Choosing Wisely India (CWI) is an initiative to identify low-value and/or potentially
harmful practices in cancer care in India. Modeled after Choosing Wisely in the US
and Canada,[1],[2],[3] the CWI project was intended to facilitate a conversation between patients, clinicians,
hospitals, and policymakers on delivering high-quality, affordable cancer care. By
identifying common low-value and/or harmful practices, this process aims to reduce
unnecessary interventions to improve the overall quality of care, reduce patient toxicity,
and reduce the financial burden on both the patient and system. The formal CWI report
has been recently published in Lancet Oncology;[4] in this commentary, we provide a summary of the process, describe the Top 10 CWI
list, and offer suggestions for future actions to improve the delivery of high-quality
cancer in India's cancer system.
The National Cancer Grid (NCG) was established in 2012 and now includes 171 cancer
centers, research institutes, patient advocacy groups, charitable organizations, and
professional societies. The NCG coordinates national efforts related to cancer control,
research, and education. A key initiative of the NCG has been the creation of context-specific
clinical practice guidelines for common cancers, the goal of which is to standardize
and improve the quality of care delivered.[5] In a parallel project, the NCG undertook CWI to identify and eventually reduce utilization
of interventions which do not offer meaningful benefit to patients. The high proportion
of out-of-pocket spending among Indian cancer patients makes this highly relevant
in a system where a substantial proportion of patients incur catastrophic health expenditures.[6] The Choosing Wisely initiative has been adopted globally by more than 20 countries
as a disease-specific process to identify unnecessary (often expensive) interventions
that should be avoided.[7] Within the US and Canada, there are now over 800 Choosing Wisely recommendations
from more than 120 national societies covering a range of diseases.[8],[9] Choosing Wisely initiatives focused on cancer have been published in the United
States and Canada.[1],[2],[3] CWI represents the first Choosing Wisely initiative within any disease area from
a low-middle income country (LMIC) and represents an important step on the path to
universal health coverage and the achievement of health Sustainable Development Goals.
In 2017, the NCG convened a nine-member CWI Task Force including two members from
national patient advocacy organizations and seven physician members from radiation,
medical, and surgical oncology. This membership included executive office bearers
from the Indian Society of Oncology, Association of Radiation Oncologists of India,
Indian Association of Surgical Oncology, and Indian Society of Medical and Pediatric
Oncology and the convener of the NCG. Each specialty had at least one representative
from each of the public and private health systems. Additional methodologic expertise
was provided by three nonvoting advisors from Canada and the UK with experience in
Choosing Wisely Canada and global cancer policy.
A long list of cancer practices to be considered was collated from clinical members
of the NCG, four professional societies, and members of the CWI Task Force, with reference
to the existing Choosing Wisely US and Canada lists. The following prioritizing factors
were considered in both creating the long list and the subsequent voting process to
identify the final Top 10 list: evidence of low value/harm, frequent use in India,
cost (including opportunity cost), be practically feasible and measurable, and relevance
to the Indian cancer context. Consensus was achieved using a modified Delphi process.[10] The CWI Task Force consensus voted on the long list and shorter list to identify
the final Top 10 list. Membership of the NCG and the four professional societies were
given the opportunity to provide input on each of the long list and final list. This
final list was reviewed and endorsed by the executive boards of the four professional
societies and the NCG. The final list consisted of 10 recommendations (available free
for download on https://www.thelancet.com/action/showPdf?pii=S1470-2045%2819%2930092-0). Of the 10 practices, four practices were new suggestions and six practices were
adapted with modifications from Choosing Wisely US and Canada lists.
The CWI initiative will contribute to ongoing policy dialog within and between clinical
and patient communities in India's cancer system. Many of the items included in the
final list represent recommendations to avoid interventions that offer no benefit
to patients and are associated with significant side effects and/or financial costs.
The Task Force was careful to ensure that while similar lists from other countries
(e.g., Canada and the US) were not ignored, India-specific recommendations were also
considered and included in the final list; by no means does this imply that the original
Choosing Wisely lists from the US and Canada were not relevant in India – it merely
indicates that there were other points which were considered higher priority for India.
The Task Force also was conscious of the fact that while some of these recommendations
were aspirational and would require systemic changes in health-care delivery (i.e.,
multidisciplinary input for all patients with curable cancer and delivery of care
closer to home), many of them could also be immediate and short-term targets to achieve
(e.g., do not order positron emission tomography–computed tomography scans to monitor
response to palliative chemotherapy).
The dual creation of the NCG clinical practice guidelines with the Choosing Wisely
list represents initial steps in a multipronged process to improve the quality, equity,
and affordability of cancer care in India.[6],[7] At the 2019 NCG annual meeting, there was resounding support to begin multicenter
data collection to measure compliance with both clinical practice guidelines and the
CWI recommendations. The international Choosing Wisely program emphasizes that costs
of care should not be a factor in finalizing the recommendations; however, in countries
such as India and other LMICs, these recommendations also serve to demonstrate more
optimal ways of deploying scarce resources and maximize public health benefit. The
Choosing Wisely recommendations for cancer care in India are also the first ever list
(in any health-care domain) developed and published from an LMIC and also the first
to include patient representatives in the Task Force. These recommendations could
well be an exemplar for other countries or geographical regions to follow.
