Purposeful Testing

An interesting conversation ensued during our monthly breast conference last week. As usual, the case was presented, a woman in her late 80’s, who presented with a lump in her breast and a suspicious mammogram. After the usual testing of ultrasound, MRI, CT and biopsy it was confirmed that she had breast cancer. Her stage was early by what we could see, however there were some unusual pathologies that led to a discussion of what would be best to fully treat this woman to the best of our ability. Again, as usual, oncotyping was discussed. Would this be something that was feasible or even useful for this woman? Oncotype Dx is a genetic testing that is used widely to help to determine the best course of treatment for patients. The problem is that unless you meet specific criteria, insurance will not cover the cost of the testing and it generally costs about $3000.

That, naturally set off a discussion of the state of healthcare and how it “will only get worse.” I guess that depends on what you think worse is. On one side of the discussion was the surgeon who had been out of practice for a while but was declaring that he could not practice that way. If you know this is the best testing available but you don’t order it because the insurance won’t pay for it, it’s, in his word “criminal.” But another side of the debate was also brought out. Would this really be the best testing for this woman? If insurance was not an issue, would you order this test? And to what end?

That was the part that I thought was the most interesting. It was nursing or social work that brought out this discussion. It was several of the physicians. They could see that, especially in these times, you do need to be more judicious about the test that you order. So maybe we could get some information about this woman’s tumor type through oncotyping. But would it change our course of treatment? What does this patient look like outside of the testing? She’s in her late 80’s and her performance status is not so great. She’s what we would commonly call an “old” 85 rather than a “85.” She would most likely not ever consider chemotherapy for herself let alone be able to tolerate it. So, do we do a test that costs thousands of dollars just for our own information?

I was quite pleased that this discussion came up via the physicians; that they do, indeed see the bigger picture. I know we are all concerned about how the new healthcare reform will affect our practice and our patients. One thing, that I’ve seen through this, is that we will all need to think more. Think about what would be the outcome of the tests we order. Will the results of testing potentially change our course of treatment or diagnosis? Or is it a nice to know situation. We will need to all start being more judicious in knowing that ordering tests just for the sake of knowing has to change. Will our practice change? Most certainly. Will it change for the better or will it change for the worse? That will depend on your outlook of what is needed and what is wanted. I’ve been on a want vs. need kick in my own personal life as well as trying to instill some of it in our staff when it comes to our nursing practice. Perhaps we all need to have a more want vs. need outlook. Who knows where that might get us.