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Conflicting guidelines on care for cancer survivors

Guidelines
guidelines – file cabinet label, bronze holder against grunge and scratched wood

Treatment guidelines on care for survivors of the most common cancers often lack specifics or offer conflicting advice about when or how often to do certain tests, a review of recent recommendations has found.

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% 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 Centre 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. “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 33m 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.

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 tumours 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%, recommended physical exams and medical history. Most addressed some form of imaging (83%), while 63% 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%, recommendations touched on lab tests to look for biomarkers of certain types of tumours, which are typically found in blood, urine or body tissue.

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% of uterine cancer recommendations and 60% of lung cancer recommendations. The most ambiguous recommendations for PET scan use were for tumours 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 Centre in Philadelphia who wasn’t involved in the study. “Clinical utility versus patient expectations versus costs must be thoughtfully balanced,” Kutikov said. “Right now our approach to post-treatment cancer surveillance is somewhat arbitrary.”

Abstract
Importance: Primary care clinicians, who are increasingly responsible for caring for the growing population of cancer survivors, may be unfamiliar with appropriate cancer surveillance strategies. Clinical practice guidelines can inform cancer follow-up care and surveillance testing. Vague recommendations and inconsistencies among guidelines can lead to overuse and underuse of health care resources and have a negative impact on cost and quality of survivorship care.
Objective: To examine the specificity and consistency of recommendations for surveillance after active treatment across cancer guidelines.
Design, Setting, and Participants: Retrospective cross-sectional analysis of national cancer guidelines from North America and Europe published since 2010 addressing posttreatment care for survivors of the 9 most common cancers. We categorized surveillance modalities into history and physical examinations, tumor markers, diagnostic procedures (eg, colonoscopy), and imaging. Within each guideline, we classified individual recommendations into 5 categories: (1) risk-based recommendation, (2) recommendation for surveillance, (3) addressed but no clear recommendation, (4) recommendation against surveillance, or (5) cases in which surveillance was not addressed. We reviewed each surveillance recommendation for frequency and a stop date, evaluated consistency among guidelines, and analyzed associations between the organizations proposing the guidelines and recommendation characteristics.
Main Outcomes and Measures: Description of guideline recommendations for cancer surveillance.
Results: We identified 41 guidelines published between January 1, 2010, and March 1, 2016. Eighty-five percent of guidelines (35) were from professional organizations. Ambiguous recommendations (ie, modality not discussed or discussed without a clear recommendation) were present in 83% of guidelines (34), and 44% (18) recommended against at least 1 test. European guidelines were more likely than North American guidelines to contain ambiguous recommendations (100% vs 68%; P < .01). Recommendations commonly specified testing frequency (from 88% [14 of 16] for tumor markers to 92% [24 of 26] for procedures and/or imaging) but infrequently provided a definitive stop time. Cross-sectional imaging recommendations varied among guidelines for each cancer. For example, among breast cancer guidelines, surveillance computed tomographic scans were recommended against in 2, discussed without a clear recommendation in 1, and not addressed in 3 guidelines.
Conclusions and Relevance: Guidelines addressing the care of cancer survivors have low specificity and consistency. As guidelines continue to be revised, developers should clarify recommendations with simple, nonambiguous, definitive language for or against the use of specific tests to optimize care quality and resource utilization.

Authors
Ryan P Merkow; Deborah Korenstein; Rubaya Yeahia; Peter B Bach; Shrujal S Baxi

[link url="http://www.reuters.com/article/us-health-cancer-guidelines-idUSKBN16R1ZC"]Reuters Health[/link]
[link url="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2610104"]JAMA Internal Medicine abstract[/link]

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