Commission on Cancer

Five Things Physicians and Patients Should Question

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1

Don’t perform surgery to remove a breast lump for suspicious findings unless needle biopsy cannot be done.

  • Needle biopsy is large bore core biopsy or vacuum-assisted large bore needle for histology or fine needle aspiration for cytology.
  • Needle biopsy may be directed by breast imaging (ultrasound, mammographic, magnetic resonance imaging) or by direct palpation.
  • Studies show that confirmation of breast cancer diagnosis prior to any surgery allows for complete multidisciplinary treatment counseling, reduces the overall number of surgical procedures needed for treatment, improves the cosmetic results of surgery and avoids mastectomy resulting from multiple surgical procedures.
  • Use of needle biopsy also makes surgery altogether unnecessary for the majority of image detected breast lesions that require biopsy but prove to be benign.
  • Needle biopsy is generally less costly than open surgical biopsy.
  • Some breast lesions require surgical biopsy because of a location in the breast that precludes image localization. This may apply to 10–15% of breast lesions. Surgeons performing surgical breast biopsy without preceding needle biopsy should document the reason for no needle biopsy.
2

Don’t initiate surveillance testing after cancer treatment without providing the patient a survivorship care plan.

  • Inappropriate or overused testing after cancer treatment is common, but provides no value in surveillance for recurrence and often leads to other unnecessary tests, potential morbidity, anxiety, uncertainty and higher cost.
  • A survivorship care plan provides the patient and their primary providers an evidence-based road map for surveillance testing and supportive care.
  • The Institute of Medicine identified the need for a survivorship care plan as a key factor to help cancer patients transition to long term surveillance care, avoid unnecessary services, and seek appropriate rehabilitative care and emotional support.
  • A survivorship care plan includes a summary of the type and stage of the cancer, treatment received, the plan for type and frequency of surveillance testing, and information on resources for rehabilitative and supportive care.
  • Templates for survivorship care plans are available from organizations including the Livestrong Foundation, the National Coalition for Cancer Survivorship, and the American Society of Clinical Oncology.
3

Don’t use surgery as the initial treatment without considering pre-surgical (neoadjuvant) systemic and/or radiation for cancer types and stage where it is effective at improving local cancer control, quality of life or survival.

  • In many cancer types, presurgical chemotherapy, hormone/endocrine therapy and/or radiation therapy followed by surgery is better than surgery as the first treatment. This often shrinks the cancer, allowing more limited surgery that maintains organ function, reduces the chances of cancer recurrence and spread, and improves the quality of life.
  • For example, pre-surgical therapy may make mastectomy unnecessary with breast cancer, a colostomy unnecessary with rectal cancer, voice-sparing surgery possible with laryngeal cancer and amputation unnecessary with extremity soft tissue sarcoma.
  • When used appropriately, there is no evidence that the cancer spreads during pre-surgical therapy and that cancer survival is the same or better as with initial surgery.
  • Despite its known advantages, many people are not provided the advantages of pre-surgical therapy.
  • Disease sites where this should be considered include:
    • Clinical Stage IIB and IIIA Non Small Cell Lung Cancer
    • Clinical T2-4a; Any N positive esophageal cancer
    • Clinical T3 and T4 rectal cancer
    • Clinical T2, T3 or Stage III breast cancer
    • Head and Neck cancer
    • Resectable pancreas cancer
    • Extremity soft tissue sarcomas where resection may affect functional outcomes.
4

Don’t perform major abdominal surgery or thoracic surgery without a pathway or standard protocol for postoperative pain control and pneumonia prevention.

