Oncology pharmacists play a significant role in clinical pathways.
All patient treatment journeys should begin with a plan; in cancer therapy, that plan is called the clinical pathway. Oncology pharmacists play an instrumental role in these clinical pathways and often are the primary member of cancer care teams providing patients with assurance that they are on the right treatment plan.
The American Society of Clinical Oncology (ASCO) defines clinical pathways as "detailed, evidence-based treatment protocols for delivering cancer care to patients with specific disease types and stages." Additionally, ASCO goes on to note that, when properly designed and implemented, these clinical pathways can act as a tool for improving care quality and reducing costs.
With oncology teams, there is an ongoing debate regarding drug savings vs evidence-based care. Further adding to the debate is the increasing role of managed care in the clinical pathway decision-making process.
When navigating this drug treatment process, highly trained oncology pharmacists, whether board certified oncology pharmacists or specialized pharmacists working in oncology settings, are well positioned to guide oncology teams. In light of this, further exploration of the oncology pharmacist's role in clinical pathway management can provide more evidence to support this position on care teams.
The Debate: Savings vs Support
It is no secret that health care costs are dramatically increasing and there is an overall shift toward a value-based health care delivery system. As a result, we have seen a significant increase in clinical pathways in oncology.
As of this year, there are an estimated 60 individual health insurance plans in the United States that are implementing oncology pathways, and more than 170 million individuals are covered by those plans and are potentially being treated under a plan-sponsored pathway.
In the community setting, both oncologists and oncology pharmacists have found treatment pathways essential when providing care for patients with different types of cancers. Clinical pathways serve as guides for these experts so they can select the optimal therapy based on the diagnosis.
Over the past couple of years, there has been an increasing influence from managed care on oncology treatment, principally driven by newly approved higher-cost cancer products and therapies hitting the market. The debate within oncology teams that has emerged is one around the pathway’s development, which has been principally driven by improving care and outcomes; however, when cost becomes the primary point of the selection process, patients may suffer.
The question then becomes one of balance: the improvement of patient care in balance with cost of care. As always, obtaining the best clinical outcome must be the overriding priority. But, in most cases, the patient will make the ultimate decision about what treatment they want before therapy is implemented.
In addition to facilitating the drug selection process, the clinical pathway often becomes an education tool by which the oncology pharmacist can assist the patient in learning about adverse effects, toxicity, efficacy, and treatment burden. The most accepted clinical pathways have embedded elements of the patient’s perspective and facilitate the patient’s ability to have ultimate authority in final treatment decision-making. In this way, clinical pathways exist primarily to achieve the highest evidence-based level of oncology care.
What Is the Right Path?
Given the acceptance of clinical pathways, several players have emerged in the field, requiring the clinical oncology team to be called on to consider the different options available. The decisions are often driven by assessing a quality pathway and finding the most currently accepted oncology treatment for a given cancer based on the patient’s diagnosis.
A significant challenge for oncology teams that has emerged as a result of payer influence is managing multiple pathways and potentially providing patients, even within a single practice, varying care depending on their insurance. Most oncology pharmacists and oncologists are uncomfortable with having different treatment pathways and standards of care based on pure economics.
The “gold standard” of treatment pathways is generally acknowledged to be those pathways established by the National Comprehensive Cancer Network (NCCN). NCCN guidelines are often updated and considered contemporary vs those driven by payers, which often have longer review cycles, thus making them potentially out of date.
Over the past decade in specialty pharmacy, oncology products have come into play as over 50% of the total drug spend. Today’s clinical guidelines often recommend a high-cost targeted therapy or immunotherapy because they offer the best efficacy and lowest toxicity. However, the concern arises around payers influencing the product selection process, as the motive of cost savings is often not the oncology team’s preferred direction.
For example, several oncology drugs have been developed, such as tyrosine kinase inhibitors (TKIs) for the treatment of chronic myeloid leukemia (CML). Although hematopoietic stem cell transplantation remains the only curative option for CML therapy, oral TKIs have transformed CML from a progressive disease with a high mortality rate into a chronic condition with dramatically reduced mortality rates. However, TKIs are costly therapies and, often, the choice of pursuing TKIs meets resistance in the payer community.
As approvals continue to provide more options for oncology teams to consider, we should anticipate this debate to continue and strengthen, thus allowing payers to leverage 1 therapy over another.
The Patient and Oncology Team's View of the Role of Oncology Pharmacists
Given the perspective of Directions in Oncology Pharmacy® principally being that of oncology pharmacists, it is important to note that patients' and fellow oncology team members' perspectives are also important for oncology pharmacists to consider when approaching the management of clinical pathways.
There is a strong general consensus, supported by a number of studies, that the role of the clinical pharmacist in enhancing patient-reported adherence rates is significant and validated by medication ratio rates. However, it remains unclear whether patient perceptions of the clinical pharmacist’s role in managing clinical pathways align with the findings of this research.
In a recent study, investigators asked patients whether they felt the clinical pharmacist plays an instrumental role in their oncology care—and the results were impressive. Of the patients surveyed, 87.5% stated that they believed the clinical pharmacist plays a critical role in their care.
When patients were asked about their overall satisfaction with their oncology pharmacy care, the results were equally impressive. Patients said that they were 100% satisfied with the role of the clinical pharmacist in their pharmaceutical care.1 Some important additional takeaways from this survey included:
The Future Is Now
As clinical pathways continue to evolve, so will the oncology pharmacist’s role. We should anticipate that we will continue to see new and innovative therapies rise in price, creating more pressure from payers to manage costs.
Many of the new, innovative therapies will be for cancers that were more challenging to treat previously; however, we are seeing replacement or updated therapies for existing treatments emerge as well. These updated therapies often create opportunities for managed care to influence product selection either through a formulary, step edit, treatment pathway, or like mechanism. For example, biosimilars are creating these opportunities in today’s market.
All oncology pharmacists have a responsibility to play a role in the rational and ethical use of therapies and the clinical application of product selection and management, whether their decisions are driven by a clinical pathway or by their professional judgment. Oncology pharmacists have before them the opportunity to spearhead initiatives that promote safe, effective, and cost-efficient medication use, allowing them to lead the efforts of patient and interprofessional education.
About the Editor: Dan Steiber, RPh, operates Genesis Pharma Consultants, a practice responsible for commercial operations and trade-supply chain strategy development. Steiber has served in senior positions in pharmacy, distribution, and industry over the course of his 40-year career, and is a licensed pharmacist in Texas, Washington, California, and Pennsylvania. He is affiliated with several professional associations and publications and is a frequent speaker on behalf of many professional organizations. Steiber graduated from Washington State University College of Pharmacy and Pharmaceutical Sciences in Spokane. He has participated in a variety of postgraduate programs in law and business development/marketing at Harvard University and Northwestern University.
Dennison T, Deal AM, Foster M, Valgus J, Muluneh B. A pharmacist-led oral chemotherapy program’s impact on chronic myeloid leukemia patient satisfaction, adherence, and outcomes. J Adv Pract Oncol. 2021;12(2):148–157. doi:10.6004/jadpro.2021.12.2.3