VOLUME

33



NUMBER

14



MAY

10

2015

JOURNAL OF CLINICAL ONCOLOGY

C O R R E S P O N D E N C E

Fewer Scans, Better Care TO THE EDITOR: Thompson et al1 recently reported in Journal of Clinical Oncology on the lack of utility of surveillance scans in patients with diffuse large B-cell lymphoma (DLBCL) who have reached complete remission and have no signs or symptoms of recurrence. As the authors properly cited, prior studies have shown that asymptomatic recurrences detected by computed tomography (CT) or positron emission tomography scans are rare and do not carry a better prognosis than symptomatic recurrences, despite the “help” of both lead time and length time bias.2-4 It is disappointing, however, that the prior literature as well as the Thompson et al study, first presented in June 2013 at the American Society of Clinical Oncology annual meeting, are not reflected in the most recent update of National Comprehensive Cancer Network (NCCN) guidelines5 that recommend CT scans “no more often than once every 6 months for up to 2 years after completion of therapy.” Similarly, the American Society of Hematology Choosing Wisely initiative recommends that physicians “limit surveillance computed tomography (CT) scans in asymptomatic patients following curativeintent treatment for aggressive lymphoma.”6 Even though both recommendations aim at reducing use of surveillance scans, they provide endorsement for the use of some surveillance scans and, in the case of the NCCN guideline, even suggest a schedule for that. This is no longer justifiable in face of the abundant evidence that surveillance scans do not improve outcomes and the considerable risk that it may hurt patients while substantially escalating the cost of care. The use of recommendations such as “do not perform surveillance CT scans in asymptomatic patients with aggressive lymphoma in remission” would be better aligned with the existing evidence. Coverage restrictions would be likely to unfold, but we would not be responsible citizens by defending payment for an intervention that has no value. Thomspon et al refrained from analyzing the cost implications of surveillance scans. However, compliance with the suggested NCCN schedule of scans would cost approximately $4,000 per patient (assuming the conservative cost of $1,000 per scan). Because only 1.6% of patients in complete remission will have a recurrence diagnosed by CT scans while asymptomatic, even if we make the exaggerated assumption that those individuals would have a 1-year gain in survival, the surveillance strategy would have an astronomical incremental costeffectiveness ratio of approximately $250,000 per year, unacceptable by most standards. I have heard from colleagues (and experienced myself) how awkward DLBCL follow-up visits can be without CT scans to review. This reflects our societal and medical culture, in which too much emphasis

is placed on ancillary studies and technology. Thompson et al show that although asymptomatic recurrences detected in scans are rare, approximately one third of the recurrences are captured at previously scheduled “routine” visits by interviewing and examining patients and obtaining a simple and inexpensive blood test (LDH). Without CTs to review, we will have plenty of time to interview and examination our patients. Lastly, we should question the notion that surveillance CT scans continue to be acceptable in the setting of clinical trials when progression-free survival is an end point. Even if the cost of those scans are covered by the trial sponsor, often but not always a powerful drug company, the potential harm of contrast-induced nephrotoxicity, radiation exposure, and unnecessary follow-up tests and biopsies for false-positive findings do remain. Asymptomatic DLBCL relapses are rare anyway, a fact that would not change in clinical trial subjects. As suggested by Thompson et al, it is far more important to ensure that clinical trial subjects in complete remission after initial therapy adhere to a planned schedule of clinical visits and that scans are performed when recurrence is suspected.

Luciano J. Costa University of Alabama at Birmingham, Birmingham, AL

AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Disclosures provided by the authors are available with this article at www.jco.org. REFERENCES 1. Thompson CA, Ghesquieres H, Maurer MJ, et al: Utility of routine posttherapy surveillance imaging in diffuse large B-cell lymphoma. J Clin Oncol 32:3506-3512, 2014 2. Nakamura K, Sasaki M, Kunitake N, et al: Relapse patterns of localized non-Hodgkin’s lymphoma of the head and neck after clinical remission: Results of a strict follow-up procedure. Int J Clin Oncol 6:302-305, 2001 3. Liedtke M, Hamlin PA, Moskowitz CH, et al: Surveillance imaging during remission identifies a group of patients with more favorable aggressive NHL at time of relapse: A retrospective analysis of a uniformly-treated patient population. Ann Oncol 17:909-913, 2006 4. Goldschmidt N, Or O, Klein M, et al: The role of routine imaging procedures in the detection of relapse of patients with Hodgkin lymphoma and aggressive non-Hodgkin lymphoma. Ann Hematol 90:165-171, 2011 5. Zelenetz AD, Gordon LI, Wierda WG, et al: NCCN Guidelines Version 4.2014: Non-Hodgkin’s Lymphomas. http://www.nccn.org/professionals/physician_gls/ f_guidelines.asp#site 6. Choosing Wisely: American Society of Hematology: Ten Things Physicians and Patients Should Question. Washington, DC, American Society of Hematology, 2013. http://www.choosingwisely.org/doctor-patient-lists/american-societyof-hematology/

DOI: 10.1200/JCO.2014.59.5207; published online ahead of print at www.jco.org on March 23, 2015

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© 2015 by American Society of Clinical Oncology

Journal of Clinical Oncology, Vol 33, No 14 (May 10), 2015: pp 1624

Information downloaded from jco.ascopubs.org and provided by at The Chinese University of Hong Kong on November 18, Copyright © 2015 American of Clinical Oncology. All rights reserved. 2015Society from 137.189.170.231

Correspondence

AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Fewer Scans, Better 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 jco.ascopubs.org/site/ifc. Luciano J. Costa Research Funding: Onyx

www.jco.org

© 2015 by American Society of Clinical Oncology

Information downloaded from jco.ascopubs.org and provided by at The Chinese University of Hong Kong on November 18, Copyright © 2015 American of Clinical Oncology. All rights reserved. 2015Society from 137.189.170.231

Fewer scans, better care.

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