Feature article

Perspectives on Oncology Clinical Pathways

Evolution of oncology clinical pathways in value-based care

Within the past decade, the introduction of groundbreaking cancer immunotherapies and molecular-target therapies has transformed the cancer treatment landscape. Globally, the cost of cancer therapies, including supportive care, grew to $133 billion in 2017, an increase from $96 billion in 2013.1 At the same time, it’s projected that major advances in cancer technology, including diagnostics and artificial intelligence, along with high-priced therapies, will continue to have a significant impact on oncology treatment and costs over the next decade.1 Despite these clinical breakthroughs, as well as the many innovations on the horizon, high-quality cancer care has and continues to be difficult for patients to access and afford.2 In recognition of the sky-rocketing costs of cancer treatment, along with a shift in healthcare from a volume-incentivized, provider-centric model to a value-based, patient-centric model, the importance of oncology clinical pathways (OCPs) to control costs and improve quality of care has increased dramatically.3

OCPs are defined as standardized, evidence-based care for specific types of cancer at various stages, presentations, and molecular subtypes of the disease.3 When properly designed and implemented, OCPs can serve as important tools in delivering the most appropriate standard of care (SOC) while improving patient outcomes and reducing costs.3,4 More prescriptive than guidelines, pathways are based on SOCs and treatment guidelines developed by major clinical cancer bodies, such as the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN).3,4 However, while guidelines are accessible to all, vendor-created pathway programs are only commercially available to health plans and provider organizations that choose to use them.4 

The continued drive toward value-based models of cancer care—including financial incentives for adhering to OCPs—has led to an explosion in pathways and requirements.5 According to the ASCO there has been tremendous growth in the use of vendor-provided programs by providers and payers.4 From 2014 to 2016 there was a 42 percent increase in oncology practices participating in a pathway program. In addition, an estimated 60 U.S. health plans have mandated oncology pathways, with more than 170 million members potentially being treated through a health plansponsored pathway.4

Based on the rapid proliferation of pathway vendors—and questions over variations in the quality and efficiency of OCPs—in 2018, ASCO reviewed six of the of leading oncology pathway vendors in the U.S., using its criteria for high-quality clinical pathways.4 These criteria focus on factors such as whether the pathway development and implementation are: expert-driven, transparent, evidence-based, patient-focused, clinically driven, timely, use analytics to promote quality improvements, and support patient participation in clinical trials.4 While ASCO's review found some differences among the OCP vendors, they also found that all vendors met key ASCO criteria for being expert-driven, patient-focused, up-to-date, and comprehensive.6 

Putting patients at the center of patient-centered care

While there is agreement among most stakeholders that OCPs can be effective in reducing costs and improving outcomes, opportunities for ongoing improvement exist, particularly around the need to provide greater access to innovative treatments, and more personalized cancer care and avoid a “one size fits all” approach.7 This is particularly relevant in terms of patient-centered care—a key component of the "triple aims" of the Institute for Healthcare Improvement ; improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.8 While OCPs have been shown to support treatment decision-making, they may not always meet the needs and preferences of patients.9 The American Association for Cancer Research’s 2016 Turning the Tide Against Cancer initiative brought together a multidisciplinary group of cancer stakeholders to examine pathways in terms of patient engagement and shared decision-making. The group’s findings indicated a greater need for transparency and accountability between patients and providers, especially around patient-facing information about pathway recommendations and goals. A key finding of particular note was the concern whether participation in a pathway would limit future treatment options.7

Balancing pathways with the pace of innovation

As more targeted cancer therapies come to market, along with advances in diagnostic and monitoring technologies, pathway vendors will be tasked with how to effectively incorporate treatment options that provide more personalized care into standardized pathways.9 For example, active surveillance is now a standard management option for men with very low to low-risk prostate cancer.10 Novel imaging techniques, such as multiparametric magnetic resonance imaging, or, mpMRI, can provide detailed information about the size and location of potential tumors that can enhance treatment decision-making.11 There are other novel imaging techniques, such as imaging genomics or radiogenomics, are a rapidly developing area of research focused on non-invasive genotyping that can be used for treatment monitoring in a wide range of cancers where biopsies aren’t feasible.12 Such advances that may improve the quality of care, increase patient choice, and potentially reduce costs by promoting earlier diagnosis and treatment, along with the appropriate academic collaboration, should be important considerations for pathway evaluation and inclusion.2,5

