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Next Five in Choosing Wisely

Posted 11/3/2013

Posted in

  This is the next chapter in an ongoing national conversation about our health care. Whatever your politics, I expect we all agree that, as a country, we need to look carefully at our practices and our costs and figure out how best to spend our health care dollars to deliver appropriate and high quality care to all Americans. There is a long list of not so smart ways that a lot of money is spent. Did you know, for example, that 30% of the total Medicare budget is spent on the last year of life, and most of that is spent on the last weeks? Please do not misunderstand me: some of those dollars are spent in exactly the right ways, but we do need to think about the overall picture. Doctors are in a pinch as they need to consider costs on the one hand, but their absolute loyalty needs always to be to the patient right in front of them.

  You may be aware of the Choosing Wisely campaign, an initiative headed by the American Board of Interal Medicine ( that is challenging all of the medical specialties (oncology, neurology, cardiology, etc.) to consider their practices and identify those that are widely used, often expensive, and whose value is not  supported by research. There are the shifty practices of some physicians who own radiology equipment and who routinely send their patients for x-rays or scans that really aren't needed. There are many more instances of physicians recommending those scans because the patient is insisting or the doctor is worrying about liability or that is just the way it is done. We need to be smarter.

  Full disclosure time: my husband has been leading the ASCO (American Society of Clinical Oncology) taskforce in this endeavor, so I have been hearing a great deal about it. In oncology, and probably in all the specialities, there have been a couple of "easy" answers and others that are much more controversial. The second round of five suggestions was announced by each group last week.  One that may grab your attention is the recommendation t to start a woman with metastatic breast cancer on a multi-drug chemotherapy regimen, rather than a single drug treatment, unless urgent symptoms relief is needed. The data don't support the benefit of multi-drug treatments in most cases, and they are likely to cause more side effects and, of course, cost more.

  Here is the start of ASCO's announcement and a link to read it all:

New ASCO Choosing Wisely® List Details Five Cancer Tests and Treatments Routinely Performed Despite Lack of Evidence

The American Society of Clinical Oncology (ASCO) today announced its second “Top Five” list of opportunities to improve the quality and value of cancer care. Published in the Journal of Clinical Oncology (JCO), ASCO’s second Top Five list was released as part of the Choosing Wisely® campaign, sponsored by the ABIM Foundation, to encourage conversations between physicians and patients aimed at curbing the use of certain tests and procedures that are not supported by clinical research. One of the first nine medical societies to join the Choosing Wisely campaign, ASCO issued its first Top Five list in April 2012.

“As physicians, we have a fundamental responsibility to provide high-quality, high-value cancer care for all of our patients,” said Lowell E. Schnipper, MD, lead author of the JCO article and chair of ASCO’s Value of Cancer Care Task Force. “That means eliminating screening and imaging tests where the risk of harm outweighs the benefits, and making sure that every choice of treatment reflects the best available evidence. By providing evidence-based care, we not only help our patients live better with cancer, we also assure they are getting high-quality care that will deliver the greatest possible benefit for the cost.”




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  • BettyB said:
    11/4/2013 10:55 PM

    Hi Hester,
    I believe you are a proponent of the AHA, maybe you could comment for us on the policy in England, a country with socialized medicine, of not allowing women over 50 get Neulasta (too expensive if you are old.) I think this is clearly 'we need to look carefully at our practices and our costs and figure out how best to spend our health care dollars to deliver appropriate..' in action and we are on our way there now. Thanks.

  • Hester Hill Schnipper said:
    11/5/2013 12:54 PM

    Thank you for your comment. Reading between the lines, I am guessing that you are a bit wary re possible restrictions in our health care system, shades of the ridiculous "Death Panel" accusations. It is, of course, reasonable and appropriate to be concerned, but I truly don't think any of us need to be worried about our continuing access to the right care.
    Re your specific question: I tried to research the use of Neulasta in women over 50 in the UK and can't find anything. I will take your word for it as their policy, but suspect there is more to it. For example, the largest use of Neulasta in breast cancer treatment is during adjuvant or neoadjuvant therapy, making it possible for women to receive chemo every two weeks instead of every three weeks. I frankly don't know if there are studies that have explored the value of DD (dose dense, every two week) adjuvant therapy vs the regular (3 week) schedule for older women. There are risks to Neulasta and often unpleasant side effects. If there is not a proven benefit to receiving chemo on the faster schedule, it doesen't seem unreasonable to question the use of Neulasta (and not just for financial reasons).