The ASCO Perspective on Oncology Clinical Pathways
An interview with Robin T Zon, MD, FACP, FASCO, chair, American Society of Clinical Oncology Task Force on Clinical Pathways
In the face of rising health care costs, oncology clinical pathways have been well documented as an effective tool for reducing inefficiency and improving quality in cancer care. A 2014 study reviewing 642 patients showed that implementing a clinical pathway for gastrointestinal cancer significantly reduced average length of hospitalization and inpatient expenditures while improving patient satisfaction.1 Another 2014 study by McKesson Specialty Health affiliate Texas Oncology demonstrated that using pathways in conjunction with patient support systems significantly reduced cancer-related costs, emergency room visits, and in-patient admissions.2
The promising results of these studies and others have encouraged institutions around the world to develop clinical pathways for multiple disease states. However, as the use of pathways for driving treatment decisions has grown, so have concerns about how they are being created and with what aims. The design of these tools often involves the same or similar processes: first, an evidence base is gathered and analyzed; efficacy, toxicity, and cost are then used to rank different treatment regimens; and, finally, a pathway is integrated into care at the clinical level to provide useful support.3 Still, there is currently no accreditation program for pathways or other similar mechanism to validate whether pathways are developed using the best, most appropriate evidence or whether they include the best options for treatment.
Citing the growing evidence that clinical pathways can improve outcomes and reduce costs, many payer organizations have been supportive of the use of pathways in oncology. Indeed, several have initiated their own pathway programs,4 offering financial incentives to physicians that adhere to pathways in their treatment decisions.5 In contrast, oncologists have expressed frustration about the restrictive nature of pathways, claiming that they interfere with physicians’ decision-making and make treatment less personalized.6 Although many physicians support pathway usage and want to provide their patients with the best, most evidence-based care, they also do not want to have their ability to prescribe the most appropriate treatment plan for their patient to be restricted. In a commentary published online, former American Society of Clinical Oncology (ASCO) president Peter Paul Yu, MD, FASCO, worried that pathways could be seen as a destination rather than a point of departure, meaning that pathways would remain static rather than improving and evolving with new research.3
Today, Dr Yu’s concerns remain on the minds of many oncologists as they continue to question the ethics of payer-initiated pathways and grapple with the decision of whether to adhere to one pathway or another. In response to those concerns, ASCO recently released a policy statement on clinical pathways in oncology.7 In that statement, ASCO recognized pathways as being an important tool for patients and oncology providers but cite growing unease among members and other stakeholders regarding their development, administrative burden, reporting, and implementation. To answer these questions, ASCO has formed a Task Force on Clinical Pathways and charged them with formulating a set of initial guidelines for the development and implementation of oncology pathways, ensuring that pathways enhance—not diminish—patient care.
Leading the ASCO Task Force on Clinical Pathways is Robin T Zon, MD, an oncologist with Michiana Hematology Oncology (Mishawaka, IN). Since joining ASCO in 1997, Dr Zon has held numerous leadership positions within the organization, including chair of the Clinical Practice Committee and member of the ASCO Board of Directors. Journal of Clinical Pathways spoke with Dr Zon to dissect the ASCO statement and discuss the areas in which pathways most need to improve in order to be successful in the future.
ASCO recently released a policy statement regarding clinical pathways; can you elaborate on ASCO’s stance regarding pathways and the circumstances that necessitated the release of the statement?
Ideally, clinical pathways are detailed, evidence-based treatment protocols for delivering quality cancer care for patients with specific disease types and stages. When properly designed and implemented, pathways can serve as an important tool in improving care quality and reducing costs.
However, the way in which these treatment management tools in cancer care have proliferated raises significant concerns about patient access, care quality, and transparency in pathway development and implementation. ASCO members are reporting growing worry that some clinical pathways may impede delivery of high-quality cancer care, which is why the ASCO Board of Directors formed the Task Force on Clinical Pathways to examine this issue and why we felt the need to issue a policy statement on clinical pathways in oncology.
Does ASCO see pathways as a viable tool for the future of clinical care? What do you see as the major barriers for the utilization of pathways today? What do you see as the major benefits?
