Value-based Considerations of CDK4/6 Inhibitors in the Treatment of Metastatic Breast Cancer - Episode 14

Breast Cancer Pathway Guidelines for Practitioners


Bruce Feinberg, DO: Joyce, critical to any of these kind of episode designs is for the providers who are participating in them, like large practices like yours, whether they’re a commercial payer or OCM [Oncology Care Model], is usually developing guidelines internally so that the practitioners are aligned, and they have a consistent approach so that you can model the cost and start to; and the leaders of the practice on the administrative side can gain some control over that.

And so I know Texas Oncology well—you’ve had extensive guideline work, Clear Value Plus among others. I mean, notable things. I don’t know what your level of involvement is in the breast cancer pathway development, but I’m curious, with what you do know, if you can share that process. And then how it translates as a front-line treatment during patient care.

Joyce A. O’Shaughnessy, MD: Sure. Texas Oncology is part of the US Oncology Network around the country. And most of the guideline work is at the US Oncology level, you know, across the country, various leaders, the practicing oncologists. Many of them kind of subspecialized in their knowledge base, et cetera. But basically, they’ve adapted the NCCN [National Comprehensive Cancer Network] Guidelines, and Bill leads the breast cancer guideline development for NCCN.

They do have a bit of a cost overlay, that’s the Clear Value Plus. So they do make some judgments if they think that the efficacy of a particular treatment is marginal compared to the comparators. And then if the cost is quite a lot more, they’ll make the judgment that that should be off the pathway, even though it may be listed as an option on NCCN. There are only a few examples of that in breast cancer.

But it’s a way to basically, as you said, get a handle on cost, and the NCCN is a very broad-based approach, evidence-based approach, and so it’s quite a reasonable set of pathways. In Texas Oncology, I think maybe each practice does it a little bit different, the expectation is that 75% to 80% of patient care across all malignancies and across first diagnosis until end of life, about 75% to 80% will fit easily within the NCCN Guidelines. But that 20%, 25% of the time, for a variety of reasons, that the guideline will not exactly fit that particular patient. And so there’s flexibility, of course, to go outside the guidelines; “off pathway,” we call it.

And from a mechanical standpoint it’s actually quite easy. It’s not a cumbersome thing when you are entering your orders into the electronic medical record, which is called iKnowMed in US Oncology. Basically if what you’ve chosen is off pathway, a screen comes up and you just type in your reason for wanting that, and that will go to, there are regional oncology directors, these are practicing oncologists, regional directors who look at it.

Bruce Feinberg, DO: All right, Joyce, I’ve just got to ask you because it gets back to that question from before. Have you ever been turned down when you’ve gone outside of pathway by a regional director?

Joyce A. O’Shaughnessy, MD: No, no, I haven’t.