Physicians need to be honest and have a frank conversation with their patients, starting with explaining whether their cancer is curable or incurable, and what the available options are. This lays the groundwork for a shared decision-making conversation that addresses the patients’ needs and values moving forward.
—Ellen L. Stovall
Over the past decade, there has been growing concern in the oncology community about overdiagnosis and overtreatment of cancers that prove to be indolent and nonlethal, resulting in unnecessary and sometimes harmful procedures. At this year’s ASCO Quality Care Symposium in Boston, this important issue was tackled from the patient’s perspective, by cancer survivor and nationally regarded patient advocate Ellen L. Stovall in a presentation subtitled “Health Policy in an Era of Choosing Wildly Wisely.”1
Wild West of Cancer
Ms. Stovall, who is Senior Health Policy Advisor at the National Coalition for Cancer Survivorship (NCCS), said that she was originally asked to speak about the Choosing Wisely program from the patient’s perspective, but she featured the substitution of wisely for wildly in her title, explaining, “I think that the way cancer care has been delivered historically is more like the Wild West than the wise way we would like to think that patients are choosing the care they would like to receive.”
Ms. Stovall noted that her organization’s central goal is to help foster a cancer care system that is evidence-based, quality-focused, and affordable and accessible to all. “After that, we’re addressing World Peace,” she joked.
“The Choosing Wisely campaign, as we see it from the patient advocacy view, is mainly geared toward physicians, and many in our community question whether Choosing Wisely is designed to do less in all circumstances regarding cancer treatment,” noted Ms. Stovall. She emphasized that from a patient’s perspective it is difficult to parse out the underlying messages of campaigns like Choosing Wisely that are designed to address overuse and also maintain high-quality care.
Personalize Patient Information
Ms. Stovall cited a recent article in The New England Journal of Medicine, in which the author noted that the Choosing Wisely campaign had partnered with Consumer Reports to create educational materials for patients on low-value care, presenting accessible information on specific health services.2 “Patient-information and decision-aid approaches are promising, but their creation and use need to be supported and studied,” stressed Ms. Stovall.
Within the context of Choosing Wisely, Ms. Stovall focused her attention on the delivery of high-quality cancer care, citing the 2013 Institute of Medicine (IOM) report, Delivering High-Quality Cancer Care: Charting a Course for a System in Crisis.3 “The recommendation from the IOM report that we’ve taken to heart is that the cancer care team should communicate and personalize all the information for their patients at key decision points along the continuum of care, using decision aids when available,” said Ms. Stovall, adding, “We also agree with the report’s recommendation that physicians should collaborate with their patients to develop a care plan that reflects their patients’ needs, values, and preferences and considers palliative and psychosocial support throughout the full course of care.”
Cancer Care Planning
She then turned her focus to the NCCS perspective. “At NCCS, our main focus is on cancer care planning, both in the delivery of care and on payment reforms. We look at this in four buckets: the patient, reimbursement, providers, and our central goal, which is cancer care planning at diagnosis and major transition points during treatment and survivorship,” she explained.
Ms. Stovall said that the delivery and payment reforms that are essential to attaining quality improvement in cancer care need to begin by changing the conversation. “Physicians need to be honest and have a frank conversation with their patients, starting with explaining whether their cancer is curable or incurable, and what the available options are. This lays the groundwork for a shared decision-making conversation that addresses the patient’s needs and values moving forward,” she noted.
On the subject of payment reforms, Ms. Stovall noted that payment reforms must be aligned to reflect improvement in communication, treatment decision-making, symptom management, and coordination of care. “The Center for Medicare & Medicare Innovation (CMMI) care model is the main focus of NCCS payment reforms. The current proposal by CMMI looks at lowering costs using a three-part payment structure reform and quality metrics intended for determining performance payments,” said Ms. Stovall.
“We’ve also had a legislative proposal moving through six sessions of Congress that ASCO and many other cancer and patient advocacy organizations have supported. Moreover, we’ve worked with the main private payers and with ASCO and the Center for American Progress on payment reform,” said Ms. Stovall.
She then enumerated the NCCS principles for payment reform, stating that any alternative payment system must: (1) include protections against underutilization or overutilization, (2) incorporate outcome, process, and patient-reported outcome measures, developed with input from patients, (3) ensure that therapeutic innovations will be rapidly incorporated into standard of care, and (4) reimburse for coordination of care, from screening through survivorship.
Summing up the challenges to enhancing quality care while also addressing payment reforms, such as those she previously discussed from the IOM report, Ms. Stovall said, “Having worked with the IOM over the past 15 years, I can say from experience that putting out proposals, supporting quality care and reform legislation, and at the same time helping patients choose wisely—well, it is a tough nut to crack.”
Beyond Choosing Wisely
Ms. Stovall stated that the goal of NCCS and other advocacy groups is to get beyond Choosing Wisely and the narrow range of issues that it lays out for physicians and their patients to consider.
“Matters related to overtreatment and undertreatment need to be addressed. Equally important, cost and value of interventions must be made transparent and factored into the doctor-patient discussion about their care. And along with a frank conversation about diagnosis and prognosis, patients’ fears about restricted access to costly treatment must be addressed when choosing which therapies are best suited to support their agreed-to goals of treatment,” she concluded.
Choosing Wisely Campaign
ASCO participates in the Choosing Wisely Campaign, which is an initiative of the American Board of Internal Medicine Foundation intended to spark conversations between providers and patients, to ensure that the right care is delivered at the right time. ASCO’s annually updated Top Five List of things physicians and patients should question is available at www.asco.org/practice-research/top-five-list. ■
Disclosure: Ms. Stovall reported no potential conflicts of interest.
1. Stovall E: Patient perspective on overtreatment: Health policy in an era of choosing wildly wisely. ASCO Quality Care Symposium. Presented October 17, 2014.
2. Colla CH: Swimming against the current—What might work to reduce low-value care? N Engl J Med 371:1280-1283, 2014.
3. Levit L, Balogh E, Nass S, et al (eds): Delivering High-Quality Cancer Care: Charting a Course for a System in Crisis. Washington, DC, National Academies Press, 2013.