Special Series: Quality Care Symposium
Original Contribution
Choosing Wisely Canada Cancer List: Ten Low-Value or Harmful Practices That Should Be Avoided In Cancer Care
Canadian Partnership Against Cancer; Ontario Institute for Cancer Research; Cancer Care Ontario; Canadian Society of Surgical Oncology; Canadian Association of Medical Oncologists; and Canadian Association of Radiation Oncology, Toronto, Ontario, Canada
Abstract Purpose: Choosing Wisely Canada, modeled after Choosing Wisely in the United States, is intended to identify low-value or potentially harmful practices relevant to the Canadian health care environment. Our objective was to use multidisciplinary, panCanadian, physician-based consensus to identify a list of lowvalue or harmful cancer practices frequently used in Canada.
Methods: A Task Force convened by the Canadian Partnership Against Cancer included physician representation from the Canadian Society of Surgical Oncology, Canadian Association of Medical Oncologists, and Canadian Association of Radiation Oncology, and an expert advisor. The methodology included four phases: identify potentially relevant items, develop a long list, refine and reduce the long list to a short list, and select and endorse a final list. A framework-driven consensus process and a series of electronic surveys and voting processes were used to capture consensus.
Introduction Choosing Wisely Canada, a campaign modeled after Choosing Wisely in the United States, was created to identify low-value, unnecessary, and/or harmful services that are frequently used in Canada. This physician-driven initiative was designed to facilitate the conversation between physicians and patients, as well as relevant health care delivery organizations, about reducing the use of these practices, with the ultimate goal of improved overall quality of care. The second wave of Choosing Wisely Canada was released on October 29, 2014, with lists of lowvalue services developed by 11 physician societies, including a cancer-specific list. This article describes the process and results of identifying the list of cancer practices frequently used in the Canadian context that are considered of low value, unnecessary, or harmful to patients.
Methods In 2013, a Tri-Society Task Force was convened by the Canadian Partnership Against Cancer, and consisted of seven members, including two members from each of the Canadian professional associations that represent physician oncology spee296
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Results: Sixty-six potentially relevant cancer-related practices were identified. The long list (41 practices) was reduced to a short list of 19 practices. Of the 10 practices on the final list, five are completely new, and five are revisions or adaptations of practices from previous US society lists. Six of the 10 involve multiple disease sites, and four are disease-site specific. One relates to diagnosis, six relate to treatment, two relate to surveillance/survivorship, and one practice spans the cancer care continuum. Conclusion: The cancer list was developed in partnership with the Canadian Society of Surgical Oncology, Canadian Association of Medical Oncologists, and Canadian Association of Radiation Oncology. Using knowledge translation and exchange efforts, this list should empower patients with cancer and physicians to assist in a targeted conversation about the appropriateness and quality of individual patient care.
cialities in Canada: Canadian Association of Radiation Oncology (CARO), Canadian Association of Medical Oncologists (CAMO), and Canadian Society of Surgical Oncology (CSSO), as well as an expert advisor. The cancer list was developed on the basis of the following parameters: the development process must be thoroughly documented and publicly available; recommendations are within the specialty’s scope of practice; tests, treatments, or procedures are frequently used and have no benefit or expose patients to harm; and recommendations are supported by evidence. The initial list of cancer practices to be considered was identified through submissions from physicians and participating professional societies, and included a review of existing US Choosing Wisely lists that were relevant to cancer including items pertaining to screening diagnosis, treatment, surveillance, andsurvivorship. A modified Delphi process was used to gain consensus throughout the process.1 Six guiding principles were used to narrow the original list. These included that the practice must (1) have evidence of low value and/or harm, (2) be frequently used in Canada, (3) have potential for reduction, (4) be clear and understandable, (5) be feasible and measureable, and (6) be
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By Gunita Mitera, PhD (C), Craig Earle, MD, MSc, Steven Latosinsky, MD, MSc, Christopher Booth, MD, FRCPC, Andrea Bezjak, MD, MSc, FRCPC, Christine Desbiens, MD, Guila Delouya, MD, MSc, FRCPC, Kara Laing, MD, FRCPC, Natasha Camuso, MSc, and Geoff Porter, MD, MSc
Special Series: Quality Care Symposium
Results A preliminary list of 66 cancer-related items was developed using the Choosing Wisely lists and physician/society submissions. This was reduced to a long list of 41 practices and further reduced to a short list of 19 practices. The final list consisted of 10 cancer practices that have been endorsed by CSSO, CAMO, and CARO before submission to Choosing Wisely Canada. Of the 10 practices, five were new suggestions, one was adopted directly from a Choosing Wisely list, and four were adopted from Choosing Wisely lists with revisions to the wording (Table 1). The final cancer list includes six treatment-related practices, tworelated to surveillance and survivorship, one related to the entire cancer continuum, and one related to diagnosis. Additionally, within this final list, six practices involve multiple disease sites, and four are disease-site specific. Our initial meeting was in December 2013, and consensus on the final list was obtained in May 2014. The following describes, in no particular order, the Choosing Wisely Canada list of 10 oncology practices considered to be low value, unnecessary, and/or harmful that are frequently used in Canada. 1. Do not order tests to detect recurrent cancer in asymptomatic patients if there is not a realistic expectation that early detection of recurrence can improve survival or quality of life.—(new suggestion) In some specific situations, early detection of local or distant cancer recurrence may increase the likelihood of survival. For example, the use of annual computed tomography scanning in the follow-up of selected patients with stage II and III colorectal cancer has been shown to increase the likelihood for potentially curative treatment of metastatic disease.2,3 However, in many clinical situations, the earlier identification of recurrent disease in a nonsymptomatic patient has not shown benefit. For example, in breast cancer follow-up, the vast majority of patients with recurrent disease present with symptoms; fewer than 10% of patients with recurrent disease are identified via imaging Copyright © 2015 by American Society of Clinical Oncology
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alone and are asymptomatic.4 Moreover, the identification of asymptomatic recurrence has not been shown to confer a survival advantage in this cohort.4 As such, most breast cancer guidelines do not advocate the use of cross-sectional imaging or tumor markers as routine follow-up practice.5,6 Similarly, in other cancers, there is paucity of evidence that routine tests in asymptomatic patients confer a survival advantage. 2. Do not perform routine cancer screening, or surveillance for a new primary cancer, in the majority of patients with metastatic disease.—New suggestion Screening can reduce cancer-specific mortality in otherwise healthy individuals. Although controversies exist, mortality reductions have been established for average-risk screening in breast, cervical, and colorectal cancer.7-10 However, the mortality benefit of such average-risk screening emerges years after the test is performed; a recent contemporary analysis of breast and colorectal cancer screening demonstrates such a lag to be in the range of 10 years.11 As opposed to the delayed benefits of screening, most potential harms are early or immediate.12 In general, patients with metastatic cancer have competing mortality risks that outweigh the mortality benefits of screening demonstrated in healthy patients. In fact, patients with metastatic disease may be more likely to experience harm because patients with limited life expectancy have poorer performance status and are more susceptible to complications of testing and treatments. Therefore, the balance of potential benefits and harms does not favor recommending screening for a new asymptomatic primary malignancy in most patients with metastatic disease. Screening may be considered in a small subgroup of patients in whom metastatic disease is relatively indolent, or its treatment is expected to result in prolonged survival.11 3. Avoid chemotherapy and instead focus on symptom relief and palliative care in patients with advanced cancer unlikely to benefit from chemotherapy (eg, performance status 3 or 4).—Revised from ASCO13 In general, cancer-directed treatments are likely to be ineffective for patients with solid tumors who are markedly debilitated by their cancer (ie, Eastern Cooperative Oncology Group performance status ⱖ 3; defined as “3 ⫽ capable of only limited self-care, confined to bed/chair ⬎ 50% of waking hours”).14 Such impaired performance status has been shown to predict poor prognosis, reduced response to chemotherapy, and increased chemotherapy-related toxicity.15 Moreover, no randomized trial has ever demonstrated the benefit of chemotherapy in this type of patient population.16 Smith and Hillner suggested that the ability to walk into a clinic is a simple practical prerequisite for receipt of chemotherapy.17 Exceptions may include patients with functional limitations due to other conditions resulting in a low performance status, or selected patients with specific disease types (eg, germ cell cancer or lymphoma) or characteristics (eg, mutations) that suggest a high likelihood of response to therapy.18 4. Do not perform routine colonoscopic surveillance every year in patients after their colon cancer surgery; •
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relevant and appropriate to the Canadian context. Owing to breadth of expertise, the Task Force did not consider average risk screening practices; however, they did consider specific screening practices among patients with cancer. The Task Force and each society’s memberships were given the opportunity to vote on the inclusion and exclusion of practices using an electronic survey and to suggest additional items. The long list was reduced to a short list by using the same electronic voting process. For each practice, the respondents were asked to specifically consider the size of the population impacted, frequency of use, cost, degree of harm, and potential for change when voting. A voting threshold of ⱖ 50% was used to include an individual practice on the short list. After voting was completed, the Task Force further deliberated, and a consensus-based ranked final list was created. This final list was circulated to each society’s membership for input and then received final endorsement by each society’s Executive Board before it was submitted to Choosing Wisely Canada.
Mitera et al
Table 1. Origin of Final Recommendations Origin of Recommendation
Do not order tests to detect recurrent cancer in asymptomatic patients if there is not a realistic expectation that early detection of recurrence can improve survival or quality of life.
New suggestion by Task Force
Do not perform routine cancer screening, or surveillance for a new primary cancer, in the majority of patients with metastatic disease.
New suggestion by Task Force
Avoid chemotherapy and instead focus on symptom relief and palliative care in patients with advanced cancer unlikely to benefit from chemotherapy (eg, performance status 3 or 4).
Revised from the American Society of Clinical Oncology88
Do not perform routine colonoscopic surveillance every year in patients after their colon cancer surgery; instead, frequency should be based on the findings of the prior colonoscopy and corresponding guidelines.
