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Clinical Pathways Guiding Treatment Selection in Multiple Myeloma


A panel of experts discuss the value of clinical pathways in MM disease management.

Ryan Haumschild, PharmD, MS, MBA: Let’s talk about clinical pathways. We’ve seen pathways continue to emerge. One good thing about pathways is they ensure a high standard of care for all patients. Someone doesn’t have to travel to the academic medical center and wait in that parking garage for 45 minutes to see a subspecialist. They can see a clinician in their geographical area and receive a high level of care. Ultimately, that’s what we want to do—provide great outcomes and help patients who might have transportation vulnerability receive great care. We see pathways continuing to develop. We see third-party pathways internally develop to help drive best practices. That being said, clinical pathways are commonly used to guide decision-making and oncology. Dr Lipe, I’m curious about your perspective as a leading researcher and practitioner. What’s the value of using clinical pathways to guide treatment selection? In particular, how do you see them emerging within multiple myeloma?

Brea Lipe, MD: Myeloma is a difficult disease to have pathways in. We have many agents for therapy, and there are more coming on board all the time. There isn’t necessarily a standard of care for how we treat patients in a certain setting. We disagree among ourselves on how we would treat our first high-risk or patient up front, so that makes it difficult to establish a pathway and say, “This is what we do.” In fact, it’s not what we do. We have our own nuances. The disease itself is nuanced. The adverse effects or comorbidities that people experience—all of that is the nuance of myeloma, and that’s what drives my practice and why I love what I do. I’m able to tailor what I do for the person in front of me. Some of that gets lost in pathways.

But there can be some benefits with pathways. When you have all these drugs and someone who doesn’t spend their life thinking about just 1 disease, it can be helpful to know what the options are and know that you’re at least falling within some standard. Maybe I would disagree or you would disagree, but it’s not so far out of the range of what’s reasonable, or substandard care. It does help elevate therapies, but it also has a role to play in some of the supportive therapies, which is important in myeloma. We need to make sure we’re giving the right premedication and that we understand the risk of infusion reactions. That can be all standardized in a pathway. There’s a role for the standardization of those things.

In our institution [the University of Rochester], we have a commercial pathways program for our community oncologists. But 1 thing we’ve been able to do at the academic center is plug in some of our supportive care things. We make sure we’re thinking about how these patients get VTE [venous thromboembolism] prophylaxis and [decide] whether they’re getting antiviral prophylaxis. It’s allowed us to do that. It’s another tool for research. It’s 1 thing to do this all day and have opinions about what’s happening. We can get a little skewed. We need to understand that the majority of our patients are not treated at academic centers. We need to know what they’re experiencing. Having these pathways allows us a mechanism to capture some data about what’s happening and how therapies are being used, whether they’re designed to be used indefinitely or not. That’s some of the value that can be seen with these pathways.

Ryan Haumschild, PharmD, MS, MBA: You did a great job of saying there are values in pathways, but multiple myeloma is unique. There are resistance patterns, there are different toxicities, and there are different combination regimens. It’s not 1 size fits all. A lot of patients in the community might need the guidance. If you have a general hematologist who might be practicing across a number of hematologic malignancies, they might need a little more guidance on CD-38 directive therapy and some of the best practices we’ve discussed. That was very fair. I appreciate that overview.

Your organization has developed pathways in house, Dr Nadeem. Can you describe your clinical pathway program for multiple myeloma? How was this program implemented?

Omar Nadeem, MD: Pathways in myeloma are inherently complex because we have so many approvals and indications, but the overall message is to get some standardization and then disseminate that information to the greater community. That was the vision when we were developing these pathways, and we revamp it constantly. The field is changing so fast. It looks very different from when it was built 3 to 4 years ago. It depends on what’s happening. As approvals come, as the labels change, as the field evolves, we’re able to have some flexibility within our pathways to share how we would approach a particular situation. That’s been the intent.

