Edward Arrowsmith, MD, discussed his recent paper on the use of clinical pathways for specific cancer types and how biosimilar development can help ensure quality of care for patients with limited therapeutic options.
Edward Arrowsmith, MD, medical director of medical oncology at CHI Memorial Hospital and an oncologist at Tennessee Oncology, discussed his recent paper on the use of clinical pathways for specific cancer types and how biosimilar development can help ensure quality of care for patients with limited therapeutic options.
You were a co-author on an article about a case study in non–small cell lung cancer (NSCLC) that addressed balancing the use of clinical pathways with specific conditions in the era of precision medicine. How does this case illustrate the issues that practices face today?
That was a piece we wrote, because we were in a variety of contexts, all of us arguing, sometimes with insurers, sometimes with others, about what we saw as a change in the role of pathways based on changes in oncology. So, maybe a little history is helpful for my view. Really, pathways started with a critical paper, which was a paper that John Schiller wrote for ECOG [Eastern Cooperative Oncology Group] in the New England Journal of Medicine comparing 4 different platinum doublets for non–small cell lung cancer, that showed that each of those 4 therapies was equivalent.
And I think that really led to a critical paper in the pathways movement, where the US Oncology Group showed that by choosing generics for situations like that—mainly generic paclitaxel instead of name brands, like Gemzar [gemcitabine] or Taxotere [docetaxel]—that you could reduce cost. What we were arguing in our paper is that that year had passed, that for the majority of patients with non–small cell lung cancer, there really was 1 best therapy. If they have an EGFR [epidermal growth factor receptor] mutation, there's an appropriate therapy. If they have a ROS1 or ALK mutation, there is an appropriate therapy. That those 4 platinum doublets for adenocarcinoma, or nonsquamous carcinomas, had been replaced with named branded pemetrexed [Alimta] and immunotherapy had entered the market. We were really arguing that in that era, there really was 1 therapy and, in particular, to think of pathways as a great tool for reducing costs was probably not the right way to think about pathways. Pathways were more a way to demonstrate high-quality clinical care.
Now, that said, since we wrote that paper, I think there has been a little bit of a shift in the oncology landscape. One huge thing is the development of biosimilars that have come on the market. And so that's an opportunity, where standardization in a practice for a biosimilar might allow continuation of excellent quality care, but the possibility of creating more value by reducing costs. There also are more and more examples where there might be 2 treatments that look very similar. So, competing immunotherapies or in some settings like BRAF-mutant melanoma, where there are some targeted therapies that appear to have the same mechanism of action and very similar outcomes. So, that era of clinical equipoise may be returning for certain disease states.