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Evidence-Based Oncology April 2016
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Cancer Care Pathways: Hopes, Facts, and Concerns
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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.
Cancer Care Pathways and Direct Medical Costs 

Cost is perhaps the outcome measure for which the evidence is most robust to support the use of CCPs. At least 3 economic evaluations suggest that adherence to CCPs reduces direct medical costs (Table). The cost-effectiveness analysis of adherence to Level I Pathways for NSCLC found that total mean direct medical costs were 35% lower in patients treated on- versus off-pathway ($18,042 vs $27,737 per patient), suggesting that pathway adherence saves costs in this disease setting.17 The study by Hoverman et al showed mean reductions in total direct medical costs of $52,641 and $60,163 associated with adherence to Level I Pathways for adjuvant and metastatic treatment of colorectal cancer, respectively.15 Chemotherapy costs accounted for most of the cost reductions in this study.
In a time series study that compared 57 practices that participated in the Cardinal Health Specialty Solutions pathway with 43 non-participant practices, pathway participation was associated with an aggregate $8.5 million in cost savings 1 year after pathway implementation, the majority of the savings being related to drug expenditures.18 In a study of the same pathway implemented in different hospitals, drug expenditures did not differ before and after pathway implementation, although mean hospitalization costs were reduced by $1400 per patient.19
Collectively, these studies provide preliminary evidence that high adherence to CCPs can improve patient outcomes and reduce costs. The effect of pathways on treatment variation remains unclear, however. The results seem to vary considerably across hospital, disease, and treatment settings. Although the analyses show a consistent favorable impact of CCP adherence on total costs, the evaluations provide conflicting data as to the components of care responsible for the cost savings (ie, chemotherapy use, hospitalization, or supportive care).
Areas of Uncertainty and Concerns 

These published studies contain several limitations that preclude an accurate estimate of the impact of CCPs on patient outcomes and costs. All study designs are observational and subject to selection bias—patients treated off-pathway may systematically differ from patients treated on-pathway with respect to characteristics that affect outcomes. Pre- and post-type of study designs do not account for changes in practice that occur over time, particularly the introduction of new expensive drugs in the market. This limitation may lead to an underestimate of any cost savings generated by adherence to CCPs. Ascertainment bias may also prevent accurate comparisons, as the availability of clinical data may differ between patients treated on- and off-pathways, respectively. Virtually no data inform about pathway adherence and its impact on patient outcomes for less common malignancies, although some programs intend to gradually cover additional cancers.14 Finally, no studies have evaluated how CCPs affect other important patient-reported outcomes (PROs), such as quality of life, symptoms, and satisfaction with care.
The oncology community has also voiced concerns about potential detrimental effects of pathway adoption on patient care and clinic workflow. The American Society of Clinical Oncology recently released a statement that outlines some of these concerns.20 Many oncology clinics are experiencing an excessive administrative burden imposed by payers that require frequent reporting of pathway adherence. This burden is particularly disruptive for clinics that have to report adherence to multiple pathways for the same disease because each payer requires the use of its own preferred pathway. Some oncologists and patient advocates worry that the process of pathway development is not as transparent as the leadership of CCPs claim it to be. Other concerns include a possible negative impact of pathway adoption on the patient–physician relationship if adherence forces physicians to significantly narrow treatment options, as well as a detrimental effect on the outcomes of patients treated off-pathways if pre-authorizations or other excessive administrative hurdles prevent timely initiation of therapy.
Future Directions

Physician adherence is critical for the successful implementation of CCPs, which implies that efforts to develop CCPs should include all physicians affected by them. Physicians need to have their voices heard in order to feel comfortable with using pathways in their daily routine.
Ideally, randomized controlled trials would provide more robust evidence on the effectiveness and economic impact of CCPs. In reality, such trials are difficult to conduct and unlikely to ever materialize because many clinics could not agree with randomization to either the intervention (pathway) or control (no pathway) arms. The oncology community will likely have to rely on the synthesis of the evidence generated by observational studies to develop a better understanding of how pathways affect variation in care, costs, and outcomes. Future investigations should focus on risk-adjusted comparisons between practices that participate in pathways versus practices that decide not to do so. Although still imperfect, this type of comparison is probably less subject to selection bias than studies that measure pathway effectiveness based on adherence.
If CCPs are to become a sustainable model of care delivery, the administrative burden of managing them has to be minimal. Payers cannot realistically expect that oncology clinics will be able to report adherence to multiple pathways for the same cancer, and even less so for different cancers, only because payers elect to use a particular pathway of their choice. A much more rational approach is to leave the choice of pathway to the oncology clinics and let the clinics manage 1 pathway for each cancer type.
Finally, the development of CCPs should include more than recommendations for drug regimens, in order to maximize the benefits of pathway use. Pathway recommendations need to cover the entire spectrum of cancer management—from early detection to end-of-life care. In doing so, pathway programs will have to face the challenge of incorporating the applications of precision oncology, including the many recommendations for biomarker-guided use of target therapies.
Although survival and hospitalizations are important metrics, PROs should become an additional outcome measure of pathway effectiveness.
In summary, preliminary evidence indicates that adherence to CCPs favorably impacts some patient outcomes and direct medical costs. The oncology community has a great opportunity to improve value in cancer care by engaging all stakeholders in transparent processes of pathway development. In order to ensure that pathways become a sustainable model of delivery of high-value cancer care, the administrative burden to oncology clinics needs to be minimal. EBO

Author information:

Bernardo Haddock Lobo Goulart, MD, MS, is a faculty member of the Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, and an assistant professor at the Division of Medical Oncology, University of Washington.
Address for correspondence:

Bernardo H. L. Goulart, MD, MS
1100 Fairview Avenue N. Seattle
Washington, 98109

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