Welcome to CME on ReachMD. The following CME activity is provided by TOPEC and the Roswell Park Cancer Institute through the generous support of BlueCross BlueShield of Western New York.
Hello, my name is Stephen Edge. I'm the Vice President for Healthcare Outcomes and Policy and a Professor of Surgery and Oncology here at Roswell Park Comprehensive Cancer Center in Buffalo, New York. We're here today to talk about pathways in oncology and how they are used as tools to ensure quality cancer care.
For the purpose of this talk, I have one disclosure to make, and that's that we receive research funding here from the National Comprehensive Cancer Network and Pfizer to study patient education based on clinical oncology pathways. The objectives of today's talk are to discuss the benefits of the use of clinical oncology pathways, to describe the optimal use of the clinical oncology pathways and recognize how the oncologist selects the primary choice for treatment when using clinical oncology pathways.
Today, we're going to review a number of topics. First off, what are pathways in cancer care? And for the non-oncologist, what benefit are they to you and to your patients? How is Roswell Park using pathways? And I might add that the way Roswell Park is using pathways is pretty much in line with the other large cancer centers that are implementing pathways around the United States. And what can you expect to see from us moving forward?
Clinical oncology pathways are tools that have been developed over the last decade to be used at the point of care to assist patients and providers in making shared decisions. These are tools that are based on national standards and guidelines. In addition to defining what the standard care is for an individual scenario, they also help to identify clinical trials that may be relevant to a specific patient and a specific circumstance. Further—and this is an area that we're specifically exploring at Roswell Park—they may serve as a base for patient education about their treatment. And finally, they provide clear and real-time, unambiguous documentation of care that may be able to be used for internal use for monitoring quality and outcomes and for use outside the practice for demonstrating care to payers and others to help with quality payments, rate negotiations and improving clinical efficiency.
For most cancers there are many different treatment options based on the type and the extent of cancer, what prior treatment has been given, the personal situation of the patient—the age, comorbid conditions and, quite frankly, patient preferences—and for this reason pathways have been developed to try to accommodate these while still giving the provider and the patient standard recommendations about what is in general considered the optimal care for a specific situation.
Guidelines and pathways really come from the same genre. Practice guidelines provide many options for each treatment situation giving the national best standards based on the efficacy of treatment and the side effect profile of treatment, and these have been developed for pretty much all cancer types. They are generally developed by multidisciplinary teams using a standardized methodology that's been developed over the last 20 years, and one of the key components of practice guidelines is that they have to be updated regularly. The most widely used practice guidelines at Roswell Park and, indeed, around the United States of America and, in fact, around the world, are the guidelines developed by the National Comprehensive Cancer Network, or NCCN. The NCCN was quite forward-looking in the early 1990s in recognizing the need for developing standard guidelines to assist doctors and patients in selecting care. The first guidelines from the NCCN were presented at the first annual meeting of the NCCN in 1996. Since that time, these guidelines have been updated at least annually or whenever a new drug or biologic or procedure changes standard clinical practice. These guidelines have now been accepted around the world as defining the standard of care and are used for many payment decisions, quality evaluations and research standards. Roswell Park staff along with members of the other NCCN comprehensive cancer center institutions are members and leaders of the national guideline development teams.
An example of these pathways is shown here, the non-small cell lung cancer pathway. This is version 3 for 2018, recognizing how quickly these pathways may be developed. Today is April 2, 2018—is when I'm doing this recording—and we're already on version 3 as the standards for lung cancer have changed. For each tumor type, guidelines make recommendations for the best treatment that can guide the decisions of patients and doctors, but guidelines have not been able to be operationalized or used at the point of care for treatment decisions, hence the development of pathways.
Pathways are tools that are based on guidelines that actually narrow very broad guidelines to key optimal treatments for each disease and extent of disease. The decision on how to narrow that is based on efficacy, really in this descending order: efficacy, side effect profile, and eventually cost. But efficacy and side effect profile are the two most important means to define the appropriate recommendations on a pathway. These then can be used at the point of care as a decision aid to actually help when patients and doctors are making decisions about treatment to show the best treatments that are available and that are up-to-date and to show the doctors and the patients any clinical trials that are available for this particular patient.
The pathways movement has really grown quite a lot, and the American Society of Clinical Oncology, ASCO, has carefully examined the pathway development programs and has actually set criteria for high-quality pathways, what constitutes a high-quality pathway that can be used in oncology practice. ASCO did this in an effort to help oncology providers and others understand what constituted a high-quality pathway. This work was based on an ASCO policy statement published in 2016 as well as stakeholder focus groups, member input and expert panel. These criteria can be used for evaluation of pathway programs and software systems.
