The American Society of Clinical Oncology (ACSO) has identified the top five opportunities to improve care and reduce costs in oncology. PET, CT and radionuclide bone scanning dominate the list of high-cost, low-yield strategies and should be avoided in specific clinical scenarios, according to ASCO. The list was detailed online April 3 in the Journal of Clinical Oncology.

ASCO’s top five list highlighted five categories of commonly used procedures that are not supported by evidence. With respect to imaging, the organization issued the following recommendations:

• Don’t perform PET, CT and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis;
• Don’t perform PET, CT and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis; and
• Don’t perform surveillance testing or imaging for asymptomatic individuals who have been treated for breast cancer with curative intent.

“Without clinical evidence demonstrating benefit from routine imaging with PET, CT, or radionuclide scanning, these tests provide no additional value to the care of the patient; waste resources needlessly; and most seriously of all, stimulate evaluations such as further invasive testing that pose a risk of unnecessary morbidity,” ASCO wrote.    

The organization took its cue for the list from the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. ASCO turned to its Costs of Care Task Force to develop a list of commonly used tests or treatments whose necessity is not supported by high-level evidence.

The task force proposed a list of potentially overused or misused practices and drafted an initial top five list for review by more than 200 clinical oncologists. The list was ultimately approved by the executive committee of the ASCO board of directors.

Recommendations at a glance

Lowell E. Schnipper, MD, of Beth Israel Deaconess Medical Center in Boston, and colleagues noted that the widespread use of prostate-specific antigen (PSA) screening has resulted in the identification of a large number of men with clinically occult prostate cancer. Many are at low risk for subsequent tumor-related mortality. However, a less widespread variant of prostate cancer can be characterized as invasive, metastatic and lethal. This has led to routine use of bone scanning, PET and PET/CT to identify occult metastases.

These exams provide no clinical benefit in men with low-risk prostate cancer unlikely to metastasize. Schnipper and colleagues noted previous researchers have estimated savings of $40 to $80 million annually if rational use imaging algorithms, which bypass imaging for men with a PSA of less than 10 ug/L and a Gleason score less than 7, were followed.  

Similarly, ASCO recommended against the use of PET, CT and radionuclide bone scans in the staging of low-risk breast cancer, and wrote, “Unnecessary imaging can lead to harm through unnecessary invasive procedures, overtreatment, unnecessary radiation exposure and misdiagnosis.”

Although the use of these tests to detect occult metastatic disease is appropriate in patients with stage III breast cancer, there is a lack of evidence demonstrating benefits in women with early-stage breast cancer.

ASCO also targeted PET, CT and radionuclide imaging as surveillance among patients treated for breast cancer with curative attempt. The organization cited studies demonstrating a lack of benefit from routine imaging in this population. “Surveillance for breast cancer recurrence in this setting is particularly low yield given the low prevalence of recurrence,” they wrote.

Schnipper and colleagues noted that surveillance must have high sensitivity and specificity and significant positive predictive value to be useful. In addition, screening should improve survival outcomes. Surveillance for breast cancer recurrence does not meet this bar. In contrast, the experts noted that mammography is useful in this setting.

ASCO also recommended against cancer-directed therapy for patients with solid tumors who meet certain criteria (low performance status, no benefit from prior evidence-based interventions, not eligible for a clinical trial and with no strong evidence supporting the clinical value of further anti-cancer treatment) and use of white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20 percent risk for the complication.