A discussion about clinical pathways for non-small cell lung cancer (NSCLC) was led by David Jackman, MD, who designed the pathways program for NSCLC at Dana Farber Cancer Institute. These pathways, Dr Jackman said, are divided by areas of treatment: first-line chemotherapy, targeted therapies, and immunotherapy. Because first-line chemotherapy options tend to have equivalent efficacy and toxicity, it is difficult to compare them on these criteria.
When discussing his approach to value assessments during clinical pathway development, Dr Jackman noted that, for treatments for which there is insufficient comparative data available in the published literature, calculation of the Net Health Benefit score in the ASCO Value Framework can be difficult. The Value Framework, he said, is “clunky” and inconvenient for physicians to use in their practices. In contrast, he said, the National Comprehensive Cancer Network (NCCN) Evidence Blocks are easier to use and allow physicians to get a sense of a treatment’s relative value fairly quickly.
Focusing on the issue of toxicity, Dr Jackman said, “A big part of pathways is not just what to use but what not to use.” Pathway developers also have to think about not just the present but also the future; how is the current treatment decision going to influence future treatment options for that patient? For example, treatment-related toxicity that leads to kidney function impairment can mean that certain treatments will not be available to the patient later on should their cancer recur.
On the issue of cost, Dr Jackman stressed that cost-effectiveness must be examined in terms that are more comprehensive than just the relative drug costs; other health care costs, including those of treating toxicities, must be factored in as well.