There are really 9 criteria that the ASCO group identified as being appropriate for a high-quality oncology pathway program. First off, under development the pathways need to be expert-driven, and they need to reflect stakeholder input, not just doctors but patients and others. The treatment that is recommended needs to be transparent. The methodology needs to be transparent. It needs to be evidence-based. They need to be clinically driven, and they need to be regularly updated and up-to-date. They need to be comprehensive, and they need to promote the availability and participation in clinical trials where appropriate. In the domain of implementation and use, there need to be clear and achievable outcomes from the use of the pathways. The pathways, as much as they possibly can, need to be integrated into electronic medical record systems. They need to be cost-effective technology, and they need to provide real-time decision support. And there needs to be efficient processes for communication and adjudication of questions about the pathways. The pathways need to provide tools for analysis of the findings. There need to be efficient and public reporting of performance metrics. There need to be outcome-driven incentives, and most importantly, they need to promote research and continuous quality improvement. To date we do not know the best way to use pathways. We do not know the best ways to deliver cancer care. And pathways can be used in cancer care delivery research.
Pathways are developed based on national standards and guidelines, usually by a pathways committee that uses these tools, such as guidelines, to define best available treatments. This schematic shows how this committee might work. Major Compendia and practice guidelines might show that there are 5 or 6 treatments of equal efficacy, and one might limit that to 3 or 4 based on a side effect profile. Assuming equal efficacy and side effect profiles, it's possible you would then limit that based on cost and end up with 1 or 2 or 3 preferred pathways based on the personal situation of the patient—very important, however, to recognize that the pathways do not require that you use the preferred pathway. What we here at Roswell Park and others do is simply ask for a reason if the preferred pathway treatment is not recommended and don't in any way infer that the doctor must select those treatments.
This is an example of how pathways and guidelines might differ. Here on the upper panel here, you see the NCCN breast cancer guidelines showing the general treatment recommendations for a patient with hormone receptor-positive and HER2-positive cancer showing that the patient should receive adjuvant chemotherapy. In the footnotes the NCCN guidelines then lead you to the list of regimens that are all considered to be of equal efficacy. The pathway committee has taken these and other evidence and has narrowed this down to specific regimens so that they show what the pathway group would say would be the best guideline or preferred recommended therapy. The doctor then recommends that or other treatments as necessary and documents their reasons and reviews that with the patients, and this shows that the preferred treatment would be weekly paclitaxel and trastuzumab followed by a trastuzumab Q21 days. This is just an example, and the pathway may be updated even at this point, but this is an example of how pathways and guidelines actually differ and how pathways really are derived in general from guidelines.
I'd like to reiterate the point that pathways provide decision support. They do not define a mandatory standard requirement for treatment. Pathways provide the patient and the doctor recommendations for their personal situation, but they do not dictate required care. It's expected that doctors will take good care of their patient and that the care is personalized to their patient's needs. The pathways decisions and the reasons for care then can be documented in the office notes, and this provides both the patient and the doctor good documentation as to why a certain treatment was selected. Here at Roswell Park we've actually worked with our payer community to have a rational way to implement pathways and a rational way to use them in quality improvement, and what we've agreed upon is that, first of all, doctors are expected to provide the best care to their patients. Doctors are not judged simply on strictly following the pathway, but they are measured on providing and documenting the patient receives the best care. Here at Roswell Park we will attest that the pathway was used, and we will provide reasons why the care was off pathway if the preferred treatments were not given. Furthermore, our disease site teams will periodically audit the off-pathway reasons to make sure that those are all appropriate, and we will actually provide the patterns of care and the results of these off-pathway audits to our payers.
We established a pathway program in 2015 in a collaboration with the H. Lee Moffitt Cancer Center in Tampa, Florida. The Moffitt Cancer Center has actually developed their own internal pathways program, very useful and very granular program that they directly integrated into their electronic medical record. We've been measuring the treatment concordance with those pathways, and actually, treatment concordance is extremely high, and where treatment is off pathway, the doctors here at Roswell Park uniformly have documented the good reasons why that's the case. But we recognized in 2016 and 2017 that we could not keep up with the constant modification that was necessary for the infrastructure to maintain pathways and we would be better off using a vendor-based software system based on national standards with some modifications at the upper end of the pathway, some modifications based on evidence and our review. So we've contracted with Via Oncology, one of the major software vendors in this field, to have Roswell Park pathways powered by Via Oncology. The implementation is about to start here at Roswell Park at our downtown campus and later this summer at all of our affiliated network sites, so if the name Roswell Park is on the door, we will be using pathways to assure high-quality care and to provide patients that decision support.
