Pathway-Based Oncology Care: Time for More Transparency
Authors: Harold J. Burstein
Journal: Journal of the National Comprehensive Cancer Network (2012)

Pathway-based oncology care has entered the mainstream of clinical practice.Experts estimate that more than 15% of patients with cancer in the United States are being treated at institutions or practices that vigorously use treatment pathways.In many respects, this is a long overdue and desirable development.Pathway-based care offers consistent, well-defined, and measurable treatment guidance.Pathways are also usually driven by high levels of clinical evidence, helping to ensure appropriate care.By homogenizing clinical practice, pathways can minimize unnecessary variation, simplify treatment offerings, and reduce medical errors, and are an integral part of many plans to contain costs in oncology care.Pathways also enable higher volumes of care, creating cost efficiencies.Finally, because they are well-defined in advance, pathways also facilitate more rational budgeting and financial planning, a big advantage for clinics and a desirable trait in the eyes of third-party payors.Pathways are being developed by individual groups and practices, academic centers, and other hospitals and clinics, including those with regional networks.They are also being written by companies and commercial enterprises.At least half-dozen companies developing oncology care pathways have emerged.Even my institution, Dana-Farber Cancer Institute, is exploring the possibilities of pathway-based care.However, the growing influence of pathway-based care means that it is also time for greater transparency in the pathway development process.• Departure Points: Developing guidelines is a time consuming and labor intensive process.Organizations like NCCN and ASCO have spent years evolving practices to create well-documented, highly annotated, comprehensive, detailed, and structured guidelines.Understandably, many pathway developers use these efforts as the foundational documents for their own pathways, not least in part because treatments endorsed in NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) are compendium listed by most insurers and third-party payors.Pathway developers should be explicit if the departure point for a pathway is a guideline from NCCN, ASCO, Cancer Care Ontario, or other well-established guideline creator.• Levels of Evidence: Many commercial pathways developers tout their reliance on evidence-based medicine, and in particular, level 1 evidence.Level 1 usually implies data from randomized trials, often even requiring meta-analyses of multiple randomized trials.However, such high levels of evidence are the exception, not the rule, for the multiple decisions that oncologists make with patients.A survey of 10 treatment guidelines from NCCN documented level 1 evidence for only 6% of the decision nodes in cancer care. 1 In none of the guidelines did level 1 evidence and consensus exceed one-third of treatment recommendations.By necessity, pathway recommendations will rely on levels of evidence far below level 1 thresholds.This means that pathway developers should be far more explicit about how decisions and choices are made, and on what degree of evidence, opinion, and habit.• Conflict of Interest: Major guideline generators have well-defined processes for disclosing, managing, and hopefully minimizing conflicts of interest among panelists and advisors.Those who seek to write pathways should be similarly transparent in disclosing and minimizing conflicts of interest, including direct financial stakes for clinical services affected by pathways.