A Conversation With
A Conversation with Dr. Lowell Schnipper about Cancer Care and the Choosing Wisely Campaign
Nine professional medical societies, including the American Society of Clinical Oncology (ASCO), each recently released a list of the five most commonly performed medical tests and procedures within their specialties that are not supported by published evidence and contribute heavily to unnecessary health care spending in the United States. The release was part of the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely campaign.
Dr. Lowell Schnipper, of Harvard Medical School and chair of the ASCO Cost of Cancer Care Task Force, which spearheaded ASCO's contribution to the Choosing Wisely campaign, spoke with the NCI Cancer Bulletin about the top-five list and the larger effort behind it.
Dr. Lowell E. Schnipper
Why is the Choosing Wisely campaign important? Is the campaign just focused on saving money, or is it broader than that?
ABIM and the specialty societies are participating in this campaign because we believe that the best care is the right amount of care.
If you deliver the right amount of care in a milieu that is otherwise characterized by the delivery of too many interventions or therapies, you will definitely spend less on health care. Nobody would dispute that as a laudatory goal, particularly in a country where we are all concerned about health care and other expenditures. However, this campaign is really about quality of care, with the assumption that if evidence-based care is the norm, the lowest possible expense will follow.
In my specialty of breast cancer, for example, when we give more care than the clinical situation warrants, we invariably expose patients to the risk of new findings that have no disease-specific relevance and may have no clinical importance. This situation frequently elicits anxiety in the patient and stimulates physicians to do more scans, more x-rays, and, not uncommonly, invasive biopsies. That's what I call too much care, which can hurt patients instead of help them.
The campaign is also directed at patients. Patients will be encouraged to discuss their care with their doctors, ask them how wise is it to do a given procedure, and ask if there are downsides to a test or procedure.
ASCO's Five Key Opportunities to Improve Cancer Care
1. Avoid unnecessary anticancer therapy, including chemotherapy, in patients with advanced solid-tumor cancers who are unlikely to benefit, and instead focus on symptom relief and palliative care.
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 patients without symptoms who have been treated for breast cancer with curative intent.
5. Avoid administering white blood cell stimulating factors to patients who have a very low risk (less than 20 percent) for febrile neutropenia.
How were these five procedures and tests selected?
The task force—which included physicians, advocates, and representatives from the pharmaceutical industry—first came up with a list of suggestions for ASCO's top-five list. We discussed them by e-mail and in person. Once we arrived at a tentative list, we distributed it to the ASCO Clinical Practice Committee, which is composed of nearly 200 oncologists, if you include the leaders of the state clinical oncology societies. I don't remember getting very many negative responses to the suggestions we distributed, although some questions or reservations certainly were brought up.
The items we honed in on had to meet certain criteria. Specifically, we wanted the top five to be supported by a body of evidence in the form of studies in the literature and/or be the subject of expert guidelines, either generated by ASCO or a respected group such as the National Comprehensive Cancer Network.
Why do you think these procedures are overused?
I think the dominant reasons that cut through all of them is the anxiety that a cancer diagnosis presents, the importance of not missing something clinically important, and the reality of an advanced cancer that's already made a person very sick and the proximity of that person's death. I think these are more than enough to motivate and frighten anybody, patient or doctor, to turn over any stone that can reasonably be overturned.
You asked if there are financial factors that underlie overuse. I believe that most of us would concur that the economic milieu in which we practice medicine today does not neatly align the incentives for physicians, society, and the patient in a way that would contribute to delivery of the least costly care. There are also real tort concerns, which motivate overuse to protect one against malpractice allegations. But I reject the idea that this is driven by greed; physicians want to do the right thing for our patients
I have patients who have undergone surgery, radiation, and chemotherapy, who come in and report being well. But they'll say, "Well, how do you know I'm okay? Don't you need to check me out, do some scans, to make sure that I'm okay?"
It's counterintuitive to a patient, and it can be counterintuitive to a doctor, to tell them that finding metastatic disease doesn't help us help them survive longer. That's really what the data that support our top five list tell us…and it's a difficult concept for the patient to absorb. Some day, novel treatments may in fact aid us in extending survival of those with metastatic disease sufficiently to warrant continuous surveillance. We are not there yet, and when evidence supports our arrival at that point, our guidelines must change.
Is it important that the top five list came from the medical community?
I really do think that's important. One of ASCO's motivating factors for forming the Cost of Cancer Care Task Force was to be responsible citizens and stewards of the nation's heath care system.
We were fully aware that major changes in health care delivery were going to happen one way or another, because the rising costs of care are becoming unsustainable. And as uncomfortable as it can be to talk about some of these issues, we much prefer that professionals in the field develop management recommendations, rather than the government or insurance companies, because [these issues] require sophisticated clinical insights.
We feel that [the medical community] is best able to identify how to provide the best care, where we can most effectively reduce unnecessary procedures, and still come out with the best results for our patients.
—Interviewed by Carmen Phillips