Room for improvement in post-treatment cancer surveillance guidelines
medwireNews: Surveillance recommendations in national guidelines for the post-treatment care of cancer survivors are often nonspecific and inconsistent, indicate study findings.
Researcher Ryan Merkow (Memorial Sloan Kettering Cancer Center, New York, USA) and co-authors, who analyzed 41 North American and European national-level guidelines across nine tumor types, explain that “[t]he specificity and consistency of recommendations across guidelines is particularly important because survivorship care is increasingly transitioned to clinicians with less familiarity with specific cancers.”
However, they found that the large majority (83%) contained ambiguous recommendations, that is, ones that were neither for nor against a particular mode of surveillance, be it history and physical examinations, tumor markers, diagnostic procedures (eg, colonoscopy), or imaging.
As reported in JAMA Internal Medicine, European guidelines were significantly more likely than North American ones to contain ambiguous recommendations.
There was also some inconsistency across guidelines addressing the same cancer type. For instance, although all six breast cancer guidelines included in the study recommend mammography for surveillance, computed tomography scans were recommended against in two, discussed without a clear recommendation in one, and not mentioned in three.
The majority of guidelines specified the testing frequency, with 88% of guidelines providing this information for tumor markers, 90% for history and physical examinations, and 92% for diagnostic procedures and/or imaging.
But a definitive stop time for history and physical examinations was given in just 31% of guidelines, while 38% of guidelines gave this information for tumor markers and the same proportion for diagnostic procedures and/or imaging.
“Reasons for infrequent stop times are unclear, although there is a clear decreased risk of recurrence over time for most malignant neoplasms, and few surveillance modalities are required indefinitely. However, [primary care physicians] may be reluctant to halt testing without clear recommendations on when to do so,” say the study authors.
Additionally, just 34% of guidelines included risk-based recommendations, which “likely reflects the limited data available to help instruct surveillance programs,” they comment. Merkow et al believe that other barriers could be “the inherent complexity of developing them and perhaps the perceived challenges with clinician interpretation.”
But they stress that “risk-based recommendations are likely to provide a more efficient, cost-effective approach to patient follow-up, and further incorporation of risk into surveillance recommendations would improve their usefulness.”
Noting that unclear and imprecise recommendations can present challenges for all healthcare providers in the oncology setting, the team concludes: “As guidelines continue to be revised, developers should clarify recommendations with simple, nonambiguous, definitive language for or against the use of specific tests to optimize care quality and resource utilization.”
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