New suggestion by Task Force
Do not delay or avoid palliative care for a patient with metastatic cancer because they are pursuing disease-directed treatment.
Revised from the American Academy of Hospice and Palliative Medicine89
Do not recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.
Adopted directly from the American Academy of Hospice and Palliative Medicine89
Do not initiate management in patients with low-risk prostate cancer (T1/T2, PSA ⬍ 10 ng/mL, and Gleason score ⬍ 7) without first discussing active surveillance.
Revised from the American Society for Radiation Oncology90
Do not initiate whole-breast radiotherapy in 25 fractions as a part of breastconservation therapy in women age ⱖ 50 years with early-stage invasive breast cancer without considering shorter treatment schedules.
Revised from the American Society for Radiation Oncology90
Do not deliver care (eg, follow-up) in a high-cost setting (eg, inpatient, cancer center) that could be delivered just as effectively in a lower cost setting (eg, primary care).
New suggestion by Task Force
Do not routinely use extensive locoregional therapy in most cancer situations where there is metastatic disease and minimal symptoms attributable to the primary tumor (eg, colorectal cancer).
New suggestion by Task Force
NOTE. This list is meant to augment upon the Choosing Wisely USA lists with specific Canadian context. As such, the lack of inclusion of any Choosing Wisely USA practices does not imply nonsupport of those practices as low-value or harmful.
instead, frequency should be based on the findings of the prior colonoscopy and corresponding guidelines.—New suggestion In the absence of heredity syndromes, the progression from polyp to cancer (adenoma carcinoma sequence) occurs over many years.19 This forms the basis of guidelines for the frequency of colonoscopy. In general, the timing of a follow-up surveillance colonoscopy should be determined on the basis of results of a previous high-quality colonoscopy. Typical colonoscopic surveillance after colon cancer surgery consists of a colonoscopy at 1 year; thereafter it should not typically exceed every 3 years after detection of an advanced polyp, or every 5 years after a normal examination or one showing small polyp.20,21 Three randomized trials22-24 and one meta-analysis25 have failed to demonstrate any benefit from more frequent colonoscopy after colorectal cancer resection. In Canada, there is both evidence of overuse of surveillance colonoscopy after colon cancer resection and a limited availability of endoscopy resources.26,27 5. Do not delay or avoid palliative care for a patient with metastatic cancer because they are pursuing disease-directed treatment.—Revised from the American Academy of Hospice and Palliative Medicine28 Uncontrolled pain and distress in patients cancerith remains a significant issue.29,30 Although the benefits of palliative care are both increasingly understood and acknowledged, many patients are not referred, and often referrals occur late in the trajectory of illness.31,32 Numerous studies, including randomized trials, have shown that palliative care improves pain and symptom control.33-36 In e298
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addition, palliative care improves family satisfaction with care37 and has been shown to reduce costs.38 Importantly, and contrary to widely held beliefs, palliative care does not accelerate death, and early palliative care may in fact prolong life in selected populations.39,40 Finally, the benefits of disease-directed treatment can be enhanced by early consideration of palliative care, and appropriate use of palliative care has been shown to reduce the use of aggressive, unbeneficial anticancer therapies near the end of life.39,41 Recently, there has been a renewed call to earlier integration of palliative care throughout cancer care, with explicit need for better integrating the service into cancer care systems.42 6. Do not recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.—Adopted directly from the American Academy of Hospice and Palliative Medicine28 External beam radiation therapy is an effective therapy for many patients with painful bone metastases; approximately 50% to 80% will have significant decrease in pain, and up to 30% will have complete resolution of pain.43 Randomized trials have established that single-fraction radiation (ie, one fraction ⫽ one dose of radiation treatment) to a previously un-irradiated, uncomplicated peripheral bone or vertebral metastasis provides comparable pain relief and morbidity compared with multiple-fraction (5-10) regimens, while optimizing patient and caregiver convenience.44 Although it results in a higher incidence of re-treatment at a later date (20% re-treatment after single fraction radiotherapy v 8% after multifraction regimens), the decreased patient burden and improved patient-caregiver convenience usually outweighs any
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Practice
Special Series: Quality Care Symposium
7. Do not initiate management of low-risk prostate cancer (LRPC; T1/T2, prostate-specific antigen ⬍ 10 ng/mL, and Gleason score ⬍ 7) without discussing active surveillance.—Revised from the American Society for Radiation Oncology48 LRPC, as defined above, has become more commonly diagnosed with the use of prostate-specific antigen screening and represents 40% to 50% of new cases.49 Although LRPC is commonly treated with local therapies such as external beam radiotherapy and radical prostatectomy, many men undergoing such active treatments may derive no clinical benefit because of the slow progression of their tumors, and this can lead to adverse events such as impotence and urinary or bowel dysfunction.50 It is now recognized that patients with LRPC have a number of reasonable treatment options including surgery, radiation, and active surveillance.50-52 Although variation in active surveillance strategies for LRPC exist, cohort studies have generally shown exceptionally low prostate cancer–specific mortality with this approach.51,52 Randomized trials have not demonstrated a benefit of surgery over active surveillance in these patients,53,54 and Canadian guidelines now include active surveillance as a treatment approach in LRPC.55 Over time, some patients undergoing initial active surveillance will be reclassified to have higher risk disease and undergo definitive intervention.56 Discussion regarding active surveillance should include both the elements and timing of such surveillance and emphasize the need for compliance. Shared decision making between the patient and the physician can lead to better alignment of patient goals with treatment and more efficient care delivery. The use of patient-directed written decision aids concerning prostate cancer can give patients confidence about their choices, and improve compliance with therapy.57 8. Do not initiate whole-breast radiotherapy (WBRT) in 25 fractions as a part of breast-conservation therapy in women age ⱖ 50 years with early-stage invasive breast cancer without considering shorter treatment schedules.—Revised from the American Society for Radiation Oncology48 WBRT is beneficial for most women with invasive breast cancer treated with breast-conservation surgery. For these patients, WBRT clearly decreases the risk of both recurrence and death as a result of breast cancer.58,59 Generally, standard WBRT is delivered to in 1.8- to 2.0-Gy daily fractions over 4.5 Copyright © 2015 by American Society of Clinical Oncology
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to 5.0 weeks to a total dose of 45 to 50 Gy, and may be followed by 1 to 2 weeks of additional radiation treatment to the tumor bed, also known as boost treatment. A hypofractionated WBRT regimen delivers 40.0 to 42.5 Gy in 2.66 Gy per fraction daily, in approximately 3 weeks with or without a boost. Recent randomized trials and a meta-analysis have shown no difference in recurrence or survival for shorter compared with conventional fractionation. Moreover, shorter fractionation schedules are associated with reduced acute and late toxicity.60,61 On the basis of these data, several organizations have called for shorter fractionation schedules to be the standard of care for WBRT.62-64 However, adoption has been variable and seen preferentially in both academic and urban settings.65 Patients and their physicians should review the options for WBRT to determine the most appropriate course of therapy. 9. Do not deliver care (eg, follow-up) in a high-cost setting (eg, inpatient, cancer center) that could be delivered just as effectively in a lower cost setting (eg, primary care).—New suggestion Cancer treatments (eg, surgery, radiation, intravenous chemotherapy) are predominantly provided in hospitals and specialized cancer centers. In large part, this is based on the need to ensure appropriate human and physical resources that are required for contemporary cancer treatment (eg, linear accelerators, operating rooms, chemotherapy infusion clinics, oncologists). Because of this, the location of cancer treatment has also been widely used as the location for cancer follow-up. However, the number of patients with cancer who survive well beyond initial treatment is increasing; there are currently almost 1 million cancer survivors in Canada. This number is expected to grow as a result of improvements in cancer screening,66 increases in life expectancy after definitive cancer treatment,66,67 and the aging population.68 In light of these factors, the traditional practice of providing routine follow-up care through specialist cancer centers places increasing demands and may interfere with other care delivery functions of such centers. Several studies, including randomized clinical trials, have demonstrated that surveillance after definitive cancer therapy can be performed equally well, and in a more patient-centered fashion, within a primary care setting.69-72 Primary care providers are willing to provide follow-up cancer care and have repeatedly assumed such responsibility.73 Despite this, the transition to primary care in Canada has been both variable and incomplete.74,75 10. Avoid routine extensive locoregional therapy in most cancer situations where there is metastatic disease and minimal symptoms attributable to the primary tumor (eg, colorectal cancer).—New suggestion In the past, extensive locoregional therapies (eg, surgery) were often provided in patients with unresectable or incurable metastatic disease, regardless of the symptomatology of the primary tumor. The foundation for this approach was a belief that (1) significant symptoms related to the primary tumor, even if not already present, would likely develop; and (2) aggressive local regional therapy may improve survival. Breast cancer,76 •
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considerations of long-term effectiveness for those with a limited life expectancy.43 In the relatively small number of patients requiring re-treatment, effective palliation has been demonstrated with a subsequent single fractionation radiation schedule.45 Despite supporting randomized trials, recent survey evidence suggests that the minority of radiation oncologists use a single fraction on a routine basis.46 There appears to be a global overall reluctance to adopt single fraction schedules for uncomplicated bone metastases; only minor increase in the use of a single fraction has been seen over the past 20 years.47
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Discussion The Choosing Wisely Canada campaign was initiated to engage both physicians and patients to collaboratively discuss evidence-based treatment options, which in turn can contribute to reducing the overuse of tests and treatments that may be unnecessary or potentially harmful to patients.90 The cancer list was uniquely developed though a multidisciplinary collaboration between CSSO, CAMO, and CARO, and all practices were considered and reviewed by entire Task Force regardless of an individual member’s oncology subspecialty. Involving multiple specialties has the advantage of potentially better representing the overall experience of patients with cancer by not being limited to a single treatment modality or disease type. However, this broad approach potentially reduces the number of true modality-specific practices selected. In addition, several of the
practices identified in the final list may be viewed as quite general (eg, practices 1, 2, 9, and 10); it is possible that a less broad mix of cancer clinicians would have selected more precise, specific practices. Although many practices were considered, including cancerrelated practices previously identified in the Choosing Wisely campaign, the Task Force primarily sought to augment the specialty-specific US Choosing Wisely lists and provide specific Canadian context. As such, the lack of inclusion of any Choosing Wisely practices does not imply nonsupport of those practices as low-value or harmful. Additionally, our cancer list is not intended to replace physician and patient consultation or independent medical judgement. Rather, the cancer list is meant to stimulate shared decision making, using a patient-centered approach. New evidence may emerge after the publication of these practices, and regular review of these practices and supporting evidence is recommended. The Canadian Partnership Against Cancer plans on collecting population-based data for several of these practices where feasible, reporting on a baseline for which system-level quality improvement initiatives can be targeted in the future. Authors’ Disclosures of Potential Conflicts of Interest Disclosures provided by the authors are available with this article at jop.ascopubs.org.
