieve. So, immune therapy finally has a foothold in breast cancer, and there are innumerable trials still ongoing to evaluate it in earlier stages of disease. So, we’ll have more information as time goes on, but that’s an example where very recent data—and that’s within the last six months or so—has been reported and because it changes how we practice, this is something that needs to be updated in the guideline very quickly so that physicians have, in a sense, the imprimatur of the NCCN guidelines to make their choice of therapy for a patient. Again, there are other examples—whether it’s with anti-hormonal therapy or anti-HER-2 therapy or new things that develop and become presented at national or international meetings and published very quickly. We want to make sure that our guidelines are very contemporaneous with that data so that they reflect the best therapies that are available to patients anywhere in the world.
Host: Fascinating and ever evolving. So, in addition to developing guidelines for specific types of cancer, doctor, NCCN also develops treatment recommendations for country’s unique needs. Northwestern Medicine and NCCN recently began working together to improve cancer care in Bolivia. Can you tell us a little bit about that project?
Dr. Gradishar: Sure. So, the NCCN has had a long-standing interest in making their guidelines available around the world. Obviously in other parts of the world, they don’t necessarily have the same resources that are available in the United States—or say in Western Europe. So, we have to take into account and be sensitive to the fact that our guidelines are not something that can be implemented even in the best of situations in many parts of the world. So, we’ve developed resource stratified guidelines and going from very basic to mid-level to very sophisticated guidelines depending on the country that’s involved, and we’ve done this, you know, for instance in Spain, which might be viewed as very similar to the United States. We’ve done it in the Middle East. We’ve done it in Africa, and the most recently, we were in Bolivia where we went through the same exercise of looking at where our guidelines exist and keep in mind the NCCN guidelines are developed principally for the United States, and once they’re established and implemented, it’s with that information that then we look at how we can adopt them in other countries, and you know, an example, not everybody in Ethiopia or Bolivia is going to have access to a PET scan or an MRI scan, or they may not have access to the immune therapy that we were talking about a moment ago. So, we have to think about what the constraints are within their own region or country and then look at our guidelines and see what’s appropriate for them. It would still be viewed as acceptable care under the constraints that they have with the resources available, and as a result, we then modify the guidelines in concert with the country and the NCCN so that they reflect the care that can be delivered in that particular country, and I think that, again, having a very evidence-based approach even if you don’t have access to everything, enhances the care even in countries—as an example, like Bolivia or in the Middle East where they don’t have access to everything or there are limited resources in certain situations. They’re still able to optimize what they are able to deliver to their patients.
Host: Wow. You know, that really is amazing, and the way that you lay that out for us, doctor, explains pretty much my next question for you is why is it important to you to be a part of an organization like NCCN? You seem to be doing such great work all over the world.
Dr. Gradishar: Well, I think one of the things that we all enjoy, obviously, as physicians—we take care of patients in our own institution, but you know, when we see an individual patient, we clearly have gratification with having hopefully an impact on that patient and their family, but in a broader context, being able to impact in a country completely different than our own or in a region completely different than our own and hopefully by extension enhancing the care that’s delivered by the physicians in that region who utilize the guidelines that we put so much effort into developing. That gives us a broader affect than just an individual patient. So, I think most of us find that one of the satisfying parts of being part of the NCCN.
Host: I would certainly think so. What a great topic. As we wrap up, what else would you like other providers to know about The National Comprehensive Cancer Network and these guidelines that you’ve been discussing so thoroughly today.
Dr. Gradishar: So, the guideline process is something that is very deliberate. It requires a great deal of work. The port product every time we finish is not perfect. So, that’s why it’s something that’s dynamic and there are guidelines that other organizations put out, and their process is a little bit different than the one the NCCN uses, and I think the biggest strength that we have is that it is a multi-institutional approach with every modality and every specialist involved, and it’s also something that’s updated with great frequency to reflect the progress that’s made in an individual disease. So, as a result, something that you might look at, at a guideline in 2015, may have been changed four or five times since that point bringing us up to 2019, and it really reflects in real time changes that are evolving, and hopefully improving the care of patients. So, I think that’s what the strength of the NCCN is.
Host: Well, it certainly is very dynamic, as you say. Thank you so much, Dr. Gradishar, for joining us today and telling us all about The National Comprehensive Cancer Network, and that wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine, please visit our website at nm.org to get connected with one of our providers. If you found this podcast as interesting as I did, please share with other providers. Share on your social media. Share with your patients and be sure not to miss all the other fascinating podcasts in our library. Until next time, I’m Melanie Cole.
