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Year : 2020  |  Volume : 16  |  Issue : 4  |  Page : 955-956

“Choosing Wisely” for cancer care in India

1 Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
2 Department of Surgical Oncology, Max Hospital, New Delhi, India
3 Department of Radiation Oncology, Apollo Hospitals, Hyderabad, Telangana, India
4 Department of Medical Oncology, Prince Aly Khan Hospital, Mumbai, Maharashtra, India
5 Department of Radiation Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
6 Tata Trusts, Mumbai, Maharashtra, India
7 Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
8 Jeet Association for Support to Cancer Patients, Mumbai, Maharashtra, India
9 Department of Surgical Oncology, Asian Institute of Oncology, Mumbai, Maharashtra, India
10 Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
11 Institute of Cancer Policy, King's College London, and King's Health Partners Comprehensive Cancer Centre, London, UK
12 Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada

Date of Submission14-Jan-2020
Date of Decision18-Jun-2020
Date of Acceptance03-Sep-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
C S Pramesh
Tata Memorial Hospital, Tata Memorial Centre, Dr. Ernest Borges Road, Parel, Mumbai - 400 012, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.294950

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How to cite this article:
Pramesh C S, Chaturvedi H, Reddy VA, Saikia T, Ghoshal S, Pandit M, Babu K G, Ganpathy K V, Savant D, Mitera G, Sullivan R, Booth CM, On behalf of the National Cancer Grid of India. “Choosing Wisely” for cancer care in India. J Can Res Ther 2020;16:955-6

How to cite this URL:
Pramesh C S, Chaturvedi H, Reddy VA, Saikia T, Ghoshal S, Pandit M, Babu K G, Ganpathy K V, Savant D, Mitera G, Sullivan R, Booth CM, On behalf of the National Cancer Grid of India. “Choosing Wisely” for cancer care in India. J Can Res Ther [serial online] 2020 [cited 2020 Sep 30];16:955-6. Available from: http://www.cancerjournal.net/text.asp?2020/16/4/955/294950

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 U.S. 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 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 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 U.S. 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 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 Indian Society of Oncology (ISO), Association of Radiation Oncologists of India (AROI), Indian Association of Surgical Oncology (IASO), and Indian Society of Medical and Pediatric Oncology (ISMPO) 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 non-voting advisors from Canada and the U.K. 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 U.S. 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. The 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 U.S. and Canada lists.

The CWI initiative will contribute to ongoing policy dialogue 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 (eg, 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 healthcare delivery (i.e. multidisciplinary input for all patients with curable cancer, delivery of care closer to home), many of them could also be immediate and short term targets to achieve (eg, do not order PET CT 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 multi-pronged 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 multi-center 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 like India and other low-middle income countries (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 is also the first ever list (in any healthcare 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.


We gratefully acknowledge the membership and executive leadership of the NCG, AROI, IASO, ISMPO, and ISO for their invaluable contributions to this initiative.

Considering the importance of the paper and the need for wider dissemination in the cancer community, this commentary is also being simultaneously published in the Indian Journal of Surgery, Indian Journal of Surgical Oncology, and the Indian Journal of Medical and Paediatric Oncology.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 > References Top

Schnipper LE, Smith TJ, Raghavan D, Blayney DW, Ganz PA, Mulvey TM, et al. American society of clinical oncology identifies five key opportunities to improve care and reduce costs: The top five list for oncology. J Clin Oncol 2012;30:1715-24.  Back to cited text no. 1
Schnipper LE, Lyman GH, Blayney DW, Hoverman JR, Raghavan D, Wollins DS, et al. American society of clinical oncology 2013 top five list in oncology. J Clin Oncol 2013;31:4362-70.  Back to cited text no. 2
Mitera G, Earle C, Latosinsky S, Booth C, Bezjak A, Desbiens C, et al. Choosing Wisely Canada cancer list: Ten low-value or harmful practices that should be avoided in cancer care. J Oncol Pract 2015;11:e296-303.  Back to cited text no. 3
Pramesh CS, Chaturvedi H, Reddy VA, Saikia T, Ghoshal S, Pandit M, et al. Choosing Wisely India: Ten low-value or harmful practices that should be avoided in cancer care. Lancet Oncol 2019;20:e218-e223.  Back to cited text no. 4
NCG Guidelines for Common Cancers. Available from: https://tmc.gov.in/ncg/index.php/guidelines/search-by-cancer-type. [Last accessed on 2019 Mar 23].  Back to cited text no. 5
Pramesh CS, Badwe RA, Borthakur BB, Chandra M, Hemanth Raj E, Kannan T, et al. Cancer burden and health systems in India 3: Delivery of affordable and equitable cancer care in India. Lancet Oncol 2014; 15: e223-33.  Back to cited text no. 6
Levinson W, Born K, Wolfson D. Choosing Wisely campaigns: A work in progress. JAMA 2018;319:1975-6.  Back to cited text no. 7
Choosing Wisely Clinician Lists. Available from: http://www.choosingwisely.org/clinician-lists/. [Last accessed on 2019 Mar 12].  Back to cited text no. 8
Choosing Wisely Canada Recommendations. Canada CW. Recommendations and Resources by Specialty. Available from: https://choosingwiselycanada.org/recommendations/. [Last accessed on 2019 Mar 12].  Back to cited text no. 9
Keeney S, Hasson F, McKenna H. Consulting the oracle: Ten lessons from using the Delphi technique in nursing research. J Adv Nurs 2006;53:205-12.  Back to cited text no. 10


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