Author Contributions Conception and design: Gunita Mitera, Natasha Camuso, Geoff Porter Collection and assembly of data: Craig Earle, Steven Latosinsky, Christopher Booth, Andrea Bezjak, Christine Desbiens, Guila Delouya, Kara Laing Data analysis and interpretation: Gunita Mitera, Geoff Porter Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Gunita Mitera, PhD (C), Canadian Partnership Against Cancer, 1 University Ave, Ste 300, Toronto, Ontario, M5J 2P1 Canada; e-mail: [email protected].
DOI: 10.1200/JOP.2015.004325; published online ahead of print at jop.ascopubs.org.
References 1. Keeney S, Hasson F, McKenna H: Consulting the oracle: Ten lessons from using the Delphi technique in nursing research. J Adv Nurs 53:205-212, 2006
7. Independent UK Panel on Breast Cancer Screening: The benefits and harms of breast cancer screening: An independent review. Lancet 380:1778-1786, 2012
2. Rodríguez-Moranta F, Saló J, Arcusa A, et al: Postoperative surveillance in patients with colorectal cancer who have undergone curative resection: A prospective, multicenter, randomized, controlled trial. J Clin Oncol 24:386-393, 2006
8. Burt RW, Cannon JA, David DS, et al: Colorectal cancer screening. J Natl Compr Canc Netw 11:1538-1575, 2013
3. Fahy BN: Follow-up after curative resection of colorectal cancer. Ann Surg Oncol 21:738-746, 2014 4. Imoto S, Jitsuiki Y: Detection of the first recurrence during intensive follow-up of breast cancer patients. Jpn J Clin Oncol 28:597-600, 1998 5. Khatcheressian JL, Wolff AC, Smith TJ, et al: American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. J Clin Oncol 24:5091-5097, 2006 6. Grunfeld E, Dhesy-Thind S, Levine M: Clinical practice guidelines for the care and treatment of breast cancer: Follow-up after treatment for breast cancer (summary of the 2005 update). CMAJ 172:1319-1320, 2005
e300
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9. Moyer VA: Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement Ann Intern Med 156:880-891; w312, 2012 10. Whitlock EP, Lin JS, Liles E, et al: Screening for colorectal cancer: A targeted, updated systematic review for the U. S. Preventive Services Task Force. Ann Intern Med 149:638-658, 2008 11. Lee SJ, Boscardin WJ, Stijacic-Cenzer I, et al: Time lag to benefit after screening for breast and colorectal cancer: Meta-analysis of survival data from the United States, Sweden, United Kingdom, and Denmark. BMJ 346:e8441, 2013 12. Fisher DA, Judd L, Sanford NS: Inappropriate colorectal cancer screening: Findings and implications. Am J Gastroenterol 100:2526-2530, 2005
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rectal cancer,77 and gastric cancer78 are examples of disease sites where resection was advocated in the setting of unresectable or incurable metastatic disease and minimal to no symptomatology of the primary tumor. However, a preponderance of evidence demonstrates that in many cases these therapies do not improve outcome; are associated with significant morbidity; and, at times, delay the more important systemic treatment of metastatic disease.79-82 Most recent guidelines have adopted less aggressive approaches to locoregional therapy in the setting of an asymptomatic to minimally symptomatic primary tumor with unresectable or incurable metastatic disease and instead prioritize systemic therapy.83-85 With such an approach, the modest number of patients who do experience disease progression and develop significant symptoms attributable to the primary tumor can often undergo less extensive locoregional therapies.81,86,87 In some specific situations, extensive locoregional therapies may provide benefit and should be considered on an individual basis. For example, adding nephrectomy to systemic therapy in metastatic renal cell carcinoma has been shown to improve overall survival in two randomized trials.88,89 However, most patients with metastatic disease from solid organ malignancies and a relatively asymptomatic primary tumor should be considered for systemic therapy as a priority; the delay in systemic therapy and potential additional morbidity arising from extensive locoregional therapies should be avoided in these patients.
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13. American Society of Clinical Oncology: 10 Things Physicians and Patients Should Question, 2013 www.choosingwisely.org/doctor-patient-lists/americansociety-of-clinical-oncology/
40. Zimmermann C, Swami N, Krzyzanowska M, et al: Early palliative care for patients with advanced cancer: A cluster-randomised controlled trial. Lancet 383: 1721-1730, 2014
14. Eastern Cooperative Oncology Group: ECOG Performance Status, 2006 www.ecog.org/general/perf_stat.html
41. Smith TJ, Temin S, Alesi ER, et al: American Society of Clinical Oncology provisional clinical opinion: The integration of palliative care into standard oncology care. J Clin Oncol 30:880-887, 2012
15. Pater JL, Loeb M: Nonanatomic prognostic factors in carcinoma of the lung: A multivariate analysis. Cancer 50:326-331, 1982
17. Smith TJ, Hillner BE: Bending the cost curve in cancer care. N Engl J Med 364:2060-2065, 2011 18. Shaw AT, Yeap BY, Solomon BJ, et al: Effect of crizotinib on overall survival in patients with advanced non-small-cell lung cancer harbouring ALK gene rearrangement: A retrospective analysis. Lancet Oncol 12:1004-1012, 2011 19. Hill MJ, Morson BC, Bussey HJ: Aetiology of adenoma– carcinoma sequence in large bowel. Lancet 1:245-247, 1978 20. Levin B, Lieberman DA, McFarland B, et al: Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: A joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 134:1570-1595, 2008 21. Leddin D, Enns R, Hilsden R, et al: Colorectal cancer surveillance after index colonoscopy: Guidance from the Canadian Association of Gastroenterology. Can J Gastroenterol 27:224-228, 2013 22. Ohlsson B, Breland U, Ekberg H, et al: Follow-up after curative surgery for colorectal carcinoma. Randomized comparison with no follow-up. Dis Colon Rectum 38:619-626, 1995 23. Mäkelä JT, Laitinen SO, Kairaluoma MI: Five-year follow-up after radical surgery for colorectal cancer. Results of a prospective randomized trial. Arch Surg 130:1062-1067, 1995 24. Schoemaker D, Black R, Giles L, et al: Yearly colonoscopy, liver CT, and chest radiography do not influence 5-year survival of colorectal cancer patients. Gastroenterology 114:7-14, 1998 25. Jeffery GM, Hickey BE, Hider P: Follow-up strategies for patients treated for non-metastatic colorectal cancer. Cochrane Database Syst Rev 1:CD002200, 2002 26. van Kooten H, de Jonge V, Schreuders E, et al: Awareness of postpolypectomy surveillance guidelines: A nationwide survey of colonoscopists in Canada. Can J Gastroenterol 26:79-84, 2012 27. Urquhart R, Folkes A, Porter G, et al: Population-based longitudinal study of follow-up care for patients with colorectal cancer in Nova Scotia. J Oncol Pract 8:246-252, 2012 28. American Academy of Hospice and Palliative Medicine: Five Things Physicians and Patients Should Question, 2013 www.choosingwisely.org/doctorpatient-lists/american-academy-of-hospice-palliative-medicine/ 29. Foley KM, Gelband H: Improving Palliative Care for Cancer: Summary and Recommendations. Washington, DC, National Academies Press, 2001 30. Field MJ, Cassel CK: Approaching Death: Improving Care at the End of Life. Washington, DC, National Academies Press, 1997 31. Hui D, Elsayem A, De la Cruz M, et al: Availability and integration of palliative care at US cancer centers. JAMA 303:1054-1061, 2010
42. Partridge AH, Seah DS, King T, et al: Developing a service model that integrates palliative care throughout cancer care: The time is now. J Clin Oncol 32:3330-3336, 2014 43. Chow E, Harris K, Fan G, et al: Palliative radiotherapy trials for bone metastases: A systematic review. J Clin Oncol 25:1423-1436, 2007 44. Lutz S, Berk L, Chang E, et al: Palliative radiotherapy for bone metastases: An ASTRO evidence-based guideline. Int J Radiat Oncol Biol Phys 79:965-976, 2011 45. Chow E, van der Linden YM, Roos D, et al: Single versus multiple fractions of repeat radiation for painful bone metastases: A randomised, controlled, noninferiority trial. Lancet Oncol 15:164-171, 2014 46. Fairchild A, Barnes E, Ghosh S, et al: International patterns of practice in palliative radiotherapy for painful bone metastases: Evidence-based practice? Int J Radiat Oncol Biol Phys 75:1501-1510, 2009 47. Popovic M, den Hartogh M, Zhang L, et al: Review of international patterns of practice for the treatment of painful bone metastases with palliative radiotherapy from 1993 to 2013. Radiother Oncol 111:11-17, 2014 48. American Society for Radiation Oncology: 10 Things Physicians and Patients Should Question, 2014 www.choosingwisely.org/doctor-patient-lists/americansociety-for-radiation-oncology/ 49. Klotz L, Emberton M: Management of low risk prostate cancer: Active surveillance and focal therapy. Curr Opin Urol 24:270-279, 2014 50. Cooperberg MR, Lubeck DP, Mehta SS, et al: Time trends in clinical risk stratification for prostate cancer: Implications for outcomes (data from CaPSURE). J Urol 170:S21-25; discussion S26-27, 2003 51. Dahabreh IJ, Chung M, Balk EM, et al: Active surveillance in men with localized prostate cancer: A systematic review. Ann Intern Med 156:582-590, 2012 52. Klotz L: Active surveillance for prostate cancer: Overview and update. Curr Treat Options Oncol 14:97-108, 2013 53. Wilt TJ, Brawer MK, Jones KM, et al: Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 367:203-213, 2012 54. Bill-Axelson A, Holmberg L, Ruutu M, et al: Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 364:1708-1717, 2011 55. Izawa JI, Klotz L, Siemens DR, et al: Prostate cancer screening: Canadian guidelines 2011. Can Urol Assoc J 5:235-240, 2011 56. Klotz L, Zhang L, Lam A, et al: Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. J Clin Oncol 28:126131, 2010 57. Stacey D, Bennett CL, Barry MJ, et al: Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 10:CD001431, 2011 58. Early Breast Cancer Trialists Collaborative Group (EBCTCG), Darby S, McGale P, et al: Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: Meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 378:1707-1716, 2011 59. Clarke M, Collins R, Darby S, et al: Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: An overview of the randomised trials. Lancet 366:2087-2106, 2005
