On a typical day, oncologist Dr. Linda Bosserman spends hours poring over lists meant to guide clinicians toward the optimal course of treatment. These “clinical pathways” are based on a cancer's stage and location in the body, and patient-specific factors, such as comorbidities. Then, after she and the patient have chosen a plan, Bosserman says she spends hours explaining to payers how and why the choice was made.
The pathways have reached the point of being an “unsustainable” administrative burden, according to the American Society of Clinical Oncology in a new policy statement, of which Bosserman was the senior author. Also, the process of developing them is laden with inadequacies and conflicts of interest. Clinical pathways were created more than a decade ago when personalized care began to trend. But some argue they have had the opposite effect.
For each patient and for each type of disease, a provider faces countless pathways incentivized by different interest groups such as payers, who offer increased reimbursement or shared savings for using a pathway. Benefit managers, or intermediaries between providers and payers, create pathways that favor cancer drugs. The protocols work on what might be described as an “if-then” format. For example, if the patient has breast cancer that has metastasized, then X has been shown to have the best results; or if the lung cancer patient also has diabetes, then Y would be better.
The Via Oncology pathway program that was created at the Pittsburgh-based UPMC system is used by many of the nation's providers, including five academic medical centers. Dr. Peter Ellis of UPMC said the full list of pathways is “more than 12,000 pages” long. He agrees it's time to regulate the process.
“The unfortunate truth is that people have bastardized what the name pathways means, using it to further other means,” he said, adding that they should result in patients getting the best evidence-based care.
ASCO suggests nine changes to the clinical pathway process, including better collaboration among payers and oncologists to adopt flexible policies; consistent and transparent methodologies for development; changes that allow real-time updates; and a greater focus on the full spectrum of care, from diagnosis to end of life.
ASCO has also been pushing efforts to help physicians and patients choose appropriate therapies amid the skyrocketing cost of cancer drugs. In June, the society released a tool for oncologists to compare various drug treatments for four common cancers based on survival rates, side effects and costs. They have also been working on CancerLinQ, a not-for-profit subsidiary that gathers data from millions of electronic health records with the goal of providing real-time feedback on cancer trends and patient outcomes.