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Oncologists were told to 'Choose Wisely'—but did that actually lead to change?

February 7, 2017

    Reducing aggressive end-of-life care is a major priority in oncology. Not only is such care costly to patients, their families, insurers, and caregivers, but it can also negatively affect patients' and caregivers' quality of life.

    To focus attention on this issue, the American Society of Clinical Oncology (ASCO) included end-of-life care in the first year of its Choosing Wisely campaign. Keep reading to see the impact these guidelines had on clinical practice.

    The Choosing Wisely campaign and end-of-life care

    Each year, the Choosing Wisely campaign—launched by ASCO and the American Board of Internal Medicine in 2012—releases five guidelines focused on treatments for which clinical value is not supported by available evidence.

    In its first year, the guidelines included the following recommendation about end-of-life care: "Don't use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anti-cancer treatment."

    This guideline was then distributed widely to oncologists around the country via partnerships with professional specialty societies. In theory, it should reduce utilization of unnecessary end-of-life care, such as ED visits, inpatient admissions, and continued chemotherapy and radiation treatments for patients who are unlikely to see clinical benefit.

    The frustrating results after two years

    Using claims data from 2012 to 2014 that included approximately 60 million individuals enrolled in Blue Cross Blue Shield plans across 14 states, researchers from UNC-Chapel Hill evaluated the utilization of end-of-life care before and after the Choosing Wisely guidelines were released. They measured the use of aggressive care, including chemotherapy, radiation therapy, hospital admissions, and ED utilization, in the last 30 days of life for cancer patients.

    Their results showed that following the publication of the 2012 guidelines, the rate of aggressive care in the last 30 days of life remained unchanged for patients under 65 with colorectal and breast cancers—and actually increased in patients with lung, pancreatic, and prostate cancers.

    What else needs to happen to change behavior?

    While the results didn't show a reduction in the use of aggressive care at the end of life, the ASCO guidelines are still an important step toward reducing unnecessary and even harmful care.

    To be truly effective, these guidelines need to be coupled with education about and utilization of urgent symptom management and palliative care. In addition, we need to help providers and patients overcome their hesitancy to discuss advance care plans and have productive end-of-life discussions.


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