Mar 22, 2019
Dr. Pennell talks with Dr. Sushil Beriwal about guideline variability and how care pathways might play a role even in situations where the best practice seems clear.
Hello, and welcome to the ASCO Journal of Oncology Practice
podcast. This is Dr. Nate Pennell, medical oncologist at the
Cleveland Clinic and consultant editor for the Journal. The best
available evidence for cancer treatment seems to change at just a
staggering pace. And yet, as physicians, we're expected to keep up
with these changes and always give the most evidence-based
treatment, which is obviously an incredible ongoing challenge.
Guidelines from major organizations can play a role in helping us
stay up to date. However, considerable variability exists, even in
situations where the best practice seems to be clear. This creates
an opportunity where things like care pathways might play a
role.
Today, we're going to be talking about this topic and about a new
paper titled "Lag time between evidence and guidelines-- can
clinical pathways bridge the gap?" which will be published in the
March 2019 JOP.
Joining me today for the podcast is the senior author of the paper
Dr. Sushil Beriwal, professor of radiation oncology at the
University of Pittsburgh and deputy director of radiation services
at UPMC Hillman Cancer Center. Dr. Beriwal, thank you for joining
me today.
It's my pleasure. Thanks for having me.
So why do you think there is so much variability in care,
especially around things where a lot of people have broad
agreement? So the example in your paper that you use is
hypofractionated whole-breast radiation, which has been part of a
major guideline since 2011. And yet, it seems as though many people
don't use it.
So we do see variability in the cancer care. And hypofractionated
radiation therapy is one of a good example. What is exactly? It's
hard to pinpoint. But I think it's for multiple reasons. Could be a
physician is used to practicing a certain why. They don't want to
change the practice. They're not aware of the newer data and
guidelines.
Or it could be the fact that they're concerned about increased side
effects and toxicities with this newer approach. They may not have
technology or resources to do it. And last, but not the least,
sometimes the fee-for-service model may have a detrimental effect
in accepting a shorter course of treatment.
Oh, I hadn't even thought of that, but that's a good point. So can
you take me a little bit through your study? What was the problem
that you were trying to solve?
As you know, there have been various studies which have come out in
the last 5 or 10 years, looking at adoption of hypofractionation
for breast cancer care, even though the randomized data suggests
that hypofractionation is similar for cancer outcome and possible
less side effects, [? with ?] the adoption rate based on the
National Cancer Database analysis, or some keyword industries, or
some state data, it's somewhere within 10% to 50%.
So there is wide variation and acceptance and adoption. And we were
trying to figure out a way to make it more uniform so the patient
get similar kind of care based on the best available evidence for
that patient.
Is care pathways or clinical pathways something that you've had
experience with working with before? And I guess, maybe just for
our listeners, kind of explain to us what a clinical pathway
is.
Clinical pathways are like additional [? aid ?] tool which
basically guides the physician to decide about the care of the
patient based on the stage, grade, and other factors associated
with that patient. So we at UPMC Hillman Cancer Center started the
clinical pathway in a very rudimentary form about 14, 15 years ago.
It has come a long way from being a paper trail to an electronic
format.
The way it works out is anybody who sees a patient in our network
of 25 sites has to enter a decision to-- in the care pathway model
created by this company called Via Oncology, which was initially
part of UPMC, but this year, it was bought by somebody. Well, it
was an outside company called [INAUDIBLE].
So say, for example, if I see a patient in my clinic, I go to care
pathway website. And automatically, it will ask me for stage,
grade, and what needs to be done. And then it gives me the option
of what to do. So if the option for that patient is
hypofractionated radiation therapy, that's what I have to
choose.
I see. And how do you decide what goes into these care pathways? Is
this determined by an outside group? Is this something that you get
to determine within your own institution?
When we started, it was within our own institution. But now we have
oncologists from all over the country who participate, who are part
of the same care pathway module. We have chair and co-chair for
each site. And we have committee members for each site.
So we meet every six months on a regular conference call. And
whatever evidence has come out in the last six months, we try to
incorporate that in our discussion and make changes accordingly. So
initially, the agenda is discussed. The committee decides and
discusses. It goes back and forth.
And once the committee agrees, then it's sent out to all the
members for voting. And once everybody agrees in the voting, then
it is implemented. And that becomes the care pathway for that
disease and stage.
And so what were the results of your intervention?
So we went by a very stepwise manner. So initially, the 10-year
data for hypofractionation from the UK group came out in 2013. So
when that came out, we as a group decided to mandate
hypofractionation for somebody who is 50 and above, like
postmenopausal women with early-stage breast cancer. When you're
trying to keep breast or just [INAUDIBLE] level to use.
And we found when we assessed the outcome that there was a very
high acceptance rate of hypofractionation. But one of the concerns
we found that the physician had in accepting hypofractionation was
how best to do it, because those papers and the data did not define
fully the best way to deliver the dose, how best to achieve dose
homogeneity, what should be the [INAUDIBLE] and the hard dose.
So within our own network, we came up with a very good guideline of
how best to achieve dose homogeneity to deliver this dose safely
and make it better for the patient. Once we got success with that,
then we took the next step of implementing this for younger
women.
