One Major Healthcare System’s Approach to Standardized Care Pathways for the Treatment of Pancreatic Cancer

Clinical Expert Commentaries   published on December 5, 2018
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Federico A. Sanchez, MD
Hematology & Oncology
Aurora Sinai Medical Center
Aurora St. Luke's Medical Center
Milwaukee, Wisconsin
One Major Healthcare System’s Approach to Standardized Care Pathways for the Treatment of Pancreatic Cancer

Introduction
Aurora Health Care in Wisconsin has developed standardized pathways to manage its patients with pancreatic cancer. The standardized approach is designed to ensure that patients in the community receive state-of-the-art treatment and access to research protocols. In this e-newsletter, Dr. Federico Sanchez reported on the benefits of using standardized pathways to manage pancreatic cancer as well as some of the challenges with creating the algorithms that guide these pathways.

Pancreatic cancer is a life-threatening disease that often leaves patients feeling scared or depressed after being diagnosed. Considering that many patients will perceive their condition to be a death sentence, it’s our job is to console them, offer hope, and provide the best treatment possible. At Aurora Health Care in Wisconsin, we launched an initiative to develop standardized care pathways for managing pancreatic cancer so that patients are optimally managed, regardless of where they live. The goal of our standardization efforts is to ensure all patients with cancer receive state-of-the-art treatment and have access to research protocols, regardless of where they live.

How Pathways Can Help
A standardized care pathway is a method for guiding community physicians on consistent, evidence-based care by providing them access to up-to-date data. This information is critical because clinicians can use it to optimize care and promote research. How each healthcare system uses pathways varies from institution to institution. Aurora Health Care treats patients over an area that extends more than 400 miles in Wisconsin, and we see approximately one-third of the region’s total population. Our network diagnoses more than 8,000 new cancer cases each year, 200 to 220 of which are pancreatic cancer. We implemented a standardized care pathway to optimize the management of patients in our network.

The Aurora Health Care Experience
The use of standardized care pathways at Aurora Health Care has been paramount to empowering clinicians to choose the most effective treatment, regardless of cost, and select therapies with the best side-effect profiles for our patients. Our emphasis on cost is important because it is often a significant barrier to care in many institutions. Standardized care pathways also provide a roadmap to better prepare for changes in care that are likely to come. At Aurora Health Care, our primary focus is on treatment effectiveness and toxicity. Some pathways can limit how physicians manage patients, but the one we developed is flexible, nimble, and gives community physicians a voice.

Getting “Buy In” & Tailoring Pathways
For standardized care pathways to be effective, it’s critical to get “buy-in” from physicians practicing at the institution. When we launched our pathways initiative at Aurora Health Care, many of the 40 oncologists under my supervision expressed concerns about implementing this strategy. However, over time, our physicians bought into the concept and began to realize that pathways help us all do our jobs well. Importantly, we don’t mandate how standardized care pathways should be used.

The current acceptance rate for our standardized care pathways exceeds 90%, but we don’t expect every patient to be treated according to a pathway. In fact, we only want 75% to 80% acceptance of pathways because this gives physicians an opportunity to think more critically when managing challenging cases. Doctors need to be flexible with how they treat patients with special circumstances or characteristics.

Regular, Consistent Information Exchange
At Aurora Health Care, we meet regularly with community and academic physicians to design optimal pathways that ensure patients achieve the best possible outcomes. These conferences allow our pathways to adapt quickly for any necessary changes. We operate within guidelines from the National Comprehensive Cancer Network and those in our pathway provider, Via Oncology. We’ve created our own system of treatment for the entire corporation.

One of the ways we exchange information is by presenting data on all our pancreatic cancer patients at a Gastrointestinal Multidisciplinary Conference. This allows us to discuss our patient cases with a group of experts that includes surgeons, gastroenterologists, radiologists, radiation therapists, medical oncologists, and others. We also collaborate with ancillary groups like rehabilitation services and dieticians. This ensures that the patients we manage are healthy enough to receive treatment. This strategy has been paramount to helping provide the best care possible and, so far, our system has yielded encouraging outcomes in the management of patients with pancreatic cancer.

A Backbone to Care
With our standardized care pathways, we create specific rules and patterns to establish the best treatment approach possible based on the patient’s unique characteristics. Our pathways serve as the backbone to the planning of patient care. For example, if a patient is newly diagnosed with pancreatic cancer, we define the treatment journey, which begins at diagnosis. We identify the first symptom, and then patients are evaluated by ancillary care teams before being presented to the oncology group.

All patients with pancreatic cancer are required to receive imaging of their chest, abdomen, and pancreas, either with CT, MRI, or magnetic resonance cholangiopancreatography. We prefer to use CT scans at as part of the pancreatic cancer protocol because it’s cost effective. Our pathway also requires that surgeons and radiologists collaborate to determine if surgical resection is an option. As part of our pathway protocol, Aurora Health Care has opted a total neoadjuvant approach for average patients in which we start with chemotherapy and following that with surgery. After patients are resected, they receive additional dose-modified chemotherapy.

An Evolving Disease Understanding
A key question about whether standardized care pathways work in pancreatic cancer is if the disease is systemic or locally advanced. Historically, survival is only about 18 to 20 months with surgery alone, even for stage I or II disease. About 45% to 55% of patients with pancreatic cancer have unresectable metastatic or locally unresectable disease. In these cases, our pathway indicates that treatment start with a gemcitabine-based regimen. This approach allows us to reserve treatments that are currently in the pipeline for second-line therapy, including irinotecan-based combinations and PARP inhibitors, among others.

To optimize treatment decisions in patients with borderline resectable cancer, it’s critical to discuss the pros and cons of all available options, most notably their efficacy and safety. Many chemotherapy regimens have significant toxicity, but newer agents may be less toxic and more tolerable. These are important considerations that must be discussed with the medical oncology team and patients. It’s important to be aggressive, but we need to consider the impact of treatment on quality of life for patients.

Pancreatic cancer has a systemic component, but we have yet to identify the most appropriate genetic targets for therapy. Research suggests that the BRCA and MEK inhibitor pathways may be potentially beneficial as targeted treatments for pancreatic cancer, but more data are needed. Furthermore, there is a low mutational burden associated with pancreatic cancer, which further limits our ability to use targeted therapy. Research in this field is ongoing.

Closing Thoughts
Standardized care pathways are important to optimizing the treatment of pancreatic cancer, a disease for which there is no known cure. These pathways guide treatment by providing a framework for selecting therapies that will ensure patients in the community setting have access to all resources available and include protocols for ensuring that those who are eligible for clinical trials are directed to these studies. Our pathways have worked well at Aurora Health Care and, with thoughtful strategic planning, can be beneficial for managing pancreatic cancer at your institution too.

Reference

  1. Pancreas cancer: Current state of therapy use of guidelines and pathways. ASCO 2018. Educational Session. Available at: https://meetinglibrary.asco.org/record/155002/video. Accessed September 20, 2018.

This activity is supported by educational grants from AstraZeneca, Celgene Corporation, Ipsen, and Merck & Co., Inc.

Last modified: November 7, 2018