When the diagnosis is cancer, many people understandably want to pull out all the stops to treat it. But some tests, treatments and procedures not only are unnecessary but also can be harmful.
“Sometimes less really is more,” says Lowell E. Schnipper, chief of hematology-oncology at Beth Israel Deaconess Medical Center in Boston and clinical director of the Boston institution’s cancer center. “It’s important to assess if what you are doing will help you stay well longer.”
Schnipper heads an expert task force that is identifying cancer-related tests and treatments that are not supported for most patients by evidence. The panel was convened by the American Society of Clinical Oncology.
Here is the panel’s list of cancer tests or treatments to question.
In diagnosing cancer, doctors use tissue and biochemical analysis to “stage” the disease — that is, to find out how aggressive it is and whether it has the potential to invade other parts of the body. If, based on those tests, it appears likely that the cancer has spread, or metastasized, doctors can proceed with imaging tests to find out where else in the body the cancer is lurking.
If staging indicates that a patient has a tumor with a low risk of metastasis, ASCO recommends against imaging tests. Low-risk tumors include:
●Early breast cancer at stages I and II, and at stage 0 (ductal carcinoma in situ, in which the cancer is confined to the ducts of the breast).
●Early-stage, low-grade prostate cancer with a Gleason score of 6 or lower and a PSA level of less than 10 nanograms per milliliter.
The specific imaging tests to avoid in early-stage breast and prostate cancers include computed tomography (CT or CAT) scans, positron emission tomography (PET) scans and bone scans. ASCO recommends against them for patients with low-risk tumors because it’s unlikely that the cancer has spread, so the risks of imaging far outweigh any potential benefit.
What to ask: What stage is my cancer? Are CT, PET or bone scans recommended? If you have an early-stage, low-grade cancer, you should question the need for those tests. On the other hand, if there’s a possibility that the cancer is advanced and your doctor doesn’t suggest imaging, ask why.
Some cancer treatments make patients vulnerable to infections. To help decrease the risk, doctors can prescribe white blood cell growth factors, also called hematopoietic (blood-forming) colony-stimulating factors (CSFs), along with chemotherapy.
However, CSFs also have dangerous downsides: They cost as much as $3,900 per dose, may require daily injections and may cause such side effects as fatigue and bone pain. ASCO recommends that only high-risk patients take CSFs.
What to ask: Does my treatment or other factors put me at high risk for low white blood cells? If so, would I benefit from being treated with a CSF?
After being treated for cancer, the first question many people ask is “How will I know if my disease has returned?” For most patients who have had breast cancer, appropriate follow-up means annual mammograms and a breast exam by an experienced clinician every six months. Some women may also benefit from magnetic resonance imaging (MRI) of the breast.
For patients who had early breast cancer and are now symptom-free, ASCO recommends against tumor marker tests and imaging of parts of the body other than the breasts. Such testing has not been shown to lengthen lives and, in fact, often leads to anxiety, wrong diagnoses and overtreatment due to false-positive results. But for patients with advanced cancer and those who experience new symptoms, such as breast lumps, pain or shortness of breath, those tests may be appropriate to help determine if the cancer has spread.
What to ask: What tests will I need and how often? If you’re disease-free and don’t have symptoms, question the need for tumor marker tests or imaging of other parts of the body. Also ask about symptoms to look out for.
Even with the best care, cancer may continue to grow and spread. The question then becomes “What’s next?” The decision to discontinue cancer-directed therapy is difficult. But shifting to a treatment plan focused on meeting the physical, mental and spiritual needs of the patient and family can enhance the quality and sometimes even the length of time patients have left.
The evidence shows that, in most cases, if a form of cancer has grown or spread after three different treatment regimens, further anti-cancer therapy doesn’t improve survival. In fact, the treatment might cause such severe side effects that it hastens death.
What to ask: What’s my prognosis and expected life span? Is there evidence that further cancer-directed therapy will help me? Are there steps I can take that would improve my quality of life? Do you recommend meeting with a palliative-care specialist?