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Care Pathway for NSCLC Cuts Chemotherapy Charges

Implementing a clinical pathway for stage IV non–small-cell lung cancer (NSCLC) led to a reduction in chemotherapy drug charges at the Cleveland Clinic, reported James Stevenson, MD.

A pathway for the management of patients with nonsquamous EGFR wild-type, ALK-negative stage IV NSCLC was developed between October 2013 and July 2014. The care pathway, implemented on July 7, 2014, was managed by an academic thoracic or community oncologist.

The pathway is evidence- and value-based, said Dr Stevenson, with the goals of improving outcome while decreasing cost. There are no penalties for nonadherence to the pathway or incentives for practitioner adherence.

The impact of the pathway on chemotherapy drug charges was measured by comparing charges among 181 patients in whom care was initiated during an 18-month period prior to implementation and a second cohort of 57 patients in whom care was initiated following pathway implementation.

“When we looked at stage IV patients, especially when we got to the nonsquamous EGFR, ALK-negative patients, we sensed a lot of variation in what was happening, especially with the use of bevacizumab,” said Dr Stevenson, Thoracic Oncologist, Cleveland Clinic, OH.

“Our thoracic oncology group looked at all the evidence, and our own clinical sense was that pemetrexed/carboplatin with pemetrexed maintenance was going to offer the best efficacy. The bevacizumab didn’t really add anything to that,” he said. “We also had some recent randomized data from MD Anderson that also suggests this.”

In the pathway, patients with ECOG performance status 0-2 and sufficient renal function (creatinine clearance [CrCl] ?45 mL/min) receive up-front pemetrexed/carboplatin for 4 to 6 cycles. For patients with CrCl <45 mL/min, the pathway calls for paclitaxel/carboplatin for 4 to 6 cycles. Maintenance pemetrexed is then recommended to disease progression. If the disease progresses after initial chemotherapy, those with ECOG performance status 0-2 proceed to second-line therapy.

“Our regional oncology doctors in network basically asked us to give them 1 or 2 choices [for frontline treatment], so that’s what we did,” said Stevenson.

Before initiation of the pathway, 71% of patients received an appropriate frontline therapy, which improved to 93% after the pathway was implemented (P = .0003). Half of the patients received carboplatin/pemetrexed up front before the pathway, which jumped to 86% following pathway implementation.

Thirty-five patients (38%) received bevacizumab in addition to a platinum-based regimen up front before the pathway creation, compared with only 2 (6%) following the pathway (P <.0001).

“When we break it down into patients who go on to maintenance therapy, we are going to cut their charge costs in half, essentially driven by taking beva­cizumab out of the pathway,” said Stevenson. Among patients who completed frontline therapy, the average drug charge per patient for frontline and maintenance therapy was $205,431 before initiation of the pathway and $107,258 afterward (P <.0001).

The findings demonstrate that implementation and measurement of adherence to a stage IV NSCLC pathway is feasible at an academic oncology practice with a regional network.

“It will be interesting to see how sustainable this is,” he said. “It’s only the first 6 months.”

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