1. DiGiulio, Sarah

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The American Society of Clinical Oncology has issued a new policy statement intended to ensure that clinical pathways in oncology promote high quality patient care. The statement, published online ahead of print in the Journal of Oncology Practice, includes nine specific recommendations (see box) to improve how these treatment management tools are developed and used (DOI:10.1200/JOP.2015.009134).

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"There's a proliferation of pathways in oncology and they're not all being developed in a transparent way," statement co-author Robin Zon, MD, FACP, Chair of ASCO's Task Force on Clinical Pathways, said in a phone interview. "ASCO decided to comment now to increase the awareness of the growing use of clinical pathways and the concerns that exist about the manner to which they are being deployed.


"The policy statement is intended to help ensure that there is quality, transparency, and consistency in the design and implementation of these treatment management tools-and also to ensure that they are used in the ways in which they are intended to be used: to improve quality care and reduce costs."


The policy statement was developed by the ASCO Task Force on Clinical Pathways and is based on a review of the current use of clinical pathways in oncology. The policy statement was adopted by the Society's Board of Directors.


Concerns Addressed

The statement and its recommendations were developed to address the following concerns about clinical oncology pathways, according to a news release from ASCO the statement:


* 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 has been 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.



ASCO President Julie M. Vose, MD, MBA, noted in the news release: "In too many cases, clinical pathways are undermining physicians' ability to optimally care for their patients with cancer and limiting patient choice."


The ASCO policy statement supports the use of pathways in oncology and recognizes that pathways are part of the answer to improve quality of cancer care, Zon added. "But, we're saying let's get back to caring for the patient and stop having to 'care' for the pathway."


The Provider's Perspective

Commenting via email for this article, Marcus Neubauer, MD, Director of Oncology Services at McKesson Specialty Health, who has been involved in developing the oncology pathway program there, said ASCO's policy statement "makes some very good points."


He explained: "There are many (too many) pathway menus out there and a practicing oncologist could have to wade through several a day. One pathway may be practice-based, another may be from a payer or third party. ... Furthermore, stakeholders may have different objectives, and this has to be reconciled."


Neubauer, who has also been involved in developing and evaluating pathway programs at other US Oncology practices (OT 3/10/10 issue), was not involved and did not contribute to the development of the ASCO policy statement.


"Speaking from the perspective of a provider, I am particularly supportive of recommendation six, 'oncology pathways should be implemented in ways that promote administrative efficiencies for both oncology providers and payers.'


"Adherence to clinical pathways takes considerable effort and, in return, there should be relief of at least some of the administrative burden. Providers should prove that they are achieving certain benchmarks and payers should determine if this is cost effective. But, during this analysis, payers should waive strict administrative hurdles for pathway adherence."


Nine Specific Recommendations

The nine recommendations in the policy statement to improve the development and use of clinical pathways in oncology are:


1. Pursue a collaborative, national approach to reduce the unsustainable administrative burdens associated with the unmanaged proliferation of oncology pathways;


2. Adopt a process for development of oncology pathways that is consistent and transparent to all stakeholders;


3. 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;


4. 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;


5. Recognize patient variability and autonomy and allow for physicians to easily diverge from pathways when evidence and patient needs dictate;


6. Implement oncology pathways in ways that promote administrative efficiencies for both oncology providers and payers;


7. Promote education, research, and access to clinical trials in oncology clinical pathways;


8. Develop robust criteria to support certification of oncology pathway programs; pathway programs should be required to quality based on these criteria, and payers should accept all oncology pathway programs that achieve certification through such a process; and


9. Support research to understand the impact of pathways on care and outcomes.



More from ASCO Clinical Pathways Task Force Chair Robin Zon, MD, FACP, on the recommendations in this issue's "3 Questions" column on page 42.