The role of Northwestern Medicine’s Lurie Cancer Center in Developing NCCN Guidelines
Melanie Cole (Host): The National Comprehensive Cancer Network brings together 28 of the leading cancer centers devoted to patient care, research, and education. NCCN is the global leader in advancing and setting the standards for high quality cancer care. Here to tell us about that today is Dr. William Gradishar. He’s the chief in the Division of Hematology and Oncology in the Department of Medicine and the deputy director for the clinical network for the Robert H. Lurie Comprehensive Cancer Center at Northwestern University. Dr. Gradishar, I’m so glad to have you with us today. Tell us a little bit about your role with NCCN, and how Northwestern Medicine as a whole is involved with developing some of these guidelines.
William Gradishar, MD (Guest): Northwestern has been part of NCCN since its inception two decades ago, and we have a number of our faculty who play critical roles in the leadership of the NCCN as well as having leadership roles in each of the individual disease site guidelines—so for lung cancer, for GI cancer, for breast cancer, which I chair, and all the other diseases. So, we’ve had a very significant role in developing the guidelines that physicians not only in the United States, but around the world, principally look to as evidence-based ways of knowing what’s best for their patients, and the other thing that’s evolved from these guidelines is actually payors, insurance companies look to them as well because they’re vetted as evidence-based guidelines for what is the most appropriate and optimal care for any given patient. So, many of the people that I mentioned who are on the faculty serve in these roles, which are voluntary along with representatives from all of the other cancer centers that make up, you know, their part of the consortium, and this is an effort that’s ongoing. It’s a dynamic process. It’s not a one-off. So, we meet in person or by teleconference frequently when new data becomes available so that we can update the guidelines in every discipline. So, they’re really very contemporary, and they represent the best information for doctors and patients.
Host: So, that’s updating. Tell us a little bit about the process for developing the guidelines for NCCN. What makes an NCCN Cancer Center?
Dr. Gradishar: What makes an NCCN Cancer Center is generally these are some of the top cancer centers in the United States. You can predictably sort of recite—among those are places like the M.D. Anderson, Memorial Sloan Kettering, Yale, Hopkins, us, you know, and a variety of other places, and it was a much smaller pool of institutions at the outset, and as I said, we were among the founding members of the NCCN, and each year that goes by, there are applications for other institutions to join, and they try to go slowly, and part of the reason for that is because the guideline process is a very laborious thing. You know, for instance, with my area, breast cancer, we meet physically once a year, and we have representatives from all the disciplines: surgery, medical oncology, radiation oncology, pathology. You name it, anybody who touches breast cancer patients are represented in the room, and each institution has the ability to send one representative. So, we have a large contingent of people that look at the guidelines that currently exist, and interestingly, if you went back to the first year we did this, the guidelines are very simplistic. This is over 20 years ago, and each year and each time we meet, we refine them. So, they’ve become very sophisticated, you know. Instead of a three-page guideline, it’s now 50 pages, and each year we look at what new evidence exists. The process in the room is actually that we create an agenda. We assign faculty members to look at specific areas, and if there’s debate about what is best, the evidence is presented and then the group as a whole votes on whether a change should be implemented to the guidelines, and then the guidelines are updated online and are available to the broader world once that deliberation is completed, and you know, we’re very open about who sits on the guideline committee. We look at who has conflicts so that we don’t run into issues about how the guidelines are generated, and you know, it’s a very open process with respect to how we arrive at our conclusions.
Host: That is so interesting. Thank you for that explanation of the process, and as you are specializing in breast cancer, NCCN recently updated guidelines for breast cancer treatment options including immunotherapy. Explain a little bit about this update and what it means for patient care.
Dr. Gradishar: Immunotherapy has been around now for several years and used in other disease sites where it’s shown to improve patient outcome—things like melanoma, lung cancer, and some other diseases. In breast cancer the utility of immune therapy hasn’t been quite as clear, but there have been recently at least a couple of clinical trials, particularly in patients with metastatic disease, where the use of immune therapy in addition to chemotherapy in a select group of patients with metastatic disease. So, it’s not all patients. They have to have very specific characteristics. May enhance the outcome of patients over what chemotherapy alone can achieve. So, immune therapy finally has a foothold in breast cancer, and there are innumerable trials still ongoing to evaluate it in earlier stages of disease. So, we’ll have more information as time goes on, but that’s an example where very recent data—and that’s within the last six months or so—has been reported and because it changes how we practice, this is something that needs to be updated in the guideline very quickly so that physicians have, in a sense, the imprimatur of the NCCN guidelines to make their choice of therapy for a patient. Again, there are other examples—whether it’s with anti-hormonal therapy or anti-HER-2 therapy or new things that develop and become presented at national or international meetings and published very quickly. We want to make sure that our guidelines are very contemporaneous with that data so that they reflect the best therapies that are available to patients anywhere in the world.