And since we already had the track record, we found that the
resistance to the acceptance of hypofractionation was much-- there
was much wider acceptance, because people knew how to do it from
the previous experience. And the acceptance was much more wider and
much more-- the numbers were close to 95% to 100%, which was very
reassuring and which was very gratifying to see that patients
across our network were getting similar kind of care.
No, actually, the numbers are staggering. I mean, in 2015, the
number was only 4.2%. But by the second intervention, you said it
was 96.5%. So were the doctors actually mandated to use this? Did
they have the option of changing it if they wanted to?
So the way our system works is the only option we had was to do
hypofractionation, but they can change it. But they need to have an
evidence-based discussion of why they want to change it.
And see, I'm department director for the breast. So anybody who
wants to do something different, then he will send an email to me,
that he doesn't agree with the pathway recommendation. And these
are the reasons why he wants to do it. If the evidence-based
discussion is consistent, then we say, go ahead and do the
conventional fractionation.
Well, it clearly was very effective. I'm curious if you saw
pushback from the doctors in making this change? Did people have a
problem with being directed towards this particular treatment?
Initially, I did. Initially, when we did it for the first time,
there was a lot of communication back and forth. And people made
different kind of arguments, like we only have 10 years' data. We
don't have 20 years' data. And we don't know whether it is safe or
not.
Or [? they could ?] quote previously have done studies which have
shown poor outcome. But they were done with different techniques
and different philosophy. So there were a lot of discussions back
and forth. And to alleviate some of the concern, I did a
[INAUDIBLE] conference in our network, where we mandated all of our
physicians to participate and listen to the [INAUDIBLE] conference,
where we defined how best to do hypofractionation in terms of dose
homogeneity, in terms of heart and lung dose.
The most important factor was dose homogeneity. And once physicians
understood that the dose homogeneity is the more important
component than the fractionation, and they could see the results
from the patient's perspective and from physician's perspective,
the adoption became like a no-brainer.
The other thing that is remarkable to me about the pathways at the
University of Pittsburgh and the people who use the Via Oncology
Pathways, so my own institution at the Cleveland Clinic, we also
come up with our own evidence-based care paths. And we try to
educate people about them. But there isn't really a good way to
track how well people adhere to them.
How important do you think having the web-based monitoring, where
people actually have to track what they're doing, is to adherence
to these care pathways?
Well, it definitely helps us, because there are two ways we monitor
it. One is like the [INAUDIBLE] tool. Then anytime you go off
pathway, it comes to the pathway director as an email for him to
respond to the rationale behind our pathway and whether he or she
agrees with it. And if he agrees with it, then it goes into the
system as "On Pathway," even though the track was not on
pathway.
And the second thing is you may say you're doing something, but you
may not be doing it. So we have an audit system built in where we
have one of our staff members audit the charts randomly across our
network and match what has been done to the patient to what has
been entered into the clinical pathway, to make sure they
match.
If other centers wanted to start adopting clinical pathways in
order to help improve the quality of their care, what are some of
the take-home lessons you learned during this process that you can
pass on to them?
I think it's important that you have the buy-in from the providers.
So in our pathway, it's not like the total is 1% of [INAUDIBLE].
It's a committee, it's a member, and it's an open discussion. If
you don't have the buy-in from the people, then it's hard to
implement it. You need to explain to the patients it's not taking
over their autonomy. The physicians still have the autonomy. It's
just helping them guide better to have uniformity of care.
And having some-- there are system guidelines. And there are other
guidance available. But they try to keep it very lighter in terms
of options. The difference between the guidelines of the pathways
is there's much more [INAUDIBLE].
Like, for example, we call it the philosophy of efficacy, toxicity,
and the cost. All things being equal, the one which is most
efficacious gets number one ranking. If it is equally efficacious,
then the toxicity gets the high ranking. And if it is equally
efficacious and toxic, then the cost gets the high ranking.
So the hypofractionation for the breast, it's similarly in
approximation to efficacy to [INAUDIBLE] fraction. The toxicity is
somewhat better with hypofractionation. And the cost is much
better.
I think that's a critical point to illustrate, that the first and
most important thing is that we make sure that it's just as
effective and also at least as tolerable, if not better. We want to
make sure people understand that the clinical pathways such as this
are not designed just to save money but also to improve actual
patient care. And what are the next steps? Where are going from
here?
So just to take this concept to the next step, like we have
recently adopted hypofractionation for prostate cancer. And we have
implemented in our data our guidelines how best to do it. So our
next step is to look at the adoption of hypofractionation for
prostate cancer, which is like nine weeks treatment versus six
weeks treatment, with the guidance of how best to do it.
And the next thing we'll be executing is whether we are able to
successfully do that or not for prostate cancer too. I think this
has given us a benchmark and a platform to take it to the next
level for other disease sites, and to make sure that we are
following the data and evidence to the best of what we can do.
Thank you for agreeing to talk to me today. I think this is going
to be really of interest to the listeners of the podcast.
Thanks for having us. And it was a pleasure talking to you. And I
hope that this can send the right message to the audience for them
to take these steps in their own practices.
I also want to thank our listeners out there who joined us for this
podcast. The full text of the paper was published online at
ascopubs.org/journal/jop on December 7, 2018, and will be in the
March 2019 JOP. This is Dr. Nate Pennell for the Journal of
Oncology Practice, signing off.