TABLE 2-1 Targets for Reduction in Resource Use with No Impact on Quantity or Quality of Life

Strategy

Comment

2nd -line chemotherapy for metastatic cancer

For instance, 2nd line chemotherapy with docetaxol improves overall survival and health-related quality of life in nonsmall cell lung cancer. Unclear if 3rd or other lines of chemotherapy have a similar effect. Most cancers have not been studied to see if 2nd or 3rd line chemotherapy is better than supportive care. Current NCCN guidelines call for switch to hospice or palliative care when chemotherapy has been tried and failed, and provide a starting point for “stopping rules.” For instance, current NCCN guidelines call for 2 types of chemotherapy in breast cancer, then switch to hospice care. The average patient receives far more types of chemotherapy.

Neoadjuvant chemotherapy and radiotherapy for many solid tumors

Proven modest benefits in resected gastric cancer, head and neck cancer, lung and esophageal cancers. For other cancers, there has been minimal impact on disease, and a marked increase in drug costs and toxicities.

Radiotherapy palliation of bone and other metastasis

1–5 fraction radiotherapy offers pain relief to the majority of patients and reduces the travel and treatment costs.

Radiotherapy palliation of advanced lung cancer

8Gy in 1 fraction or 16 Gy in 2 fraction offers symptom relief to the majority of patients and reduces travel and treatment cost; much higher doses are often used.

Carcinoembryonic Antigens (CEAs), CA 27.29, CA 15.3 blood tests; bone scans, liver ultrasounds, chest X-rays, computerized axial tomography (CATs) and other follow-up tests in breast, lung, and colon cancer

With the exception of the CEA in resected colorectal cancer, these tests offer no advantage in life-years saved, and the cost is prohibitive (for instance, estimates of follow up costs for breast cancer alone are over $1 billion annually), these tests are not recommended by the American Society of Clinical Oncology; for details see the website at www.asco.org and go to the “People Living with Cancer” section.

Discuss “code status” with all patients while they are stable, and document whether resuscitation and ICU stay is medically indicated or desired by the patient and family

The majority of physicians have acted against their conscience in providing aggressively futile care; this costly and tragic waste can be prevented by addressing the issue beforehand.

Consolidation of provider visits, with switch to a primary care provider

Patients may see a radiotherapist, surgeon, medical oncologist, and their primary care physician; only one is necessary, and the primary care provider may be less likely to order low-yield, high-cost diagnostic tests.

Thomas J.Smith, personal communication, 2001.

NCCN=National Comprehensive Cancer Network.



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