Scope and Characteristics of Choosing Wisely in Cancer Care Recommendations by Professional Societies

In the United States, the cost of cancer care is increasing exponentially, and cancer care–related spending was projected to be $173 billion in 2020.¹ A proportion of this expenditure is attributed to unnecessary medical services, which account for an estimated 21% of all health care services provided in the United States.² Addressing financial toxic effects and wasteful medical practices, the Choosing Wisely campaign is an international multispecialty initiative that aims to reduce the use of unnecessary tests, treatments, and procedures.³ Thus far, more than 80 professional societies have participated in this effort, generating a list of more than 550 examples of unnecessary and low-value services. Oncological and other societies have targeted routine tests and treatments that are associated with increasing health care costs and patient harm without improving quality of life or survival.⁴ However, the scope of Choosing Wisely recommendations for cancer care is not well defined. This quality improvement study characterizes the scope of these recommendations, focusing on the de-implementation of low-value cancer care, and identifies potential gaps for future work.

The University of Michigan institutional review board deemed this study exempt as it is not human subjects research. From August 2019 to February 2020, we systematically reviewed all of the Choosing Wisely recommendations and established that these recommendations pertained to the cancer care continuum if they were related to the screening, diagnosis, treatment, or surveillance of patients with any invasive or noninvasive cancer. This determination was made regardless of the recommending society. Recommendations were classified by cancer type, phase of care (ie, screening, diagnosis and staging, treatment, or surveillance), and service type (ie, laboratory test, imaging, medication, radiation, or procedure).

Thirty-three oncological societies made 108 recommendations across the cancer care continuum (Table). Two recommendations of avoiding neglecting a high-value process were excluded. The most frequently targeted cancer types were breast (n = 16 [15.1%]), cervical (n = 13 [12.3%]), and prostate (n = 10 [9.4%]). Of the 106 recommendations, nearly one-third (n = 31 [29.2%]) targeted cancer screening by unnecessary laboratory testing, imaging, or procedures. Among the 27 recommendations (25.5%) that targeted diagnosis and staging, 14 encouraged reduced use or frequency of imaging.

A total of 35 recommendations (33.0%) targeted low-value cancer therapies or the management of their toxic effects (n = 7). Six of these 35 low-value treatments were surgical procedures primarily for breast or ovarian cancer in well-defined clinical scenarios. These procedures included those performed concurrently with another indicated procedure, procedures with a less invasive alternative, and reoperations when not clinically indicated. Radiation therapy (n = 9) was another of the 35 low-value treatments and included recommendations for reduction in dose or fraction number (n = 3), omission of adjuvant radiation (n = 4), or use of an effective but lower-cost technique over a more expensive alternative (n = 2). Seven of the 35 low-value therapies targeted included the management of treatment-related adverse events rather than addressing the overuse of such treatments itself.

Thirteen of the 106 recommendations (12.3%) targeted surveillance. The most frequent surveillance recommendation was reduction of unnecessary imaging (n = 7), which was followed by decrease of laboratory tests (n = 2), procedures (n = 2), and combination of the 2 (n = 2).

Given that this study’s aim was to characterize the scope of the Choosing Wisely recommendations, it is limited in that it does not directly assess the implications of these recommendations for current oncology practices.

The recommendations promoted by the Choosing Wisely initiative span the cancer care continuum. Most recommendations focused on avoiding unnecessary laboratory tests and imaging rather than decreasing treatments that are harmful, costly, and invasive (eg, surgical procedures and radiation therapy). The recommendations frequently targeted some lower-risk cancers susceptible to overtreatment (ie, early-stage breast cancer and prostate cancer) but did not include all of them (eg, thyroid cancer and nonmelanoma skin cancer).^5,6 These gaps represent not only areas for actionable improvement but also an opportunity to enhance the value of these recommendations for patients with cancer. To promote this improvement, oncological societies should expand the focus of their recommendations to a broader set of cancer types, including lower-risk cancers that are susceptible to overtreatment, with a renewed effort to target the cancer therapies and services that, when overused, are associated with the greatest cost and patient harm.

Accepted for Publication: April 21, 2020

Corresponding Author: Lesly A. Dossett, MD, MPH, Department of Surgery, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (ldossett@med.umich.edu).

Published Online: July 23, 2020. doi:10.1001/jamaoncol.2020.2066

Author Contributions: Dr Dossett had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Baskin, Wang, Skolarus, Dossett.

Acquisition, analysis, or interpretation of data: Baskin, Berlin, Skolarus, Dossett.

Drafting of the manuscript: Baskin, Berlin, Skolarus, Dossett.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: Dossett.

Supervision: Wang, Skolarus, Dossett.

Conflict of Interest Disclosures: Dr Wang reported receiving grants from the National Cancer Institute (NCI) during the conduct of the study. Dr Skolarus reported receiving grants from the NCI outside the submitted work. Dr Dossett reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was funded by grant T32 CA009672 from the NCI (Dr Wang), the National Clinician Scholars Program (Dr Berlin), grant R37CA222885 from the NCI (Dr Skolarus), and grant K08 HS026030-02 from the AHRQ (Dr Dossett).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: The results of this study were presented at the Academic Surgical Congress; February 5, 2020; Orlando, Florida.