32. Wentlandt K, Krzyzanowska MK, Swami N, et al: Referral practices of oncologists to specialized palliative care. J Clin Oncol 30:4380-4386, 2012
60. James ML, Lehman M, Hider PN, et al: Fraction size in radiation treatment for breast conservation in early breast cancer. Cochrane Database Syst Rev 11: CD003860, 2010
33. Elsayem A, Smith ML, Parmley L, et al: Impact of a palliative care service on in-hospital mortality in a comprehensive cancer center. J Palliat Med 9:894-902, 2006
61. Whelan TJ, Pignol JP, Levine MN, et al: Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med 362:513-520, 2010
34. Gelfman LP, Meier DE, Morrison RS: Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage 36:22-28, 2008
62. Eblan MJ, Vanderwalde NA, Zeman EM, et al: Hypofractionation for breast cancer: Lessons learned from our neighbors to the north and across the pond. Oncology (Williston Park) 28:536-546, 2014
35. Higginson IJ, Finlay IG, Goodwin DM, et al: Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers? J Pain Symptom Manage 25:150-168, 2003
63. Smith BD, Bentzen SM, Correa CR, et al: Fractionation for whole breast irradiation: An American Society for Radiation Oncology (ASTRO) evidencebased guideline. Int J Radiat Oncol Biol Phys 81:59-68, 2011
36. Delgado-Guay MO, Parsons HA, Li Z, et al: Symptom distress, interventions, and outcomes of intensive care unit cancer patients referred to a palliative care consult team. Cancer 115:437-445, 2009
64. Holloway CL, Panet-Raymond V, Olivotto I: Hypofractionation should be the new ‘standard’ for radiation therapy after breast conserving surgery. Breast 19: 163-167, 2010
37. Jordhøy MS, Fayers P, Saltnes T, et al: A palliative-care intervention and death at home: A cluster randomised trial. Lancet 356:888-893, 2000
65. Wang EH, Mougalian SS, Soulos PR, et al: Adoption of hypofractionated whole-breast irradiation for early-stage breast cancer: A national cancer data base analysis. Int J Radiat Oncol Biol Phys 90:993-1000, 2014
38. Elsayem A, Swint K, Fisch MJ, et al: Palliative care inpatient service in a comprehensive cancer center: Clinical and financial outcomes. J Clin Oncol 22: 2008-2014, 2004 39. Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733-742, 2010
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66. Berry DA, Cronin KA, Plevritis SK, et al: Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 353:1784-1792, 2005 67. American Cancer Society: Cancer Treatment & Survivorship Facts & Figures 2012-2013. Atlanta, GA, American Cancer Society, 2012
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jop.ascopubs.org
e301
Information downloaded from jop.ascopubs.org and provided by at UNIVERSITY LEEDSHEALTH SCIEN on May 20, 2015 from 129.11.21.2 Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
16. Outcomes of cancer treatment for technology assessment and cancer treatment guidelines. American Society of Clinical Oncology. J Clin Oncol 14:671-679, 1996
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68. Smith BD, Smith GL, Hurria A, et al: Future of cancer incidence in the United States: Burdens upon an aging, changing nation. J Clin Oncol 27:2758-2765, 2009 69. Grunfeld E, Levine MN, Julian JA, et al: Randomized trial of long-term follow-up for early-stage breast cancer: A comparison of family physician versus specialist care. J Clin Oncol 24:848-855, 2006 70. Wattchow DA, Weller DP, Esterman A, et al: General practice vs surgicalbased follow-up for patients with colon cancer: Randomised controlled trial. Br J Cancer 94:1116-1121, 2006
trolled trial. Presented at the San Antonio Breast Conference, December 11, 2013 (abstr S2-02) 80. Kleespies A, Füessl KE, Seeliger H, et al: Determinants of morbidity and survival after elective non-curative resection of stage IV colon and rectal cancer. Int J Colorectal Dis 24:1097-1109, 2009 81. Nitzkorski JR, Farma JM, Watson JC, et al: Outcome and natural history of patients with stage IV colorectal cancer receiving chemotherapy without primary tumor resection. Ann Surg Oncol 19:379-383, 2012 82. Cirocchi R, Trastulli S, Abraha I, et al: Non-resection versus resection for an asymptomatic primary tumour in patients with unresectable stage IV colorectal cancer. Cochrane Database Syst Rev 8:CD008997, 2012
72. Murchie P, Nicolson MC, Hannaford PC, et al: Patient satisfaction with GPled melanoma follow-up: A randomised controlled trial. Br J Cancer 102:14471455, 2010
83. National Comprehensive Cancer Network: NCCN clinical practice guidelines in oncology: Colon Cancer, version 3, 2014 www.nccn.org/professionals/physician_gls/pdf/ rectal.pdf
73. Del Giudice ME, Grunfeld E, Harvey BJ, et al: Primary care physicians’ views of routine follow-up care of cancer survivors. J Clin Oncol 27:3338-3345, 2009
84. National Comprehensive Cancer Network: NCCN clinical practice guidelines in oncology: Rectal Cancer, version 3, 2014 www.nccn.org/professionals/physician_gls/pdf/ rectal.pdf
74. Grunfeld E: Looking beyond survival: How are we looking at survivorship? J Clin Oncol 24:5166-5169, 2006 75. Ristovski-Slijepcevic S: Environmental Scan of Cancer Survivorship in Canada: Conceptualization, Practice And Research. Toronto, Canada, Cancer Journey Portfolio, Canadian Partnership Against Cancer, 2008 76. Rapiti E, Verkooijen HM, Vlastos G, et al: Complete excision of primary breast tumor improves survival of patients with metastatic breast cancer at diagnosis. J Clin Oncol 24:2743-2749, 2006 77. Cook AD, Single R, McCahill LE: Surgical resection of primary tumors in patients who present with stage IV colorectal cancer: An analysis of surveillance, epidemiology, and end results data, 1988 to 2000. Ann Surg Oncol 12:637-645, 2005 78. Shridhar R, Almhanna K, Hoffe SE, et al: Increased survival associated with surgery and radiation therapy in metastatic gastric cancer: A Surveillance, Epidemiology, and End Results database analysis Cancer 119:1636-1642, 2013 79. Badwe R: Surgical removal of primary tumor and axillary lymph nodes in women with metastatic breast cancer at first presentation: A randomized con-
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85. National Comprehensive Cancer Network: NCCN clinical practice guidelines in oncology: Breast Cancer, version 3, 2014 www.nccn.org/professionals/physician_gls/pdf/ breastl.pdf 86. Poultsides GA, Servais EL, Saltz LB, et al: Outcome of primary tumor in patients with synchronous stage IV colorectal cancer receiving combination chemotherapy without surgery as initial treatment. J Clin Oncol 27:3379-3384, 2009 87. Sarela AI, Yelluri S, Leeds Upper Gastrointestinal Cancer Multidisciplinary Team: Gastric adenocarcinoma with distant metastasis: Is gastrectomy necessary? Arch Surg 142:143-149; discussion 149, 2007 88. Flanigan RC, Salmon SE, Blumenstein BA, et al: Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renalcell cancer. N Engl J Med 345:1655-1659, 2001 89. Mickisch GH, Garin A, van Poppel H, et al: Radical nephrectomy plus interferon-alfa-based immunotherapy compared with interferon alfa alone in metastatic renal-cell carcinoma: A randomised trial. Lancet 358:966-970, 2001 90. Choosing Wisely Canada. www.choosingwiselycanada.org/
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71. Grunfeld E, Mant D, Yudkin P, et al: Routine follow up of breast cancer in primary care: Randomised trial. BMJ 313:665-669, 1996
Special Series: Quality Care Symposium
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Choosing Wisely Canada Cancer List: Ten Low-Value or Harmful Practices That Should Be Avoided In Cancer Care The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jop.ascopubs.org/site/misc/ifc.xhtml.
Craig Earle Consulting or Advisory Role: UnitedHealthcare Patents, Royalties, Other Intellectual Property: UpToDate
Guila Delouya Honoraria: Ferring, Bayer, Paladin Consulting or Advisory Role: Bayer Research Funding: Janssen Oncology, Abbvie Travel, Accommodations, Expenses: Donaldson Marphil, Bayer
Christopher Booth No relationship to disclose
Kara Laing Honoraria: Roche Consulting or Advisory Role: Roche Travel, Accommodations, Expenses: Roche, Amgen
Andrea Bezjak No relationship to disclose
Natasha Camuso No relationship to disclose
Christine Desbiens No relationship to disclose
Geoff Porter No relationship to disclose
Steven Latosinsky No relationship to disclose
Copyright © 2015 by American Society of Clinical Oncology
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Gunita Mitera No relationship to disclose
Original Contribution
Choosing Wisely Canada Cancer List: Ten Low-Value or Harmful Practices That Should Be Avoided In Cancer Care
Canadian Partnership Against Cancer; Ontario Institute for Cancer Research; Cancer Care Ontario; Canadian Society of Surgical Oncology; Canadian Association of Medical Oncologists; and Canadian Association of Radiation Oncology, Toronto, Ontario, Canada
Abstract Purpose: Choosing Wisely Canada, modeled after Choosing Wisely in the United States, is intended to identify low-value or potentially harmful practices relevant to the Canadian health care environment. Our objective was to use multidisciplinary, panCanadian, physician-based consensus to identify a list of lowvalue or harmful cancer practices frequently used in Canada.
