Abstract P4-10-02: Validation of a clinical informatics system for online multidisciplinary expert opinions: Mapping treatment recommendations to the NCCN resource-Stratified framework
Authors: Badwe RA , Gupta S , Feldman N , Pramesh CS , Ramarajan N , Srivastava G , Nair N , Anderson BO 
Published: February 2018

Background: Most cancer patients in Low and Middle Income Countries (LMIC) cannot afford effective, expensive, evidence based therapies. Therefore, oncologists must tailor treatment plans to individual resource constraints. To support this, NCCN has created a Resource-Stratified Framework® (NCCN-RSF), which is an evidence-based four-tier prioritization scheme. Further, only a fraction of patients in LMIC have ready access to oncologists. In India, there are only ˜1600 oncologists for 1.8 million patients. To bridge this gap, Navya's clinical informatics based mobile ExpertApp combines learning from evidence, prior tumor board decisions, patient resource constraints, and quick review from TMC NCG oncologists to recommend tailored treatment plans to patients via an online expert opinion service. 11865 patients in 22 LMIC have reached out to receive an online expert opinion through Navya (ASCO 2017). This study maps Navya to NCCN-RSF as an evidence-based index for resource-sensitive treatment selection.

Methods: All breast cancer patients who received an online expert opinion from TMC NCG Navya between July 1st 2014 and April 30th 2017 were included. Navya systematically gathered information on patient resource constraints (such as affordability for Trastuzumab). Navya recommendations (breast and nodal surgery, radiation site and fractionation, drug and dose density etc.) were mapped to NCCN-RSF resource tiers (Basic, Core, Enhanced, Parent guideline). Reasons were categorized for Navya recommendations not present in NCCN-RSF.

Results: 616 patients (36.3% metastatic), mostly from India, received 1203 recommendations. At the specific treatment protocol level, 88.3% of Navya recommendations mapped with at least one NCCN-RSF resource tier (Table 1). 78.5% mapped to the Enhanced tier. Only 8.6% of recommendations mapped to Parent guidelines, and did not require tailoring for resource constraints. Fewer than 2% recommendations mapped to Core and none to Basic. 11.7% recommendations were not present in NCCN-RSF, for minor reasons such as substitution of a drug within the same class (35.8%) (e.g., Epirubicin for Adriamycin), dose dense protocols (14.3%) (e.g., 3 weekly Paclitaxel vs weekly Paclitaxel), and recommending Trastuzumab for less than a year for patients unable to afford year long therapy (14.3%), currently not included in NCCN-RSF.

Table 1- Mapping Navya to NCCN RSFNCCN RSF TiersHIGH LEVEL: Multimodality treatment and sequencing (1203)INTERMEDIATE: Within modality treatment categories (1188)GRANULAR: Specific treatment protocols (1140)E.g.Neoadjuvant vs Adjuvant ChemoAnthracycline vs TaxaneHypofractionation vs Standard XRTAt least one Tier98.8%±0.696%±1.188.3%±2Enhanced94.4%±1.391%±1.778.5%±2.7Core1.9%±5.61.2%±5.71.2%±5.8Parent NCCN2.4%±5.63.8%±5.68.6%±5.5

Conclusion: Navya's treatment recommendations are sensitive to resource constraints and map to peer reviewed and evidence based NCCN RSF, primarily at the Enhanced tier. Navya's clinical informatics based online service scales access to resource constrained treatment selection for large numbers of patients in LMIC without easy access to oncologists.

Citation Format: Badwe RA, Gupta S, Feldman N, Pramesh CS, Ramarajan N, Srivastava G, Nair N, Anderson BO. Validation of a clinical informatics system for online multidisciplinary expert opinions: Mapping treatment recommendations to the NCCN resource-Stratified framework [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-02.