In 2010, Howard Brody, MD, PhD, director of the Institute for Medical Humanities and a family medicine professor at the University of Texas, challenged medical specialty societies to each identify a “Top Five” list of tests and treatments that are commonly performed in their respective fields despite a lack of evidence that they provide meaningful benefit to major categories of patients.
ASCO and the oncology community took this challenge to heart. As a participant in the American Board of Internal Medicine Foundation’s Choosing Wisely® Campaign, ASCO is one of nine specialty societies that have developed Top Five lists of tests and treatments that are commonly used despite a lack of supporting evidence, and should be questioned within their respective fields. The Top Five list for oncology represents some of the most significant opportunities to improve quality – and value – in cancer care today. The concept of value focuses on maximizing the patient benefits achieved for each dollar spent, and accounts for the importance of quality, safety and meeting each patients’ individual needs.
“Backed by the expertise of more than 30,000 member oncologists, ASCO is in a unique position to identify opportunities to prevent the misuse and overuse cancer tests and treatments that are not supported by clinical evidence,” said Lowell E. Schnipper, MD, chair of ASCO’s Cost of Cancer Care Task Force. “We hope this list will help oncology providers make more informed decisions and provide their patients with the best possible care.”
The “Top Five” list for oncology was developed by a panel of cancer specialists serving on ASCO’s Cost of Cancer Care Task Force. It was based on a review of published studies and current guidelines from ASCO and other organizations. The list was vetted by more than 200 oncology professionals from community and academic settings as well as state societies and cancer advocacy groups.
“Our members are constantly looking for ways to improve the quality of care that they provide to patients. We hope the Top Five list for oncology will help foster a culture of self-examination among oncologists and help them provide high value cancer care to all patients,” said Dr. Schnipper
The Oncology Top Five List
1. For patients with advanced solid-tumor cancers who are unlikely to benefit, do not provide unnecessary anticancer therapy, such as chemotherapy, but instead focus on symptom relief and palliative care.
Overtreatment near the end of life is common. For example, a sample of more than 5,000 patient charts reviewed as part of ASCO’s QOPI® program showed that nearly 12 percent of patients received chemotherapy with the last 14 days of life, even though evidence shows that such treatment generally does little to improve survival or quality of life.
Instead of cancer-directed therapy, ASCO recommends that physicians prioritize palliative care and symptom management in advanced solid tumor patients with the following characteristics: low performance status (capable of only limited self-care, confined to bed or chair more than 50% of waking hours) no benefit from multiple prior evidence-based interventions, not eligible for a clinical trial, and the absence of strong evidence, e.g., actionable mutations, supporting the clinical value of further anti-cancer treatment. This approach is most likely to enhance quality of life, improve patient comfort and dignity, and in some cases, can increase survival.
“As oncologists, our commitment to patients drives us to do everything possible to give them the best chance of survival. At the same time, maximizing a patient’s quality of life should be a top priority throughout the course of their treatment, particularly among patients with advanced disease that has proven refractory to the available therapies,” Dr. Schnipper said.
The Top Five lists notes important exceptions to this recommendation based on patient circumstances – including patients who have disease characteristics such as specific genetic mutations– for which further therapy could be beneficial.
2. Do not use PET, CT and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis.
3. Do not use PET, CT and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.
ASCO recommends against using these imaging tests for staging in patients with:
- Newly identified stage I or II breast cancer or ductal carcinoma in situ (DCIS), which are unlikely to have spread beyond the breast and nearby lymph nodes at the time of diagnosis.
- Newly diagnosed low-grade prostate cancer (Gleason score less than or equal to 6) in men with a PSA level of less than 10 ng/ml.
Use of PET, CT or radionuclide bone scans to find metastatic disease in those found to have early-stage cancers has not been shown to extend survival, is costly, and in some cases can even lead to harm. False positive results from these tests raise the risk of unnecessary invasive procedures, and over-treatment, which can ultimately impact quality of life and potentially shorten survival.
One study estimated that as many as 99 percent of men with low-risk prostate cancer do not benefit from these scans. That same study suggested that up to $80 million could be saved each year by using these tests only for patients that are likely to benefit based on available evidence. Yet, a recent review of Medicare data found that over one-third of men with low-risk prostate cancer underwent such high-cost scans.
4. For individuals who have completed curative breast cancer treatment and have no physical symptoms of cancer recurrence, routine blood tests for biomarkers and advanced imaging tests should not be used to screen for cancer recurrences.
ASCO recommends against using routine blood tests for measurement of the carcinoembryonic antigen (CEA), CA 15-3, and CA 27-29 biomarkers, as well as routine use of advanced imaging tests (PET, CT, radionuclide bone scans) to screen for cancer recurrences in this population.
Most individuals diagnosed with breast cancer today have early-stage disease and, after institution of proper treatment, have a low chance of recurrence. Yet, many undergo screening tests as part of routine surveillance in an attempt to detect recurrences. To date, the available medical evidence indicates that even when such tests do identify early metastases, there is no difference in survival. Moreover, as a consequence of false positive results these tests can lead to invasive procedures, over-treatment, and misdiagnosis that can severely impact patients’ quality of life.
“Effective communication between an oncologist and the patient plays an essential role in monitoring for breast cancer recurrence. Patients with a history of breast cancer need to be reassured that clinical evidence, including guidelines from ASCO, emphasize the importance of routine physical exams and mammography remain the most effective surveillance strategy for those who are symptom-free following treatment delivered with curative intent,” Dr. Schnipper said.
5. Avoid administering colony stimulating factors (CSFs) to patients undergoing chemotherapy who have less than a 20 percent risk for febrile neutropenia
There is growing evidence that suggests these therapies are misused, overused and cost health systems millions of dollars. Evidence shows that despite clinical guidelines on the use of CSFs from ASCO and other organizations, their utilization varies across the U.S. One study estimated that 10 percent of patients at very low risk (less than 20 percent) for febrile neutropenia received these treatments unnecessarily. The CanCORS (Cancer Care Outcome Research and Surveillance Consortium) study evaluated a large Medicare cohort of patients with lung and colorectal cancer and demonstrated that only 17 percent of patients treated with high-risk chemotherapy regimens received appropriate G-CSFs. Yet, 18 percent of patients with intermediate risk of febrile neutropenia and 10 percent of patients with low risk received G-CSFs.
“Much has been written about the use and misuse of these therapies, and major professional organizations, like ASCO, have recognized the opportunities and challenges their availability represents,” Dr. Schnipper said. “ASCO believes eliminating the unnecessary use of CSFs is an achievable goal which will result in better care for patients and substantial costs savings.”
ASCO guidelines recommend these treatments only when the risk of febrile neutropenia from chemotherapy is greater than 20 percent and when effective alternatives to high risk therapy are unavailable. However, some exceptions exist, such as for patients at higher risk for chemotherapy-related febrile neutropenia because of other complications (including age, medical history, or disease characteristics).
The Top Five list for oncology not only highlights a set of specific practices that should be questioned, but also—and perhaps more importantly—provides an opportunity to emphasize the importance of using evidence-based medicine to arrive at clinical decisions. Over the coming months, ASCO will continue to educate both physicians and patients about the effort and provide tools and resources providers need to consider the issues fully and make wise choices. For more information, on the Top Five list and the Choosing Wisely campaign, visit asco.org/topfive.