Patients with Cancer Are Not Asking for Low-Value Tests or Therapies

Wayne Kuznar

August 2014, Vol 5, No 6 - Economics of Cancer Care


Chicago, IL—Contrary to common belief, there appears to be little demand on the part of patients with cancer for unsuitable, high-cost, low-value tests or therapies. Furthermore, oncologists and nurse practitioners (NPs) are not ordering such services often, according to Keerthi Gogineni, MD, MSHP, an oncologist at the Abramson Cancer Center, University of Pennsylvania, Philadelphia. He presented his findings at the 2014 American Society of Clinical Oncology meeting.

Data from a large survey of oncologists and NPs revealed that “the frequency of requested testing was unusual in itself. In only about 9% of 3800 encounters did a patient ask for something,” she said. “The likelihood of acting on inappropriate requests was even lower. When we asked the providers to rank the appropriateness of that request, it was pretty infrequent that even they thought it was an inappropriate request, and even less likely that they would act on an inappropriate request.”

Dr Gogineni and colleagues assessed whether and how often patients are seeking expensive or low-value therapies and treatments from their providers. Past studies have indicated that many patients with cancer, as well as oncologists and the public, believe that healthcare costs are, to some extent, propelled by patients seeking unnecessary treatments, she said.

For the study, oncologists and NPs at 2 sites affiliated with an academic cancer center were questioned soon after patient visits to measure how often patients demanded potentially unnecessary treatments, whether the demands were acceptable to providers, whether physicians followed through on the requests, and why the providers chose to agree to certain tests.

Of the 2050 encounters assessed, 73.1% of patients were white, 42% had stage IV or refractory disease, and 66.3% were receiving active therapy. A total of 26 clinicians were surveyed.

In 177 (8.6%) encounters, the patients requested some form of testing. Clinicians were recommended to rank the appropriateness of patient requests on a 10-point Likert scale (1 = not at all appropriate, 10 = extremely appropriate).

Study Results
More than 80% of the requests were categorized as appropriate. These included requests for imaging, blood work, and treatments for pain or nausea. Providers denied patients’ requests in 32 (18.1%) cases; for 27 of these instances, physicians reported that they declined the test or therapy, because they viewed it as unnecessary or saw no clinical advantage to doing it. In 4 of the 2050 (<1%) encounters, the provider requested a test or therapy that was considered unsuitable. Clinicians viewed requests by patients as inappropriate in only 24 (13.6%) encounters.

Patients with early-stage cancer were more likely to make an inappropriate request, said Dr Gogineni. Patients with late-stage disease who were undergoing surveillance were nearly twice as likely to make an inappropriate request compared with patients receiving treatment.

Of note, patients who were being treated with a goal to cure were more often seeking unnecessary treatments than patients who received palliative care.

To limit low-value care, the researchers suggest educating patients on evidence-based surveillance, because patients with early-stage cancer who are under observation are often more likely to seek inadvisable treatments or therapies. In this survey, patients undergoing observation were 9 times more likely to make inappropriate requests than patients with advanced-stage cancer.