Old checklist for doctors: order that test, write that prescription. New checklist for doctors: first ask yourself if the patient really needs it.
Nine medical societies, including the American Society of Clinical Oncology and the American College of Cardiology, representing nearly 375,000 physicians are challenging the widely held perception that more health care is better, releasing lists Wednesday of tests and treatments their members should no longer automatically order.
The 45 tests and procedures considered to be overused include:
Antibiotics for mild- to-moderate sinusitis unless symptoms last for seven or more days or worsen
Dr. Christine Cassel, president of the American Board of Internal Medicine, said the goal is to reduce wasteful spending without harming patients. She suggested some may benefit by avoiding known risks associated with medical tests, such as exposure to radiation.
"We all know there is overuse and waste in the system, so let's have the doctors take responsibility for that and look at the things that are overused," said Cassel. "We're doing this because we think we don't need to ration health care if we get rid of waste." Her group sets standards and oversees board certification for many medical specialties.
The recommendation likely to stir controversy, and even revive charges of "death panels," is to not use chemotherapy and other treatments in patients with advanced solid-tumor cancers such as colorectal or lung who are in poor health and did not benefit from previous chemo.
Such treatment is widespread. At one large health maintenance organization, for instance, 49 percent of patients with a common form of lung cancer but with poor "performance status" (they were largely confined to a bed or chair and capable of only limited self-care) received chemo. Research shows, however, that it is unlikely to extend their life or improve its quality.
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Similarly, many patients receive three and even four kinds of chemo after not responding to earlier rounds. Yet in the largest study of its kind, only 2 percent of lung-cancer patients responded to a third form of chemo; 0 percent responded to a fourth form. In another study, withholding fourth-line chemotherapy from patients with non-small-cell lung cancer or colorectal cancer did not shorten their lives compared to that of similar patients receiving last-ditch treatments.
ASCO therefore recommends that such very ill, weak, and non-responsive patients receive only palliative and other end-of-life care. An important exception: a cancer whose molecular fingerprint makes it vulnerable to a targeted therapy such as AstraZeneca's Iressa for non-small-cell lung cancer.
"In no way do we want to deprive a desperately-ill patient of something that might be helpful," said Schnipper. And every oncologist should continue to base medical decisions on the individual patient, he said.
"But if nature is telling us that something will not help, it is our obligation to do no harm," he added. Giving chemo to a seriously ill patient whose cancer has not responded to earlier treatment "might let grandma live another few weeks. But she is very likely to be made toxic by the chemo and suffer big time. There is a real risk it will make a patient worse."