In the United States to date, the primary focus of pathways has been on medical oncology due to the very high and the increasing cost of the drugs as well as the documented variation in care, particularly in the variation in end-of-life care. At Roswell Park our pathways have been multidisciplinary, and while we are starting with medical oncology and some surgical fields here with the Via Oncology pathways, we will be expanding to true multidisciplinary pathways across the spectrum of cancer care.
As its pathways tool, Roswell Park has selected the Via Oncology tool so that Roswell Park will have the Roswell Park pathways powered by Via Oncology. This is a national program based on guidelines and other evidence using a national committee to update these at least quarterly. Roswell Park doctors do sit on these pathway development teams, and in fact, one of our doctors was just asked to be the co-chair of one of these teams. Roswell Park does make changes where the disease team feels it's absolutely necessary to ensure optimal care, though we expect this will not happen very often.
The pathways provide a number of different areas where they provide value to Roswell Park and to our patients. The first of these is in the promotion and understanding of clinical trials. Clinical trial care is often very valuable to patients. In fact, many people come to Roswell Park asking to participate in clinical trials. And for many patients they offer what may be the best treatment option, both in the adjuvant setting and particularly in the advanced-disease setting. The pathways incorporate clinical trials directly into the pathway as the initial option for a specific treatment situation. So, for example, in the example I gave a minute ago with a woman with a hormone receptor-positive HER2-positive breast cancer, if there was a clinical trial available for that, that would be provided and shown to the provider before they got the standard treatment options, and then the doctor would provide a reason why they either were giving or not entering the patient on the trial. Here at Roswell Park we display only those trials that are open at Roswell Park.
Pathways also provide value in our ability to assess quality. We know that from retrospective reviews that we have done that our patients receive high-quality care, guideline-appropriate care in a timely manner, but now we will for the first time be able to know in near real-time exactly who we're treating, exactly how they’re treated and how that treatment compares to national standards. We'll be able to feed that information back to the provider groups on a weekly or monthly or quarterly basis. It also provides feedback to not only the doctors but to our disease site specialty groups, both here and across our affiliates, so that not only will the pathways be used here at our main campus at Roswell Park at the Cancer Center but also across our Roswell Park affiliate network through our medical oncology colleagues at the Roswell Park Oncology Professional Corporation as well as hospital affiliates that we've developed across the state. This will allow us to demonstrate in-depth knowledge about the quality that's not previously been available.
In addition, the pathways provide value to our patients. We are revamping patient education for chemotherapy based on the pathways. We are going to face the pathways out to the patients so that they know that we're using pathways and they see the value in them. We are actually going to be providing the patient education materials around chemotherapy with a face sheet saying what is the status of their cancer, the stage of their cancer, what is the treatment that is recommended by the pathway for their situation, whether their doctor is recommending that treatment, or if their doctor has recommended some other treatment, the reason why the doctor is recommending some other treatment, and that reason will be entered by the doctor directly into the pathways system and communicated to the patient. We're doing a small research study here to look at the quality of life issues surrounding the use of pathways. We've also reviewed this with our Roswell Park Patient Advisory Panel that is very enthusiastic because we're actually going to be doing truly individualized patient educational materials.
Finally, we think that this provides real value to our primary care colleagues. They will be able to know that we will be monitoring and ensuring the right care at the right time at the right place in a real-time basis. We will be reviewing the care that is off pathway so that the disease teams will be able to see that, will be able to modify the pathways as needed and be able to address any concerns. There will be clear documentation of the recommended treatment and the reasons for that recommendation in the medical record that goes to our primary care colleagues, therefore allowing us to give rapid feedback to our colleagues on the treatment care plan.
We think the pathway program here is going to be a key cornerstone of developing our program here as well as our network, ensuring the right care and personalized to the patient’s need across our entire Roswell Park system, provide us better opportunities to feed this back to our colleagues and improve the patient experience.
With that I'd like to thank you for listening today, and I'd be happy to entertain any questions. My e-mail address is here, and you're welcome to call us here at Roswell Park if you have any questions about our pathways program. Thank you once again.
The preceding activity was provided by TOPEC and the Roswell Park Cancer Institute, through the generous support of BlueCross BlueShield of Western New York.
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