Cancer tests and treatments to question

Choose wisely to avoid unneeded—and possibly harmful—interventions

Published: September 2012

When the diagnosis is cancer, many people understandably want to pull out all the stops to treat it. But some tests, treatments, and procedures are not only unnecessary but could also be harmful.

“Sometimes less really is more,” says Lowell E. Schnipper, M.D., chief of hematology-oncology at Beth Israel Deaconess Medical Center in Boston and clinical director of its Cancer Center. “It’s important to assess if what you are doing will help you stay well longer.”

Schnipper heads an expert task force that is identifying cancer-related tests and treatments that are not supported by evidence for most patients. The panel was convened by the American Society of Clinical Oncology (ASCO), a professional medical society dedicated to research, education, prevention, and high-quality, high-value cancer care. The list is part of the Choosing Wisely project, an effort led by the ABIM Foundation and a coalition of medical societies to identify tests and treatments that doctors themselves say are done too often.

“This is not a ‘never’ list,” says Douglas Blayney, M.D., medical director at the Stanford Cancer Institute in California and a member of the ASCO task force that developed the recommen­dations. “It’s a tool to help you discuss options with your provider and choose wisely among them.” Exceptions to the recommendations may be appropriate, for example, if you’re enrolled in a clinical trial and you may need to receive the therapy in order to continue participating. Here are the panel’s list of cancer tests or treatments to question.

Imaging tests for early breast or prostate cancer

When a patient is diagnosed with cancer, doctors use tissue and biochemical analysis to “stage” the disease, that is, to find out how aggressive it is and whether it has the potential to invade other parts of the body. If, based on those tests, it appears likely that the cancer has spread, or metastasized, doctors can proceed with imaging tests to find out where in the body the cancer is lurking.

If staging indicates that a patient has a tumor with a low risk of metastasis, ASCO recommends against imaging tests. Low-risk tumors include:

  • Early breast cancer at stages I and II, and at stage 0 (ductal carcinoma in situ in which the cancer is confined to the ducts of the breast).
  • Early-stage low-grade prostate cancer with a Gleason score of 6 or less and a PSA level of less than 10 nanograms per milliliter.

The specific imaging tests to avoid in early-stage breast and prostate cancers include computed tomography (CT or CAT) scans, positron emission tomography (PET) scans, and bone scans. ASCO recommends against them for patients with low-risk tumors because it’s unlikely that the cancer has spread, so the risks of imaging far outweigh any potential benefit.

One obvious downside to unnecessary testing is the expense; imaging can add thousands of dollars to the cost of treatment. But there are patient safety costs as well. Scans sometimes turn up abnormal-looking areas that often prove noncancerous, but lead to additional tests and procedures to find that out. The false alarms are time-consuming and cause needless worry. And while not invasive, imaging tests are hardly benign, Blayney points out. “Most of these tests expose patients to radiation, the effects of which are cumulative over a lifetime,” he says. “Excessive imaging actually increases your risk of cancer.”

What to ask: What stage is my cancer? Are CT, PET, or bone scans rec­ommended? If you have an early-stage low-grade cancer, you should question the need for those tests. On the other hand, if there’s a possibility that the cancer is advanced and your doctor doesn’t suggest imaging, ask why.

Medication to help prevent infection

Some cancer treatments make patients vulnerable to infections. To help decrease the risk, doctors can prescribe white blood cell growth factors, also called hematopoietic (blood-forming) colony-stimulating factors (CSFs), along with chemotherapy.

However, CSFs also have dangerous downsides: They cost as much as $3,900 per dose, may require daily injections, and may cause such side effects as fatigue and bone pain. ASCO recommends that only high-risk patients take CSFs—filgrastim (Neupogen), pegfilgras­tim (Neu­lasta), and sargramostim (Leukine). That includes those undergoing a chemotherapy regimen that carries a higher infection risk and people with individual risk factors, such as being older than 65, frail, or having a compromised immune system due to factors such as kidney failure or previous cancer treatments.

What to ask: Does my treatment or other factors put me at high risk for low white blood cells? If so, would I benefit from being treated with a CSF?

Follow-up tests for early-stage breast cancer

After being treated for cancer, the first question many people ask is, “How will I know if my disease has returned?” For most patients who have had breast cancer, appropriate follow-up means annual mammograms and a breast exam by an experienced clinician every six months. Some women may also benefit from magnetic resonance imaging (MRI) of the breast, including premenopausal women with dense, less fatty breasts and those at very high risk for recurrence because they carry a genetic factor, such as the BRCA mutation, or have a strong family history of the disease.

