As part of the American Board of Internal Medicine Foundation’s “Choosing Wisely” campaign, the American College of Surgeons (ACS) and the Commission on Cancer (CoC) have developed lists of five measures focusing on tests or procedures that are commonly ordered but not always necessary in surgery and surgical oncology. Although the ACS and CoC developed their own sets of measures, each organization strongly supports the other, according to Stephen B. Edge, MD, FACS, an executive committee member of the CoC. “These measures address the care of different patients,” he says. “The CoC addresses cancer patients in many parts of their care, whereas the ACS addresses all surgical patients.”
The Commission on Cancer Measures
After vetting a long list of potential measures, the CoC arrived at the measures listed in Table 1. Strong evidence supports using needle biopsy to determine if an abnormal finding may be indicative of breast cancer. Needle biopsy for a worrisome finding on breast imaging or examination improves treatment outcomes when compared with a diagnostic surgical lumpectomy, says Dr. Edge.
In 2006, the Institute of Medicine recommended that all patients completing cancer treatment be given a summary of the therapies they received as well as a survivorship care plan. “This recommendation, however, is not being followed for most cancer patients,” Dr. Edge says. “The reasons are multi-faceted and include the time and effort it takes to create these plans and the difficulty in defining exactly how they should be constructed.” He adds that a survivorship plan explaining what tests patients should expect—and informing them that having more tests performed will not help—may reduce anxiety, uncertainty, and cost.
Historically, initial treatment for most cancer types has been surgical resection, followed perhaps by drug therapy, chemotherapy, and/or radiation. “Over the last 15 to 20 years, studies have shown that providing chemotherapy or radiation prior to surgery for many cancers makes operations easier to perform and more likely to be successful,” says Dr. Edge. “This approach may also allow for less aggressive surgery in some cases. However, there’s evidence that this strategy is not as widely used as it should be. We hope that the CoC’s recommendation to consider reversing the order will save money and improve outcomes for those cancer types and situations with which it improves outcomes.”
Major abdominal and thoracic surgeries have high risks for significant complications, including pneumonia and other infections. “Postoperative pneumonia increases the risks for long-term, serious complications and mortality from surgery,” Dr. Edge explains. “It also dramatically increases costs. Aggressively controlling pain and preventing pneumonia from developing after surgery can substantially reduce the risk of major complications and markedly reduce costs.”
According to Dr. Edge, many patients with advanced cancer believe that the palliative care they receive is curative. “In many cases, patients who initially felt that their best approach was to do everything in their power to fight the disease instead choose palliative or hospice care when they learn that they’re unlikely to benefit from treatment and that the treatment is likely to make them sick,” Dr. Edge says. “Studies show that well-counseled patients may make different choices about their treatment. Physicians should ensure that their patients understand why they’re getting particular treatments. This should be done with sensitivity and support in mind. There’s a chance we can also reduce costs by avoiding unnecessary treatments.”
The ACS Measures
Of the five measures created by ACS, three are related to surgical oncology (Table 2). With regard to staging the axilla for positive lymph nodes, research indicates that sentinel node biopsy is effective and has been shown to have fewer short- and long-term side effects when compared with axillary lymph node dissection. If the sentinel lymph nodes are negative for cancer, invasive axillary dissection can be avoided for patients with stages I and II breast cancer.
The ACS recommends against screening for colorectal cancer in asymptomatic patients who are not expected to live beyond 10 years and in those who have no family history of the disease. This is because the risks of colonoscopy increase with age and comorbidities and because screening and surveillance modalities have been deemed inappropriate when risks outweigh benefits.
In addition, the ACS recommends against routine admission or preoperative chest x-rays for ambulatory patients who do not have other specific reasons for this test. Only 2% of these diagnostic imaging modalities lead to changes in care, according to the ACS.
Only the Beginning
“These measures are designed to encourage providers to look carefully at their current practices,” says Dr. Edge. “The goal is to ensure that we’re providing the highest value care, and therefore the best quality of care. We’ve only just begun engaging physicians and other healthcare professionals in defining the best pathways to improve quality of care. Through this type of engagement, it’s hoped that we’ll continue to improve the quality of life for cancer patients and the American public.”
American College of Surgeons. Five things physicians and patients should question. Available at http://www.choosingwisely.org/doctor-patient-lists/american-college-of-surgeons.
Commission on Cancer. Five things physicians and patients should question. Available at http://www.choosingwisely.org/doctor-patient-lists/commission-on-cancer.
Giuliano A, Hunt K, Ballman K, et al. Axillary dissection vs. no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305:569-575.
Weeks J, Satalano P, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:1616-1625.
Cowens-Alvarado R, Sharpe K, Pratt-Champman M, et al. Advancing survivorship care through the National Cancer Survivorship Resource Center: developing American Cancer Society guidelines for primary care providers. CA Cancer J. Clin. 2013;63:147-150.
Burkhardt J, Sunshine J. Core-Needle and surgical breast biopsy: comparison of three methods of assessing cost. Radiology. 1999;212,181-188.