Oncologists Debate the Place of Pathways and Guidelines in Clinical Practice

Daniel Denvir

April 2011, Vol 2, No 2 - ACCC Conference

Washington, DC—Physicians are tugged in different directions by patients, payers, and society at large (expressed via the legal system), with expectations involving physician autonomy, best practices, adherence to local standards of care, as well as national guidelines.

At the 2011 Association of Community Cancer Centers Annual Meeting, oncologists debated the increasing role of pathways and guidelines in clinical practice.

Variation in Treatment Not Always a Bad Thing
Cary A. Presant, MD, FACP, an oncologist at the Wilshire Oncology Medical Group at the California Cancer Medical Center and Professor of Clinical Medicine at the University of Southern California Keck School of Medicine, said that the 3 major trends in medicine today—physician autonomy, guidelines or pathways, and personalized medicine—often seem to be in conflict with one another.

Physician autonomy goes to the core of the profession, back to the Hippocratic Oath of treating the patient to the “best of my ability and judgment,” Dr Presant said. “Physician autonomy should not be let go of in a setting where everyone seems to be moving toward guidelines and pathways,” Dr Presant said.

“Whatever is working seems to change very quickly. Therefore, basing the guideline on what has been working may be basing the guideline on something that is really unsustainable,” he reiterated.

A clinical oncologist is able to account for factors such as the presence of multiple comorbidities that guidelines may not sufficiently take into account, or to analyze increasingly sophisticated genetic testing. In this sense, physician autonomy and personalized medicine can go hand in hand. “Society,” according to Dr Presant, “grants doctors that autonomy.”

It is well established that guidelines or pathways seek to diminish the variation in treatment, which can lead to poor care and higher costs. This variation, however, is not simply a result of bad providers, Dr Presant claims; many physicians disagree about what works best. Imposing a single standard can often be counterproductive.

The narrowness of clinical trials further makes it difficult to generalize some standards to a broader patient population, he said, noting that guideline authors often have undisclosed conflicts of interest. “Decisions cannot be made by one single guideline, or by a computer, or by one single laboratory evaluation.”

Pathways Allow for Patient Variation
Presenting the other side of this debate, Roy A. Beveridge, MD, Executive Vice President and Medical Director at US Oncology, said he did not perceive such tension between pathways and physician autonomy, or personal medicine.

“In the pathways as they are now, there are already provisions made for those patients who have premeno pausal or postmenopausal breast cancer; those patients who are PR [progesterone receptor} positive or PR negative; those patients with colon cancer who are KRAS positive and KRAS negative; those patients with certain chromosomal abnormalities in terms of leukemia or in terms of myeloma,” Dr Beveridge said.

US Oncology, a cancer healthcare network with 460 community cancer practices in 39 states, has developed Level I Pathways known as Innovent Oncology (www.innoventoncology. com). Innovent Oncology is continuously developed and maintained by US Oncology member physicians, who access the system through a web portal and electronic health records.

“The development and use of evidence- based medicine by physicians allows for physician autonomy and continues to apply the logic of Level I understanding of treatments, which allows for there to be even more personalized care,” Dr Beveridge said.

A study completed by Aetna showed that providers using the Level I Pathways lowered outpatient costs by 35% for patients treated for non– small-cell lung cancer, and these patients had the same 12-month overall survival rate as patients not managed with this pathway.

Dr Beveridge also countered concerns that effective treatments are being put aside because of cost; the best evidence-based treatment available is always considered first line, and if 2 treatments have equal efficacy, toxicity will be taken into account to determine use. If efficacy and toxicity are equal, the cost to patient and payer will be considered as a pathway guide.

Innovent Oncology also encourages patient accrual to clinical trials; insufficient patient participation in clinical trials continues to hinder drug research and development, according to Dr Beveridge.