Methods: A Task Force convened by the Canadian Partnership Against Cancer included physician representation from the Canadian Society of Surgical Oncology, Canadian Association of Medical Oncologists, and Canadian Association of Radiation Oncology, and an expert advisor. The methodology included four phases: identify potentially relevant items, develop a long list, refine and reduce the long list to a short list, and select and endorse a final list. A framework-driven consensus process and a series of electronic surveys and voting processes were used to capture consensus.
Introduction Choosing Wisely Canada, a campaign modeled after Choosing Wisely in the United States, was created to identify low-value, unnecessary, and/or harmful services that are frequently used in Canada. This physician-driven initiative was designed to facilitate the conversation between physicians and patients, as well as relevant health care delivery organizations, about reducing the use of these practices, with the ultimate goal of improved overall quality of care. The second wave of Choosing Wisely Canada was released on October 29, 2014, with lists of lowvalue services developed by 11 physician societies, including a cancer-specific list. This article describes the process and results of identifying the list of cancer practices frequently used in the Canadian context that are considered of low value, unnecessary, or harmful to patients.
Methods In 2013, a Tri-Society Task Force was convened by the Canadian Partnership Against Cancer, and consisted of seven members, including two members from each of the Canadian professional associations that represent physician oncology spee296
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Results: Sixty-six potentially relevant cancer-related practices were identified. The long list (41 practices) was reduced to a short list of 19 practices. Of the 10 practices on the final list, five are completely new, and five are revisions or adaptations of practices from previous US society lists. Six of the 10 involve multiple disease sites, and four are disease-site specific. One relates to diagnosis, six relate to treatment, two relate to surveillance/survivorship, and one practice spans the cancer care continuum. Conclusion: The cancer list was developed in partnership with the Canadian Society of Surgical Oncology, Canadian Association of Medical Oncologists, and Canadian Association of Radiation Oncology. Using knowledge translation and exchange efforts, this list should empower patients with cancer and physicians to assist in a targeted conversation about the appropriateness and quality of individual patient care.
cialities in Canada: Canadian Association of Radiation Oncology (CARO), Canadian Association of Medical Oncologists (CAMO), and Canadian Society of Surgical Oncology (CSSO), as well as an expert advisor. The cancer list was developed on the basis of the following parameters: the development process must be thoroughly documented and publicly available; recommendations are within the specialty’s scope of practice; tests, treatments, or procedures are frequently used and have no benefit or expose patients to harm; and recommendations are supported by evidence. The initial list of cancer practices to be considered was identified through submissions from physicians and participating professional societies, and included a review of existing US Choosing Wisely lists that were relevant to cancer including items pertaining to screening diagnosis, treatment, surveillance, andsurvivorship. A modified Delphi process was used to gain consensus throughout the process.1 Six guiding principles were used to narrow the original list. These included that the practice must (1) have evidence of low value and/or harm, (2) be frequently used in Canada, (3) have potential for reduction, (4) be clear and understandable, (5) be feasible and measureable, and (6) be
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By Gunita Mitera, PhD (C), Craig Earle, MD, MSc, Steven Latosinsky, MD, MSc, Christopher Booth, MD, FRCPC, Andrea Bezjak, MD, MSc, FRCPC, Christine Desbiens, MD, Guila Delouya, MD, MSc, FRCPC, Kara Laing, MD, FRCPC, Natasha Camuso, MSc, and Geoff Porter, MD, MSc
Special Series: Quality Care Symposium
Results A preliminary list of 66 cancer-related items was developed using the Choosing Wisely lists and physician/society submissions. This was reduced to a long list of 41 practices and further reduced to a short list of 19 practices. The final list consisted of 10 cancer practices that have been endorsed by CSSO, CAMO, and CARO before submission to Choosing Wisely Canada. Of the 10 practices, five were new suggestions, one was adopted directly from a Choosing Wisely list, and four were adopted from Choosing Wisely lists with revisions to the wording (Table 1). The final cancer list includes six treatment-related practices, tworelated to surveillance and survivorship, one related to the entire cancer continuum, and one related to diagnosis. Additionally, within this final list, six practices involve multiple disease sites, and four are disease-site specific. Our initial meeting was in December 2013, and consensus on the final list was obtained in May 2014. The following describes, in no particular order, the Choosing Wisely Canada list of 10 oncology practices considered to be low value, unnecessary, and/or harmful that are frequently used in Canada. 1. Do not order tests to detect recurrent cancer in asymptomatic patients if there is not a realistic expectation that early detection of recurrence can improve survival or quality of life.—(new suggestion) In some specific situations, early detection of local or distant cancer recurrence may increase the likelihood of survival. For example, the use of annual computed tomography scanning in the follow-up of selected patients with stage II and III colorectal cancer has been shown to increase the likelihood for potentially curative treatment of metastatic disease.2,3 However, in many clinical situations, the earlier identification of recurrent disease in a nonsymptomatic patient has not shown benefit. For example, in breast cancer follow-up, the vast majority of patients with recurrent disease present with symptoms; fewer than 10% of patients with recurrent disease are identified via imaging Copyright © 2015 by American Society of Clinical Oncology
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alone and are asymptomatic.4 Moreover, the identification of asymptomatic recurrence has not been shown to confer a survival advantage in this cohort.4 As such, most breast cancer guidelines do not advocate the use of cross-sectional imaging or tumor markers as routine follow-up practice.5,6 Similarly, in other cancers, there is paucity of evidence that routine tests in asymptomatic patients confer a survival advantage. 2. Do not perform routine cancer screening, or surveillance for a new primary cancer, in the majority of patients with metastatic disease.—New suggestion Screening can reduce cancer-specific mortality in otherwise healthy individuals. Although controversies exist, mortality reductions have been established for average-risk screening in breast, cervical, and colorectal cancer.7-10 However, the mortality benefit of such average-risk screening emerges years after the test is performed; a recent contemporary analysis of breast and colorectal cancer screening demonstrates such a lag to be in the range of 10 years.11 As opposed to the delayed benefits of screening, most potential harms are early or immediate.12 In general, patients with metastatic cancer have competing mortality risks that outweigh the mortality benefits of screening demonstrated in healthy patients. In fact, patients with metastatic disease may be more likely to experience harm because patients with limited life expectancy have poorer performance status and are more susceptible to complications of testing and treatments. Therefore, the balance of potential benefits and harms does not favor recommending screening for a new asymptomatic primary malignancy in most patients with metastatic disease. Screening may be considered in a small subgroup of patients in whom metastatic disease is relatively indolent, or its treatment is expected to result in prolonged survival.11 3. Avoid chemotherapy and instead focus on symptom relief and palliative care in patients with advanced cancer unlikely to benefit from chemotherapy (eg, performance status 3 or 4).—Revised from ASCO13 In general, cancer-directed treatments are likely to be ineffective for patients with solid tumors who are markedly debilitated by their cancer (ie, Eastern Cooperative Oncology Group performance status ⱖ 3; defined as “3 ⫽ capable of only limited self-care, confined to bed/chair ⬎ 50% of waking hours”).14 Such impaired performance status has been shown to predict poor prognosis, reduced response to chemotherapy, and increased chemotherapy-related toxicity.15 Moreover, no randomized trial has ever demonstrated the benefit of chemotherapy in this type of patient population.16 Smith and Hillner suggested that the ability to walk into a clinic is a simple practical prerequisite for receipt of chemotherapy.17 Exceptions may include patients with functional limitations due to other conditions resulting in a low performance status, or selected patients with specific disease types (eg, germ cell cancer or lymphoma) or characteristics (eg, mutations) that suggest a high likelihood of response to therapy.18 4. Do not perform routine colonoscopic surveillance every year in patients after their colon cancer surgery; •
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relevant and appropriate to the Canadian context. Owing to breadth of expertise, the Task Force did not consider average risk screening practices; however, they did consider specific screening practices among patients with cancer. The Task Force and each society’s memberships were given the opportunity to vote on the inclusion and exclusion of practices using an electronic survey and to suggest additional items. The long list was reduced to a short list by using the same electronic voting process. For each practice, the respondents were asked to specifically consider the size of the population impacted, frequency of use, cost, degree of harm, and potential for change when voting. A voting threshold of ⱖ 50% was used to include an individual practice on the short list. After voting was completed, the Task Force further deliberated, and a consensus-based ranked final list was created. This final list was circulated to each society’s membership for input and then received final endorsement by each society’s Executive Board before it was submitted to Choosing Wisely Canada.
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Table 1. Origin of Final Recommendations Origin of Recommendation
Do not order tests to detect recurrent cancer in asymptomatic patients if there is not a realistic expectation that early detection of recurrence can improve survival or quality of life.
New suggestion by Task Force
Do not perform routine cancer screening, or surveillance for a new primary cancer, in the majority of patients with metastatic disease.
New suggestion by Task Force
Avoid chemotherapy and instead focus on symptom relief and palliative care in patients with advanced cancer unlikely to benefit from chemotherapy (eg, performance status 3 or 4).
Revised from the American Society of Clinical Oncology88
Do not perform routine colonoscopic surveillance every year in patients after their colon cancer surgery; instead, frequency should be based on the findings of the prior colonoscopy and corresponding guidelines.
