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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
Clinical Pathways: A Systems Approach Toward More Patient-Centric Cancer Care Delivery
Joseph Alvarnas, MD
Are Oncology Clinical Pathways a Value Framework in the Making?
Surabhi Dangi-Garimella, PhD
The Healthcare System's Struggle With Oncology Care Pathways
Surabhi Dangi-Garimella, PhD
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.
Physicians used 168 and 136 distinct regimens in the years pre- and post-pathways implementation, respectively, which represents an 8% absolute reduction in treatment variation (Table). Interestingly, 10% of the study population accounted for 81% of the reduction in the number of drug regimens used, suggesting that a minority of patients drive most of the treatment variation, perhaps because of higher disease complexity. Although this single report does not provide any firm conclusions about the effects of pathways on treatment variation, the reduction in the number of chemotherapy regimens used was quite modest. An important point to note is that the report does not provide any information on the cost of the chemotherapy regimens avoided to establish a causal relationship between reductions in treatment variation and costs.

Cancer Care Pathways and Patient Outcomes

At least 1 report indicates that adherence to CCPs reduces the number of emergency department (ED) visits and hospital admissions for treatment-related complications (Table). Kreys et al evaluated the effect of adherence to the Cardinal Health Specialty Solutions supportive care pathways on ED visits and hospitalizations for neutropenia, anemia, and chemotherapy-induced nausea and vomiting in patients with breast, lung, and colorectal cancers. Compared with patients who received off-pathway supportive care, pathway adherence was associated with a 15% absolute reduction in ED visits and hospitalizations for neutropenia (adjusted odds-ratio, 0.42; 95% CI, 0.30-0.58).16 The study demonstrated no clinically or statistically significant differences in admissions for anemia or chemotherapy-induced nausea and vomiting. Pathway adherence was associated with lower expenditures for hospitalizations to manage neutropenia and anemia, and with lower expenditures related to the use of granulocyte colony–stimulating factors and antiemetics.
Current evidence suggests that adherence to CCPs results in either a neutral or favorable effect on survival outcomes, depending on the disease and treatment setting (adjuvant vs metastatic) (Table). Using EHR and pathway reporting data, Neubauer et al conducted a cost-effectiveness analysis of adherence to Level I Pathways among 1409 patients with non-small cell lung cancer (NSCLC) treated at several US Oncology network clinics. After adjusting for patient characteristics and line of therapy, the study showed no statistically significant difference in 1-year overall survival (OS) (HR, 0.95; 95% CI, 0.77-1.16) between patients treated on- versus off-pathway.17 Hoverman et al also utilized EHR and claims data to compare disease-free survival (DFS) and OS in patients treated on versus off Level I Pathways with adjuvant and palliative chemotherapy for stage III and IV colorectal cancer, respectively.15 Pathway adherence was associated with a substantial increase in DFS (HR, 4.98; 95% CI, 2.11-11.74 for non-adherence) in the adjuvant setting and prolongation of OS (HR, 1.57; 95% CI, 1.04-2.39 for non-adherence) in the metastatic setting, respectively.

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