When time, money, habit, fear, science, and patient expectations compete for an oncologist's attention, science often gets jostled to the back seat.
That's why oncologists who applaud the American Society of Clinical Oncology's leadership in the “Choosing Wisely” campaign nonetheless are saying that they expect many of their colleagues will still continue choosing expeditiously—as opposed to wisely—when they make treatment decisions.
As part of the “Choosing Wisely” campaign announced this spring, ASCO released a “Top Five” list of oncology services that are commonly delivered even though scientific evidence does not support them (see box). The goal is to encourage physicians and patients to discuss those practices before embarking on unnecessary procedures and tests.
Like the other oncologists interviewed for this article, J. Leonard Lichtenfeld, MD, Deputy Chief Medical Officer for the American Cancer Society, likes ASCO's approach but wonders what impact it will have.
For example, the first item on the list—avoiding futile therapy for patients near death—may seem obvious to an outside observer. But it appears on the Top Five list for the very reason that futile therapy is so common.
“We have a substantial amount of maturation to do in this country, on both the medical side and the patient side, in order to get anywhere close to this particular recommendation,” he said.
So he does not expect entrenched treatment patterns to fall away quickly: “I think this is a start, but this is a very long and slow process.”
What is Choosing Wisely?
Two and a half years ago, Howard Brody, MD, PhD, Director of the Institute for Medical Humanities at the University of Texas, proposed in a Perspective article in the New England Journal of Medicine that medical specialties identify five costly and common practices that are not rooted in evidence (NEJM 2010;362:283–285).
The American Board of Internal Medicine (ABIM) ran with the idea, and this year launched the “Choosing Wisely” campaign as a way of highlighting the prevalence of tests and procedures that are not supported by medical evidence.
ASCO joined the American College of Physicians, American College of Cardiology, and six other specialty societies that jumped into the campaign at the first opportunity. Each society is promoting its own list of “Five Things Physicians and Patients Should Question.”
“When the ABIM sent out invitations for societies to participate, we were primed to respond because we were already engaged in precisely this type of thinking,” said Lowell E. Schnipper, MD, Chair of ASCO's Cost of Cancer Care Task Force.
That task force, comprised of about 25 health care economists, oncologists, pharmaceutical industry representatives, and patient advocates, has been considering how cost might factor into physicians and patients' decisions about evaluations and treatments since 2007. In response to the ABIM's call, the task force created the Top Five list and distributed it to ASCO's clinical practice committee, state society leaders, and the executive committee of the board of directors for feedback.
ASCO intends to monitor adherence to the Top Five by incorporating queries into the Quality Oncology Practice Initiative (QOPI) pertaining to each of the items. Questions are currently being developed.
Barriers to Wise Choices
The “Choosing Wisely” campaign pushes against a wide range of barriers to delivering evidence-based cancer care. One of the most ingrained barriers: a longstanding habit of overtreatment and over-surveillance in American medicine.
“That's especially true in cancer, and has been true since we first discovered the early cancer-treating therapies,” said Ira Klein, MD, of Aetna. “If some was good, then more was better. And that's the lens through which oncologists have been trained, and that's the philosophy they use.”
Debra Patt, MD, a medical oncologist with Texas Oncology, a practice in the US Oncology Network, says patients and their families sometimes share the “more is better” ethos. She said she occasionally sees patients who expect scans to follow their treatment after curative attempt for early-stage breast cancer, and trying to re-educate them is a time-consuming process that may risk the relationship.
“Changing those perceptions takes a great deal of time and effort on the part of the oncologist, and oftentimes, it's unsuccessful. If you spend 20 or 30 minutes in the room with a patient, trying to dissuade them from their need for a follow-up scan, and then they get angry with you and go see another oncologist, that's not exactly a fruitful exchange.”
Meanwhile, fear of malpractice lawsuits lingers as a big concern for many physicians. As long as some oncologists are using scans inappropriately, many patients and family members may see that as best-practice medicine.
“I think the driving aspect is that there's still the fear of malpractice,” said George Kovach, MD, an oncologist with Iowa Cancer Specialists in Davenport, Iowa, and president of the Association of Community Cancer Centers. “If acceptance of the guidelines is not universal, the impact of the guidelines will be undermined.”
He agrees that the U.S. medical system currently encourages physicians to order expensive tests regardless of whether there is evidence to support their use.
“Frankly, the incentive in our system, both financially and legally, is to test for everything all the time,” he said. “Because if you're a doctor and you test for everything all the time, you will make more money and get sued less. What physician in today's system would not test as frequently as they think that it's somewhat appropriate, knowing that the bias is that more is better?”
