As an oncologist, I see a lot of patients who are concerned about their health and want to do everything they can to stay on top of their cancer. One patient that comes to mind is a woman who I saw the other day with stage 1 rectal cancer treated with a trans anal excision alone 1-2 years ago.
She was seeing one of our colorectal surgeons who referred her to me for a second opinion because she felt her local oncologist was ordering unnecessary tests? When I reviewed her medical records, I noticed that she was having PET/CT scans done every six months? If you’re a medical oncologist, you know that this is egregiously excessive for stage 1 rectal cancer! Come to find out that these PET scans were done in the same medical oncologist’s private office. Conflict of interest?
Now, don’t get me wrong – surveillance testing is an important part of cancer treatment, but it’s crucial that we follow evidence-based guidelines to ensure that our patients are receiving appropriate care without unnecessary radiation exposure or healthcare costs. If a patient has low-risk or early-stage breast cancer, colorectal cancer, melanoma, prostate cancer, most guidelines suggest that staging and/or surveillance imaging is completely unnecessary with few exceptions. Perhaps consider focused imaging if concerning symptoms.
Most US medical oncologists and payers follow the NCCN guidelines for guidance on what is appropriate surveillance. These are well-thought-out guidelines that consider a variety of clinical and pathologic factors such as tumor type, stage, patient performance status, age, recurrence risk, and patient preferences.
For example, patients with stage 1 melanoma do not require any staging or periodic imaging unless there are suspicious symptoms to evaluate. Otherwise, visits are based on clinical and physical evaluation alone. This contrasts with high-risk stage 3 or 4 melanoma or colorectal cancer, where periodic imaging may be necessary to catch disease when it is most treatable and possibly curable. For example, local recurrent colorectal cancers, limited resectable liver or lung disease. For melanoma, earlier diagnosis can lead to a greater “window of opportunity” to treat with multiple immuno-therapeutic or targeted therapy options. Why wait till the house is burning down when perhaps we can treat it when it is a burning matchstick?
NCCN guidelines are based on the latest scientific research and are created by experts in the field. They are designed to help healthcare providers provide the best care possible to their patients. Additionally, following guidelines can help reduce healthcare costs and prevent unnecessary procedures and tests. ASCO also promotes a “Choose Wisely” approach when considering potentially unnecessary tests. I could probably add 5 more items to this list per year. Think about it – if you’re a young, healthy individual with no signs of cancer, do you really need to be getting PET/CT scans every six months? Probably not.
On the flip side, if you are a high-risk individual for having recurrent or metastatic cancer in the future based on the initial staging, clinical-pathologic factors, following guidelines may mean getting more frequent imaging tests to catch any potential issues early on. It’s important for oncologists to discuss surveillance plans with their patients and to consider each patient’s unique situation. For example, an elderly patient with multiple health issues may not be a good candidate for aggressive cancer treatment even if their cancer is caught early. Perhaps it would be better to consider imaging if the patient develops symptoms. Surveillance is important for providing the best care possible to our patients. By following our evidence-based guidelines and tailoring treatment plans to each individual patient, we can ensure that our patients are receiving appropriate care without unnecessary costs or risks.
About the author
Dr. Sajeve Thomas is a distinguished medical professional and a compassionate guide in the field of oncology. With over a decade of dedicated experience as a board-certified medical oncologist/internal medicine specialist, Dr. Thomas has become a trusted expert in the treatment of melanoma, sarcoma, and gastrointestinal conditions. Currently practicing at the renowned Orlando Health Cancer Institute, he brings a wealth of expertise to the complex and challenging world of oncology.
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