OneOncology’s Arrowsmith Looks Forward to Real-time Dynamics in Clinical Pathways

The role of clinical pathways is evolving, said Edward Arrowsmith, MD, MPH, who in January became medical director for Clinical Pathways across OneOncology, a Nashville, Tennessee-based network that allows its community oncology practices to collaborate on clinical, technological, and research initiatives at scale. Arrowsmith, a medical oncologist in Chattanooga, also serves as executive director of clinical informatics for Tennessee Oncology, one of the founding practices of the network.

As described by Hipp et al, clinical pathways allow practices “to reduce variations in practice and align decisions with evidence-based medicine, operational efficiency, and quality.”¹ Across OneOncology, Arrowsmith said, pathways offer a vehicle for physicians to agree on best practices and to implement them throughout the network’s 13 member practices. The process, he said, is led by Lisa Sowinski-Raff, PharmD, BCPS, BCOP, who is senior director of pharmacy, therapeutics, and pathways at OneOncology.

Arrowsmith spoke with Evidence-Based Oncology™ (EBO) about his role and the future of clinical pathways in a recent interview. This interview has been edited for length and clarity.

EBO: Can you describe your role as the medical director for clinical pathways, and how you work with practices across OneOncology?

Arrowsmith: This is still very much a work in progress in that we have a long way to go to fully enact our vision—we the pathways team having a team-based approach—led by Lisa Raff—to do 2 big things. One is to coordinate the expert opinion of the clinicians; all the OneOncology practices get a set of clinical best practices. And the second is to help practices implement them.

I think that’s what sets us apart from other pathways programs; in some cases, you create a PDF or maybe an electronic tool and that’s the end of the process. We do other things in…analytics and in identifying patients, particularly for targeted therapeutics. For example, how do we integrate next-generation sequencing to make sure we’re finding every patient with a KRAS [G12C] mutation? There are many therapies [that] are typical for what we’ve been doing for a long time—including targeted therapy, cytotoxic chemotherapy, immunotherapy. But there are more new treatments coming on board that are different—either in their testing or their [adverse] effects, or in how they’re given [to patients]. For example, the recent approval [of tebentafusp-tebn] for uveal melanoma involves HLA (human leukocyte antigen) testing.² Or, what can we expect with an upcoming approval of a radiopharmaceutical for prostate cancer?³ These are examples of where helping practices know how to do testing and administer those drugs is helpful. Sharing clinical and operational expertise across the network is an important part of what we do.

We’re tightly connected with provider education. When a treatment comes on board or there’s a change in a pathway, we’ll have a video and handouts or even live programs to make sure everyone knows which patients should receive the therapy and how to best give that therapy. We also work with a product called Flatiron Assist^4; Flatiron [Health], the maker of OncoEMR [electronic medical record], is our technology partner. Flatiron has a point-of-care tool for use when you’re ordering a regimen and we are working with [Flatiron] to customize it, so that when physicians are ordering it’s easy to follow the pathways for their patients.

EBO: Pathways have been around for a while now. What kind of feedback, good and bad, do you receive from the physicians in practice? Do physicians like using pathways, or are there still things that need work?

Arrowsmith: The practices in OneOncology are focused on optimizing patient care. Philosophically, we’re all aligned around having a pathways program—and particularly one like this, where we have a voice in it, rather than, say, an insurer’s pathway program, where we wouldn’t have a voice. It’s really around implementing the pathways where we get a lot of feedback—both around the kind of tools and education, such as Flatiron Assist. But this is an ongoing effort to help busy clinicians follow the pathways. Everyone is trying to do what’s best for their patient. I always use the example of a physician who’s alone in office, maybe in a rural setting; this doctor sees lots of patients and every type of cancer that comes through the door, because we’re trying to treat patients in their own communities. On a busy afternoon, when [that physician] is behind schedule and has a sick patient with a lot of needs, how can we help that physician do his or her best to follow what is a changing pathway in that setting? It’s that implementation piece where we get a lot of feedback.

EBO: You coauthored an article about a case study in non–small cell lung cancer that addressed the issue of balancing clinical pathways with specific conditions as we move forward in precision medicine.⁵ How does that case illustrate the balancing issues that come up today?