Effect on Oncology Practice
Despite their discouraging assessment of the current milleu, oncologists who are interested in high-quality, low-cost care said they do think ASCO's Top Five list will support incremental change.
“It is very consistent with what we are trying to do with the oncology medical home,” said Bruce Gould, MD, President and Medical Director of Northwest Georgia Oncology Centers (NGOC) in Marietta, Georgia, who chairs the steering committee for the Community Oncology Alliance's medical home initiative. The committee is working to create a cancer care delivery model that will satisfy three groups of stakeholders—patients, physicians and payers (OT 4/25/12).
“We're working on a three-legged stool—the wants of the patients, the ‘how’ of how practices can meet patients' wants, and the reporting to payers,” he said. “I see this as part of the ‘how.’”
He said he hopes that practices that adhere to the Top 5 list might be relieved from payers' requirement that many services be preauthorized if physicians want to be paid: “We've got to go through this long diatribe of trying to get [services] approved…and they don't deny it, So I'm wasting an hour and a half of my staff's time getting something approved that is appropriate.”
In fact, within the next year, Aetna expects to reduce the pre-certification burden to physicians who document—and electronically report—that they are following evidence-based guidelines.
“I do think that that is going to be a future state of affairs in oncology, where oncologists who practice in evidence-based, ASCO-endorsed patterns will have relief from pre-certification,” he said.
Mike Thompson, MD, PhD, a hematologist/oncologist at ProHealth Care in Waukesha, Wisconsin, said he hopes the Top Five list will help oncologists re-set their definition of good patient care, since in most cases, physicians who prescribe tests and therapies without evidence to back them are motivated by trying to do the best thing for their patients.
“In the past, I think we took that as a badge of pride that we were not focusing on cost and we were just wanting to do the right thing,” he said. “Now, part of doing the right thing is finding the best value.”
Changing Patient Expectations
The campaign attempts to sell not just physicians but also patients and their family members on the idea that more conversations about the value of treatments and tests will lead to restraint in some cases.
“The Choosing Wisely campaign has as its goal enhancing conversations between physicians and their patients in order to help both focus on evidence-based decision-making,” said Schnipper.
Consumer Reports, the ABIM's campaign partner, has assembled 11 consumer-oriented organizations that each have the potential to influence at least a million patients. One of those organizations, AARP, highlighted the campaign in last month's issue of the AARP Bulletin, with a cover story titled “7 Medical Procedures You Don't Need.”
Patt said she thinks changing the public's perception about cancer treatment is important to changing treatment patterns—and that the Top Five guidelines will help define expectations more clearly.
“When patients are diagnosed with an advanced cancer, it's hard for people to understand that advanced care planning and palliation are treatments for cancer. Patients have the perception that if they're not getting chemo, they're not really being treated.
“ASCO and other organizations need to make efforts to have a paradigm shift for people to understand that best supportive care and palliation are essential components of the treatment. That will take time, and this is one step in the right direction.”
PODCAST: In an interview on the iPad edition of this issue, Lowell E. Schnipper, MD, Chair of ASCO's Cost of Cancer Care Taskforce and Chief of Hematology/Oncology at Beth Israel Deaconess Medical Center in Boston, talks about the thinking behind ASCO's Top Five list.
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ASCO's Top Five Tests/Procedures to ‘Think Carefully About Before Undertaking’
As a leader in the “Choosing Wisely” campaign, ASCO identified five tests and procedures that, in the society's words, are “expensive, widely employed, and not supported by clinical evidence.” ASCO encourages oncologists and patients to think carefully before undertaking any of the following:
1. For patients with advanced solid-tumor cancers who are unlikely to benefit, avoid unnecessary anticancer therapy and focus on symptom relief and palliative care instead.ASCO recommends eliminating treatment that is unlikely to be effective in patients who meet all of the following criteria: low performance status (3 or 4); no benefit from prior standard therapy; no further standard treatment options for their disease; not eligible for a clinical trial.
2. Do not use PET, CT, and radionuclide bone scans in the staging of early breast cancer that is at low risk of spreading.
3. Do not use PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk of spreading.
4. For individuals who have completed curative breast cancer treatment and have no symptoms of cancer recurrence, avoid using routine blood tests for biomarkers such as CEA, CA 15–3, CA 27–29, and PET, CT and radionuclide bone scans to screen for cancer recurrences.
5. Avoid administering white-cell stimulating factors to patients undergoing chemotherapy who have less than a 20 percent risk for febrile neutropenia.
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