ASCO Calls for Improvements to Clinical Pathway Programs in Oncology
ASCO released a new policy statement with recommendations to ensure that clinical pathways in oncology promote—not hinder—the care of patients with cancer. Published by Zon et al in the Journal of Oncology Practice, the statement asserts that the way in which these treatment management tools in cancer care have proliferated raises significant concerns about patient access, care quality, and transparency in pathway development and implementation.
Clinical pathways are ideally detailed, evidence-based treatment protocols for delivering quality cancer care for patients with specific disease types and stages. When properly designed and implemented, notes the report, “ASCO Policy Statement on Clinical Pathways in Oncology”, pathways can serve as an important tool in improving care quality and reducing costs. Cancer physicians, however, report growing concern that clinical pathways are being developed and implemented today in a manner that 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 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 being treated under a health-plan–sponsored pathways program—many under active treatment for cancer.
Developed by the ASCO Task Force on Clinical Pathways and adopted by the Society's Board of Directors, the ASCO Policy Statement on Clinical Pathways in Oncology points to a number of issues that may pose significant barriers to providing high-quality, evidence-based cancer care. ASCO is calling for clinical pathways to 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 in evidence-based clinical practice. ASCO is also calling for a reduction in the administrative burden that pathways place on physicians, so that more time can be devoted to serving patients.
Clinical Pathway Concerns
Based on an extensive review of the rapidly evolving landscape of oncology pathways in the United States, the ASCO Task Force on Clinical Pathways has raised a number of concerns about the way in which clinical pathway programs are currently 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 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.
“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 more quickly 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.”
ASCO's policy statement also warns that the proliferation of oncology pathways has created a major administrative burden on physicians, who already report spending as much as one-sixth of their day on paperwork, limiting time with their patients. Practices are forced to sift through the requirements of each payer's pathway program on a patient-by-patient basis, with some oncology practices reporting that they must adhere to eight or more different pathways for the same type and stage of cancer. Additionally, the amount of time spent seeking approval for off-pathway treatment can lead to harmful delays and erode the doctor-patient relationship and the overall quality of care, creating “a shift from caring for the patient to caring for the pathway,” the ASCO statement noted.
ASCO Recommendations
The ASCO policy statement includes the following key recommendations to improve the development and use of clinical pathways in oncology:
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 qualify based on these criteria, and payers should accept all oncology pathway programs that achieve certification through such a process.
9. Support research to understand the impact of pathways on care and outcomes.
Dr. Zon is the corresponding author for the Journal of Oncology Practice report.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
