Implementing a clinical pathway for stage IV non–small-cell lung cancer (NSCLC) led to a reduction in chemotherapy drug costs at the Cleveland Clinic, reported James P. Stevenson, MD, a thoracic oncologist and quality improvement officer with the Cleveland Clinic, OH, at ASCO 2015.
A pathway for the management of patients with nonsquamous EGFR wild-type/anaplastic lymphoma kinase (ALK)-negative stage IV NSCLC was implemented on July 7, 2014, and was managed by an academic thoracic oncologist or a community oncologist.
The pathway is evidence-based and value-based, said Dr Stevenson, with the goals of improving outcomes while decreasing costs. There are no penalties for nonadherence to the pathway and no incentives for provider adherence.
The impact of the pathway on chemotherapy drug costs was measured by comparing the costs among 181 patients whose care was initiated during the 18 months before pathway implementation, and a second cohort of 57 patients whose care was initiated after the implementation of the pathway.
“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.
“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 M.D. Anderson that also suggest this.”
In the pathway, patients with Eastern Cooperative Oncology Group (ECOG) Performance Status 0 to 2 and sufficient renal function (creatinine clearance of ≥45 mL/min) receive upfront pemetrexed plus carboplatin for 4 to 6 cycles. For patients with creatinine clearance of <45 mL/min, the pathway calls for paclitaxel plus carboplatin for 4 to 6 cycles. Maintenance pemetrexed is then recommended until disease progression. If the disease progresses after the initial chemotherapy, patients with ECOG Performance Status 0 to 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 Dr Stevenson.
Before the institution of the pathway, 71% of patients received an appropriate frontline therapy, which improved to 93% after the pathway was implemented (P = .003). Of the patients, 50% received carboplatin plus pemetrexed up front before the pathway, which jumped to 86% after the implementation of the pathway.
A total of 35 (38%) patients received bevacizumab in addition to a platinum-based regimen up front before pathway creation compared with only 2 (6%) patients after the pathway (P <.001).
“When we break it down into patients who go on to maintenance therapy, we are going to cut their costs in half, essentially driven by taking bevacizumab out of the pathway,” said Dr Stevenson. Among patients who completed frontline therapy, the average drug cost per patient for frontline treatment and maintenance was $205,431 before the institution of the pathway and $107,258 afterward (P <.001).
The findings demonstrate that the 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,” Dr Stevenson said. “It’s only the first 6 months.”