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Cancer surveillance guidelines lack specificity, consistency

Recommendations for surveillance after cancer treatment in survivors across guidelines are often nonspecific and inconsistent; therefore, clarification for or against the use of specific tests is warranted in current guidelines, according to findings published in JAMA Internal Medicine.

“Primary care clinicians, who are increasingly responsible for caring for the growing population of cancer survivors, may be unfamiliar with appropriate cancer surveillance strategies,” Ryan P. Merkow, MD, MS, from the department of surgery at Memorial Sloan Kettering Cancer Center, and colleagues wrote. “Clinical practice guidelines can inform cancer follow-up care and surveillance testing. Vague recommendations and inconsistencies among guidelines can lead to overuse and underuse of health care resources and have a negative impact on cost and quality of survivorship care.”

To evaluate the specificity and consistency of cancer guidelines for the posttreatment care for survivors, Merkow and colleagues performed a retrospective cross-sectional analysis of 41 national cancer guidelines from North America and Europe published between Jan. 1, 2010 and March 1, 2016 addressing surveillance testing in survivors of nine common cancers, including breast, colorectal, non–small cell lung, prostate, melanoma, uterine corpus, bladder, thyroid and testicular cancer. They examined the frequency and stop date for each recommendation, the consistency among guidelines and the associations between the developers of the guidelines and recommendation characteristics.

Surveillance modalities were categorized as history and physical examinations, tumor markers, diagnostic procedures and imaging. Individual recommendations within each guideline were classified as either a risk-based recommendation, recommendation for surveillance, addressed but no clear recommendation, recommendation against surveillance or cases in which surveillance was not addressed. The researchers noted that 85% of the guidelines analyzed were from professional organizations and 49% were from North America.

Results indicated that 83% of guidelines contained ambiguous recommendations, defined as not discussing modality or discussing without a clear recommendation. Recommendations against at least one surveillance test were seen in 44% of guidelines. Ambiguous recommendations were more frequent in European guidelines (100%) than North American guidelines (68%). A majority of guidelines (90%) across all cancer types recommended medical history and physical examinations for surveillance testing, while other surveillance assessments, including imaging (83%), endoscopic procedures (63%) and tumor markers (56%), were less frequently mentioned and varied more among cancer type.

Testing frequency was frequently specified in the assessed recommendations – from 88% for tumor markers to 92% for procedures and/or imaging. However, a definitive stop time was not commonly cited. Guidelines for each cancer had differing cross-sectional imaging recommendations.

“The number of cancer survivors is growing, and optimizing cancer surveillance is an important issue for individual patients, payers, and clinicians,” Merkow and colleagues concluded. “Our review of 41 surveillance recommendations from clinical practice guidelines across 9 cancer types found a lack of specificity and consistency that hinders optimal patient care. As cancer guidelines are reviewed and revised, we believe developers should clarify recommendations with simple, nonambiguous, definitive language for, or against, the use of specific tests and specific recommendations based on patient risk.” – by Alaina Tedesco

Disclosure: The researchers report receiving support from the National Institute of Health/National Cancer Institute (NIH/NCI), the Kaiser Foundation Health Plan and the Laura and John Arnold Foundation.