Choosing wisely

In an unusual move, several professional societies jointly released a set of principles entitled "Choosing Wisely" (see choosingwisely.org) – five tests and treatments for each of several specialties that physicians and patients should question. Things that eventually cause more harm than good and also tend to drive up healthcare costs. The ones that are listed for cancer are available at:choosingwisely.org/wp-content/uploads/2012/04/5things_12_factsheet_Amer_Soc_Clin_Onc.pdf.While these recommendations will need to be tailored to individual situations, they have the common theme that these tests that are done for "reassurance" or early detection of recurrence or metastasis of cancer when the chances of having a positive test are low, even lower than the chances of "false-positive" results that commonly lead to further testing or even harmful procedures. Also, there are two recommendations to avoid medical treatments (white blood count boosting drugs and chemotherapy for advanced cancers) in situations where there is no proven benefit. However, there is certainly going to be vocal opposition and there are already some who are criticizing this as some type of healthcare rationing. In particular, the recommendation to withhold chemotherapy in patients who have almost no chance of being helped by such treatment will be hard for many to accept.This illustrates one of the key dilemmas of medical care and one of the reasons that our healthcare costs are the highest in the world whereas our health outcomes are clearly not the best. In the U.S., doctors and patients are quick to request tests and procedures that on the average may yield a very small chance of benefit and a greater chance of unnecessary treatment. But if you happen to be one of the rare patients that is helped by one of these tests, your viewpoint may be different. At the moment, the public (and most lawmakers who are elected by the public) have no appetite for advocating any restrictions on what a doctor and patient feel is the best course of care. But as patients are burdened with more costs of insurance and co-pays, they are starting to "self-ration" care. In the last couple of years, more patients are opting to defer test and even cancer treatments mostly because of cost. Despite the controversy this movement will stir, it is clear that patients and physicians need to have information available to prioritize what test and treatments can be omitted without any (or minimal) change in outcome. But will our society be willing to accept these statistics and forgo the long shot?