Cancer Patients, By and Large, Not Pursuing Costly, Excessive Tests

Keerthi Gogineni, MD

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Contrary to belief, there appears to be little demand on the part of cancer patients for unsuitable, high-cost, low-value cancer-related tests or therapies. Further, oncologists and nurse practitioners are not frequently ordering such services, found Keerthi Gogineni, MD.

Data from a survey of oncologists and nurse practitioners revealed that “the frequency of requested testing was unusual in itself. In only about 9% of 3,800 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.�

Gogineni, a medical oncologist at the Abramson Cancer Center, University of Pennsylvania, Philadelphia, and colleagues assessed whether and how often patients are seeking from their providers expensive or low-value therapies and treatments. Past studies have indicated that many patients with cancer, as well as oncologists and the public, believe that health care costs are, to some extent, propelled by patients seeking unneeded treatments, she said.

For the study, oncologists and nurse practitioners 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 lastly why the providers chose to agree to certain tests.

A total of 2050 encounters were assessed for the study. Of those, 73.1% of patients were white (mean age, 60 years). A total of 42% had stage IV or refractory disease; 66.3% were receiving active therapy, about half of whom (49.5%) had symptom-treating objectives. Twenty-six clinicians were surveyed.

In 8.6% of encounters, patients requested some form of testing (177/2050). Clinicians were recommended to rank the appropriateness of patient requests on a 10-point Likert scale (1 = not at all appropriate; 10 = extremely appropriate). Clinicians viewed requests by patients as inappropriate in just 13.6% of encounters (24/177).

More than 80% of requests were categorized as appropriate. These included requests for imaging, blood work, and pain/nausea treatments. Providers denied patients’ requests in 18.1% of cases (32/177); for 84.4% (27/32) of these instances, physicians reported they declined the test or therapy because they viewed it as unnecessary or saw no clinical advantage to doing it. In <1% of cases (4/2,050) would the provider request a test or therapy considered unsuitable.

Patients with early-stage cancers were more likely to make an inappropriate request, said Gogineni. Late-stage patients undergoing surveillance were nearly twice as likely to make an inappropriate request compared with those receiving treatment.

Of note, researchers also found that patients who were being treated with a goal to cure were more often seeking unneeded treatments compared with those who were being treated to comfort for palliative reasons.

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

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