So Many Choices: Choosing Wisely and Shaping the Debate on the Future of Care

So Many Choices: Choosing Wisely and Shaping the Debate on the Future of Care

Clifford A. Hudis, MD, FASCO, FACP

@CliffordHudis
Nov 12, 2013

Sometimes life and events unfold in ways that suggest the presence of planning and forethought. It is hard to be sure since, faced with randomness and coincidence, some have suggested that we have been selected through evolution to see patterns and associations even when none exist.

In this light, I have been thinking about several events that are probably coincidental but may appear to be associated. Regardless, their timing highlights an important intersection of science and society and provides an opportunity to carefully consider some difficult but critical decisions ahead, while recognizing that we don’t always know what will follow.

50th anniversary logoASCO at its 50th Anniversary is one example. Lots of thought and skill went into the myriad decisions that shaped and steered your Society to make it what you see today, but I doubt that any of our early leaders precisely envisioned what we have now become.

However, today I am thinking about three intersecting issues: the Choosing Wisely campaign, the increasing focus on cost of care, and the building of CancerLinQ. We are and will be making uncountable decisions in the years ahead, each one as well informed as possible, but perhaps the only thing we can probably agree on is that we don't know exactly how this will play out. Nonetheless, the co-existence of these issues in cancer care gives us the opportunity to consider what we want health care to become as it inevitably changes.

Why are these three topics—Choosing Wisely, cost of care, and CancerLinQ—important now and how are they related? Apart from the easy answer—we want and need to be responsible stewards of limited resources (mainly money)—the broadening national discussion of cost, the supremacy of either societal or individual benefits, the assessment of value, and the role of autonomy will continue to raise challenging debates, all of which require the input of an informed public. Our oncology community has the privilege and responsibility of shaping and leading parts of this important discussion.

Choosing Wisely: The next “Top Five”

Let’s start with both the cost of care and the Choosing Wisely campaign, specifically ASCO’s 2013 “Top Five” list. The second Top Five list of recommendations extends and builds upon the first list released in 2012. More important than the highlighted specifics is the concept that the process raises. Some patients and providers may argue, against the available data, that the effort is wrong, inadequate, or misinterpreted. They may even believe there is no role for such an effort.

Such critics of the campaign should be answered with a challenge to engage and contribute future recommendations. Others may pick at the specifics, arguing, for example, that the routine scan to screen for metastasis, now labeled suboptimal, made a difference in an individual patient's life. They should be reminded of the need for data when exposing patients to potential interventions, harm, and cost. Just because something makes sense to an individual doesn't make it legitimate.

Still others will argue that this is all about cost. They should be reminded that the components of the Choosing Wisely campaign were not made on the basis of cost, but on risk-to-benefit assessments by experts. This, in turn, requires that we are prepared to communicate the strengths and limits of these recommendations by explaining the concepts that underlie them. This is an educational opportunity, but it also demonstrates the increasing complexity of cancer biology and care. We have to ask and answer: what constitutes good treatment and what is its value? Then we can tell this story accurately to our patients, peers, and the general public so that the related discussions about cost, value, and quality are better informed.

The conversations fostered in our clinical practices by the publication of the Choosing Wisely “Top Five” items are often challenging and sometimes uncomfortable. Patients and the doctors responsible for their care quickly feel the tension that develops between personal desire ("I want to do everything that might help me") and resource limitations. There are real limits as to what society is willing to spend, even if we avoid considering such limits at the individual level.

New nonhormonal cancer drugs now cost, on average, significantly more than the median family's annual income in the U.S., a significant leap from several decades earlier. New technologies, with unknown impact on survival or quality of life, gain wide use often at significantly increased cost, without much critical assessment of any marginal benefit. Given these realities, either we can continue to simply track and follow this evolving situation, we can allow market forces (such as they are in the distorted health care "market") to influence use and price, or we can seize the opportunity to re-examine data; consider uncertainty in the face of experience, training, and tradition; and ask ourselves hard questions about our treatment choices. The advantage in rising to this challenge is that only then can we, to some extent, control the destinies of our patients' care and our careers. The question is—how do we proactively do this?

All of this came into sharp focus as I participated recently in the Advanced Breast Cancer Second International Consensus Conference (ABC2) in Lisbon. Recognizing that the treatment of advanced and incurable metastatic breast cancer can be heterogeneous, variably effective, somewhat toxic, and expensive (a perfect storm of modern medicine), Drs. Fatima Cardoso, Eric Winer, Alberto Costa, and Larry Norton led an international team of highly respected clinicians who tackled the historically intractable challenge of establishing clinically relevant and meaningful global guidelines for treatment. The ensuing discussions were predictably heated (usually in inverse proportion to the existence of actual data) but enlightening. Values and the passion within our community to do the right thing were the most obvious features of the consensus panel that met and voted on the final morning.

The road ahead: CancerLinQ

This brings me, as all roads do these days, to CancerLinQ. Learning from every patient instead of only from the 3% of adults enrolling on prospective treatment studies, benchmarking our decisions and implementation against agreed-upon standards, feeding back actual outcomes that provide evidence-based adjustment of guidelines, and assessing cost and comparative effectiveness should be our goals. CancerLinQ has the potential to enable all of this and more, which will lead to better guidelines that will be easier to defend when challenged.

Guidelines and consensus, in the end, have meaning only if they are accepted and utilized. This acceptance can be voluntary and based on goodwill or it can be inflicted on us by external forces, such as insurers, regulators, or administrators. The choice is ours, but to shape cancer care, we have to own these processes wherever possible, and we have to measure up to quality indicators.

Choosing Wisely is another step toward more rational, effective, and meaningful care, and CancerLinQ is a related initiative. We should embrace these efforts and use the issues Choosing Wisely raises to engender more open discussions with society about how we can achieve our vision of a “world free from the fear of cancer.” Then our future accomplishments will exceed those of our first 50 years.

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