Other advances that may dramatically improve patient outcomes in the coming years, and significantly impact current treatment pathways, include: non-invasive surgery with robots that could significantly reduce risk and complications, innovations in artificial intelligence, developments in 3D printing such as bio-printing of replacement organs for cancer patients, the increasing role of patient analytics in treatment decision-making, potential uses for telemedicine, and the growing role of digital apps in patient monitoring and treatment.In recognition of the potential impact these clinical and technological advances will have on cancer treatment, ASCO is convening Breakthrough: A Global Summit for Oncology Innovators, an international gathering of scientists, clinicians, and researchers focused on “the intersection of medicine, scientific discovery, and innovations in technology” to be held October 2019 in Thailand.13 

As advances in cancer treatment and technologies continue to provide remarkable breakthroughs in treatment, diagnostics, and supportive care, the oncology community increasingly needs to balance innovations in cancer treatment and technology with the tenets of value-based care; to make certain that these treatment advances meet the criteria for high quality, cost-effectiveness, and patient-centered care. The major oncology bodies that create cancer treatment guidelines, the vendors involved in developing treatment pathways based on these guidelines, and the payers and providers that use them will need to raise and address questions regarding whether new therapies and technologies will be included in oncology pathways; those discussions would maintain the critical role of OCPs in providing access to affordable, up-to-date, transparent, and personalized patient care.

 

References

  1. Global Oncology Trends 2018, Copyright © 2018 IQVIA. https://www.iqvia.com/institute/reports/global-oncology-trends-2018. Accessed February 10, 2019.  
  2. Balancing innovation and value in cancer-care spotlight-on-non-small-cell-lung-cancer-treatment. Value-Based Cancer Care, February, 2017. http://www.valuebasedcancer.com/issue-archive/special-issues/february-2017-vol-8-no-1-supplement-1-balancing-innovation-and-value-in-cancer-care-spotlight-on-non-small-cell-lung-cancer-treatment/. Accessed February 22, 2019. 
  3. Perspectives on the use of clinical pathways in oncology care. American Society of Clinical Oncology 2017. http://ascopubs.org/doi/full/10.1200/EDBK_175533. Accessed February 6, 2019
  4. Charting the landscape of pathway providers Journal of Oncology Practice: Oncology Clinical Pathways, 2018. http://ascopubs.org/doi/full/10.1200/JOP.17.00033.  Accessed February 6, 2019.  
  5. American Society of Clinical Oncology: The state of cancer care in America, 2017: A report by the American Society of Clinical Oncology. J Oncol Pract 13: 2017. http://ascopubs.org/doi/full/10.1200/JOP.2016.020743?green-bar=& Accessed February 8, 2019.  
  6. ASCO examines the current oncology clinical pathways landscape new report is first robust assessment of the nation's oncology pathway vendors,[News Release] February 7, 2018 https://www.asco.org/about-asco/press-center/news-releases/asco-examines-current-oncology-clinical-pathways-landscape
  7. Clinical Pathways: Recommendations for Putting Patients at the Center of Value-Based Care, Clin Cancer Res, August, 2017. Accessed February 8, 2019.
  8. Institute for Healthcare Improvement, IHI Triple Aim Initiative http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx
  9. Oncology pathways reconcile standardization with personalization, July 22, 2018, Pharmaceutical Commerce, https://pharmaceuticalcommerce.com/brand-marketing-communications/oncology-pathways-reconcile-standardization-with-personalization/. Accessed February 8, 2019.  
  10. Active surveillance of prostate cancer: use, outcomes, imaging, and diagnostic tools. Am Soc Clin Oncol Educ Book. 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4917301/ Accessed February 8, 2019.  
  11. Multiparametric magnetic resonance imaging for active surveillance of prostate cancer. Balkan Med J. 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5635625/ Accessed February 8, 2019.
  12. Non-invasive tumor genotyping using radiogenomic biomarkers, a systematic review and oncology-wide pathway analysis. Oncotarget. 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5929452/ April, 2018. Accessed February 8, 2019.  
  13. ASCO to Convene Global Summit on Latest Innovations in Technology and Cancer. [Release] January 3, 2019.  https://connection.asco.org/magazine/society-member-news/asco-convene-global-summit-latest-innovations-technology-and-cancer Accessed February 27, 2019.