  • Uncontrolled pain and pneumonia after major abdominal and thoracic surgery are factors that lead to other serious complications and prolonged hospitalization.
  • Coordinated care efforts and established care pathways to control pain and prevent pneumonia reduce the frequency of complications and reduce length of hospital stay and should be in place.
  • Fewer pulmonary complications occur when adequate analgesia is provided making postoperative pain protocol and pulmonary plan as essential elements of care.
    • Facilities that conduct flow analyses in patients with lung cancer have improved quality care.
  • Institutions or hospitals in collaboration with the surgeons and other medical staff should develop these pathways, standard protocol or procedures and assure their implementation.
    • Improvement efforts need to address documentation and standardization of process of care.
5

Don’t initiate cancer treatment without defining the extent of the cancer (through clinical staging) and discussing with the patient the intent of treatment.

  • Treatment intent may be diagnostic, curative, maintenance, or palliative.
  • Many patients, especially those with advanced or metastatic cancer, do not have a full understanding of the intent of cancer treatment – they identify that treatment may be curative when in fact it is given only with palliative intent. They often do not understand the costs, risks and potential side effects of the treatment.
  • Palliative therapy may provide relief of symptoms or short term prolongation of survival, but often can cause substantial toxic effects and can interfere with the patient’s quality of life.
  • This directive should be applied to all phases of cancer treatment from initial therapy to treatment for recurrent and metastatic cancer.
  • Clinical staging should be performed and documented using information from history and physical examination, relevant biopsy, and appropriate imaging based on the type and stage (extent) of the cancer.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The Commission on Cancer (CoC) is a consortium of 50 professional organizations dedicated to improving survival and quality of life for cancer patients through standard-setting, prevention, research, education, and the monitoring of comprehensive quality care.

Established by the American College of Surgeons in 1922, the multidisciplinary CoC establishes standards to ensure quality, multidisciplinary, and comprehensive cancer care delivery in health care settings; conducts surveys in health care settings to assess compliance with those standards; collects standardized data from CoC-accredited health care settings to measure cancer care quality; uses data to monitor treatment patterns and outcomes and enhance cancer control and clinical surveillance activities, and develops effective educational interventions to improve cancer prevention, early detection, cancer care delivery, and outcomes in health care settings. For more information, visit www.facs.org.

How this list was created: The American College of Surgeons concluded in its review of this opportunity that it was optimal to submit a separate list of interventions related to cancer from the American College of Surgeons Commission on Cancer. The Commission on Cancer appointed a multidisciplinary task force that met in person in September, 2012 and subsequently by conference call and electronic communications.

Recommendations for candidate interventions were solicited from panel members and other leaders from the Commission on Cancer. These panel members were provided a written charge to identify measures that would support the Commission’s standards for accreditation in use in more than 1,500 cancer programs across the U.S. In addition, panel members were provided with a full description of the Choosing Wisely® campaign and the interventions previously recommended by other organizations both for cancer and all other disorders.

Following initial submission of the candidate interventions, the panel discussed each intervention specifically evaluating the significance of the intervention, the potential scope of variation in care affected by the intervention, and the potential numbers of persons affected by this. The group also discussed the impact on short-term and long-term cost to be gained by implementation of each intervention. The panel voted on each intervention to select the final list of recommended interventions. The panel members then reviewed and refined the wording of each intervention and completed the bulleted supporting documentation and literature citations. The final list of interventions was then approved by the panel and submitted to the leadership of the American College of Surgeons for final approval. The Commission on Cancer’s disclosure and conflict of interest policy can be found at www.facs.org.

Commission on Cancer Panel Members

  • Stephen Edge, MD, FACS, Chair, Roswell Park Cancer Institute, Buffalo, NY
  • David Bentrem, MD, FACS, Northwestern Memorial Hospital, Chicago, IL
  • Daniel Kollmorgen, MD, FACS, University of Iowa, Des Moines, IA
  • Daniel McKellar, MD, FACS, Wayne Healthcare, Greenville, OH
  • Christopher Pezzi, MD, FACS, Abington Memorial Hospital, Abington, PA
  • Lee Wilke, MD, FACS, University of Wisconsin Health System, Madison, WI
  • David Winchester, MD, FACS, Medical Director, Cancer Programs, American College of Surgeons

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