Arrowsmith: That’s a piece we wrote because we were in a variety of contexts—sometimes arguing with insurers, sometimes with others—about what we saw as a change in the role of pathways based on changes in oncology. A little history is helpful: in my view, pathways started with a paper that [Dr] Joan Schiller wrote for ECOG [Eastern Cooperative Oncology Group] in the New England Journal of Medicine,⁶ comparing 4 different platinum doublets for non–small cell lung cancer that show that each of those 4 therapies was equivalent. That led to a critical paper in the pathways movement, where The US Oncology Network showed that by choosing generics for situations like that, mainly generic paclitaxel, instead of name brands, such as Gemzar (for gemcitabine) or Taxotere (for docetaxel), that you could reduce costs.⁷

What we were arguing in our paper is that era had passed. For the majority of patients with non–small cell lung cancer, there really was one best therapy. If they have an EGFR mutation, there’s one appropriate therapy; if they have a ROS1 or an ALK mutation, there is an appropriate therapy. Those 4 platinum doublets for adenocarcinoma or nonsquamous carcinomas had been replaced with name-brand pemetrexed, and immunotherapy had entered the market. We were really arguing that in that era, there really was one therapy, and to think of pathways as a great tool for reducing costs was probably not the right way to think about pathways—the pathways were more a way to demonstrate high-quality clinical care.

Since we wrote that paper, I think there has been a 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, with standardization in a practice, for a biosimilar to allow continuation of excellent quality care but the possibility of creating more value by reducing costs. There are more examples where there might be 2 treatments that look very similar…competing immunotherapies, or in some settings such as BRAF mutant melanoma, where there are some targeted therapies that appear to have the same mechanism of action and very similar outcomes. That era of clinical equipoise may be returning for certain disease states.

EBO: How do you see the use of pathways evolving both within a practice and across the network with OneOncology?

Arrowsmith: There are a few things. One is that over the [past] 12 to 18 months, we’re really seeing an explosion in the rate of change in clinical care. In some weeks, there are 2 or 3 FDA approvals in oncology. For us, it’s critical that we not wait for the pathways committee to meet quarterly for updates on new data, but to update pathways in real time to help patients. One big change I see in the future is a dynamic, real-time aspect of pathways. The other is the integration of pathways with clinical practice, especially data analytics, so that when there’s a change in pathways, we go through all the steps to really make sure that change feeds down to individual clinicians and patients to improve care. Another would be integration with the strategic aspects of the practice, particularly around value and payer contracting. Then hopefully we’ll have some type of replacement for the Oncology Care Model…that will apply to Medicare patients. Using pathways to drive standardization and value is another ongoing frontier.

EBO: You touched on the use of pathways in value-based contracting. Can you elaborate?

Arrowsmith: We see pathways as a 360-degree process, where you have a pathway, you have data analytics to help you find the right patient, but you also do want to do analysis on the back end to see how you’re doing. Having that sort of 360-degree process is what we think is best for value-based care arrangements. Contracts in the future will [consider] this dynamic change in oncology, so that payers and OneOncology practices can work together to develop what’s really best for…all the stakeholders in cancer care.

References

1. Hipp R, Abel E, Weber RJ. A primer on clinical pathways. Hosp Pharm. 2016;51(5):416-421. doi:10.1310/hpj5105-416
2. FDA approves tebentafusp-tebn for unresectable or metastatic uveal melanoma. FDA. Updated January 26, 2022. Accessed March 12, 2022. https://bit.ly/37rgopL
3. For advanced prostate cancer, radiopharmaceutical improves survival. National Cancer Institute. June 29, 2021. Accessed March 12, 2022. https://bit.ly/3tVkZrE
4. Flatiron Assist: your go-to solution for evidence-based care. Flatiron Health. Accessed March 12, 2022. https://flatiron.com/oncology/clinical-decision-support/
5. Schleicher SM, Chaudhry B, Dickson NR, et al. Time to rethink the role of clinical pathways in the era of precision medicine: a lung cancer case study. JCO Oncol Pract. 2021;17(7):379-381. doi:10.1200/OP.21.00073
6. Schiller JH, Harrington D, Belani CP, et al; Eastern Cooperative Oncology Group. Comparison of four chemotherapy regimens for advanced non-small-cell lung cancer. N Engl J Med. 2002;346(2):92-98. doi:10.1056/NEJMoa011954
7. Weissman CH, Reynolds CH, Neubauer MA, Pritchard S, Kobina S, Asmar L. A phase III randomized trial of gemcitabine-oxaliplatin versus carboplatin-paclitaxel as first-line therapy in patients with advanced non-small cell lung cancer. J Thorac Oncol. 2011;6(2):358-364. doi:10.1097/JTO.0b013e3181ffe8ef