Although some studies have shown that pathways can reduce costs while improving—or at least maintaining—the quality of cancer care, data are not complete. This is one of the reasons that, in its policy statement recommendations, ASCO is calling for additional research to understand the impact of pathways on care and outcomes. As stated above, these treatment management tools can serve to improve care quality and reduce costs, but the Task Force’s review of clinical pathways raised concerns about variation in quality and utility, too great an emphasis on controlling costs rather than improving clinical outcomes, and lack of transparency in pathway development and implementation. ASCO believes it’s important that these and other issues be addressed to ensure that our patients in pathway programs get the best and most appropriate evidence-based cancer care possible.
What changes need to be made to improve pathways and make them a better resource for physicians?
A number of things. We believe, first, that there needs to be more consistency and transparency in the development and implementation of clinical pathways. Pathways should address the full spectrum of cancer care: diagnostic evaluation; medical, surgical, and radiation treatments; surveillance, including imaging and laboratory testing; survivorship; and end-of-life care. Pathways should be updated continuously to reflect new scientific knowledge as well as insights gained from clinical experience, patient outcomes, and rapid learning data, in order to promote the best possible evidence-based care. Rapid learning data particularly has tremendous potential for improving care, because these data are based on 100% of the population, whereas clinical trials come to conclusions and approvals based on 3-4% of patients. Therefore, pathways must include these new data sets as they emerge as reliable and trustworthy sources of evidence. Another important consideration is that patients who are on pathways need to be able have access to clinical trials. Pathways should recognize patient variability and autonomy and should allow for physicians to easily diverge from pathways when evidence and patient needs dictate doing so. Finally, pathways must be implemented in ways that promote administrative efficiencies, rather than burdens, for both oncology providers and payers.
What are the roles and responsibilities of each of the major stakeholders—physicians, payers, pathway developers, and patients—in ensuring that pathways are used appropriately?
ASCO envisions a collaborative process for strengthening clinical pathways that involves all stakeholders—a specific recommendation articulated in its policy statement. Transparency, consistency, and the full promise of clinical pathways will not be fully realized until all concerns and perspectives are considered and thoughtfully addressed.
What do you hope will be the outcome of the policy statement and its recommendations for pathways?
The ASCO Task Force on Clinical Pathways hopes the policy statement serves to engage all stakeholders in clinical pathways in oncology and facilitate a constructive dialogue for moving forward. The policy statement sets forth specific and concrete recommendations that can provide the structure for this much-needed dialogue.
As the leader of the ASCO Task Force on Clinical Pathways, can you tell us about the Task Force’s goals for the future? How do you see ASCO playing a role in guiding the use of oncology pathways going forward?
Recognizing the critical importance of this issue for physicians and patients throughout the United States, ASCO’s Task Force on Clinical Pathways will continue its efforts to ensure that pathways are developed in such a way that ensures consistency and transparency to all stakeholders. The policy statement sets forth nine specific recommendations that will form the basis of this work and will involve consulting with patients, providers, payers, vendors, and others to develop a collaborative approach to ensure that clinical pathways promote—and don’t hinder—high-quality patient care. I view ASCO as a convener and facilitator for moving that mission forward.
1. Song XP, Tian JH, Cui Q, Zhang TT, Yang KH, Ding GW. Could clinical pathways improve the quality of care in patients with gastrointestinal cancer? A meta-analysis. Asian Pac J Cancer Prev. 2014;15(19):8361-8366.
2. Hoverman JR, Klein I, Harrison DW, et al. Opening the black box: the impact of an oncology management program consisting of level I pathways and an outbound nurse call system. J Oncol Pract. 2014;10(1):63-67.
3. Yu PP. Pathways: how do we know they got it right? ASCO Connection website. http://bit.ly/1WWk5Ho. Published October 21, 2013. Accessed February 10, 2016.
4. Doyle C. Anthem’s Clinical Pathways Demonstrate Value: The Payer Perspective. American Health & Drug Benefits. 2015;8(Spec Issue):28.
5. Clinical Pathways: An Evolutionary Approach to Cancer Care. OncLive website. http://bit.ly/1KFzars. Published June 14, 2013. Accessed February 10, 2016.
6. Rinde, M. Oncologists Say Clinical Pathways Are Too Confining. OncLive website. http://bit.ly/1PSX838. Published September 10, 2015. Accessed February 10, 2016.
7. Zon RT, Frame JN, Neuss MN, et al. American Society of Clinical Oncology Policy Statement on Clinical Pathways in Oncology [published online ahead of print January 12, 2016]. J Oncol Pract. 2016. pii: JOPR009134.