We start with some standardization, in terms of what the NCCN [National Comprehensive Cancer Network] Guidelines say or the FDA label says. But we also have some flexibility to share some of the pearls: how to give a particular medication, the dosing of carfilzomib. There’s been some confusion over many years in terms of the optimal dosing and combination. These pathways are constantly revised. We have stakeholders who are our internal faculty members. Anybody who comes onto our pathways is able to meet at our regular review meetings. Every time new data comes out—we do this several times a year—there’s a whole panel, and we all review it and have a decision and a discussion together. Is this something we want to implement and incorporate within our pathways? More important, where does it fit within this pathway? As we think about wanting to give guidance to physicians, particularly those who don’t do multiple myeloma constantly, how can give them guidance to think about this regimen vs that 1? It’s a very robust discussion that occurs several times a year among many stakeholders. That’s how it keeps developing and keeps getting bigger.

Ryan Haumschild, PharmD, MS, MBA: Some of the best decisions come through shared decision-making. Everyone has their preferences, but when you can overlap on some ideas, it allows best practice to move forward. A lot of people use your pathways. I know you all use them internally, but other outside institutions rely on that expertise as well. That’s a great way to share that information.

I want to talk about an organization using third-party pathways. Dr Thertulien, talk about third-party pathways. Which are you using? Discuss the impetus behind why you all took the third-party pathway.

Raymond Thertulien, MD, PhD: At our institution [Novant Health], we use a third-party vendor, Via Oncology Clinical Pathways [ClinicalPath]. We have a committee that works specifically on myeloma clinical pathways, and I serve on that committee. We meet quarterly to develop, review, and add new regimens, depending on what’s being approved and where we see the field going. We have several teams at our institution that will look at the regimens in that third vendor’s clinical pathway and adopt them. [We] have a link to those clinical pathways. Sometimes our provider will want to develop a regimen that’s not available in clinical pathways. They’ll meet with a clinical pharmacist, pull the data and the prescribing information, and develop that pathway with our pharmacist. It has to go through a tumor council, which will look at it, review it, and then incorporate it. That would be considered off-pathway because it didn’t come from our third-party vendor. We have a hybrid system.

We have that pathway available because we’re a big network. We have community oncologists within our network, and they’re on the same EMR [electronic medical record]. These pathways are available to them as well. We monitor the use of those pathways because it has value. It’s very difficult to standardize treatment for multiple myeloma, particularly in the second, third, and fourth lines. It has value to give our colleagues something they can look at in standardized treatment for multiple myeloma and try to bring quality, not just at the big centers but also at the community level. I’m sure the hospital administrators are looking at it as well. We have a target of 80% use in our system that’s being monitored by hospital leadership.

Ryan Haumschild, PharmD, MS, MBA: You bring up a great point about pathway and adherence. At a lot of institutions, even a new EMR, like Epic, has protocol deviation. You can see which providers are deviating from pathways, and you want to figure out if they know something better than the whole group. Should that go back to the whole group? Is someone practicing different from what they’ve established as best practice? What’s the best way to incorporate that feedback? It’s interesting to hear you say that.

A lot of people who aren’t familiar with third-party pathways may be wondering if you copy and paste this into your order sets. How do you align your formulary with third-party pathways? Tell us a little about that.

Raymond Thertulien, MD, PhD: We have a team of clinical pharmacists who look at this. All these regimens in pathways have to go to our P&T [pharmacy and therapeutics] committee, which will review it and bring those drugs on formularies. A lot of these drugs are already on formularies. In myeloma, we make a lot of those triplets by taking 1 PI [proteasome inhibitor],1 anti-CD-38, and 1 IMiD [immunomodulatory drug]. That’s why we have so many combinations in multiple myeloma. All of these are already on our internal formulary. It’s a matter of building the regimen so that it’s available to us but also to our community physicians, based on the available data.

Ryan Haumschild, PharmD, MS, MBA: When you’re talking through that, you have community oncology representatives. I’ve heard of the term disease state working groups for those developing clinical pathways. That means you get not just the disease state expertise but also a representative from the community oncology group, maybe a local hospital system, so many people have their voice heard. If they’re going to adopt these clinical pathways, they want to understand how they’re being built, how the data are being looked at, and how they can bring those data to their local practice.

Transcript edited for clarity.

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