OneOncology’s Arrowsmith looks forward to real-time dynamics in clinical pathways


In OneOncology, explains Edward Arrowsmith MD, MPH, clinical pathways provide a way for physicians to agree on best practices and implement them across the network. Earlier this year, Arrowsmith became medical director of Clinical Pathways, OneOncology.

The role of clinical pathways is changing, said Edward Arrowsmith, MD, MPH, who in January became medical director of Clinical Pathways through OneOncology, a Nashville, Tennessee-based network that enables his community oncology practices to collaborate on clinical, technological and research aspects. large-scale initiatives. Arrowsmith, a medical oncologist in Chattanooga, is also executive director of clinical informatics for Tennessee Oncology, one of the network’s founding practices.

As described by Hipp et al, clinical pathways enable practices “to reduce variation in practice and align decisions with evidence-based medicine, operational efficiency and quality”.1 In OneOncology, Arrowsmith said, pathways provide a way for physicians to agree on best practices and implement them across the network’s 13 member practices. The process, he said, is being led by Lisa Sowinski-Raff, PharmD, BCPS, BCOP, who is senior director of pharmacy, therapeutics and pathways at OneOncology.

Arrowsmith spoke with Evidence-based oncology™ (EBO) on his role and the future of clinical pathways in a recent interview. This interview has been edited for length and clarity.

EBO: Can you describe your role as medical director of clinical pathways and how you work with OneOncology practices?

Arrow : This is still a work in progress as we have a long way to go to fully realize our vision – we, the lanes team, have a team approach – led by Lisa Raff – to make 2 big things. One is to coordinate the expert opinion of clinicians; all OneOncology practices receive a set of clinical best practices. And the second is to help practices implement them.

I think that’s what sets us apart from other Pathway programs; in some cases you create a PDF or maybe an electronic tool and that’s the end of the process. We do other things in… analytics and patient identification, especially for targeted therapies. For example, how do we integrate next-generation sequencing to ensure that we find every patient with KRAS [G12C] mutation? There are many therapies [that] are typical of what we’ve been doing for a long time, including targeted therapy, cytotoxic chemotherapy, immunotherapy. But there are more new treatments on board that are different, either in their testing or in their [adverse] effects, or in the way they are given [to patients]. For example, the recent approval [of tebentafusp-tebn] for uveal melanoma involves an HLA (human leukocyte antigen) test.2 Or, what can we expect with an upcoming approval of a radiopharmaceutical for prostate cancer?3 These are examples where aid practices know how to test and administer these drugs. Sharing clinical and operational expertise across the network is an important part of what we do.

We are closely linked to supplier training. When a treatment comes on board or there is a change in a pathway, we will have video and handouts or even live programs to make sure everyone knows which patients should receive the therapy and how to give best this therapy. We also work with a product called Flatiron Assist4; Iron [Health]the manufacturer of OncoEMR [electronic medical record], is our technology partner. Flatiron has a point of service tool to use when you order a diet and we work with [Flatiron] to personalize it, so that when doctors order, it’s easy to follow their patients’ journeys.

EBO: The trails have been around for a while now. What kind of feedback, good and bad, do you receive from physicians in practice? Do doctors like using the trails or are there still things that need to be improved?

Arrow : OneOncology practices are focused on optimizing patient care. Philosophically, we’re all okay with having a Pathway program — and especially one like this, where we have a voice, rather than, say, an insurer’s Pathway program, where we wouldn’t have a say. It’s really around the lane implementation that we get a lot of feedback, both on the type of tools and education, like Flatiron Assist. But it’s an ongoing effort to help busy clinicians stay on track. Everyone tries to do what is best for their patient. I always use the example of a doctor who is alone in his office, perhaps in a rural setting; this doctor sees a lot of patients and all types of cancer that come up, because we try to treat patients in their own communities. On a busy afternoon, when [that physician] is late and has a sick patient with a lot of needs, how can we help this doctor do his best to follow what is a changing journey in this environment? It’s this piece of implementation where we get a lot of feedback.

EBO: YesYou co-authored a case study article on non-small cell lung cancer that addressed the question of balancing clinical pathways and specific conditions as we move forward in precision medicine.5 How does this case illustrate the balancing issues that arise today?

