In collaboration with the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely® campaign, ASCO recently released a second “Top Five” opportunities list of common practices or procedures in oncology whose clinical value is not supported by available evidence and if eliminated, can improve the quality and value of patient care.

Value of Cancer Care Task Force

Like the original “Top Five” list, published in 2012, the new list was developed under the leadership of
ASCO’s Value of Cancer Care Task Force, a multidisciplinary group of oncologists that was formed to address the rising cost of cancer care in this country while tackling solutions to improve quality and value.

“Even in an area of care like oncology, where you are dealing with a scary illness with uncertain outcomes, doing everything possible for a patient is not always helpful,” said Lowell E. Schnipper, MD, Chair of the Value of Cancer Care Task Force. “There are plenty of things that we automatically do that may not add value to the patient.”

According to Dr. Schnipper, ASCO members widely supported ASCO’s initial “Top Five” opportunities list, which called for the elimination of unnecessary chemotherapy for patients with advanced disease who were unlikely to benefit, the use of costly imaging technologies for detecting breast cancer recurrence and for the staging of early breast and prostate cancers that are unlikely to metastasize, and the use of drugs to prevent febrile neutropenia for patients at low risk for the complication.

When the ABIM Foundation recently asked ASCO to participate in a second “Top Five” list, the Task Force began the work of soliciting ideas from ASCO committee members, which include clinical oncologists in the community and in academia with a wide variety of expertise.

“ASCO has devoted considerable energy in focusing on value in cancer care, and identifying and rationalizing key areas where medical activity is not producing value,” said Derek Raghavan, MD, PhD, a member of ASCO’s Value of Cancer Care Task Force. “This campaign has focused on common cancers where common patterns of practice— either diagnostic tests or patterns of treatment—no longer provide value to patients, neither improving outcomes or prognosis, nor reducing side effects.

Top Suggestions from Experts

The following was developed from a list of top suggestions from ASCO committee members, which was compiled, ranked by importance, and narrowed down to five.

1. Do not give antiemetics intended for use with a chemotherapy regimen with a high risk of causing severe nausea and vomiting to an asymptomatic patient who is starting on a regimen that has a low or moderate risk of causing nausea and vomiting.

2. Do not use combination chemotherapy instead of single-agent chemotherapy when treating a patient for metastatic breast cancer unless the patient needs a rapid response to relieve tumor-related symptoms.

3. Avoid using advanced imaging techniques, such as PET or PET/CT scanning, as part of routine follow-up care to monitor for cancer recurrence in asymptomatic patients who have finished initial treatment to eliminate the cancer unless there is high-level evidence that such imaging will change the outcome.

4. Do not perform PSA testing for prostate cancer screening in men with no symptoms of the disease when they are expected to live less than 10 years.

5. Do not use a targeted therapy intended for use against a specific gene mutation if a patient’s tumor does not have that specific gene mutation.

Vetting Process

Members of the Task Force with expertise in each area were asked to vet the recommendations by evaluating the literature to make sure each recommendation was evidence-based, and that, whenever possible, they were consistent with guidelines issued by professional societies like ASCO or the National Comprehensive Cancer Network. The “Top Five” list was published in the Journal of Clinical Oncology with explanations of how eliminating each practice can add value and improve the quality of patient care (See related news item here). 

“Oncologists would do well to understand that the recommendations on the ASCO list will reduce cost dramatically, will save patients unnecessary inconvenience (and, in some cases, side effects and cost), but will not adversely impact quality of life or duration of survival,” Dr. Raghavan said. “ASCO is focused on providing the best care to patients, but also on ensuring that the things we do actually improve outcomes.”

To learn more about the Top Five and ASCO’s participation in Choosing Wisely, visit asco.org/topfive. ■