“When appropriately designed and implemented, oncology pathways are detailed, evidence-based treatment protocols for delivering quality cancer care for specific patient presentations, including the type and stage of disease.”
So asserts the American Society of Clinical Oncology's recently released policy statement on “Clinical Pathways in Oncology” (see article, page 24). But the discussion about clinical pathways for cancer care is not so simple, also begging consideration of the potential harms and the challenges to implementing and using the treatment management tools, along with how they might streamline cost-effective care delivery.
In a phone interview, Robin T. Zon, MD, FACP, Chair of ASCO's Task Force on Clinical Pathways, co-author of the policy statement, and a Vice President and Senior Partner at Michiana Hematology-Oncology, P.C. told OT why ASCO determined it was necessary to make the nine recommendations in the statement and what's ahead for clinical pathways in oncology.
1. What is a clinical oncology pathway—and why do they have the potential to improve the value of cancer care?
“To briefly explain, it's important to distinguish pathways from clinical practice guidelines. Guidelines are recommendations to optimize patient care that are developed through a very onerous, systematic review of evidence and assessment of the benefits and harms for various care options. They tend to be very broad and rather flexible—much more so than clinical pathways. And guidelines typically don't incorporate cost information into their process. The guideline are developed through a robust, transparent, peer-reviewed process and are usually held to very high standards.
“Clinical pathways on the other hand factor in treatment costs and they often tend to be much narrower in scope (versus clinical guidelines), often offering fewer options for oncology patients. A clinical guideline for a specific stage of a cancer may offer ten options and may not talk about cost, while a clinical pathway for that very same stage in cancer may offer only two or three options—using cost to determine those preferred care options.
“Pathways are intended to provide quality care and reduce costs—and there's a lot of potential for pathways. It isn't an issue of what's wrong or what's good about the pathways—it's really a question of what's the greatest potential of what can be achieved with the pathways. Currently many pathways are focused only on the treatment, but there's great potential to improve the entire cancer care continuum for the patient from day one from evaluation and diagnosis, right on through the end of life—and that in fact is one of [ASCO's] major recommendations.”
2. What are the concerns about the use of clinical pathways in oncology that prompted ASCO to form this Task Force and issue its recommendations?
“There was concern raised by many [ASCO] members that they were having to comply with multiple pathways in their practice—some oncologists reporting they had to adhere to eight or more pathways for exactly the same type and stage of cancer, with different payers putting forth different requirements. There's quite a bit of redundancy in terms of the pathways out there and lack of transparency in the design and implementation of these tools.
“Also, an informal survey by ASCO of the Society's state affiliates showed that up to 86 percent of the respondents using clinical oncology pathways said that they limit treatment options—and I personally would agree with that.
“Pathways need to respect that there is patient variability and autonomy; and to be 100 percent compliant with pathways is actually dangerous. Many times the patients that we are taking care of on a daily basis don't look anything like the patients who are on the clinical research trials that ultimately led to the evidence that formed clinical guidelines and pathways. So there has to be allowance for variability.
“We do believe at the end of the day, clinical pathways can be extremely valuable in oncology. But, we need to assure that these pathways are benefitting all the stakeholders involved in the cancer care continuum—the provider, the payer, and most importantly, the patient.”
3. Should there be more oversight or regulation of clinical pathways in oncology?
“More oversight or even going as far as having standards for clinical pathways in oncology is something that we, the Task Force, talked about as a possibility. And our nine recommendations [in the policy statement] are going to form the basis of work where we intend to consult with payers, vendors, and others who are developing pathways to ensure we are promoting high quality care, as the next step.”