For patients who had early breast cancer and are now symptom-free, ASCO recommends against tumor marker tests and imaging of other parts of the body beside the breasts. Such testing has not been shown to lengthen lives and, in fact, often leads to anxiety, wrong diagnoses, and overtreatment due to false-positive results.

But for patients with advanced cancer and those who experience new symptoms, such as breast lumps, pain, or shortness of breath, those tests may be appropriate to help determine if the cancer has spread.

What to ask: What tests will I need and how often? If you’re disease-free and don’t have symptoms, question the need for tumor marker tests or imaging of other parts of the body. Also ask about symptoms to look out for.

Cancer-directed therapy at the end of life

Even with the best care, cancer may continue to grow and spread. The question then becomes, what’s next? The decision to discontinue cancer-directed therapy is difficult. But shifting to a treatment plan focused on meeting the physical, mental, and spiritual needs of the patient and family can enhance the quality and sometimes even the length of time patients have left.

ASCO’s guidance on oncology directed therapy at the end of life refers specifically to cancers that form solid tumors, such as those of the breast, colon, or lung. These cancers follow a reasonably predictable course, says Thomas J. Smith, M.D., director of palliative medicine at Johns Hopkins Medical Institutions in Baltimore and a member of the ASCO task force. “When you treat them the first time, you are hoping for a good and long benefit,” he says. “But when they grow despite treatment, the chance of benefit gets progressively less.”

The evidence shows that, in most cases, if a form of cancer has grown or spread after three different treatment regimens, further anti-cancer therapy doesn’t improve survival. In fact, the treatment might cause such severe side effects that it hastens death.

For patients with advanced, solid-tumor cancers, ASCO recommends shifting from cancer-directed therapy to supportive or palliative care to help manage symptoms when all of the following are the case:

  • Previous treatments have not worked and there are no additional evidence-based options to treat the cancer.
  • Patients have a poor performance status—that is, they can’t care for themselves and are spending most of their time in a bed or chair rather than in everyday activities.
  • Patients are not eligible for a clinical trial.

While a majority of oncologists discuss end-of-life issues with patients who have advanced cancer, Smith’s research suggests that for a variety of reasons, about one-fourth do not. Patients may feel obligated to keep fighting the disease, especially if their prognosis and the risks and benefits of treatment haven’t been explained clearly. “It’s hard for doctors to deliver bad news and it’s hard for patients to hear,” Smith says. “But when you avoid that discussion, you deny people the right to decide what’s important to them and what they want to do with the time they have left.”

For example, the experts we spoke with said that almost all their patients appreciate the chance to set their affairs in order and spend time with family and friends. “It allows you to use the time you have wisely,” Blayney says.

Some people worry that stopping the treatments to fight cancer will shorten their life, but the evidence suggests that the opposite is true. Several studies have found that patients receiving palliative or hospice care live just as long or even longer than those who don’t, and that their quality of life is much better. Some data suggest that hospice care also has significant bene­fits for caregivers.

“We can’t always make people live longer, but we can help them live better,” Smith says. He points to data showing that terminally ill patients not receiving hospice care are seven times more likely to be hospitalized and eight times more likely to be admitted to intensive care.

What to ask: What’s my prognosis and expected life span? Is there evidence that further cancer-directed therapy will help me? Are there steps I can take that would improve my quality of life? Do you recommend meeting with a palliative-care specialist?

What's involved in hospice care?

Hospice is a form of care that is generally recommended for patients with a life expectancy of six months or less. It can take place in a patient’s home, a hospital, or a hospice facility.

Hospice care doesn’t mean getting less care; instead, it shifts the focus of therapy from treating the disease to meeting the day-to-day and even the hour-to-hour needs of a patient and his or her family.

Hospice care covers a wide range of services, including doctor and nursing care, pain management, physical and speech therapy, dietary counseling, grief counseling, social worker services, and even respite care so that caregivers can have a break. Ask your doctor for a referral to a hospice coordinator, or contact the National Hospice and Palliative Care Organization (800-658-8898).

Editor's Note:

This article first appeared in the Consumer Reports on Health newsletter.

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