For Oncologists, Some Food for Thought in the New Era of Healthcare Reform
San Francisco, CA—At the 2013 Breast Cancer Symposium, Lawrence N. Shulman, MD, Senior Vice President for Medical Affairs, Dana-Farber Cancer Institute, Boston, told oncologists that in the current era of healthcare reform, they will need to think beyond treatment outcomes, toxicities, and personal preferences.
Dr Shulman told oncologists they will need to “factor in” cost considerations and payment reform. “Ideally, our treatment decisions would be the same, but several factors cause us to rethink our approaches to cancer care,” he said.
Guidelines versus Pathways
For one thing, guidelines will no longer suffice. Guidelines are focused on a particular decision point in care, whereas pathways describe an entire course of treatment that may include preoperative imaging, preoperative systemic imaging options, surgical choices, nodal sampling options, radiation therapy guidelines, chemotherapy options, and posttreatment surveillance plans.
“It is important in the development of a pathway to think broadly about all aspects of care. In particular, you are specifying not only what should be done, but also what should not be done,” Dr Shulman said.
For example, routine cardiac monitoring for left-ventricular ejection fraction by a multigated acquisition scan or echocardiogram is a common practice for patients with breast cancer who are about to receive anthracycline therapy, but in the absence of symptoms or a history of cardiac disease, its use is not supported by the evidence, Dr Shulman pointed out.
He emphasized that pathways must include total cost of care, with careful consideration as to what is “really needed.” Pathway developers will need “to make some tough choices,” Dr Shulman suggested. Although efficacy and toxicity of regimens should be the first 2 priorities in decision-making, when these outcomes are equal between regimens, “the less expensive regimen or test should be chosen,” he advised.
Evidence in Clinical Practice
Too frequently, the evidence to back a physician’s management decision may be lacking. “Much of what we do day-to-day in the clinic has only weak evidence to tell us the best treatment choices,” Dr Shulman said. In the absence of phase 3 prospective randomized clinical trial data, he said oncologists should avoid “shooting from the hip” and should try to “reason out the best we can, in the theoretical.”
The lack of evidence contributes to variation in care and variation in the cost of care, he said. “We must include issues of utilization and cost as we plan cancer care, and must do this prospectively rather than patient by patient,” Dr Shulman emphasized.
He added that it is a mistake when treatment choices are not patient-centered. “We all try, but sometimes the system makes this very difficult. We need to keep the patient front and center.”