In this series, we speak with cancer care practitioners about how pathways are being used in their practices, how they are being applied in a particular disease state, and what challenges remain for treatment decision-making.
For this installment of Pathways in Practice, we spoke with Stacey A Cohen, MD, Seattle Cancer Care Alliance (SCCA); assistant professor, Division of Medical Oncology, University of Washington School of Medicine; assistant member, Clinical Research Division, Fred Hutchinson Cancer Research Center, (Seattle, WA). Her work focuses on the influence of genetics on high-risk gastrointestinal cancers and cancer treatment. In addition to her work in the above roles, Dr Cohen serves on the colon, rectal, anal, and small bowel National Comprehensive Cancer Network (NCCN) committee in developing and updating guidelines.
We asked Dr Cohen to describe how the pathways at SCCA are designed and implemented, specifically focusing on the care outlined in their colorectal cancer pathway.
How are clinical pathways developed and used at SCCA?
Dr Cohen: We have a specific pathways department where staff members are tasked with drafting pathways in accordance with national guidelines. We generally use the NCCN Guidelines as a starting point. Then we, as a group, talk about any nuances where we think that we should be more clear to establish our practice patterns and determine if there are any differences that we might want to include in general.
The NCCN Guidelines represent evidence-based medicine, but we take time to deliberate beyond them becausmany times in NCCN guidance there are ranges for when certain things need to occur, or there are multiple options for treatments or possible approaches. As clinicians, we want to be as clear as possible about what our own institutional preferences are. Also, in areas where there is a lack of evidence or insufficient evidence, then there is a range of possibilities that are considered acceptable; we know that nationally, from institution to institution, there are preferences. We have tried to encapsulate some of those preferences into our pathways.
Our goal is to accurately represent how we are and should be treating patients but with the attitude that these pathways will probably only fit maybe 80% to 90% of our patients. We understand that no pathway will ever dictate the care of all patients—there should be room to individualize care for unique situations. There are various issues understood between a doctor and a patient about why a pathway designated treatment might not suit a particular patient. It may be due to a patient’s preference or it may be a question of whether a treatment is medically necessary based on stage of disease, costs, goals of care, etc.
No pathway is going to capture every patient. What we are trying to do is represent what high-quality, evidence-based care would be for the vast majority of our patients. Then we also provide these pathways to some of our community partners who are also under the SCCA umbrella, so that they can get a sense of what might happen at our main campus.
What is the decision and documentation process for when a particular patient will be treated off pathway? Is there a review process before or after the fact?
Dr Cohen: At this point, we have designed these pathways and use them, but our providers are not beholden to following the pathways. It is meant to be a source document if there is confusion or concern about giving a clear starting point for how, as an institution, we feel things should flow. We would eventually like to move toward more data and decision capture, but it has not reached that level of prospective use.
What type of individuals are involved on this pathway committee? And what evidence is assessed to determine SCCA’s institutional preferences for the pathways?
Dr Cohen: In terms of who works on the pathways, the efforts are centrally spearheaded by our institutional administrative Clinical Pathways team. This team then reaches out to cancer experts across our institution.
Then there are physician experts in each of the included areas: medical oncology, surgery, and radiation oncology. For colorectal cancer, we include both colorectal surgery specialists as well as hepatobiliary specialists and radiology. We try to include a physician expert in each of the relevant areas to provide input and be a lead in that area. Then any question that might be relevant to the group at large, that person would circulate it to their colleagues. For example, as a medical oncologist, if I thought that a certain chemotherapy pathway made sense, but there might be room for discussion, then I could circulate that to my colleagues to see what they had to say.
Could you provide a brief overview of the way SCCA has designed their pathway for colorectal cancer in terms of its comprehensiveness? Does it follow the patient through their entire journey, or is it specific to treatment?
Dr Cohen: The colorectal cancer pathway was designed over the last couple of years starting in 2017. I was most heavily involved in the decisions pertaining to the medical oncology items.
Like the NCCN Guidelines, the goal is to start with somebody who has suspicion of cancer and determine what the appropriate workup would be. The pathway includes directives on discussion and multidisciplinary clinic and possible outcomes, including different chemotherapy, surgery, or radiation options. It goes through a few different scenarios, such as somebody who has synchronous metastatic disease, someone who might have resectable metastatic disease, or someone who has an obstructive lesion such that maybe they needed a brain callosotomy in the beginning. It includes guidance for metastatic patients, eg, chemotherapy options, trying to highlight what might be most preferred.
