Choosing Wisely

My specialty society, the American Society for Radiation Oncology (ASTRO for short) is a participant of Choosing Wisely®, an effort to support and engage physicians in being better stewards of finite health care resources. The goal is to identify commonly ordered procedures or treatments that not only may not be necessary but, in fact, may be harmful. Each participating specialty provides five such procedures they believe are over-utilized or inappropriately ordered.

I was struck by two of these treatments in particular, the first because of its technological "sophistication" and the second because it points to new standard of care.

The "sophisticated" procedure is proton therapy. Unfortunately, the "new" in medicine is often assumed to be the "best". After all, technology only improves our lives, right? Sometimes investors are too cozy with equipment manufacturers who then get the federal government to reimburse a technology well before that technology has been proven to be any more effective than what is currently available.

In the case of proton therapy, investors saw a way to make a LOT of money, because proton therapy was originally being reimbursed at more than six times the rate of standard radiation therapy ($850 per daily proton treatment versus $132 for standard radiation treatment). Proton installations cost tens of millions of dollars to install. MD Anderson's cost $125 million when it was built in 2006. The Houston Police Officers' Pension System was one large backer ($10 million) expecting a sizeable return on their investment.

ASTRO, in a bold move that was sure to ruffle the feathers of some of its profit-minded members, announced last week at our meeting in Atlanta that one of its Choosing Wisely® recommendations is: "Don't routinely recommend proton beam therapy for prostate cancer outside a prospective clinical trial or registry." Their reason? After seven years of proton profit in the marketplace, "There is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy."

Bravo. I have bemoaned for years the grab for the money that goes on in medicine, and how that leaves the poor and under- or uninsured with even fewer healthcare resources, as these expensive technologies are, for the most part, only available to those with means to pay for them. I am proud that the House of Medicine is taking steps to control healthcare costs by pointing out our own dirty laundry. Let's hope these recommendations are taken to heart. (I'm not holding my breath.)

The second recommendation is far more positive, and will be a game changer in my specialty: "Don't initiate whole breast radiotherapy as a part of breast conservation therapy in women age >50 with early stage invasive breast cancer without considering shorter treatment schedules." A just-released important study concluded that a particular treatment schedule common in Europe is equivalent to a longer schedule of treatment that we use in the US, and that long term side effects are less! The benefit for women is that a typical course of treatment will be reduced from 5-6 1/2 weeks down to 3-4 weeks. For women who have to travel longer distances to get in for treatment, this can be significant. In addition, it is less expensive. Again, Bravo.

Healthcare is, indeed changing. I have given you two examples of change - one negative, one positive. Educate yourself, and choose wisely.

For information on Choosing Wisely® and recommendations across medical specialties, visit www.choosingwisely.org. Do your part to help cure cancer; enroll in CPS-3 at www.CancerStudyTX.org.