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Choosing Wisely: What CancerTests and Treatments Do You Really Need?

Choosing Wisely logoOncologists have joined eight other physician specialty organizations in the Choosing Wisely® campaign with a list of the Top Five Cancer-Related Tests, Procedures, and Treatments That Many Patients Do Not Need.

Choosing Wisely asked each of the specialist groups to come up with a list of five things doctors and patients should question in order to improve evidence-based care, avoid tests or treatments that don’t help, and reduce the burden of health care costs. Here are the Top Five lists from the other groups.

The American Society of Clinical Oncology  built the Top Five List for Oncology, based on work that ASCO’s Cost of Care Task Force has been doing for several years to identify diagnostic tests or treatments that are commonly ordered, expensive, and of unproven value.

While the Top Five list is based on evidence for effective cancer care, its recommendations are not written in stone. They are guidelines for patients, families, and doctors to begin a conversation about tests and treatments and costs in order to make good decisions about the best care for each individual.

Briefly the Top Five list recommends

  1. Stop active cancer treatment when patients are too ill to benefit, aren’t eligible for a clinical trial, previous treatments haven’t worked, and there are no more standard treatment options.
  2. Don’t use advanced imaging tests (CT, PET, bone scans) for early prostate cancer which has a low risk of spreading.
  3. Don’t use similar imaging tests for early breast cancer that has a low risk of spreading.
  4. Don’t use PET, CT, bone scans or biomarkers to follow-up breast cancer patients without symptoms after treatment intended to cure them.
  5. Don’t give medicines to stimulate white cells in patients with a low risk of developing low counts with fever.

More specifically the Top Five for Oncology published ahead of print in the Journal of Clinical Oncology April 3  are:

  1. Do not use cancer-directed therapy for patients with solid tumors who have the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and with no strong evidence supporting the clinical value of further anticancer treatment.
  2. Don’t perform PET, CT and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis.
  3. Don’t perform PET, CT and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis
  4. Don’t perform surveillance testing (biomarkers) or imaging (PET, CT and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.
  5. Don’t use white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20% risk for this complication.

Patients with advanced colorectal cancer and their families may be alarmed at the recommendation to stop chemotherapy when performance status is poor and there are no standard, evidence-based treatments.

Patients with a performance status of 3 spend at least half their day in bed or in a chair and have difficulty taking care of themselves. Poor performance status is often a sign of increasing toxicity from chemo, reduced response to the chemo drugs, and poor survival time. Treatment may do more harm than good.

A rule of thumb for performance status is whether a patient can walk without help into the chemotherapy suite.

At this point supportive care may benefit patients more than additional chemotherapy. It’s time for a frank discussion with the doctor about the benefit and harm of more treatment.

Lowell E. Schnipper and the team who developed the Top Five write,

The available guidelines established by expert panels have all concluded that if a patient’s cancer has grown during three different regimens, the likelihood of treatment success is so poor and toxicity so high that further anticancer treatment is not recommended.

While patients and families may urge doing everything possible, this is not always the best course.

Schipper and his colleagues conclude,

The Top 5 list represents a series of practices in frequent use in common clinical scenarios that are not supported by strong evidence. Reconsidering their use, one patient at a time, is likely to improve the value of care that is provided, which in this case means the desired clinical outcome at the lowest cost to the patient and society. Nonetheless, ASCO recognizes that the care of every person with a life threatening disease is challenging and must be responsive to unique features of that particular individual’s circumstances. For that there will never be a substitute.

 

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2 Comments

  1. B. Ander - Paid Clinical Trials Volunteer said:

    How ethical is it to refuse cancer-directed therapy to patients with solid tumors who are not eligible for a clinical trials. I think this is outrageous. Correct me if am wrong but this seems to me to be the wrong approach. If there is even the slightest possibility of supporting someone it should be approved. I have read countless winning stories from medical research volunteers on both treatment and paid clinical trials.

  2. Kate Murphy said:

    The important point of the Top Five list is not to refuse treatment to anyone but to start important conversations about the benefits and side effects of more treatment.

    I think it is unethical for doctors not to be honest about the evidence for cancer treatment including how effective it can be and what side effects are.

    Good supportive care is an ethical option for people at the end of life.

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