New suggestion by Task Force
Do not delay or avoid palliative care for a patient with metastatic cancer because they are pursuing disease-directed treatment.
Revised from the American Academy of Hospice and Palliative Medicine89
Do not recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.
Adopted directly from the American Academy of Hospice and Palliative Medicine89
Do not initiate management in patients with low-risk prostate cancer (T1/T2, PSA ⬍ 10 ng/mL, and Gleason score ⬍ 7) without first discussing active surveillance.
Revised from the American Society for Radiation Oncology90
Do not initiate whole-breast radiotherapy in 25 fractions as a part of breastconservation therapy in women age ⱖ 50 years with early-stage invasive breast cancer without considering shorter treatment schedules.
Revised from the American Society for Radiation Oncology90
Do not deliver care (eg, follow-up) in a high-cost setting (eg, inpatient, cancer center) that could be delivered just as effectively in a lower cost setting (eg, primary care).
New suggestion by Task Force
Do not routinely use extensive locoregional therapy in most cancer situations where there is metastatic disease and minimal symptoms attributable to the primary tumor (eg, colorectal cancer).
New suggestion by Task Force
NOTE. This list is meant to augment upon the Choosing Wisely USA lists with specific Canadian context. As such, the lack of inclusion of any Choosing Wisely USA practices does not imply nonsupport of those practices as low-value or harmful.
instead, frequency should be based on the findings of the prior colonoscopy and corresponding guidelines.—New suggestion In the absence of heredity syndromes, the progression from polyp to cancer (adenoma carcinoma sequence) occurs over many years.19 This forms the basis of guidelines for the frequency of colonoscopy. In general, the timing of a follow-up surveillance colonoscopy should be determined on the basis of results of a previous high-quality colonoscopy. Typical colonoscopic surveillance after colon cancer surgery consists of a colonoscopy at 1 year; thereafter it should not typically exceed every 3 years after detection of an advanced polyp, or every 5 years after a normal examination or one showing small polyp.20,21 Three randomized trials22-24 and one meta-analysis25 have failed to demonstrate any benefit from more frequent colonoscopy after colorectal cancer resection. In Canada, there is both evidence of overuse of surveillance colonoscopy after colon cancer resection and a limited availability of endoscopy resources.26,27 5. Do not delay or avoid palliative care for a patient with metastatic cancer because they are pursuing disease-directed treatment.—Revised from the American Academy of Hospice and Palliative Medicine28 Uncontrolled pain and distress in patients cancerith remains a significant issue.29,30 Although the benefits of palliative care are both increasingly understood and acknowledged, many patients are not referred, and often referrals occur late in the trajectory of illness.31,32 Numerous studies, including randomized trials, have shown that palliative care improves pain and symptom control.33-36 In e298
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addition, palliative care improves family satisfaction with care37 and has been shown to reduce costs.38 Importantly, and contrary to widely held beliefs, palliative care does not accelerate death, and early palliative care may in fact prolong life in selected populations.39,40 Finally, the benefits of disease-directed treatment can be enhanced by early consideration of palliative care, and appropriate use of palliative care has been shown to reduce the use of aggressive, unbeneficial anticancer therapies near the end of life.39,41 Recently, there has been a renewed call to earlier integration of palliative care throughout cancer care, with explicit need for better integrating the service into cancer care systems.42 6. Do not recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.—Adopted directly from the American Academy of Hospice and Palliative Medicine28 External beam radiation therapy is an effective therapy for many patients with painful bone metastases; approximately 50% to 80% will have significant decrease in pain, and up to 30% will have complete resolution of pain.43 Randomized trials have established that single-fraction radiation (ie, one fraction ⫽ one dose of radiation treatment) to a previously un-irradiated, uncomplicated peripheral bone or vertebral metastasis provides comparable pain relief and morbidity compared with multiple-fraction (5-10) regimens, while optimizing patient and caregiver convenience.44 Although it results in a higher incidence of re-treatment at a later date (20% re-treatment after single fraction radiotherapy v 8% after multifraction regimens), the decreased patient burden and improved patient-caregiver convenience usually outweighs any
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Practice
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7. Do not initiate management of low-risk prostate cancer (LRPC; T1/T2, prostate-specific antigen ⬍ 10 ng/mL, and Gleason score ⬍ 7) without discussing active surveillance.—Revised from the American Society for Radiation Oncology48 LRPC, as defined above, has become more commonly diagnosed with the use of prostate-specific antigen screening and represents 40% to 50% of new cases.49 Although LRPC is commonly treated with local therapies such as external beam radiotherapy and radical prostatectomy, many men undergoing such active treatments may derive no clinical benefit because of the slow progression of their tumors, and this can lead to adverse events such as impotence and urinary or bowel dysfunction.50 It is now recognized that patients with LRPC have a number of reasonable treatment options including surgery, radiation, and active surveillance.50-52 Although variation in active surveillance strategies for LRPC exist, cohort studies have generally shown exceptionally low prostate cancer–specific mortality with this approach.51,52 Randomized trials have not demonstrated a benefit of surgery over active surveillance in these patients,53,54 and Canadian guidelines now include active surveillance as a treatment approach in LRPC.55 Over time, some patients undergoing initial active surveillance will be reclassified to have higher risk disease and undergo definitive intervention.56 Discussion regarding active surveillance should include both the elements and timing of such surveillance and emphasize the need for compliance. Shared decision making between the patient and the physician can lead to better alignment of patient goals with treatment and more efficient care delivery. The use of patient-directed written decision aids concerning prostate cancer can give patients confidence about their choices, and improve compliance with therapy.57 8. Do not initiate whole-breast radiotherapy (WBRT) in 25 fractions as a part of breast-conservation therapy in women age ⱖ 50 years with early-stage invasive breast cancer without considering shorter treatment schedules.—Revised from the American Society for Radiation Oncology48 WBRT is beneficial for most women with invasive breast cancer treated with breast-conservation surgery. For these patients, WBRT clearly decreases the risk of both recurrence and death as a result of breast cancer.58,59 Generally, standard WBRT is delivered to in 1.8- to 2.0-Gy daily fractions over 4.5 Copyright © 2015 by American Society of Clinical Oncology
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to 5.0 weeks to a total dose of 45 to 50 Gy, and may be followed by 1 to 2 weeks of additional radiation treatment to the tumor bed, also known as boost treatment. A hypofractionated WBRT regimen delivers 40.0 to 42.5 Gy in 2.66 Gy per fraction daily, in approximately 3 weeks with or without a boost. Recent randomized trials and a meta-analysis have shown no difference in recurrence or survival for shorter compared with conventional fractionation. Moreover, shorter fractionation schedules are associated with reduced acute and late toxicity.60,61 On the basis of these data, several organizations have called for shorter fractionation schedules to be the standard of care for WBRT.62-64 However, adoption has been variable and seen preferentially in both academic and urban settings.65 Patients and their physicians should review the options for WBRT to determine the most appropriate course of therapy. 9. Do not deliver care (eg, follow-up) in a high-cost setting (eg, inpatient, cancer center) that could be delivered just as effectively in a lower cost setting (eg, primary care).—New suggestion Cancer treatments (eg, surgery, radiation, intravenous chemotherapy) are predominantly provided in hospitals and specialized cancer centers. In large part, this is based on the need to ensure appropriate human and physical resources that are required for contemporary cancer treatment (eg, linear accelerators, operating rooms, chemotherapy infusion clinics, oncologists). Because of this, the location of cancer treatment has also been widely used as the location for cancer follow-up. However, the number of patients with cancer who survive well beyond initial treatment is increasing; there are currently almost 1 million cancer survivors in Canada. This number is expected to grow as a result of improvements in cancer screening,66 increases in life expectancy after definitive cancer treatment,66,67 and the aging population.68 In light of these factors, the traditional practice of providing routine follow-up care through specialist cancer centers places increasing demands and may interfere with other care delivery functions of such centers. Several studies, including randomized clinical trials, have demonstrated that surveillance after definitive cancer therapy can be performed equally well, and in a more patient-centered fashion, within a primary care setting.69-72 Primary care providers are willing to provide follow-up cancer care and have repeatedly assumed such responsibility.73 Despite this, the transition to primary care in Canada has been both variable and incomplete.74,75 10. Avoid routine extensive locoregional therapy in most cancer situations where there is metastatic disease and minimal symptoms attributable to the primary tumor (eg, colorectal cancer).—New suggestion In the past, extensive locoregional therapies (eg, surgery) were often provided in patients with unresectable or incurable metastatic disease, regardless of the symptomatology of the primary tumor. The foundation for this approach was a belief that (1) significant symptoms related to the primary tumor, even if not already present, would likely develop; and (2) aggressive local regional therapy may improve survival. Breast cancer,76 •
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considerations of long-term effectiveness for those with a limited life expectancy.43 In the relatively small number of patients requiring re-treatment, effective palliation has been demonstrated with a subsequent single fractionation radiation schedule.45 Despite supporting randomized trials, recent survey evidence suggests that the minority of radiation oncologists use a single fraction on a routine basis.46 There appears to be a global overall reluctance to adopt single fraction schedules for uncomplicated bone metastases; only minor increase in the use of a single fraction has been seen over the past 20 years.47
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Discussion The Choosing Wisely Canada campaign was initiated to engage both physicians and patients to collaboratively discuss evidence-based treatment options, which in turn can contribute to reducing the overuse of tests and treatments that may be unnecessary or potentially harmful to patients.90 The cancer list was uniquely developed though a multidisciplinary collaboration between CSSO, CAMO, and CARO, and all practices were considered and reviewed by entire Task Force regardless of an individual member’s oncology subspecialty. Involving multiple specialties has the advantage of potentially better representing the overall experience of patients with cancer by not being limited to a single treatment modality or disease type. However, this broad approach potentially reduces the number of true modality-specific practices selected. In addition, several of the
practices identified in the final list may be viewed as quite general (eg, practices 1, 2, 9, and 10); it is possible that a less broad mix of cancer clinicians would have selected more precise, specific practices. Although many practices were considered, including cancerrelated practices previously identified in the Choosing Wisely campaign, the Task Force primarily sought to augment the specialty-specific US Choosing Wisely lists and provide specific Canadian context. As such, the lack of inclusion of any Choosing Wisely practices does not imply nonsupport of those practices as low-value or harmful. Additionally, our cancer list is not intended to replace physician and patient consultation or independent medical judgement. Rather, the cancer list is meant to stimulate shared decision making, using a patient-centered approach. New evidence may emerge after the publication of these practices, and regular review of these practices and supporting evidence is recommended. The Canadian Partnership Against Cancer plans on collecting population-based data for several of these practices where feasible, reporting on a baseline for which system-level quality improvement initiatives can be targeted in the future. Authors’ Disclosures of Potential Conflicts of Interest Disclosures provided by the authors are available with this article at jop.ascopubs.org.
