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 Researchers examined cancer guidelines from North America and Europe
that have been published since 2010 to advise doctors on the best
ways to care for survivors of nine malignancies: breast, colorectal,
lung, prostate, melanoma, uterine, bladder, thyroid and testicle.
They found ambiguous recommendations in 83 percent of the
guidelines.
In particular, different guidelines for the same type of cancer
often didn’t address all the same surveillance tests, and few tests
were universally recommended, noted lead study author Dr. Ryan
Merkow of Memorial Sloan Kettering Cancer Center in New York. When
guidelines did endorse tests, they rarely specified how long
patients should continue to get tested.
“Often our instincts as providers are to order more tests - it makes
us feel like we are caring for the patient, and it makes the patient
feel like they are being cared for,” Merkow said by email.
“In certain instances this is absolutely the correct approach, in
others, it may lead to additional and unnecessary procedures and
patient anxiety,” Merkow added. “We have to approach surveillance in
a deliberate and thoughtful manner as the risk of over and
under-treatment is real.”
Worldwide, an estimated 33 million people are cancer survivors, and
their ranks are expected to grow due to rising cancer rates in an
aging population as well as improved survival odds with advances in
diagnosis and treatment, researchers note in JAMA Internal Medicine.
For the current study, Merkow’s team focused on what’s known as
surveillance, or efforts to detect the return of cancer or the
development of tumors in other parts of the body. This can include
invasive tests like biopsies that come with their own risks and side
effects as well as expensive imaging like positron emission
tomographic (PET) scanning.
They reviewed 41 guidelines addressing post-treatment surveillance,
with three to six recommendations focused on each of the nine cancer
types examined.
Overall, 37 of these guidelines, or 90 percent, recommended physical
exams and medical history. Most addressed some form of imaging (83
percent), while 63 percent covered what’s known as endoscopic
procedures that involve doctors using a flexible tube with a camera
to examine the inside of the digestive tract.
In 23 of the guidelines, or 56 percent, recommendations touched on
lab tests to look for biomarkers of certain types of tumors, which
are typically found in blood, urine or body tissue.
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Guidelines for using PET scans offer a snapshot of the mixed
messages in surveillance recommendations. Only one of the guidelines
in the study recommended patients get this scan, and it was for
bladder cancer.
Other guidelines either didn’t address PET scans or advised against
them, which was the case for 67 percent of uterine cancer
recommendations and 60 percent of lung cancer recommendations.
The most ambiguous recommendations for PET scan use were for tumors
of the bladder, prostate and breast.
European guidelines were more likely than North American guidelines
to contain ambiguous recommendations, the study also found.
Limitations of the study include its focus on national
recommendations, which excluded widely followed provincial practice
guidelines in Canada, the authors note. The study also didn’t
include recommendations published after February 2016.
Even so, the results highlight the work that still needs to be done
to better standardize care for patients who have undergone cancer
treatment, said Dr. Alexander Kutikov, a researcher at Fox Chase
Cancer Center in Philadelphia who wasn’t involved in the study.
“Clinical utility versus patient expectations versus costs must be
thoughtfully balanced,” Kutikov said by email. “Right now our
approach to post-treatment cancer surveillance is somewhat
arbitrary.”
SOURCE: http://bit.ly/2mloeZI JAMA Internal Medicine, online March
20, 2017.
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