Seven Cancer Treatment Practices That May Be Discontinued

Ever since the proposal of Obamacare, American medical experts have been looking for ways to avoid rationing medical care to reduce costs, but rather to avoid waste in medical care to reduce costs and also to improve outcomes for their patients.

Three years ago, Dr. Howard Brody of the University of Texas Medical Branch challenged American doctors to identify common tests that don't make a difference in good medical care. Since early 2013, the American Board of Internal Medicine Foundation and consumer watchdog organization Consumer Reports have collaborated in the Choosing Wisely campaign, alerting doctors to procedures that lack a scientific basis.

Through the Choosing Wisely campaign, the American College of Surgeons  recommends that oncologists stop:

• Removal of lymph nodes (a procedure that often results in lymphedema, uncontrollable swelling in the arms) in women treated for stage I or stage II breast cancer, without a procedure called sentinel node biopsy, which can show that lymph nodes are not yet cancerous.

• Routine colonoscopy of people whose life expectancy is less than 10 years who do not have a personal or family history of colon cancer. This change would eliminate routine colonoscopies for most people over the age of 75.

Also, the Commision on Cancer recommends that doctors avoid:

• Starting cancer treatment before determining the extent of the cancer and discussing the treatment plan with the patient.

• Performing major surgery on the chest or abdomen without first making sure that breathing passages can be kept open in case of pneumonia and there are veins available for administering IV pain medication.

• Using surgery as a first line of treatment for cancer without considering whether other methods would offer better quality of life.

• Performing mastectomy for breast lumps that are not known to be cancerous unless a needle biopsy cannot be done.

Also the Commission on Cancer recommended that cancer doctors plan for success. Cancer patients should be subjected to follow-up cancer monitoring without the doctor offering the patient a "survivorship plan," an outline of what future treatment will be, before testing for the recurrence of cancer.

Doctors should not duplicate the efforts of other doctors, and medical procedures should be limited to those that are "truly necessary" and "free from harm," and doctors should avoid the rest.

But what if the best efforts of doctors don't result in remission?

The Choosing Wisely campaign has also created new guidelines for end of life care, for people who have cancer and for people who suffer from other terminal ages.

Treatment Guidelines For Cases In Which Cancer Care Is Unsuccessful

Even with the best tools of modern medicine, cancer care often does not result in remission. When cancer care becomes end of life care, the Choosing Wisely campaign also recommends major changes that reduce costs of care without compromising the dignity of the patient, allowing for the control of pain throughout the course of the disease. Earlier in 2013, the campaign recommended:

• Patches and gels to control nausea should not be given to terminal cancer patients, because they usually don't work. Cancer patients should get other kinds of treatment for nausea.

• Unless the objective is to relieve pain or discomfort, terminal cancer patients should not be given antibiotics for urinary tract infections (UTIs).  Many cancer patients have to have catheters, and develop infections as a result. Treating these infections with antibiotics sometimes "misses" some of the disease-causing bacteria so that the cancer patient gets temporary relief, but bacteria that are even more aggressive, and unresponsive to antibiotics, come back later. The new guidelines recommend that antibiotics only be offered when the infection is causing discomfort to the patient.

• Implantable cardioverter devices, also known as defibrillators, should be deactivated when the patient reaches the later stages of cancer. Implantable defibrillators provide a potent electric charge to the heart to shock the heart back into rhythm. Some people report the experience is like getting kicked in the chest. (As a personal note, I can only report that I found the experience completely painless, although I was brought back after several minutes of full arrest.) The new guidelines recommend turning off implanted defibrillators--but not pacemakers--in patients who are otherwise near death. Surgery to remove the defibrillator is not necessary. It can be deactivated with a hand-held magnet.

• Medications for "tight control" of diabetes should be discontinued at the end of life. Extremely high blood sugar levels should be avoided, but the usual goal of achieving an HbA1C of 7.5%, usually corresponding to an average blood sugar level of 160 mg/dl or 59 mmol/mol, is not an important goal.

• Sleeping pills should be offered for insomnia, not for agitation or anxiety. The effects of sleeping pills don't wear off just because it is morning. Cancer patients given unnecessary sleeping pills are at greater risk for accidents causing bruising or broken bones.

• Feeding tubes should not be offered to patients who are unconscious or who suffer dementia. There is no evidence that feeding tubes prolong life, because they tend to exacerbate bed sores. They can cause aspiration pneumonia, especially if a patient who is not of sound mind attempts to remove them.