ASCO released a new policy statement earlier this year with recommendations to ensure that clinical pathways in oncology promote—and do not hinder—the care of patients with cancer. Published in Journal of Oncology Practice, the statement asserts that the way in which these treatment management tools in cancer care have proliferated raises substantial concerns about patient access, care quality, and transparency in pathway development and implementation.
Clinical pathways are detailed, evidence-based treatment protocols for delivering quality cancer care to patients with specific disease types and stages. When properly designed and implemented, pathways can serve as an important tool in improving care quality and in reducing costs. Cancer physicians, however, report growing concerns that the way clinical pathways are developed and implemented today may impede delivery of high-quality cancer care.
“It’s time to seriously examine the way clinical pathways are designed and implemented to ensure they consistently enhance, rather than diminish, patient care,” said 2015–2016 ASCO President Julie M. Vose, MD, MBA, FASCO. “In too many cases, clinical pathways are undermining physicians’ ability to optimally care for their patients with cancer and limiting patient choice.”
Currently used by institutions, health care providers, commercial organizations, and other health systems, pathways are also increasingly being adopted by insurance companies, with an estimated 60 individual health insurance plans in the United States currently implementing oncology pathways. More than 170 million individuals covered by those insurance plans are potentially treated under a health plan-sponsored pathways program—many under active treatment for cancer.
The ASCO Policy Statement on Clinical Pathways in Oncology, developed by the ASCO Task Force on Clinical Pathways and adopted by the Society’s Board of Directors, points to a number of issues that may pose substantial barriers to providing high-quality, evidence-based cancer care. ASCO believes clinical pathways should better accommodate the diverse circumstances and characteristics of patients with cancer.
Pathways should be expanded to address the full spectrum of cancer care and updated regularly to reflect the latest advances in evidence-based clinical practice. ASCO calls for a reduction in the administrative burden that pathways place on physicians, so that more time is spent serving patients.
Pathways May Not Reflect Advances or Encompass Full Spectrum of Care
Based on an extensive review of the rapidly evolving landscape of oncology pathways in the United States, the ASCO Task Force on Clinical Pathways raised a number of concerns about how clinical pathway programs are developed and implemented in oncology practice, including the following:
- Oncology pathways are not developed or applied consistently by insurers and other pathways creators, resulting in wide variations in quality and utility.
- Oncology pathways are often too rigid, and many place too much emphasis on cost control. These relatively simplistic pathways may restrict patient choices and may conflict with physicians’ clinical judgment.
- Oncology pathways are often focused only on the selection of anticancer agents and do not include other critical aspects of cancer care, including diagnostic evaluation, laboratory testing, and palliative care services, which are central to quality patient care.
- The oncology pathway development process today, in many cases, is not transparent to patients and providers. As a result, there is no assurance that a given set of pathways were developed without conflict of interest and in a manner that ensures they reflect the latest scientific evidence.
- There is no system in place to guarantee the integrity of pathways coming to market, or to ensure they are implemented in a manner that supports high-quality patient care.
“Oncologists are finding that cookie-cutter approaches to treatment can impede our ability to personalize care and meet every patient’s needs,” said Robin T. Zon, MD, FACP, FASCO, chair of ASCO’s Task Force on Clinical Pathways. “In an era when medical advances come faster than ever, inflexible pathways may get in the way of better outcomes. When doctors diverge from a clinical pathway, even for well-justified reasons, payers are likely to either deny coverage or require prior authorization, which can delay treatment and threaten patients’ health.”
The ASCO policy statement includes the following key recommendations to improve the development and use of clinical pathways in oncology:
- Pursue a collaborative, national approach to reduce the unsustainable administrative burdens associated with the unmanaged proliferation of oncology pathways.
- Adopt a process for development of oncology pathways that is consistent and transparent to all stakeholders.
- Ensure that pathways address the full spectrum of cancer care, from diagnostic evaluation through medical, surgical, and radiation treatments, and include imaging, laboratory testing, survivorship, and end-of-life care.
- Update pathways continuously to reflect new scientific knowledge, as well as insights gained from clinical experience and patient outcomes, to promote the best-possible evidence-based care.
- Recognize patient variability and autonomy and allow for physicians to easily diverge from pathways when evidence and patient needs dictate.
- Implement oncology pathways in ways that promote administrative efficiencies for both oncology providers and payers.
- Promote education, research, and access to clinical trials in oncology clinical pathways.Develop robust criteria to support certification of oncology pathway programs; pathway programs should be required to qualify based on these criteria, and payers should accept all oncology pathway programs that achieve certification through such a process.
- Support research to understand the impact of pathways on care and outcomes.
View the complete ASCO policy statement here.
– Amy Hindman