BY ALLEN S. LICHTER, MD
American Society of Clinical Oncology
Oncologists share a commitment to do whatever it takes to extend our patients’ lives and ensure their peace of mind. This commitment is the driving force behind the tremendous progress we’ve achieved against cancer in recent decades.
Yet we are coming to understand that this same imperative can sometimes lead to providing our patients with unnecessary care. Driven by the desire to offer patients the best possible chance at survival, it is not uncommon to offer tests or procedures that just might offer some benefit, even though clinical evidence does not support their use. But at best, these procedures contribute to today’s runaway increases in health care costs. At worst, they cause harm.
The oncology community has a shared responsibility to maximize the value of the care we provide. By “value,” I mean care that is driven by the best available evidence and by patient needs, while minimizing unnecessary and unproven interventions.
With high-value cancer care, everyone benefits -- patients and oncologists, and a healthcare system that has been pushed to the brink. Achieving high-value care is at the core of ASCO’s mission, and is reflected in our work to provide oncologists with clinical guidelines, education, quality initiatives and other resources.
Today, ASCO took another major step in this direction. As one of nine specialty societies participating in the Choosing Wisely® campaign, ASCO issued a “Top Five” list of commonly used, often costly procedures in oncology that are not supported by evidence, and whose use should be questioned.
The Top Five list is based on a thorough review of medical literature conducted by ASCO’s Cost of Cancer Care Task Force. It was informed by input from more than 200 members of the oncology community, including physicians, other medical professionals and patient advocates.
The list includes five common practices for some of the most common cancers:
1. Use of chemotherapy for patients with advanced cancers who are unlikely to benefit, and who would gain more from a focus on palliative care and symptom management.
2&3. For early breast cancer, and for early prostate cancer, use of advanced imaging technologies (i.e., CT, PET and radionuclide bone scans) in cancer staging.
4. Routine use of advanced imaging and blood biomarker tests for women treated with curative therapy for breast cancer and who have no symptoms of recurrence.
5. Use of white cell stimulating factors for patients who are at low risk for febrile neutropenia.
As anyone who has spent a career caring for people with cancer knows, frequent use of these procedures is driven by the best of intentions. In some specific cases, they may actually be warranted by circumstances facing a particular patient, and such exceptions are noted in the published list.
In general, however, these practices need to be curtailed. In each case, the evidence is clear that patients fare as well, or better, when they do not receive these interventions.
Putting the top-five list into practice will require a collaborative effort, and it won’t happen overnight. To help inform the oncology community, the task force that developed the list has published a summary of supporting evidence in the Journal of Clinical Oncology. ASCO will also be doing its part to support the oncology community in carrying out the recommendations, through webcasts and other physician and patient resources in the coming months.
In the end, though, it will come down to the choices of individual physicians and patients. The Choosing Wisely® campaign is really about sparking the critical conversations that need to happen -- among oncologists, and between oncologists and their patients -- to ensure that patients receive the best possible treatment for their cancer while avoiding unnecessary tests and therapy.
Working together, I am confident that our field will continue raising the standards of patient care so that more and more patients live long and fulfilling lives.