JCO Article Describes Five Common Cancer Procedures and Tests Not Supported by Evidence as Part of the Choosing Wisely® Campaign
ALEXANDRIA, Va. - The American Society of Clinical Oncology (ASCO) today published a detailed review of the "Top Five" opportunities to improve the quality and value of cancer care by curbing use of common tests and treatments that are not supported by clinical evidence. Published in the Journal of Clinical Oncology, the new article coincides with the announcement of several Top Five lists as part of the Choosing Wisely® campaign. ASCO is one of nine specialty societies participating in the campaign, which is sponsored by the American Board of Internal Medicine (ABIM) Foundation.
The JCO article summarizes each element of the oncology Top Five list, which includes: unnecessary use of chemotherapy for patients with advanced cancers who are unlikely to benefit; use of advanced, costly imaging technologies for staging of early breast and prostate cancers and for detection of breast cancer recurrence; and overuse of drugs to stimulate white blood cell production in patients receiving chemotherapy.
"As oncologists, we have a responsibility to help ensure that all cancer care is high-value care," said Michael P. Link, MD, president of ASCO. "That means providing the highest quality of care to our patients, while avoiding treatments that have little or no proven benefit. In the process, we also do our part to address the unsustainable cost increases that threaten our nation's health care system.
The concept for the Choosing Wisely campaign was first proposed in 2010 commentary in the New England Journal of Medicine by Howard Brody, MD, PhD, director of the Institute for the Medical Humanities and a family medicine professor at the University of Texas. Dr. Brody challenged medical specialties to take a critical look at their fields and to each identify five practices that are commonly performed despite a lack of supporting evidence.
"At ASCO, we took this challenge to heart," said Lowell E. Schnipper, MD, lead author of the JCO article and chair of ASCO's Cost of Care Task Force. "By tackling the overuse of treatments and tests for some of the most common cancers, we hope to achieve substantial improvements in the quality of cancer care in the U.S. The Top Five list is just the first step in an ongoing ASCO effort to help physicians and patients implement these recommendations."
The Top Five List for Oncology
The Top Five list was developed by members of ASCO's Cost of Cancer Care Task Force, a multidisciplinary group of oncologists that seeks ways to increase the value of cancer care. The list is based on a comprehensive review of published studies and guidelines from ASCO and other organizations. It reflects input from more than 200 members of the oncology community, including the leadership of the state and regional oncology societies, other leading oncologists and patient advocates.
The list includes the following recommendations:
1. Avoid unnecessary anticancer therapy, including chemotherapy, in patients with advanced solid-tumor cancers who are unlikely to benefit, and instead focus on symptom relief and palliative care.
Data have shown that a significant number of cancer patients receive chemotherapy in the last two weeks of life, even though such treatment generally does little to improve survival or quality of life, causes side effects and carries the unintended consequence of increasing costs. Data have shown that as many as 10 to 15 percent of patients with cancer receive chemotherapy in the last two weeks of life. Such care may also postpone patients' access to palliative care, including hospice care.
ASCO recommends that cancer-directed therapy not be used for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anti-cancer treatment. Because further treatment is unlikely to be effective in these patients, emphasis should be placed on palliative and supportive care, which can increase quality of life and, in some cases, extend survival.
2-3. For early-stage breast cancer (2) and prostate cancer (3) that are at low risk of spreading, do not use advanced imaging technologies (positron emission tomography (PET), CT and radionuclide bone scans) for determining the cancer's spread.
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. (In these patients, staging is done according to a physical examination, the size of the tumor and nearby lymph nodes, and common blood tests.)
- 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.
For these patients, the use of advanced imaging technologies to search for cancer spread has not been shown to improve detection of additional tumors or to extend survival. Rather, these tests are known to increase the risk of misdiagnosis or false-positive results, which can lead to unnecessary invasive procedures or treatments that can ultimately diminish quality of life or even shorten patients' lives.
4. For individuals who have completed curative treatment for breast cancer, and who have no symptoms of recurrence, advanced imaging tests (PET, CT and radionuclide bone scans) and routine blood tests for certain biomarkers (CEA, CA 15-3, CA 27-29) should not be used to screen for cancer recurrences.
The majority of individuals diagnosed with breast cancer today have early-stage disease and, because of treatment advances, most have a normal life expectancy with a very low risk of recurrence. While current guidelines emphasize that routine physical exams and mammography are the safest and most effective strategies for detecting recurrences, many individuals also undergo additional blood and imaging tests, even though they have not been shown to improve survival.
The authors note that false-positive results are very common with these tests and can lead to invasive procedures, over-treatment and misdiagnosis that can severely affect quality of life.
5. Avoid administering white blood cell stimulating factors to patients who have a very low risk for febrile neutropenia (less than 20%).
White blood cell growth factors, also called colony-stimulating factors (CSF), boost the body's production of white blood cells, which can be destroyed during certain chemotherapy regimens. Extremely low levels of white blood cells can lead to a highly dangerous side effect of chemotherapy called febrile neutropenia.
ASCO guidelines recommend that white blood cell stimulating factors be used only when the risk of febrile neutropenia from chemotherapy is greater than 20 percent and effective alternative therapies are unavailable. However, data suggests these drugs are often not used according to evidence-based guidance, costing health systems millions and potentially causing unnecessary side effects for patients (e.g., bone aches, low-grade fever and malaise). In one study, 10 percent of patients at low risk (less than 20%) for febrile neutropenia received these treatments. Another study showed that Medicare spent at least $40 million in 2005 on CSF therapy for women with ER-positive breast cancer, even though studies have not demonstrated a benefit for such patients.
The JCO article notes that important exceptions exist for all five elements of the top-five list, based on specific patient circumstances. For example, in the case of recommendation No. 5, guidelines allow for use of white blood cell stimulating factors for patients at higher risk for chemotherapy-related febrile neutropenia due to age, medical history or disease characteristics.
Implementing the Top Five List
Over the coming months, ASCO will work with its more than 30,000 members, and with other partners in the cancer community, to help implement these recommendations. ASCO is developing additional tools and publications for physicians, along with new resources to help patients have informed discussions with their physicians about the quality and value of the care they receive.
The American Society of Clinical Oncology (ASCO) is the world's leading professional organization representing physicians who care for people with cancer. With more than 30,000 members, ASCO is committed to improving cancer care through scientific meetings, educational programs and peer-reviewed journals. ASCO is supported by its affiliate organization, the Conquer Cancer Foundation, which funds ground-breaking research and programs that make a tangible difference in the lives of people with cancer. Patient-oriented cancer information is available at www.cancer.net.
About the Journal of Clinical Oncology
The Journal of Clinical Oncology is the tri-monthly peer-reviewed journal of the American Society of Clinical Oncology (ASCO), the world's leading professional society representing physicians who treat people with cancer.