Host: Fascinating and ever evolving. So, in addition to developing guidelines for specific types of cancer, doctor, NCCN also develops treatment recommendations for country’s unique needs. Northwestern Medicine and NCCN recently began working together to improve cancer care in Bolivia. Can you tell us a little bit about that project?
Dr. Gradishar: Sure. So, the NCCN has had a long-standing interest in making their guidelines available around the world. Obviously in other parts of the world, they don’t necessarily have the same resources that are available in the United States—or say in Western Europe. So, we have to take into account and be sensitive to the fact that our guidelines are not something that can be implemented even in the best of situations in many parts of the world. So, we’ve developed resource stratified guidelines and going from very basic to mid-level to very sophisticated guidelines depending on the country that’s involved, and we’ve done this, you know, for instance in Spain, which might be viewed as very similar to the United States. We’ve done it in the Middle East. We’ve done it in Africa, and the most recently, we were in Bolivia where we went through the same exercise of looking at where our guidelines exist and keep in mind the NCCN guidelines are developed principally for the United States, and once they’re established and implemented, it’s with that information that then we look at how we can adopt them in other countries, and you know, an example, not everybody in Ethiopia or Bolivia is going to have access to a PET scan or an MRI scan, or they may not have access to the immune therapy that we were talking about a moment ago. So, we have to think about what the constraints are within their own region or country and then look at our guidelines and see what’s appropriate for them. It would still be viewed as acceptable care under the constraints that they have with the resources available, and as a result, we then modify the guidelines in concert with the country and the NCCN so that they reflect the care that can be delivered in that particular country, and I think that, again, having a very evidence-based approach even if you don’t have access to everything, enhances the care even in countries—as an example, like Bolivia or in the Middle East where they don’t have access to everything or there are limited resources in certain situations. They’re still able to optimize what they are able to deliver to their patients.
Host: Wow. You know, that really is amazing, and the way that you lay that out for us, doctor, explains pretty much my next question for you is why is it important to you to be a part of an organization like NCCN? You seem to be doing such great work all over the world.
Dr. Gradishar: Well, I think one of the things that we all enjoy, obviously, as physicians—we take care of patients in our own institution, but you know, when we see an individual patient, we clearly have gratification with having hopefully an impact on that patient and their family, but in a broader context, being able to impact in a country completely different than our own or in a region completely different than our own and hopefully by extension enhancing the care that’s delivered by the physicians in that region who utilize the guidelines that we put so much effort into developing. That gives us a broader affect than just an individual patient. So, I think most of us find that one of the satisfying parts of being part of the NCCN.
Host: I would certainly think so. What a great topic. As we wrap up, what else would you like other providers to know about The National Comprehensive Cancer Network and these guidelines that you’ve been discussing so thoroughly today.
Dr. Gradishar: So, the guideline process is something that is very deliberate. It requires a great deal of work. The port product every time we finish is not perfect. So, that’s why it’s something that’s dynamic and there are guidelines that other organizations put out, and their process is a little bit different than the one the NCCN uses, and I think the biggest strength that we have is that it is a multi-institutional approach with every modality and every specialist involved, and it’s also something that’s updated with great frequency to reflect the progress that’s made in an individual disease. So, as a result, something that you might look at, at a guideline in 2015, may have been changed four or five times since that point bringing us up to 2019, and it really reflects in real time changes that are evolving, and hopefully improving the care of patients. So, I think that’s what the strength of the NCCN is.
Host: Well, it certainly is very dynamic, as you say. Thank you so much, Dr. Gradishar, for joining us today and telling us all about The National Comprehensive Cancer Network, and that wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine, please visit our website at nm.org to get connected with one of our providers. If you found this podcast as interesting as I did, please share with other providers. Share on your social media. Share with your patients and be sure not to miss all the other fascinating podcasts in our library. Until next time, I’m Melanie Cole.