Will Clinical Pathways Go the Way of the Dinosaur?

Kathy D. Miller, MD


September 15, 2014

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This is Dr. Kathy Miller, from Indiana University, with a quick thought for you. It was a very special morning in my household today. Both of my kids are back at school today, and they were so excited to see all of their friends at the school's annual bell-ringing ceremony. Last night my son was reading to me from a new book about dinosaurs. He was talking about the end of the dinosaurs' time on Earth, how they had gotten bigger and more powerful and then a sudden change in environment occurred and they couldn't adapt. We talked about how the ability to adapt to changes in the environment, no matter what drives them, is crucial to survival.

That got me thinking this morning when the first thing that greeted me in my inbox was an automatic reminder from the Pathways system that Indiana University has engaged in. I didn't chart my treatment on all of the patients I saw in clinic last week. I am sure many of you have engaged in a Pathways system of one sort or another. These systems are designed in hopes of standardizing our care and delivering the best evidence-based care, but at their core they assume that one patient is like another; that our diseases are finite in number; and that the appropriate first-, second-, and third-line treatment can be identified on the basis of the disease, not taking into account who the patients are.

That is completely counter to the other big shift in our field, which is the shift towards using genetic testing and molecularly defined assays to break large diseases into smaller subsets. We no longer think about "lung cancer." We think about ALK-positive lung cancer, EGFR-mutated lung cancer, and ROS-positive lung cancer, and I just recently learned about triple-negative lung cancer. The same is true for colon cancer, for which treatments may differ on the basis of KRAS mutations. That certainly has been true for breast cancer as well. As more of the molecular details of our diseases become clear, large, common diseases become a collection of independent small, niche diseases, which are not at all suitable for Pathways.

Right now in some circles, Pathways are all the rage. It makes me wonder whether they are about to go the way of the dinosaur, continuing to grow bigger and bigger for several years but unable to adapt to the changes in our landscape, in our environment driven by the explosion of molecular information. I don't know.

In time we will see, and now I will let you get back to that charting. Let me know your thoughts on Pathways and whether they are here to stay.


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