In the second session of the 2019 OCPC meeting, three panelists discussed two mock patient cases and explained how the pathways at their institution would clinically guide decision-making in that disease setting as well as how the physicians interact in a practical sense with each institution’s pathways.
Stephen B Edge, MD, FACS, FASCO, Roswell Park Comprehensive Cancer, moderated this session, which included Karen K Fields, MD, Moffitt Cancer Center, representing Moffitt’s in-house pathways, and Neelima Denduluri, MD, Virginia Cancer Specialists, representing US Oncology Network’s Value Pathways powered by NCCN.
Dr Edge began by going over the first patient details: a woman diagnosed with left breast cancer at age 40. Seventeen months following initial diagnosis, she presented to her family physician with new onset of shortness of breath/fatigue. Computed tomography showed left-sided pleural effusion; two masses left lung (1 cm and 2 cm) and single 1.5 cm suspicious liver lesion. Thoracentesis showed exudative effusion; malignant cells; cell block showed ER+; PR-; consistent with breast primary.
Dr Fields showed attendees how the Moffitt pathways would guide treatment for this patient and showed a slide of a few parts of the actual pathway algorithm. She stressed that all treatment pathways begin with a note that hyperlinks to all the available clinical trials at Moffitt in that disease state, which is updated regularly. She also highlighted the push at Moffitt to have therapy driven by genomic testing. Treatment options and guidance are directed by National Comprehensive Cancer Network (NCCN) guidelines as well as current research and trial data. When next steps in care are less straight-forward, the pathways have active links to studies and other data sources to help physicians weigh the evidence to determine the appropriate course.
Dr Edge said he is impressed by Moffitt’s work to integrate other service lines into their pathways and predicted that “the next generation of pathways from any vendors will have to reflect multidisciplinary care—the continuum of care that the patient moves through—and not stay within just one discipline or service line.”
Dr Denduluri displayed a screenshot of the pathways platform US Oncology Network practices use to interface with their Value Pathways. All NCCN guideline options for the stage of treatment are displayed, along with pathway-prescribed options, which have been narrowed down by efficacy, toxicity, and cost. The evolution of their Level 1 Pathways into the Value Pathways powered by NCCN has strengthened the content of the pathways guidance—many NCCN committee members, experts in their specialty, also serve on the pathways committees to assist in optimizing the pathways options. This partnership also benefits US Oncology Network in their conversations with payers.
Dr Edge posed questions about hard stops in pathways—can clinicians ignore a pathway? What measures are in place if physicians decide to go off pathway? Do they need to input the reasons into the electronic platform, and how often are reasons reviewed?
Both Dr Denduluri and Dr Fields noted that physicians are never restrained by the pathways; rather, it is hoped that they treat patients according to what they feel is the best course and those options are ideally reflected in the pathways. If physicians do not believe the pathway options reflect the best course of treatment, they are encouraged to document why that is and choose the better option. These checks are in place so that pathways committees can see physicans’ rationale, not for punitive reasons, but to determine how they may improve the pathway, whether there is new data that should be reflected in the choices, or if it was simply a case of having a unique patient/patient circumstance.
Dr Denduluri summarized the patient details in the second case and displayed on the screen how the Value Pathways dashboard for multiple myeloma appears. She noted that, as a breast cancer specialist, this is a perfect example of how helpful a pathway can be for physicians who may not always treat patients in other disease states. The pathways not only provide the NCCN guideline therapy possibilities and more specific pathways guidance but also prompts/reminders for when supportive care and palliative care should be considered.
Input from the audience was solicited as far as questions on prescribed treatment; Blaise N Polite, MD, MPP, FASCO, stepped up to the microphone. He asked: How do we get providers to think more about value when making treatment choices, especially in multiple myeloma? He noted that multiple myeloma costs approximately $70,000 a year for first-line therapy alone.
Dr Denduluri responded that, in the Value Pathways, prompts show the price of the regimens, but providers will not be told that they cannot use a therapy due to cost. However, she agreed that we do need to change how we do things in terms of considering value at these junctures and how to proceed with that information in mind, or at least consistently display how much regimens cost.
Dr Fields also responded, saying that we should always first ask clinicians about evidence and consensus on best therapy options. After that priority, integrating cost is a challenge. It is difficult to even present costs in a meaningful way in a pathway, as those presentations may not line up with acquisition costs or total cost of care for a patient. We still need to figure out the best way to determine costs. She said they are currently trying to price out an entire pathway to let clinicians know what a line of therapy or section of a pathway would end up costing cumulatively.
Dr Edge joined in, adding that trying to then add calculations on the costs to the patient (not just to the institution) and factoring that into the value conversation is even more difficult, especially with trying to determine patient costs in the context of all the different insurance plans.