Nine medical societies are challenging the widely held perception that more health care is better.
The old checklist for doctors: order that test, write that prescription. The new checklist for doctors: first ask yourself if the patient really needs it.
Nine medical societies, including the American Society of Clinical Oncology and the American College of Cardiology, representing nearly 375,000 physicians are challenging the widely held perception that more health care is better, releasing lists Wednesday of tests and treatments their members should no longer automatically order.
The 45 tests and procedures considered to be overused include:
- Repeat colonoscopies within 10 years of a first test
- Early imaging for most back pain
- Brain scans for patients who fainted but didn’t have seizures
- Antibiotics for mild- to-moderate sinusitis unless symptoms last for seven or more days or worsen
- Stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present
- PAP smears on women younger than 21 or who have had a hysterectomy for a non-cancer disease
- Advanced imaging or bone scans in patients with early-stage breast or low-grade prostate cancer
- Bone scan screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors
- Routine cancer screening on dialysis patients with limited life expectancies
- Chemotherapy for sickest cancer patients
Dr. Christine Cassel, president of the American Board of Internal Medicine, said the goal is to reduce wasteful spending without harming patients. She suggested some may benefit by avoiding known risks associated with medical tests, such as exposure to radiation.
“We all know there is overuse and waste in the system, so let’s have the doctors take responsibility for that and look at the things that are overused,” said Cassel. “We’re doing this because we think we don’t need to ration health care if we get rid of waste.” Her group sets standards and oversees board certification for many medical specialties.
Other advocates agreed. “I am shocked, surprised, and pleased,” said Fran Visco, president of the National Breast Cancer Coalition and a breast-cancer survivor. “Shocked because ASCO has long been loath to say, ‘do less.’ Pleased because it appears that they are trying to follow the science, which is nice.”
The recommendations come at a time when American health care is undergoing far-reaching changes. No matter what the Supreme Court decides on President Barack Obama’s health overhaul, employers, lawmakers, insurers and many doctors are questioning how the United States spends far more on medical care than any other economically advanced country and still produces mediocre results overall.
The recommendation likely to stir controversy, and even revive charges of “death panels,” is to not use chemotherapy and other treatments in patients with advanced solid-tumor cancers such as colorectal or lung who are in poor health and did not benefit from previous chemo.
Such treatment is widespread. At one large health maintenance organization, for instance, 49 percent of patients with a common form of lung cancer but with poor “performance status” (they were largely confined to a bed or chair and capable of only limited self-care) received chemo. Research shows, however, that it is unlikely to extend their life or improve its quality.
Similarly, many patients receive three and even four kinds of chemo after not responding to earlier rounds. Yet in the largest study of its kind, only 2 percent of lung-cancer patients responded to a third form of chemo; 0 percent responded to a fourth form. In another study, withholding fourth-line chemotherapy from patients with non-small-cell lung cancer or colorectal cancer did not shorten their lives compared to that of similar patients receiving last-ditch treatments.
ASCO therefore recommends that such very ill, weak, and non-responsive patients receive only palliative and other end-of-life care. An important exception: a cancer whose molecular fingerprint makes it vulnerable to a targeted therapy such as AstraZeneca’s Iressa for non-small-cell lung cancer.
“In no way do we want to deprive a desperately-ill patient of something that might be helpful,” said Schnipper. And every oncologist should continue to base medical decisions on the individual patient, he said.
“But if nature is telling us that something will not help, it is our obligation to do no harm,” he added. Giving chemo to a seriously ill patient whose cancer has not responded to earlier treatment “might let grandma live another few weeks. But she is very likely to be made toxic by the chemo and suffer big time. There is a real risk it will make a patient worse.”
The challenge for physicians as well as insurers will be balancing the needs of the vast majority of patients against the rare cases. Studies have shown that when very ill lung-cancer patients were given a common chemotherapy, the average survival was half that of stronger patients, but nevertheless, 3.4 months.
The recommendation that physicians not perform advanced imaging or bone scans in patients with early-stage breast or low-grade prostate cancer that is unlikely to spread also reflects research that contradicts what many patients believe.
In these patients, imaging such as PET and CT to search for metastasis does not improve detection of metastases or extend survival. Moreover, said Schnipper, “finding metastases early does not improve survival in breast cancer.” But the expensive imaging ($2,500 to $5,000) does misdiagnose some harmless changes as cancer, leading to unnecessary invasive procedures or treatments that can shorten lives.
Again, there are exceptions. The most authoritative review found that 99 percent of patients with early-stage, seemingly low-risk prostate cancer do not benefit from imaging or bone scans. That suggests 1 percent might.
In breast-cancer patients who have been successfully treated, such as Shari Baker, neither the advanced imaging nor blood tests for molecules associated with tumors improve survival. (The tests do help patients treated for colorectal cancer, however.) Most recurrences are found through a physical exam or mammogram. Yet the advanced tests are routine.
“Why do doctors keep doing them?” Schnipper asks. “Most of them are aware of the evidence that these tests don’t benefit patients. But in my own experience treating breast-cancer patients, sometimes when I go through the explanations of how these things don’t help a patient will say, ‘but it will help me sleep at night.’ And I do it.”
Dr. James Fasules of the American College of Cardiology said the goal is to begin changing attitudes among patients and doctors.
“We kind of have a general feeling that if you don’t get a test, you haven’t been cared for well,” said Fasules. “That has permeated American culture now.” The new advice isn’t meant to override a doctor’s judgment, Fasules added, but to inform and support decisions.
The recommendations will be circulated to consumers and doctors by a coalition calling itself Choosing Wisely, which includes employer groups, unions, AARP and Consumer Reports. Neither the insurance industry nor the federal government was involved in process.
Each of the nine medical societies submitted five tests or treatments they viewed as overused. Their work was coordinated by a foundation that’s an offshoot of Cassel’s group. Eight other medical societies are developing additional recommendations, Cassel said.
The medical societies don’t have any power of enforcement, and fear of malpractice lawsuits may well prompt many doctors to keep ordering as many tests as ever.
Insurers will certainly take a close look at the recommendations, but what they do may be limited. That’s because most of the questionable tests and treatments in the lists don’t particularly stand out in the avalanche of bills processed daily by insurance companies.
Take a recommendation for no annual EKGs for low-risk patients with no heart symptoms. Dr. John Santa, director of the Consumer Reports Health Ratings Center, said he used to routinely order EKG’s when he was a general adult medicine practitioner. EKGs cost $50 to $60. A medical assistant would do the tests, and it would take Santa just a couple of minutes to read them. Yet 2 percent to 3 percent of his income came from EKGs, enough to make a difference in a tight year.
“It’s very difficult for an insurance company to tell the difference when an EKG is being used as a diagnostic tool and when it is being used as a screening test,” said Santa. “It would probably cause more trouble for insurance companies.”
The medical groups that participated are: American Academy of Allergy, Asthma & Immunology; American Academy of Family Physicians, American College of Cardiology, American College of Physicians, American College of Radiology, American Gastroenterological Association, American Society of Clinical Oncology, American Society of Nephrology, and American Society of Nuclear Cardiology.
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