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Clinical Pathways Based on Latest Clinical Evidence Can Influence Patterns of Care for Bone Metastases

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SAN ANTONIO, Texas – Implementing a clinical pathway to help radiation oncologists determine the right course of palliative care for patients with cancer that has spread to their bones can standardize practice patterns that are based on the latest, evidence-based guidelines, according to a study by UPMC CancerCenter radiation oncologists that is being presented at the 57th Annual Meeting of the American Society for Radiation Oncology (ASTRO).

Cancer spreading to bones, or bone metastases, often are painful, and past studies have suggested that doing a course of radiation therapy with fewer treatments may be just as effective in relieving that pain as courses with more treatments. In fact, despite guidelines from ASTRO cautioning against routinely using extended courses, some recent studies have shown the rate of oncologists nationally using shorter courses were below 5 percent. But by including the latest scientific evidence in its pathways—which are presented to oncologists electronically at the point of care and guide what treatments patients receive—UPMC CancerCenter showed significant improvements in the rates of physicians following ASTRO guidelines.

“We wanted to see what impact our clinical pathways had on oncologists and how they were treating bone metastases. Because we have a large cancer network that is designated as a comprehensive cancer center by the National Cancer Institute, we had a large patient base from which to evaluate these pathways,” said Brian Gebhardt, M.D., a UPMC radiation oncologist and lead author of the study.

UPMC CancerCenter, partner with the University of Pittsburgh Cancer Institute, first began using pathways for the management of bone metastases in 2003. In 2014, the pathway was modified based on clinical evidence to encourage radiation therapy courses with single treatments, while those courses with 10 treatments or more were considered off pathway.

Researchers found that 12,678 unique courses of radiation therapy were delivered from 2003 to 2014. During that time, the rate for a course with a single treatment rose from 7.6 percent to 15.8 percent. The rate for using courses with multiple treatments decreased from 18.6 percent to 9.7 percent during the same time. By 2014, the study found that more than 90 percent of courses were delivered with fewer than 10 treatments.

“This study really shows how having a clinical pathway can have a transformative effect on care,” said Dwight E. Heron, M.D., FACRO, FACR, director of radiation services, UPMC CancerCenter, and professor of radiation oncology, otolaryngology and head & neck surgery, University of Pittsburgh School of Medicine.

In addition to Dr. Heron, other collaborators on the study were Malolan S. Rajagopalan, M.D., Beant S. Gill, M.D., Susan M. Rakfal, M.D., John C. Flickinger, M.D., and Sushil Beriwal, M.D., all of UPMC.