COMMENTARY

10 Ways to Improve the Value of Cancer Care

David J. Kerr, CBE, MD, DSc, FRCP, FMedSci

Disclosures

July 23, 2019

This transcript has been edited for clarity.

I'm David Kerr, professor of cancer medicine at the University of Oxford. Many times I've appeared on Medscape to talk about how we could deliver better-value healthcare.

Various estimates have been made in different healthcare systems, but perhaps as much as 25% or 30% of cancer care is of little value to the patient.[1] What do I mean? This care adds little comfort, quality of life, or improvement in survival but has costs in terms of dollars spent as well as side effects or potential harm. It seems crazy to want to deliver cancer care that offers no benefit and may actually harm the patient, both financially as well as personally in terms of toxicity.

A really nice paper was published recently in Lancet Oncology by C.S. Pramesh and senior Indian colleagues representing the Indian National Cancer Grid.[2] Their well-designed effort brought together public- and private-sector experts from all the multidisciplinary areas to identify 10 areas of cancer care in India that could be omitted safely and purposefully without any harm to patients. It was based on the Choosing Wisely Program, which has been so interesting in the United States and Canada.[3,4,5]

I will read their list of low-value or harmful practices and then talk about them a little more.

1. "Do not delay or avoid palliative care for a patient with metastatic cancer because they are pursuing disease-directed treatment." I think few of us would disagree with that.

2. "Avoid chemotherapy and instead focus on symptom relief and palliative care in patients with advanced cancer that are unlikely to benefit from chemotherapy." These are generic words of wisdom that would work in Europe and the United States as well.

3. "Do not order tests to detect recurrent cancer in asymptomatic patients if there is not a realistic expectation that early detection of recurrence can improve survival or quality of life." The origin of this recommendation was from Choosing Wisely Canada. I couldn't possibly agree more. I think we should streamline and simplify follow-up for exactly those reasons.

4. "Do not order PET/CT scans to monitor response to palliative chemotherapy." This is a new suggestion, and I think there is growing evidence for this.

5. "Do not decide treatment for potentially curable cancers without inputs from a multidisciplinary oncology team." This is a new suggestion in comparison to the Choosing Wisely Northern American Programs, but one I would wholeheartedly support. We've talked about multidisciplinary cancer care before, and in the United Kingdom, it is mandatory that the full multidisciplinary team discusses the case of every single new patient. It's fantastic that our Indian colleagues are pursuing this practice of medicine also.

6. "Do not treat patients with advanced metastatic cancer in the intensive care unit unless there is an acutely reversible event." This is a new suggestion from our Indian colleagues. In the heat of the moment, this is a difficult one. It is usually an emotional decision with a younger patient, someone you feel it may be possible to resuscitate acutely. It's difficult oftentimes not to leap into that, but I do take the point. We know that recovery rates from cancer patients who require intensive care treatment are singularly poor. I do see that there is some underpinning logic for this suggestion.

7. "Do not used advanced radiation techniques where conventional radiation can be just as effective." This is a new suggestion coming forward from the Indian subcontinent. I agree entirely.

8. "Do not deliver care in a high-cost setting when it could be delivered just as effectively in a lower-cost setting." This recommendation was made initially by Choosing Wisely Canada. In a sense, this is about the geographic democratization of cancer care. In India, patients sometimes have to travel 2-3 days with their families to get to a major cancer center. There are models in India suggesting that it should be possible to share care with the district hospitals and district physicians. Can chemotherapy be simplified? Can we make it oral? Could metronomic low-dose, continuous chemotherapy be used? We need to think more about how we can democratize the delivery of cancer care and take away the "mighty empires" that are inaccessible to the vast majority of India's huge population.

9. "Do not initiate whole breast radiotherapy in 25 fractions as a part of a breast conservation therapy in women age ≥ 50 years with early-stage invasive breast cancer without considering shorter treatment schedules." This recommendation was made by the Choosing Wisely Canada team. I don't know enough about radiation therapy to comment specifically, but why go for a longer, more complex regimen if shorter, cheaper, and simpler is as effective? It seems like a no-brainer.

10. "Do not use white-cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20% risk for this complication." This recommendation originated from Choosing Wisely USA. I agree entirely. It is relatively unusual for us to use mild supportive growth factors.

I think this was an important exercise. Indian experts came together to create and adapt some excellent recommendations from the Choosing Wisely schemes in Northern America for the Indian subcontinent. I do hope that these practical rules, suggestions, and recommendations somehow find a way to improve the accessibility of cancer care, particularly in rural India.

I'd be really interested in any of your comments on this nice piece of work.

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