Choosing Wisely questions more tests


The latest recommendations from Australia’s medical experts on the screening, testing and treatment of a range of common health conditions have today been released under the Choosing Wisely Australia initiative.

The recommendations, developed by Australian medical societies and colleges, aim to guide important conversations between clinicians and their patients about the relevancy of particular tests, treatments and procedures.

The ultimate aim is to improve the quality of healthcare for each individual and eliminate any unecessary testing or therapies.

The Choosing Wisely Australia initiative is health profession-led and facilitated by NPS MedicineWise. Speciality societies and colleges releasing lists today are the:

  • Human Genetics Society of Australasia;
  • Gastroenterological Society of Australia;
  • Royal Australian and New Zealand College of Radiology’s Faculty of Radiation Oncology; and
  • Australasian Chapter of Sexual Health Medicine.

 

The Human Genetics Society of Australasia says that with genetic information being made more widely available, their recommendations will assist both clinicians and patients with conversations about making wise choices related to genetic testing—ensuring safe, ethical and effective use of genetic information in healthcare.

Clinical Professor Jack Goldblatt from HGSA says, “Releasing our lists of recommendations today raises awareness of how unnecessary genetic testing can lead to further unnecessary investigations, worry, ethical, social and legal (like insurance) issues. In particular, we are cautioning people to not initiate testing on their own.

“Of increasing concern is the ‘direct to consumer’ genetic testing for MTHFR and APOE genes.

“MTHFR is an enzyme that converts folate. MTHFR variants are very common in the general population and folic acid supplementation has been shown to increase folate levels, regardless of MTHR status. Having a variant in the gene does not generally cause health problems.

“APOE is considered a risk or susceptibility factor for Alzheimer’s disease, but having a test only shows a probability, so people undertaking a test for APOE can also risk being falsely reassured.

“If the likelihood of improved outcomes from the use of a test for the gene is extremely low, then it should not be undertaken. Genetic tests are best performed in a clinical setting with the provision of personalised genetic counselling and professional interpretation of tests results, for patients to understand the further implications of the results.”

 

Gastroenterology

Professor Anne Duggan from the Gastroenterological Society of Australia says, “Our list of recommendations supports high-quality care for gastroenterology patients.

“One of the recommendations is to not undertake genetic testing for coeliac disease. As a coeliac gene can be found in one third of the population and a positive result does not make coeliac disease a certainty, serological testing is the appropriate first line screening tests for coeliac disease (this is done in a patient consuming an appropriate amount of gluten).

“Another of our focuses is on colonoscopy, an invasive procedure, with a small but not insignificant risk of complications. Our recommendation is to not repeat colonoscopies more often than recommended by the National Health and Medical Research Council guidelines.

“Follow up intervals are recommended depending on the number and size of adenomas removed. Surveillance colonoscopies place a significant burden on endoscopy services, so surveillance should be targeted at those who are most likely to benefit at the minimum frequency required to provide adequate protection against the development of cancer.

“Colonoscopy can come with side effects including bleeding, tears, inflammation or infection.”

 

Treatment of cancer – radiation oncology

The Royal Australian and New Zealand College of Radiologists’ Faculty of Radiation Oncology has released five recommendations today on whole-breast radiation therapy, management of low risk prostate cancer, bone metastases, brain radiation therapy and locoregional (recurrence of cancer cells at the site as the original tumour) therapy.

“Radiation treatment is a powerful weapon against cancer in its many manifestations, and cancer treatment consumes a large portion of healthcare expenditure.

“About one in every three Australians will develop cancer in their lifetime and over half will require radiation therapy as part of their treatment,” Dr Dion Forstner, Dean of the Faculty of Radiation Oncology says.

“With the discovery of new treatments, the management of cancer has become more challenging and complex, and radiation treatment should be used within clinical decision making guidelines where they exist so it is appropriate and accountable.

“Patients and their families require information and conversations to ensure they can make wise health care decisions during cancer treatment.

“One of our recommendations relates to a medical situation where radiation oncology may not be immediately required. Management of low-risk prostate cancer should always involve discussing active surveillance first.

“Patients with prostate cancer have options including radiation therapy and surgery, as well as monitoring without therapy (so called active surveillance) in some cases. Patients are encouraged to discuss all possible options with their health care professionals including the providers of each type of treatment before making a treatment choice

“As well, whole-breast radiation therapy decreases local recurrence and improves survival of women with invasive breast cancer.

“Recent studies, however, have demonstrated equivalent tumour control and cosmetic outcome in specific patient populations with shorter courses of therapy (approximately four weeks). Patients, along with their radiation oncologists, should review these options to determine the most appropriate course of therapy,” says Dr Forstner.

 

Sexual health medicine

President of the Australasian Chapter of Sexual Health Medicine, Dr Graham Neilsen, says, “Many of our Choosing Wisely recommendations focus on screening and testing which is not generally helpful for people who have not experienced symptoms.

“Some of the tests we specify in our list can often be inaccurate and there are the potential harms of receiving false-positive results, which leads to social and emotional distress.

“One of our recommendations today points to the importance of good conversations between clinicians and patients on appropriate care.

“Many women with recurrent and persistent yeast infections (valvovaginal candidiasis) self-administer, or are prescribed, topical and oral anti-fungal treatment. It is important to rule out other causes of vulvovaginal symptoms such as genital herpes or bacterial vaginosis (a very common cause of vaginal infection), so that other infections are not left untreated.

“As well as the importance of ruling out other causes before commencing anti-fungal agents, inappropriate use of antifungal drugs can lead to increased fungal resistance.”

The full lists are available on the Choosing Wisely Australia website at www.choosingwisely.org.au/recommendations.

 

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