Cancer care: sometimes less is more

By | July 13, 2017

Preparing for radiation. Photo: Russ Scalf

Cancer is a dreaded disease – and in the US, a typical response to a cancer diagnosis is to try every treatment available in hopes that something might work. Understandable! But cancer overtreatment is a serious problem that drives up costs, causes avoidable morbidity and mortality, and reduces the quality of care.

What is overtreatment? Simply defined, it is medical care that has no benefit, or for which harms outweigh potential benefits. According to some estimates, about 30% of all US medical expenditures are attributable to overtreatment.

But is overtreatment common in cancer care? This month’s issue of Medical Care includes a systematic literature review answering that question. The review, by Dr. Shrujal Baxi and colleagues at Sloan Kettering and other institutions, is a well-conducted, focused review of recent studies of cancer overtreatment.

The authors found 59 articles meeting their review inclusion criteria–almost all focusing on adult and geriatric populations–that assessed the overuse of 154 distinct services associated with cancer diagnosis (56% of services), surveillance (23%), active treatment (19%), and end of life (1%). Consistent with the emphasis on diagnosis and surveillance, imaging was the most frequently studied service (71%), followed by radiation (6%), hormonal therapy (5%), chemotherapy (3%), targeted therapy (1%) and other therapies (6%).

Most studies reported the overuse rate as the percentage of the population receiving a non-recommended service, with ranges from 0 to 100% across the services. Many studies (46%) used claims data to identify overuse. Three studies looked at two types of data, claims and either chart review or clinical data. One of those (Hahn 2015), found that among women receiving imaging for low-risk breast cancer, the services received were documented as clinically relevant (and guideline-concordant) about half the time–although, as Baxi and colleagues note in their excellent discussion of the methodological issues involved in this area of research, it is impossible to know how much of the documentation is accurate.

Another interesting study (Weeks 2014), looking at National Comprehensive Cancer Network data on over 25,000 patients, found that overtreatment rates for chemotherapy were around 40% in patients with metastatic lung cancer and poor performance status, 36% in postmenopausal women with limited metastatic breast cancer, and 55% in premenopausal women with limited metastatic breast cancer.

These rates are especially concerning given that these data were from major cancer centers, presumably the best places to get cancer care, yet overtreatment was rampant. Note that in comparison, a French study using data from 2 academic centers reported that about 21% of all chemotherapy administered was non-concordant with national guidelines–this is not just a US problem.

Given the high costs of cancer treatment, it is regrettable that so few recent studies have focused on costs of overuse in general, and particularly overuse during the active treatment phase. It is also unfortunate that few have studied interventions to reduce overuse, especially since one intervention led to reductions in both overuse and recommended services. Across populations, the “right” amount of treatment is hard to define and measure, and perhaps even harder to achieve.

For more information on overtreatment, check out the Choosing Wisely campaign. They provide evidence-based recommendations, organized in lists for both doctors and patients, to help make decisions about appropriate and necessary treatment.

Lisa Lines

Lisa Lines

Health services researcher at RTI International
Lisa M. Lines, PhD, MPH is a health services researcher at RTI International, an independent, non-profit research institute. She is also an Instructor in Quantitative Health Sciences at the University of Massachusetts Medical School. Her research focuses on quality of care, care experiences, and health outcomes among people with chronic illnesses; emergency department utilization; and person-centered care and patient-centered medical homes, among other topics. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She also serves as chair of the APHA Medical Care Section's Health Equity Committee. In 2015, Dr. Lines was appointed to a 3-year term on the National Quality Forum's Neurology Standing Committee. Views expressed are the author's and do not necessarily reflect those of RTI or UMass Medical School.
Lisa Lines
Lisa Lines

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About Lisa Lines

Lisa M. Lines, PhD, MPH is a health services researcher at RTI International, an independent, non-profit research institute. She is also an Instructor in Quantitative Health Sciences at the University of Massachusetts Medical School. Her research focuses on quality of care, care experiences, and health outcomes among people with chronic illnesses; emergency department utilization; and person-centered care and patient-centered medical homes, among other topics. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She also serves as chair of the APHA Medical Care Section's Health Equity Committee. In 2015, Dr. Lines was appointed to a 3-year term on the National Quality Forum's Neurology Standing Committee. Views expressed are the author's and do not necessarily reflect those of RTI or UMass Medical School.