In Oncology Clinical Pathways, the Variability Isn’t With the Drugs

Experts who took part in Patient-Centered Oncology Care® 2021 said when guidelines recommend high-cost targeted therapies or immunotherapies, the focus must turn to areas such as imaging, diagnostic tests, and other elements that contribute to the cost of care.

Ann Nguyen, PharmD, was working with a payer when oncology clinical pathways first came on the scene a decade ago, and she vividly recalls the reaction.

“I have a bunch of scars,” she told the audience during the final panel discussion at Patient-Centered Oncology Care®, the multistakeholder meeting presented September 23-24, 2021, by The American Journal of Managed Care®. “There was a lot of resistance,” Nguyen said, and her organization was called to appear at the state legislature to explain what pathways were.

Why are you doing this? What are you creating? You’re taking away physician choices. “It was very intimidating,” said Nguyen, now vice president of Pharmacy for the OptumCare/UnitedHealth Group.

Thus came the process of taking feedback, meeting with focus groups from both academic and community oncology practices. And slowly, pathways gained not just acceptance but an embrace, and both academic centers and large community oncology networks developed their own pathways, often built on the framework of a commercial product.

Tracing this evolution were moderator Kashyap Patel, MD, CEO of Carolina Blood and Cancer Care Associates, event co-chair, and the current president of the Community Oncology Alliance, along with Nguyen and the following:

  • Kerin Adelson, MD, associate professor, chief qualify officer, and deputy chief medical officer at Smilow Cancer Hospital, Yale Cancer Center;
  • Lee Schwartzberg, MD, FACP, chief medical officer, OneOncology, and professor of medicine, University of Tennessee Health Science Center;
  • Joshua Howell, PharmD, BCOP, vice president, Pharmacy and Clinical Programs, The US Oncology Network, McKesson; and
  • David Jackman, MD, medical director, Clinical Pathways, Dana-Farber Cancer Institute; assistant professor of medicine, Harvard Medical School.

As Nguyen recalled, The US Oncology Network was a pioneer in the pathways movement, but there was distrust when payers made their foray into the space because there were fears the motive was cost savings—picking the lowest-cost drug even if it’s not what the doctor would pick first.

But Adelson said today’s clinical guidelines often recommend a high-cost targeted therapy or immunotherapy because they offer the best efficacy and lowest toxicity. Thus, relying on pathways to close the variability gap may miss the point.

The focus, she said, must turn to areas such as imaging, diagnostic tests, and other elements that contribute to the cost of care. “There really is a need now for pathways to encompass the disease trajectory from screening and diagnosis all the way through survivorship and end of life care, and target the multidisciplinary aspects of how we manage cancer, because it’s those other areas outside of the systemic therapy pathways where we see so much variability today.”

Schwartzberg said clinical pathways are a comprehensive decision making tool, that gives a busy physician an immediate way to access the best choices for patients—and there may be more than one choice.

“We do like to have preferred arrangements based on what the clinical evidence is, which is changing very quickly,” he said. But the desire for having these reference points is balanced by the fact that physicians have no desire to add more “clicks” to their day—the concept is to create an efficient system that gives physicians the options quickly.

He agreed with Adelson that pathways may spot the outliers, but by themselves will not drive down drug spending. Integrating pathways into a data system where they can be used to monitor a patient’s hospitalizations or emergency department visits may ultimately save money.

Savings vs Support

Pathways have gained acceptance, the panelists agreed, because oncologists ultimately found them helpful—Adelson said oncologists in the community who see many different types of cancers felt more confident that they were not selecting the wrong therapy, for example. Howell said processes that build pathways with decision leaders from The US Oncology Network help with buy-in.

“Physicians are part of that; they go into the evidence, and then we roll that out to the practices,” he said, which “really helps with the engagement.”

But do pathways exist primarily to achieve savings or to ensure that patients are receiving evidence-based care?

Patel recalled an early product that was payer funded that generated a lot of skepticism from oncologists. By contract, at Dana-Farber, Jackman leads pathways development driven by physicians. Schwartzberg sees the evolution of one of the pathways processing maturing.

Said Jackman, “As a practicing physician, I can only say that pathways first and foremost have to be thinking about improving care. Cost needs to be part of the discussion, but if cost is the main point of any system, then we should all pack up our tents.…

“We have to always be striving [to improve] the patient experience," Jackman continued. "First and foremost, how do I improve care for the patient in front of me? And then writ large, I want to think about improving care across a population. Yes, cost has to be part of this. I think we're silly if we’re writing off cost, but it can't be the primary focus of anything that we do. It has to be one element of a larger system.”

“That’s a great question,” Schwartzberg said. “I think we'd all agree that the value of pathways is to improve care. First and foremost, that's what we're trying to do here, at least from the perspective of patient-centered oncology care. So, can you do both?”

He said 2 points are relevant: What constitutes a quality pathway? And second, how do pathways deal with timely changes?

One issue practices are dealing with is the need for payers to recognize that practices cannot be expected to juggle multiple pathways—and give patients different care based on insurance. At Yale, Adelson said, a clear decision has been made that physicians will not do that—the cancer center’s pathway is followed and all patients receive the same care. Schwartzberg said that OneOncology’s pathways are based on guidelines from the National Comprehensive Cancer Network (NCCN), but pathways can be slower to update than the NCCN guideline themselves.

Ultimately, Adelson said, she sees pathways evolving into shared decision-making tools—and is doing research on this.

“You'll have clinical decision support facing the physician, that it functions like a pathway or a guideline, but the patient will make the ultimate decision about the treatment they want,” she said. “And the pathway on the patient facing side is an educational tool where they can learn things about side effects, toxicity, efficacy, treatment burden.…I think that that is what the ideal pathway would be—it would incorporate the patient perspective and give the patient a little bit of control in those decisions.”