Author Contributions Conception and design: Gunita Mitera, Natasha Camuso, Geoff Porter Collection and assembly of data: Craig Earle, Steven Latosinsky, Christopher Booth, Andrea Bezjak, Christine Desbiens, Guila Delouya, Kara Laing Data analysis and interpretation: Gunita Mitera, Geoff Porter Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Gunita Mitera, PhD (C), Canadian Partnership Against Cancer, 1 University Ave, Ste 300, Toronto, Ontario, M5J 2P1 Canada; e-mail: [email protected].
DOI: 10.1200/JOP.2015.004325; published online ahead of print at jop.ascopubs.org.
References 1. Keeney S, Hasson F, McKenna H: Consulting the oracle: Ten lessons from using the Delphi technique in nursing research. J Adv Nurs 53:205-212, 2006
7. Independent UK Panel on Breast Cancer Screening: The benefits and harms of breast cancer screening: An independent review. Lancet 380:1778-1786, 2012
2. Rodríguez-Moranta F, Saló J, Arcusa A, et al: Postoperative surveillance in patients with colorectal cancer who have undergone curative resection: A prospective, multicenter, randomized, controlled trial. J Clin Oncol 24:386-393, 2006
8. Burt RW, Cannon JA, David DS, et al: Colorectal cancer screening. J Natl Compr Canc Netw 11:1538-1575, 2013
3. Fahy BN: Follow-up after curative resection of colorectal cancer. Ann Surg Oncol 21:738-746, 2014 4. Imoto S, Jitsuiki Y: Detection of the first recurrence during intensive follow-up of breast cancer patients. Jpn J Clin Oncol 28:597-600, 1998 5. Khatcheressian JL, Wolff AC, Smith TJ, et al: American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. J Clin Oncol 24:5091-5097, 2006 6. Grunfeld E, Dhesy-Thind S, Levine M: Clinical practice guidelines for the care and treatment of breast cancer: Follow-up after treatment for breast cancer (summary of the 2005 update). CMAJ 172:1319-1320, 2005
e300
JOURNAL
OF
ONCOLOGY PRACTICE
•
9. Moyer VA: Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement Ann Intern Med 156:880-891; w312, 2012 10. Whitlock EP, Lin JS, Liles E, et al: Screening for colorectal cancer: A targeted, updated systematic review for the U. S. Preventive Services Task Force. Ann Intern Med 149:638-658, 2008 11. Lee SJ, Boscardin WJ, Stijacic-Cenzer I, et al: Time lag to benefit after screening for breast and colorectal cancer: Meta-analysis of survival data from the United States, Sweden, United Kingdom, and Denmark. BMJ 346:e8441, 2013 12. Fisher DA, Judd L, Sanford NS: Inappropriate colorectal cancer screening: Findings and implications. Am J Gastroenterol 100:2526-2530, 2005
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rectal cancer,77 and gastric cancer78 are examples of disease sites where resection was advocated in the setting of unresectable or incurable metastatic disease and minimal to no symptomatology of the primary tumor. However, a preponderance of evidence demonstrates that in many cases these therapies do not improve outcome; are associated with significant morbidity; and, at times, delay the more important systemic treatment of metastatic disease.79-82 Most recent guidelines have adopted less aggressive approaches to locoregional therapy in the setting of an asymptomatic to minimally symptomatic primary tumor with unresectable or incurable metastatic disease and instead prioritize systemic therapy.83-85 With such an approach, the modest number of patients who do experience disease progression and develop significant symptoms attributable to the primary tumor can often undergo less extensive locoregional therapies.81,86,87 In some specific situations, extensive locoregional therapies may provide benefit and should be considered on an individual basis. For example, adding nephrectomy to systemic therapy in metastatic renal cell carcinoma has been shown to improve overall survival in two randomized trials.88,89 However, most patients with metastatic disease from solid organ malignancies and a relatively asymptomatic primary tumor should be considered for systemic therapy as a priority; the delay in systemic therapy and potential additional morbidity arising from extensive locoregional therapies should be avoided in these patients.
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13. American Society of Clinical Oncology: 10 Things Physicians and Patients Should Question, 2013 www.choosingwisely.org/doctor-patient-lists/americansociety-of-clinical-oncology/
40. Zimmermann C, Swami N, Krzyzanowska M, et al: Early palliative care for patients with advanced cancer: A cluster-randomised controlled trial. Lancet 383: 1721-1730, 2014
14. Eastern Cooperative Oncology Group: ECOG Performance Status, 2006 www.ecog.org/general/perf_stat.html
41. Smith TJ, Temin S, Alesi ER, et al: American Society of Clinical Oncology provisional clinical opinion: The integration of palliative care into standard oncology care. J Clin Oncol 30:880-887, 2012
15. Pater JL, Loeb M: Nonanatomic prognostic factors in carcinoma of the lung: A multivariate analysis. Cancer 50:326-331, 1982
17. Smith TJ, Hillner BE: Bending the cost curve in cancer care. N Engl J Med 364:2060-2065, 2011 18. Shaw AT, Yeap BY, Solomon BJ, et al: Effect of crizotinib on overall survival in patients with advanced non-small-cell lung cancer harbouring ALK gene rearrangement: A retrospective analysis. Lancet Oncol 12:1004-1012, 2011 19. Hill MJ, Morson BC, Bussey HJ: Aetiology of adenoma– carcinoma sequence in large bowel. Lancet 1:245-247, 1978 20. Levin B, Lieberman DA, McFarland B, et al: Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: A joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 134:1570-1595, 2008 21. Leddin D, Enns R, Hilsden R, et al: Colorectal cancer surveillance after index colonoscopy: Guidance from the Canadian Association of Gastroenterology. Can J Gastroenterol 27:224-228, 2013 22. Ohlsson B, Breland U, Ekberg H, et al: Follow-up after curative surgery for colorectal carcinoma. Randomized comparison with no follow-up. Dis Colon Rectum 38:619-626, 1995 23. Mäkelä JT, Laitinen SO, Kairaluoma MI: Five-year follow-up after radical surgery for colorectal cancer. Results of a prospective randomized trial. Arch Surg 130:1062-1067, 1995 24. Schoemaker D, Black R, Giles L, et al: Yearly colonoscopy, liver CT, and chest radiography do not influence 5-year survival of colorectal cancer patients. Gastroenterology 114:7-14, 1998 25. Jeffery GM, Hickey BE, Hider P: Follow-up strategies for patients treated for non-metastatic colorectal cancer. Cochrane Database Syst Rev 1:CD002200, 2002 26. van Kooten H, de Jonge V, Schreuders E, et al: Awareness of postpolypectomy surveillance guidelines: A nationwide survey of colonoscopists in Canada. Can J Gastroenterol 26:79-84, 2012 27. Urquhart R, Folkes A, Porter G, et al: Population-based longitudinal study of follow-up care for patients with colorectal cancer in Nova Scotia. J Oncol Pract 8:246-252, 2012 28. American Academy of Hospice and Palliative Medicine: Five Things Physicians and Patients Should Question, 2013 www.choosingwisely.org/doctorpatient-lists/american-academy-of-hospice-palliative-medicine/ 29. Foley KM, Gelband H: Improving Palliative Care for Cancer: Summary and Recommendations. Washington, DC, National Academies Press, 2001 30. Field MJ, Cassel CK: Approaching Death: Improving Care at the End of Life. Washington, DC, National Academies Press, 1997 31. Hui D, Elsayem A, De la Cruz M, et al: Availability and integration of palliative care at US cancer centers. JAMA 303:1054-1061, 2010
42. Partridge AH, Seah DS, King T, et al: Developing a service model that integrates palliative care throughout cancer care: The time is now. J Clin Oncol 32:3330-3336, 2014 43. Chow E, Harris K, Fan G, et al: Palliative radiotherapy trials for bone metastases: A systematic review. J Clin Oncol 25:1423-1436, 2007 44. Lutz S, Berk L, Chang E, et al: Palliative radiotherapy for bone metastases: An ASTRO evidence-based guideline. Int J Radiat Oncol Biol Phys 79:965-976, 2011 45. Chow E, van der Linden YM, Roos D, et al: Single versus multiple fractions of repeat radiation for painful bone metastases: A randomised, controlled, noninferiority trial. Lancet Oncol 15:164-171, 2014 46. Fairchild A, Barnes E, Ghosh S, et al: International patterns of practice in palliative radiotherapy for painful bone metastases: Evidence-based practice? Int J Radiat Oncol Biol Phys 75:1501-1510, 2009 47. Popovic M, den Hartogh M, Zhang L, et al: Review of international patterns of practice for the treatment of painful bone metastases with palliative radiotherapy from 1993 to 2013. Radiother Oncol 111:11-17, 2014 48. American Society for Radiation Oncology: 10 Things Physicians and Patients Should Question, 2014 www.choosingwisely.org/doctor-patient-lists/americansociety-for-radiation-oncology/ 49. Klotz L, Emberton M: Management of low risk prostate cancer: Active surveillance and focal therapy. Curr Opin Urol 24:270-279, 2014 50. Cooperberg MR, Lubeck DP, Mehta SS, et al: Time trends in clinical risk stratification for prostate cancer: Implications for outcomes (data from CaPSURE). J Urol 170:S21-25; discussion S26-27, 2003 51. Dahabreh IJ, Chung M, Balk EM, et al: Active surveillance in men with localized prostate cancer: A systematic review. Ann Intern Med 156:582-590, 2012 52. Klotz L: Active surveillance for prostate cancer: Overview and update. Curr Treat Options Oncol 14:97-108, 2013 53. Wilt TJ, Brawer MK, Jones KM, et al: Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 367:203-213, 2012 54. Bill-Axelson A, Holmberg L, Ruutu M, et al: Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 364:1708-1717, 2011 55. Izawa JI, Klotz L, Siemens DR, et al: Prostate cancer screening: Canadian guidelines 2011. Can Urol Assoc J 5:235-240, 2011 56. Klotz L, Zhang L, Lam A, et al: Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. J Clin Oncol 28:126131, 2010 57. Stacey D, Bennett CL, Barry MJ, et al: Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 10:CD001431, 2011 58. Early Breast Cancer Trialists Collaborative Group (EBCTCG), Darby S, McGale P, et al: Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: Meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 378:1707-1716, 2011 59. Clarke M, Collins R, Darby S, et al: Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: An overview of the randomised trials. Lancet 366:2087-2106, 2005
