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Evidence-Based Oncology April 2016
ASCO Policy Statement on Clinical Pathways in Oncology: Why Now?
Robin Zon, MD, FACP, FASCO
The Oncology Medical Home - Beyond Clinical Pathways
Daniel P. McKellar, MD, FACS; Charles Bane, MD; M. Asa Carter, MBA, CTR; Allison Knutson, CCRP; Vicki Chiappetta, RHIA, CTR; Bo Gamble
Recommendations for the Role of Clinical Pathways in an Era of Personalized Medicine
Alan J. Balch, PhD; Charles M. Balch, MD; Al Benson III, MD; Deborah Morosini, MD; Robert M. Rifkin, MD; Loretta A. Williams, PhD
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Cancer Care Pathways: Hopes, Facts, and Concerns
Bernardo Haddock Lobo Goulart, MD, MS
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Conference Coverage: ACCC
Surabhi Dangi-Garimella, PhD

Cancer Care Pathways: Hopes, Facts, and Concerns

Bernardo Haddock Lobo Goulart, MD, MS
Cancer pathways can potentially improve patient outcomes and reduce costs. Recent concerns about pathway adoption deserve attention, including excessive administrative burden to clinics.

Why Use Cancer Care Pathways?

The oncology landscape is rapidly changing, in great part due to unprecedented innovations in diagnostic and treatment technologies.Ironically, the same advances in cancer therapeutics that now benefit many patients also dramatically increase the complexity and costs of oncologic care.The latter have forced stakeholders to develop new strategies to provide high-quality, state-of-the-art cancer care while simultaneously bending the cost curve.Among the several new models of cancer care delivery and reimbursement that are currently under evaluation, cancer care pathways (CCPs) are emerging as a strategy to provide evidence-based oncology care at lower costs through reductions in unnecessary treatment variations.4

The rationale for adopting CCPs departs from the following assumptions:
  1. Cancer care and costs vary substantially across clinics and providers, a concern that many studies have confirmed to be true.5-8
  2. Low-value treatments account for at least a fraction of the variation, including the use of costly, but marginally effective, drug regimens.9
  3. Adoption of CCPs can change physician behavior to prioritize the use of high-value evidence-based treatments, thereby improving patient outcomes and reducing the use of costly therapies that are either marginally effective or more toxic.10
To the extent that these assumptions hold true, CCPs have great potential to succeed as a model for the delivery of high-value cancer care. But do they hold true?
As an increasing number of cancer care clinics are adopting CCPs, either voluntarily or as required by payers, an early look at pathways’ performance becomes necessary to inform stakeholders whether the investments in CCPs have resulted in the expected returns and what efforts need to take place to optimize pathway development, if any.
Our goal here is to discuss the impact of adoption of CCPs on treatment variation, patient outcomes, and cancer care costs, based on published literature. This review focuses on commercially available CCPs (ie, computer-based treatment decision programs offered by vendors as part of oncology management programs) because most of the available literature pertains to this particular type of pathway. Several academic cancer centers have developed their own CCPs for internal use, including the University of Washington, Dana-Farber Cancer Institute, and University of Tennessee, to name a few.11-13 A review of these programs is beyond the scope of this article, as very little published literature is available to inform their performance. Although this review is by no means comprehensive or exhaustive, it provides some insights about the promises and concerns regarding adoption of CCPs.
The Process of Developing Cancer Care Pathways

To ensure an informed discussion of how CCPs impact outcomes, a brief explanation is in order to define CCPs and clarify the process by which pathways are developed. Pathways consist of complex electronic treatment decision support tools that provide evidence-based treatment recommendations to physicians at the point-of-care for individual patients. These tools are often integrated with electronic health records (EHRs) in a manner that allows managers to evaluate whether the treatments actually delivered were concordant or discordant with pathway recommendations. This information is relevant for monitoring pathway adherence. Pathways, in general, cover several cancers at all stages. With a primary focus on drug regimens, some CCP programs have also developed content for supportive care and radiation therapy.10,14
CCP programs typically apply a hierarchical order of criteria to select the treatments to be included in the pathways. The first criterion is treatment efficacy, wherein regimens of superior efficacy receive top priority for pathway inclusion. As a side note, the available literature does not clearly specify the disease endpoints used to measure efficacy (eg, overall vs progression-free survival, response rates, etc.). Toxicity is the next selection criterion applied to regimens of similar efficacy; those with lower toxicity and similar efficacy receive priority. Drug cost is the third and last selection criterion; pathways prioritize regimens of lower cost when efficacy and toxicity are similar.
Most CCPs emanate from collaborative efforts involving physician network groups, healthcare payers, and oncology management–program consulting firms. Physicians elect disease-specific committees that appraise the current evidence and select the treatments for pathway inclusion. Leaders of several CCP programs have publically declared that the committees offer an opportunity to all physicians using the pathways to comment on the contents and participate in the process of pathway treatment selection.10,14,15 The committees are also in charge of continuously updating pathway contents—as evidence becomes available—to support the use of novel therapies.
Once physician committees decide on the contents of a pathway, the oncology management programs integrate the treatments into the electronic supporting tools and offer technical assistance to network physicians using the pathways in daily practice. Oncology management programs also assist clinics in reporting pathway adherence to healthcare payers, and help monitor patient outcomes and costs. Payers offer financial incentives to maximize pathway adherence, usually in the form of higher fees for on-pathway drugs and by increasing the reimbursement for evaluation and management charges for adherent physicians.
Cancer Care Pathways and Treatment Variation

The central hypothesis for CCP use is that adherence to pathways reduces costs and maintains quality of care by curtailing the use of unnecessary and costly oncologic treatments. Surprisingly, there is very scant published evidence to support or reject this hypothesis. After a short PubMed literature search, I could only retrieve 1 article reporting on the impact of the Cardinal Health Specialty Solutions (formerly, P4 Healthcare) pathway on treatment variations. The study compared the number of chemotherapy regimens used for breast, lung, and colorectal cancers in the year preceding and the year following pathway implementation, in several practices located in Michigan.10

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