On Sunday at ASCO I attended the Health Services Research Education Session, which was entitled “Overdiagnosis and Overtreatment in Cancer: Point/Counterpoint.” With cancer care costs rising rapidly there is increased pressure to search for value in how we care for our patients. This session provided perspectives on this very important and timely issue from both a surgical oncologist and a radiation oncologist. The topic of screening and treatment of breast cancer was selected to illustrate the issues related to overdiagnosis and overtreatment. Below, I share some observations and highlights from this thought-provoking session:
The room was packed. As anyone who’s attended a scientific meeting already knows, presentations often take place in large rooms and sometimes many seats are empty. This session was extremely full, with just a few open seats available. Clearly, this year's ASCO attendees voted with their feet, showing that they think the topic of overdiagnosis and overtreatment is extremely relevant to oncologists today.
Our understanding of the cancer paradigm continues to evolve. Historically, oncologists and researchers thought of cancer progression as a methodical and orderly process that progressed from cellular atypia, to in situ lesion, to local invasive spread, to regional spread, and ultimately to distant spread of disease. This was the basis for recommending 'early detection' for the past 30 years, and public perceptions still very much adhere to this paradigm of thought. However, as we continue to better understand the biology and natural history of cancer, we are learning that perhaps a more nuanced view is needed. Many types of cancer have an indolent course that may ultimately be unlikely to ever even manifest as clinical disease (eg, certain cases of low-risk prostate cancer or ductal carcinoma in situ [DCIS]). However, using the “early detection saves lives” paradigm, these indolent lesions are detected through screening, which then causes patient anxiety and often provokes aggressive local treatments that may be associated with patient toxicity (both medical toxicity and financial toxicity). Conversely, many cancers that are destined to become clinically apparent have a much faster course of progression, and they lack the long progression “window” that is necessary for screening to be effective. The ultimate result of this is that a shift in thinking (for both medical providers and patients) is required: While it certainly is true that sometimes early detection saves lives, many other times this simply is not the case.
Informed decisions. So how best can we mitigate the consequences of our more nuanced view of cancer? One topic of discussion during the session was the development of decision-aid tools for patients and providers to use to interpret the results of screening tests. For example, women with DCIS have an exceedingly low cancer-specific mortality. However, many options for women with DCIS exist (that may be used in combination):
1. Lumpectomy alone
2. Lumpectomy with radiotherapy
3. Lumpectomy with tamoxifen (if ER/PR positive)
5. No treatment
Data were presented that showed how decision-aid tools can be used to help providers and patients discuss all of these options, including risks and benefits, to help the patient make the best informed decision regarding treatment. Also discussed was a study published by Greenup et al that showed the potential for a 43% reduction in treatment costs by using an algorithm to help patients decide between treatment options for early-stage breast cancer and DCIS.
Moment of applause. During the after-presentation Q&A session, one of the questions received enthusiastic applause from the audience (this is a rare occurrence at scientific meetings). The question related to the fact that providers do not have incentives to reduce potentially unnecessary diagnostic tests and/or treatments. Potential strategies to mitigate this critically important issue were discussed. For example, state legislatures can pass “safe harbor” legislation, which protects providers from liability if they forego screening tests in accordance with published national guidelines. Also, the current fee-for-service reimbursement model incentivizes more care, though not necessarily better care. Potential changes to payment models (fee-for-quality and payment bundling) may, in the future, help create a financial incentive to deliver high-value and high-quality care.
Most importantly however, is the need to tone down the rhetoric regarding this potentially contentious issue. Through thoughtful use of evidence-based medicine, we can push for the change needed so that our healthcare system can deliver the best value care for our patients.