32. Wentlandt K, Krzyzanowska MK, Swami N, et al: Referral practices of oncologists to specialized palliative care. J Clin Oncol 30:4380-4386, 2012
60. James ML, Lehman M, Hider PN, et al: Fraction size in radiation treatment for breast conservation in early breast cancer. Cochrane Database Syst Rev 11: CD003860, 2010
33. Elsayem A, Smith ML, Parmley L, et al: Impact of a palliative care service on in-hospital mortality in a comprehensive cancer center. J Palliat Med 9:894-902, 2006
61. Whelan TJ, Pignol JP, Levine MN, et al: Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med 362:513-520, 2010
34. Gelfman LP, Meier DE, Morrison RS: Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage 36:22-28, 2008
62. Eblan MJ, Vanderwalde NA, Zeman EM, et al: Hypofractionation for breast cancer: Lessons learned from our neighbors to the north and across the pond. Oncology (Williston Park) 28:536-546, 2014
35. Higginson IJ, Finlay IG, Goodwin DM, et al: Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers? J Pain Symptom Manage 25:150-168, 2003
63. Smith BD, Bentzen SM, Correa CR, et al: Fractionation for whole breast irradiation: An American Society for Radiation Oncology (ASTRO) evidencebased guideline. Int J Radiat Oncol Biol Phys 81:59-68, 2011
36. Delgado-Guay MO, Parsons HA, Li Z, et al: Symptom distress, interventions, and outcomes of intensive care unit cancer patients referred to a palliative care consult team. Cancer 115:437-445, 2009
64. Holloway CL, Panet-Raymond V, Olivotto I: Hypofractionation should be the new ‘standard’ for radiation therapy after breast conserving surgery. Breast 19: 163-167, 2010
37. Jordhøy MS, Fayers P, Saltnes T, et al: A palliative-care intervention and death at home: A cluster randomised trial. Lancet 356:888-893, 2000
65. Wang EH, Mougalian SS, Soulos PR, et al: Adoption of hypofractionated whole-breast irradiation for early-stage breast cancer: A national cancer data base analysis. Int J Radiat Oncol Biol Phys 90:993-1000, 2014
38. Elsayem A, Swint K, Fisch MJ, et al: Palliative care inpatient service in a comprehensive cancer center: Clinical and financial outcomes. J Clin Oncol 22: 2008-2014, 2004 39. Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733-742, 2010
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66. Berry DA, Cronin KA, Plevritis SK, et al: Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 353:1784-1792, 2005 67. American Cancer Society: Cancer Treatment & Survivorship Facts & Figures 2012-2013. Atlanta, GA, American Cancer Society, 2012
•
jop.ascopubs.org
e301
Information downloaded from jop.ascopubs.org and provided by at UNIVERSITY LEEDSHEALTH SCIEN on May 20, 2015 from 129.11.21.2 Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
16. Outcomes of cancer treatment for technology assessment and cancer treatment guidelines. American Society of Clinical Oncology. J Clin Oncol 14:671-679, 1996
Mitera et al
68. Smith BD, Smith GL, Hurria A, et al: Future of cancer incidence in the United States: Burdens upon an aging, changing nation. J Clin Oncol 27:2758-2765, 2009 69. Grunfeld E, Levine MN, Julian JA, et al: Randomized trial of long-term follow-up for early-stage breast cancer: A comparison of family physician versus specialist care. J Clin Oncol 24:848-855, 2006 70. Wattchow DA, Weller DP, Esterman A, et al: General practice vs surgicalbased follow-up for patients with colon cancer: Randomised controlled trial. Br J Cancer 94:1116-1121, 2006
trolled trial. Presented at the San Antonio Breast Conference, December 11, 2013 (abstr S2-02) 80. Kleespies A, Füessl KE, Seeliger H, et al: Determinants of morbidity and survival after elective non-curative resection of stage IV colon and rectal cancer. Int J Colorectal Dis 24:1097-1109, 2009 81. Nitzkorski JR, Farma JM, Watson JC, et al: Outcome and natural history of patients with stage IV colorectal cancer receiving chemotherapy without primary tumor resection. Ann Surg Oncol 19:379-383, 2012 82. Cirocchi R, Trastulli S, Abraha I, et al: Non-resection versus resection for an asymptomatic primary tumour in patients with unresectable stage IV colorectal cancer. Cochrane Database Syst Rev 8:CD008997, 2012
72. Murchie P, Nicolson MC, Hannaford PC, et al: Patient satisfaction with GPled melanoma follow-up: A randomised controlled trial. Br J Cancer 102:14471455, 2010
83. National Comprehensive Cancer Network: NCCN clinical practice guidelines in oncology: Colon Cancer, version 3, 2014 www.nccn.org/professionals/physician_gls/pdf/ rectal.pdf
73. Del Giudice ME, Grunfeld E, Harvey BJ, et al: Primary care physicians’ views of routine follow-up care of cancer survivors. J Clin Oncol 27:3338-3345, 2009
84. National Comprehensive Cancer Network: NCCN clinical practice guidelines in oncology: Rectal Cancer, version 3, 2014 www.nccn.org/professionals/physician_gls/pdf/ rectal.pdf
74. Grunfeld E: Looking beyond survival: How are we looking at survivorship? J Clin Oncol 24:5166-5169, 2006 75. Ristovski-Slijepcevic S: Environmental Scan of Cancer Survivorship in Canada: Conceptualization, Practice And Research. Toronto, Canada, Cancer Journey Portfolio, Canadian Partnership Against Cancer, 2008 76. Rapiti E, Verkooijen HM, Vlastos G, et al: Complete excision of primary breast tumor improves survival of patients with metastatic breast cancer at diagnosis. J Clin Oncol 24:2743-2749, 2006 77. Cook AD, Single R, McCahill LE: Surgical resection of primary tumors in patients who present with stage IV colorectal cancer: An analysis of surveillance, epidemiology, and end results data, 1988 to 2000. Ann Surg Oncol 12:637-645, 2005 78. Shridhar R, Almhanna K, Hoffe SE, et al: Increased survival associated with surgery and radiation therapy in metastatic gastric cancer: A Surveillance, Epidemiology, and End Results database analysis Cancer 119:1636-1642, 2013 79. Badwe R: Surgical removal of primary tumor and axillary lymph nodes in women with metastatic breast cancer at first presentation: A randomized con-
e302
JOURNAL
OF
ONCOLOGY PRACTICE
•
85. National Comprehensive Cancer Network: NCCN clinical practice guidelines in oncology: Breast Cancer, version 3, 2014 www.nccn.org/professionals/physician_gls/pdf/ breastl.pdf 86. Poultsides GA, Servais EL, Saltz LB, et al: Outcome of primary tumor in patients with synchronous stage IV colorectal cancer receiving combination chemotherapy without surgery as initial treatment. J Clin Oncol 27:3379-3384, 2009 87. Sarela AI, Yelluri S, Leeds Upper Gastrointestinal Cancer Multidisciplinary Team: Gastric adenocarcinoma with distant metastasis: Is gastrectomy necessary? Arch Surg 142:143-149; discussion 149, 2007 88. Flanigan RC, Salmon SE, Blumenstein BA, et al: Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renalcell cancer. N Engl J Med 345:1655-1659, 2001 89. Mickisch GH, Garin A, van Poppel H, et al: Radical nephrectomy plus interferon-alfa-based immunotherapy compared with interferon alfa alone in metastatic renal-cell carcinoma: A randomised trial. Lancet 358:966-970, 2001 90. Choosing Wisely Canada. www.choosingwiselycanada.org/
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71. Grunfeld E, Mant D, Yudkin P, et al: Routine follow up of breast cancer in primary care: Randomised trial. BMJ 313:665-669, 1996
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AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Choosing Wisely Canada Cancer List: Ten Low-Value or Harmful Practices That Should Be Avoided In Cancer Care The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jop.ascopubs.org/site/misc/ifc.xhtml.
Craig Earle Consulting or Advisory Role: UnitedHealthcare Patents, Royalties, Other Intellectual Property: UpToDate
Guila Delouya Honoraria: Ferring, Bayer, Paladin Consulting or Advisory Role: Bayer Research Funding: Janssen Oncology, Abbvie Travel, Accommodations, Expenses: Donaldson Marphil, Bayer
Christopher Booth No relationship to disclose
Kara Laing Honoraria: Roche Consulting or Advisory Role: Roche Travel, Accommodations, Expenses: Roche, Amgen
Andrea Bezjak No relationship to disclose
Natasha Camuso No relationship to disclose
Christine Desbiens No relationship to disclose
Geoff Porter No relationship to disclose
Steven Latosinsky No relationship to disclose
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Gunita Mitera No relationship to disclose
