Marc Shapiro, MD
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In an effort to improve the consistency of lung cancer care, Cleveland Clinic investigators developed a care path in 2014 for stage IV non-small cell lung cancer (NSCLC). A recent study that evaluated this care path found improvement in the reduction of practice variability and costs, according to oncologist Marc Shapiro, MD, the study’s lead author.
Adherence to evidence-based and cost-effective care is an increasing priority in all areas of medicine. Care paths represent efforts to reduce practice variability and contain costs, and have demonstrated efficacy in published studies. Dr. Shapiro says evidence shows that “healthcare delivery is inefficient and unsustainable” because of practice variations.
Cleveland Clinic’s purpose in developing the care path and subsequent study, says Dr. Shapiro, is “to take the lead at our institution and nationally to deliver cancer care in a more efficient and patient-centered way.” Containing costs may allow more patients to access effective care with less financial burden, he said.
Study results were featured at the American Society of Clinical Oncology’s 2015 ASCO Annual Meeting in Chicago.
Decrease in practice variation and costs
Under the new care path, patients with non-squamous, EGFR wild-type/ALK-negative NSCLC with ECOG performance status of 0-2 and adequate renal function receive front-line therapy with carboplatin/pemetrexed followed by maintenance therapy with pemetrexed, rather than treatment with bevacizumab.
The Cleveland Clinic study was designed to evaluate the impact of the care path on treatment decisions and associated healthcare costs in two patient cohorts with metastatic NSCLC: a population treated in 2014 after implementation of the care path and a group treated in 2012-2013 before path implementation. Treatment patterns were reviewed through January 2015.
The care path’s influence on practice decisions and cost was apparent in the study’s results. Ninety-three percent of patients in the care path group received the recommended front-line regimen, versus 71 percent in the comparison group. Significantly fewer patients in the care path group received non-recommended bevacizumab (9 percent versus 39 percent). At the same time, overall chemotherapy charges decreased 48 percent under the care path — from $205,431 to $107,258.
Weighing data to select care path
Bevacizumab is an angiogenesis inhibitor that targets vascular endothelial growth factor (VEGF) and is used for multiple types of cancer. It is indicated for non-squamous NSCLC as first-line chemotherapy when administered with carboplatin and paclitaxel in patients with unresectable, locally advanced, recurrent or metastatic disease.
Pemetrexed is a folate analog metabolic inhibitor also indicated for non-squamous, locally advanced or metastatic NSCLC, both as front-line treatment in combination with cisplatin and as maintenance therapy.
As with any chemotherapy agent, both bevacizumab and pemetrexed have potential adverse effects, although bevacizumab carries a black box warning about gastrointestinal perforation, wound healing complications and hemorrhage.
Benefits of treatment must be weighed against the potential for toxicity, especially in patients with heavily treated metastatic disease. In general, more data support the use of pemetrexed maintenance than bevacizumab.
“Multiple different standards of care exist for NSCLC, and no one standard of care has proven to be better for survival” than others, Dr. Shapiro says. In the current study, he and his colleagues selected the regimen that the evidence shows has the “best value for care”– meaning lower costs and lower rates of adverse effects, while achieving the same survival rates and comparable quality of life.
Large scale phase III trials strongly suggest survival with the chosen regimen is comparable to that of regimens using bevacizumab. Survival data in the pilot patients at Cleveland Clinic will be evaluated in the future to ensure the care path ensures optimal survival outcomes.
Future trials expected to replicate results
Standardization of care has obvious advantages for physician practice and overall healthcare spending, but the most important benefit is for patients. The research results are “important for the nation and for individual patients as well, because cancer care is a major cause of bankruptcy,” says Dr. Shapiro.
Similar trials of cancer care paths are in progress at Cleveland Clinic for several other types of cancer, says Dr. Shapiro. The expectation in each case, as in the current NSCLC trial, is that evidence-based guidelines will improve cancer care consistency and sustainability.
Dr. Shapiro is a medical oncologist in Cleveland Clinic’s Department of Hematology and Oncology.