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How Tennessee Oncology Navigates Clinical Pathway Challenges and Advancements: Dr Edward Arrowsmith


Edward "Ted" Arrowsmith, MD, MPH, medical director for pathways at OneOncology and managing partner at Tennessee Oncology, talks about challenges and changes in clinical pathways and the importance of keeping them updated.

Key challenges with clinical pathways at Tennessee Oncology include ensuring they are actionable at the point of care, integrating them into the electronic medical record (EMR), addressing the difficulty of changing treatment plans once communicated to patients, and staying up-to-date with the rapidly evolving landscape of cancer care, according to Edward "Ted" Arrowsmith, MD, MPH, medical director for pathways at OneOncology and managing partner at Tennessee Oncology.


What are some key challenges with clinical pathways at Tennessee Oncology?

There are always a couple challenges with pathways. One is having them actionable at the point of care, both having them built into the EMR and then even how do you get [pathways] kind of in the head of the oncologist when he or she is making decisions or thinking through what's next for treatment. It's always hard, whether it's a pathway or a clinical trial, if you've already talked to the patient and told them a plan, to change that plan based on a pathway or to bring up a clinical trial late. Having a kind of thorough plan of both from the beginning is really important. So we're working on a variety of technical approaches to really try to help that clinician at the point of care.

The other big struggle is just updating the past pathways. We're so fortunate that we live in this age of discovery where cancer care is improving, but it actually then becomes kind of a big administrative and intellectual problem to think through each FDA approval, every paper presented at [the annual meetings of the American Society of Clinical Oncology or the European Society of Medical Oncology], and think about [whether] we need to update the pathways for this. And that involves often reading those studies really carefully, because in an age of targeted therapies, exactly who are the right patients for this new approach isn't always really straightforward.

How do Tennessee Oncology and OneOncology go about updating their clinical pathways in a timely manner?

In terms of our pathways, we have regular quarterly meetings where we look to update the pathways, but [we] also have a more kind of ad hoc process for data that emerges—usually FDA approvals, new publications, or presentations at major conferences. [For] those, we rely both on members of the disease groups and the OneOncology and Tennessee Oncology pharmacy staffs to help us find those exciting new updates. And then, depending on the sort of controversy around that, [we'll] either call an unscheduled meeting or occasionally just use a group email to update the pathways in real time.

The other thing we're working for as more and more trials are targeting specific populations at the time we're rolling out those pathway updates is including sort of a plan for identifying patients. A good example of that was with the original data for KRAS G12C mutations, first in lung cancer and then more recently in colon cancer, is using our database of mutations to identify patients to where that might be an appropriate therapy.

Does it seem like clinical pathways are evolving into something different or a next generation of pathways?

We talked about how pathways in some ways were designed for an earlier era when we were choosing among 2 or 3 different cytotoxic chemotherapies for big disease groups, like all of non–small cell lung cancer or adjuvant therapy for all of breast cancer. As we've moved toward a more targeted world, I think just having a PDF is not enough. What we need to do is have the disease group leaders who form the pathways also work with the clinical team, the technology team, physician education, staff education, kind of every approach to help guide us towards what's the best therapy for this patient sitting in front of us today. There's so much going on that [for] a busy clinician on a Tuesday afternoon, we need help to let that physician know about a trial that was just presented in Europe 10 days ago.

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