The American College of Surgeons (ACoS) and Commission on Cancer (CoC) have released separate lists of specific tests or procedures in surgery and surgical oncology that are commonly ordered, but potentially unnecessary, as part of the American Board of Internal Medicine Foundation's “Choosing Wisely” campaign. Each organization has identified five targeted, evidence-based recommendations to support discussions between physicians and patients about care options that may not be necessary.
“This initiative will help provide cancer patients with a highly credible resource to obtain reliable information when discussing certain aspects of their care with their physicians,” said David P. Winchester, MD, FACS, Medical Director of the ACoS's Cancer Programs.
To develop its list, ACoS solicited recommendations from the organization's Committee on Trauma and Advisory Councils for Colon and Rectal Surgery, General Surgery, and Pediatric Surgery, as well as from the Commission on Cancer. All of the recommendations collected were reviewed, and five items were selected for the final list. They are:
- Do not perform axillary lymph node dissection for clinical stages I and II breast cancer with clinically negative lymph nodes without attempting sentinel node biopsy;
- Avoid the routine use of “whole-body” diagnostic computed tomography (CT) scanning in patients with minor or single system trauma;
- Avoid colorectal cancer screening tests on asymptomatic patients with a life expectancy of less than 10 years and no family or personal history of colorectal neoplasia;
- Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam; and
- Do not use CT for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.
The CoC appointed a multidisciplinary task force to develop its list. The recommendations for candidate interventions were solicited from panel members and other CoC leaders. The panel voted on each intervention to select the final list of recommended interventions, which are:
- Do not perform surgery to remove a breast lump for suspicious findings unless needle biopsy cannot be done;
- Do not initiate surveillance testing after cancer treatment without providing the patient a survivorship care plan;
- Do not use surgery as the initial treatment without considering neoadjuvant systemic and/or radiation for cancer types and stage where it is effective at improving local cancer control, quality of life, or survival;
- Do not perform major abdominal surgery or thoracic surgery without a pathway or standard protocol for post-operative pain control and pneumonia prevention; and
- Do not initiate cancer treatment without defining the extent of the cancer (through clinical staging) and discussing intent of treatment with the patient.
Both lists are posted online at: www.facs.org/choosingwisely. With the release of these new lists, the Choosing Wisely campaign will have covered some 250 tests and procedures in various subspecialties that the individual society partners say are overused and inappropriate, and that physicians and patients should discuss.