Arrow : This is an article we wrote because we were in a variety of contexts – sometimes arguing with insurers, sometimes with others – about what we saw as a change in the role of lanes depending changes in oncology. A little history is helpful: in my opinion, Pathways started with an article that [Dr] Joan Schiller wrote for the ECOG [Eastern Cooperative Oncology Group] in the New England Journal of Medicine,6 comparing 4 different platinum doublets for non-small cell lung cancer which show that each of these 4 therapies was equivalent. This led to a critical article in the pathways movement, where the US Oncology Network showed that by choosing generics for situations like this, mostly generic paclitaxel, instead of name brands, such as Gemzar (for gemcitabine) or Taxotere (for docetaxel), you may save costs.7

What we were saying in our article was that those days were over. For the majority of patients with non-small cell lung cancer, there truly was a better therapy. If they have an EGFR mutation, there is appropriate therapy; if they have a ROS1 or ALK mutation, there is an appropriate therapy. These 4 platinum doublets for adenocarcinomas or non-squamous cell carcinomas had been replaced by the brand name pemetrexed (Pemfexy) and immunotherapy had entered the market. We were really arguing that at that time there really was only one therapy, and looking at pathways as a great tool to cut costs probably wasn’t the right way to think about pathways – pathways were more a way to demonstrate high quality clinical results. care.

Since we wrote this article, I think there has been some change in the landscape of oncology. A huge thing is the development of biosimilars that have come to market. And so it’s an opportunity, with standardization in a practice, for a biosimilar to allow the continuation of excellent quality care but the possibility of creating more value by reducing costs. There are other examples where there could be 2 treatments that seem very similar… competing immunotherapies, or in some settings such as BRAF mutant melanoma, where there are targeted therapies that seem to have the same mechanism of action and very similar results. This era of clinical equilibrium could return for certain disease states.

EBO: How do you see the use of pathways evolving both within a practice and across the network with OneOncology?

Arrow : There are a few things. One is that on the [past] 12 to 18 months, we really see an explosion in the rate of change in clinical care. Within weeks, there are 2 or 3 FDA approvals in oncology. For us, it is essential not to wait for the pathway committee to meet quarterly for updates on new data, but to update the pathways in real time to help patients. One big change I see in the future is a dynamic, real-time aspect to courses. The other is the integration of pathways with clinical practice, particularly data analysis, so that when there is a change in pathways, we go through all the stages to really make sure the change happens. impacts clinicians and patients to improve care. Another would be integration with strategic aspects of the practice, particularly around value and payer contracts. Then hopefully we will have some type of replacement for the oncology model of care…that will apply to Medicare patients. Using lanes to drive standardization and value is another permanent boundary.

EBO: You mentioned the use of gateways in value-based contracts. Can you elaborate?

Arrow : We see journeys as a 360 degree process, where you have a journey, you have data analytics to help you find the right patient, but you also want to do background analytics to see how you’re doing . This kind of 360-degree process is what we think is best for value-based care arrangements. Future contracts will be [consider] this dynamic change in oncology, so that payers and OneOncology practices can work together to develop what is truly best for… all stakeholders in cancer care.


1. Hipp R, Abel E, Weber RJ. An introduction to clinical pathways. Hospital Pharm. 2016;51(5):416-421. doi:10.1310/hpj5105-416
2. FDA approves tebentafusp-tebn for unresectable or metastatic uveal melanoma. FDA. Updated January 26, 2022. Accessed March 12, 2022.
3. For advanced prostate cancer, radiopharmaceuticals improve survival. National Cancer Institute. June 29, 2021. Accessed March 12, 2022.
4. Flatiron Assist: Your go-to solution for evidence-based care. Flatiron Health. Accessed March 12, 2022.
5. Schleicher SM, Chaudhry B, Dickson NR, et al. Time to rethink the role of clinical pathways in the age of precision medicine: a case study in lung cancer. JCO Oncol Pract. 2021;17(7):379-381. doi:10.1200/OP.21.00073
6. Schiller JH, Harrington D, Belani CP, et al; Eastern Oncology Cooperative Group. Comparison of four chemotherapy regimens for advanced non-small cell lung cancer. N Engl J Med. 2002;346(2):92-98. doi:10.1056/NEJMoa011954
7. Weissman CH, Reynolds CH, Neubauer MA, Pritchard S, Kobina S, Asmar L. A randomized phase III trial comparing gemcitabine-oxaliplatin with carboplatin-paclitaxel as first-line therapy in patients with prostate cancer. advanced non-small cell lung. J Thorac Oncol. 2011;6(2):358-364. doi:10.1097/JTO.0b013e3181ffe8ef

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