Then in supportive care, there are at least brief nuances to various supportive care options including nutrition, physical therapy, palliative care, psychiatry, chaplaincy, as well as brief descriptions about the services that we have at the SCCA and how to contact those providers. We cover pain, survivorship, social work—all of the things that might be necessary with the hope that anybody trying to implement quality care in the system have all of the resources, both conceptually and also practically, understanding what they might be able to obtain through our system.
Can you explain your decision-making process regarding inclusion of metastatic chemotherapy, adjuvant medical oncology options, or the SCCA’s preferred chemotherapy options in either of these settings?
Dr Cohen: There are definitely regional variations in how chemotherapy is given. As an example, FOLFOX and FOLFIRI are considered relatively equivalent regimens. There had been multiple trials not really proving one to outperform the other. At the time that our pathways were done, which is now about 2 years ago, we had stated that FOLFOX plus bevacizumab would be our preferred option. That was partly based on the fact that we had a trial in the second-line setting that was based on an irinotecan backbone.
At the time, we also wanted to somewhat streamline the order that chemotherapy was given because it would optimize trial enrollment. Most clinical trials that we have had open tend to assume that there is going to be the oxaliplatin-based therapy in the first line and then irinotecan-based therapy in the second line. We wanted to highlight that in our pathways to recognize that that flow would best fit with the clinical trials that we potentially have open.
Subsequently, now there have been studies looking at sidedness in colorectal cancer as well as studies expanding our molecular testing. It becomes even more complicated to state what is the correct guidelines for the NCCN.
As a member of both the pathway committee and the NCCN panel, it is very difficult to try and describe how even most patients should be treated, because there are
so many nuances. That is why the NCCN has so many possible first-line options. As an institution, to be supportive of our trials, we did try to highlight that a little bit in our pathways.
If we could update the pathways more often, then we could do an even better job encouraging trial enrollment, or rather not impede it, by giving something that would make someone not eligible. It is a very difficult process because trials are coming and going more frequently than our pathways are updated.
Does SCCA include clinical trials when applicable within the pathways themselves? Is a clinical trial considered a preferred first treatment option for your patients?
Dr Cohen: We do have a note on our pathways that say enrollment in a clinical trial is the preferred treatment option for eligible patients at all times.
As an institution, we support enrollment in clinical trials. For an individual patient, of course, we are always going to discuss with them whether or not it is the correct option, but we are very supportive of trials. We have not included trials specifically but rather just put a disclaimer on there that, if trials are an option, we recommend it.
What are some of the challenges you have faced in optimizing therapeutic decision-making at SCCA? How have you overcome such challenges or plan to combat them?
Dr Cohen: One of our biggest limitations is the pathways sometimes feel like they are out of date as soon as they are finalized. The process of updating them can take so long to get consensus that new information can come out at any time that can make them virtually outdated almost immediately.
Even these pathways done 2 years ago have many things missing on them related to the nuances we have learned, such as how best to manage chemotherapy for metastatic patients. It does require a concerted effort for the pathways team to be aware and dedicated to keeping pathways up-to-date.
Unlike for an institutional pathway, the national guidelines often have pharmaceutical companies coming to them with positive data to request consideration for a guideline update that would include their drug. However, an institutional guideline relies on internal expertise for updating the pathways. This is a process that requires more dedicated time and the experts to not just keep on top of the data but also to remember what data are new vs the last time things were edited. That requires a certain amount of effort.
Thankfully, we do have the NCCN Guidelines as sort of a beacon for what we want to mirror in our own institution, and so interplay between our internal pathways and the NCCN Guidelines is how we try and optimize our care.
Do you have any parting comments related to pathways?
Dr Cohen: I do think that it is helpful to streamline and document best practices because we hope that patients who come to our institution are getting excellent care regardless of which provider they are seeing. The pathway is a way of summarizing that, such that providers can make sure that their practices are in line with high-quality evidence-based care that we would consider appropriate for the majority of patients.
It is helpful to understand that there is more than one way to correctly take care of our patients and to be able to see clearly what the options are while also still having room to apply independent decision-making.
