Optimizing NSCLC Clinical Pathways

Featuring Edward R. (Ted) Arrowsmith, MD, MPH

Please share your name, title, and a brief overview of your professional history. 

Edward R. (Ted) Arrowsmith MD, MPH: I’m Edward R (Ted) Arrowsmith MD, MPH. I’m a practicing Medical Oncologist with Tennessee Oncology based in Chattanooga, TN. Currently, I serve as the Executive Vice President for Therapeutics for Tennessee Oncology and the Medical Director for Pathways for OneOncology. In those roles, I’m involved with drug management by helping Tennessee Oncology and OneOncology practices choose the right drugs both for optimal clinical care of patients but also the optimal drugs, when clinical equipoise exists among regimens, for value-based care programs.
 
Could you share a brief overview of your research related to the impact of clinical pathways on treatment utilization and cost in non–small-cell lung cancer (NSCLC)?

Dr Arrowsmith: One of the seminal papers in the development of oncology pathways was the report by Dr Neubauer and colleagues at US Oncology showing that adherence to US Oncology pathways reduced cost. Specifically, during the 2006-2007 timeline studied, patients with non-small cell lung cancer (NSCLC) treated on pathway in the first line setting had an average cost of $18,042 compared to off-pathway patients with an average cost of $27,737. During that era of platinum-based doublets, value could be driven through utilization of a low-cost generic drug. 
 
In our 2021 article, we set to relook at the first-line NSCLC space and how pathway adherence might no-longer predict decreased cost in the era of targeted therapies and immunotherapy.
 
What were your overall findings? Did any of the findings surprise you? 
 
Dr Arrowsmith: We first reported the potential for cost savings by drug selection in the era before targeted therapies and immunotherapy – in 2014 the Average Sales Price (ASP) for 3 months of generic paclitaxel was $138 while the ASP for 3 months of pemetrexed, which was then only available as a branded on-patent agent, was $24,100. The potential for savings was clear and obvious. However, by 2021 two things had occurred. First, targeted therapies had emerged for some subtypes of NSCLC. For example, in 2021 osimertinib was the standard first-line treatment for patients with epidermal growth factor receptor (EGFR) mutated NSCLC. There was no lower-cost, generic option. Second, immunotherapy had become part of therapy. This raised overall costs. For example, we noted that the 2020 ASP for 3 months of pemetrexed plus pembrolizumab was $68,528.
 
We argued that cost of care in 2021 was largely driven not by the choice of one agent over another but by the utilization of particular agents. When there is one best choice clinical choice, that is where clinical equipoise does not exist among two or more regimens, then cost of care will be driven by the unit costs of drugs rather the selection of the lowest cost agent among several options. In fact, in time when efficacious but expensive therapies are becoming available, a successful pathway program might increase overall cost of care by driving early adoption of these therapies.
 
How have advancements in precision medicine and targeted therapies influenced the treatment landscape for NSCLC, and what implications does this have for the role of clinical pathways in guiding treatment decisions?
 
Dr Arrowsmith: Targeted therapy and immunotherapy have created tremendous value for patients. Every clinic day I see patients with NSCLC who are alive and doing well years after they would have died if treated with a platinum doublet alone. I often think back on specific patients I treated before the discovery of targets such as ALK, ROS1, and NTRK and the years of high-quality life that might have gained in the modern era.
 
Until very recently, we saw the role of the OneOncology Pathways program to be in assisting clinicians in keeping track of the rapidly proliferating numbers of targets in both the first-line and second-line spaces and guiding their choice of an optimal therapy. We were really focused on helping clinicians order the right molecular testing for patients and choose the approved agent for that specific driver mutation.
 
Are there specific strategies or interventions within clinical pathways that you believe might be effective in managing treatment costs for NSCLC? 
 
Dr Arrowsmith: We think the NSCLC space is changing rapidly. There are an increasing number of targets, and targeted therapy and immunotherapy are expanding into early stages of NSCLC. Also, there is an expansion of both the number of drugs and drug combinations in various settings.  For example, there are now several options for the first-line treatment of EGFR-mutated NSCLC.
 
We think that clinical pathways will need to become more subtle and will need to be linked to provider education and point-of-care clinical decision support tools to optimize therapy for our patients. We’re working hard to make that happen. There are also options to manage costs. Choosing a regimen with the toxicity profile that is appropriate for an individual patient can avoid costs associated with ER visits and hospitalizations. We think of this patient-focused part of precision medicine.
 
However, there are ways in which we are moving a little bit toward the 2006-2007 world. There are beginning to be some areas across oncology including NSCLC where clinical equipoise exists. For example, there are some indications for which two or more PD-1 inhibitors are approved. In these setting, a pathways or drug management program might be able to increase utilization of the less expensive option for value-based care arrangements.
 
What key message related to your research would you like our audience to walk away with?  
 
Dr Arrowsmith: Our work in 2021 argued that the management of NSCLC (and other cancers) is always changing and that what was true of a pathways program in the past may not be true now. Clinical pathways need to be updated continuously and so do the expectations around what a pathways program can accomplish. Always and everywhere, helping patients with cancer live longer and better needs to be at the center of our work.