2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Driving Evidence-Based Standardization of
Care within a Framework of Personalized
Medicine
By Adam Brufsky, MD, PhD, Kathleen Lokay, BBA, and Melissa McDonald, MS
Overview: Cancer care in the United States faces a number of
key challenges today that are causing payers, referring physicians,
and patients alike to question the value of the care, in
terms of both outcomes and costs. New technologies in the
form of pharmaceuticals and biologics, prognostic tests, and
new radiation therapy tools and techniques offer the promise
of improved outcomes, but their cost-effectiveness is often
unclear. Oncologists themselves are caught in the middle, as
they are the prescribers of such technologies and the entity
billing for such services but have only limited ability to
influence the pricing models for these services. Finally, as
BY 2004, the University of Pittsburgh Medical Center
(UPMC) Cancer Centers had expanded to approximately
40 sites of services in a 100-mile radius in Western
Pennsylvania. Concerns over the consistency and quality of
care across such a diverse network were validated through
the results of internal surveys that demonstrated wide variability
in approaches to cancer care. Pressures and concerns
from the large payers in the region were also driving an
imperative to collaborate around a solution to containing the
rising costs. In addition, with the University of Pittsburgh
Cancer Institute (UPCI) as its NCI-designated cancer center,
UPMC needed tools for increasing awareness of, and
accrual to, clinical trials. The solution for all of these needs
was the development and implementation of the Via Oncology
Pathways program to improve quality, ensure consistency
of care, reduce hospital admissions, and reduce total
cost of care. To date, the program has served UPMC well for
more than 7 years and provides a firm foundation for UPMC’s
overall health care reform strategy for accountable care.
Differences between Via Oncology Pathways and
Oncology Guidelines
Although excellent sources of oncology guidelines exist
today, adherence to these guidelines is more difficult to
assess, especially in community-based oncology practices,
where more than 80% of cancer care is delivered. A recent
analysis by IntrinsiQ of its data set of more than 17,000
patients per month suggests that, for example, for non–
small cell lung cancer, adherence to guidelines is 100% for
first-line therapy but only 60% for second- and third-line
therapies (Ed Kissell, IntrinsiQ, email communication, September
2009). Even within guidelines, case studies routinely
collected through physician surveys by reputable third parties
suggest that a substantial amount of unexplained variability
exists, in large part due to the inclusive nature of
multiple options as standards of care. Case study surveys
conducted in 2005 within the UPMC Cancer Centers
(UPMC-CC) revealed a high amount of variability within
guidelines that could not be easily explained. No one will
dispute that cancer is a very complex disease or that the
nature of decision making is highly dependent on physician
judgment for each unique patient. However, experiences in
other fields of business suggest that oncology care will
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oncology care becomes more complex because of increased
understanding of the pathogenesis of the many subtypes of
cancer, the community-based oncologist who cares for patients
with all cancer subtypes is confronted with maintaining an
up-to-date knowledge base that is expanding rapidly. Although
no single solution for these issues exists in oncology today,
the experience at the University of Pittsburgh Medical Center
has demonstrated that a clinical pathways program can reduce
unwarranted variability in both treatment and outcomes,
drive adherence to evidence-based medicine, and, in the process,
reduce the growth rate in the total costs of cancer care.
benefit from a certain level of standardization for the majority
of clinical presentations.
Development and Maintenance of Via
Oncology Pathways
Starting in 2005, UPMC developed and maintained algorithms
(Via Oncology Pathways) for oncology clinical decision
making that UPMC physicians use to determine the
best management for any given state and stage of cancer.
This effort has been painstaking and has involved the
cooperation of the majority of the academic and clinical
experts at UPMC as well as numerous physicians from other
practices. A committee exists for each major disease category
(eg, colorectal) and consists of two chairpersons: one
academically based oncologist specializing in that disease
and one community-based oncologist with a background and
patient concentration in that disease. The disease committees
are composed of practicing oncologists from UPMC as
well as all other practices that use the Via Oncology Pathways
program. The committees convene quarterly to review
new clinical literature, pathway results, and the appropriateness
of the granularity of the algorithms (eg, defining
the states and stages of disease and unique patient scenarios
at which decisions should be made). Through their collaborative
work, a single “best” treatment for the majority of
clinical scenarios in oncology care is defined. These best
treatments are based on reviewing the literature in a consistent
decision hierarchy. First, the committees look for the
most effective treatment based on the current literature. In
cases where there is a single “best” (i.e., most effective)
treatment, that becomes the Via Oncology Pathway for that
case. However, if there is more than one treatment with
comparable efficacy, then the committees look for the least
toxic therapy with the goal of maximizing patient quality of
life and outcomes and minimizing unnecessary costs of
From the University of Pittsburgh, Pittsburgh, PA; D3 Oncology Solutions (Via Oncology
Pathways), an affiliate of the University of Pittsburgh Medical Center, Pittsburgh, PA.
Authors’ disclosures of potential conflicts of interest are found at the end of this article.
Address reprint requests Adam Brufsky, MD, PhD, Division of Hematology/Oncology,
University of Pittsburgh Cancer Center, 300 Halket St, Pittsburgh, PA 15213; email:
brufskyam@msx.upmc.edu.
© 2012 by American Society of Clinical Oncology.
1092-9118/10/1-10