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58 views8 pagesOncología Parte 1
Uploaded by
Claudia María Mejía QuintanillaCopyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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/ 8
Oncology High Value Care
Recommendations
‘The American College of Physicians, in collaboration with
multiple other organizations, is engaged in a worldwide
initiative to promote the practice of High Value Care
(HVC). The goals of the HVC initiative are to improve
health care outcomes by providing care of proven benefit
and reducing costs by avoiding unnecessary and even
harmful interventions. The initiative comprises several
programs that integrate the important concept of health
care value (balaneing clinical benefit with costs and
harms) for a given intervention into a broad range of
educational materials to address the needs of trainees,
practicing physicians, and patients.
HVC content has been integrated into MKSAP 19 in sev-
eral important ways. MKSAP 19 includes HVC-identified
key points in the text, HVC-focused multiple-choice ques-
tions, and, in MKSAP Digital, an HVC custom quiz. From
the text and questions, we have generated the following,
list of HVC recommendations that meet the definition
below of high value care and bring us closer to our goal
of improving patient outcomes while conserving finite
High Value Care Recommendation: 4 recommendation to
choose diagnostic and management strategies for patients
{in specific clinical situations that balance clinical benefit
with cost and harms with the goal of improving patient
outcomes.
Below are the High Value Care Recommendations for the
Oncology section of MKSAP 19.
+ Imaging studies such as PET, CT, or bone sean for staging
are not recommended in asymptomatic patients with
newly diagnosed stage 0 to II breast cancer,
+ Surveillance blood tests and other imaging tests for breast
‘cancer should not be routinely performed and should be
guided by a patient’s symptoms or findings on examina-
ton that raise concern for recurrence.
Neither radiation therapy nor hormonal therapy provides
benefit ater bilateral mastectomy for patients with ductal
carcinoma in situ (see Item 70).
* Multigene recurrence assays or gene expression profiles
have dramatically improved the ability to avoid chemo-
therapy for patients at low risk of recurrence who will
not benefit from chemotherapy and to identify patients
at greater risk who do benefit from chemotherapy (see
Item 45).
Consensus guidelines indicate that pregnancy after breast
cancer should not be discouraged (see Iter 16).
+ Second-look laparotomy to assess pathologic response
following chemotherapy of ovarian cancer should not be
performed,
Annual cervical or vaginal cytology should be done on all
cervical cancer survivors; additional surveillance imaging
and laboratory studies for cervical cancer survivors are
recommended only if there are signs or symptoms sug
gestive of recurrence,
‘+ PET scans should not be used for preoperative staging or
postoperative surveillance in colorectal cancer.
PET scans do not add value in the staging of pancreatic
cancer and are not part of standard management,
Well-differentiated neuroendocrine tumors are indolent
and often initially only require observation and serial
Imaging.
‘Anal cancer is often curable with combined irradiation,
and chemotherapy; surgery is typically not indicated
(Gee Item 22).
Patients with poor performance status and advanced
‘non-small cell lung cancer without a driver mutation do
‘not benefit from chemotherapy nor immunotherapy and
are best served with supportive care (see Item 25)
+ Routine imaging for head and neck cancer after a nega-
tive posttreatment scan Is not indicated unless signs and
symptoms suggest recurrent disease,
Although patients who receive radiation therapy that
includes the thyrold bed are at increased tisk of thyroid
‘cancer, screening thyroid ultrasonography is not
Indicated
In men with low-risk prostate cancer, active surveillance
{sa reasonable strategy because some men will never
require treatment, and outcomes are no worse if men.
‘with low. grade cancer are treated at the time of progres:
sion rather than when first diagnosed (see Item 38)
Patients with prostate- specific antigen-only recurrence
‘of prostate cancer may be treated with androgen depri
vation therapy, although observation is also a reasonable
choice.
+ Patients with CT findings pathognomonic for renal cell,
carcinoma do not need a biopsy to confirm the diagnosis.
Chronic lymphocytic leukemia is typically an indolent
dlisease, and many patients require no therapy for many
years (see Item 49)
Physical examination and PET/CT are used to stage
patients with Hodgkin lymphoma; laparotomy and.
splenectomy are no longer performed.
* Chemotherapy without irradiation is a treatment option
{or early-stage Hodgkin lymphoma after a complete ‘metabolic response assessed by interim PET/CT after (wo
to three cycles of treatment (risk-adapted therapy) (see
Item 36).
* Inpatients with a metastatic cancer of unknown primary
site, CT and histologic, endoscopic, and gender-specific
cancer evaluations are reasonable; however, nonspecific
‘tumor markers, PET, and gene expression arrays should
not be done,
* Palliative or hospice care is appropriate for patients with
‘an unfavorable subtype of cancer of unknown primary
site who have comorbidities and poor performance
status.
‘+ Nodal metastases are uncommon in thin melanomas
(Breslow depth less than 0.8 mm) and need not be
assessed
‘+ Most patients with neutropenic fever should be managed
‘with monotherapy with an antipseudomonal B-lactam
agent.
‘+ There is no better therapeutic success but rather an
Increased risk of toxicity from adding an aminoglycoside
toa broad-spectrum B-lactam in the treatment of febrile
neutropenia (see Item 33)
+ Growth factors are not routinely used in the treatment
of patients with neutropenic fever unless the patient has
severe neutropenia («100/iL [0.1 x 10/L]) expected to
last more than 10 days o has other high-risk features,
+ Loop diuretics are not indicated in the treatment of
hypercalcemia of malignancy unless kidney failure or
heart fallure is present; in these circumstances, intrave-
nous expansion of vascular volume should precede the
administration of loop diuretics (see tem 43).
* Spinal cord compression from radiosensitive tumor
types, such as leukemia, Iymphoma, myeloma, and germ
cell tumors, may not require initial surgical decompres-
sion; instead, patients may be treated urgently with radi-
ation therapy alone (see Item 63). Oncology
Issues in Oncology
Introduction
Medical oncology is undergoing constant change and
Improvement. Among the most important advances of the
ppast decade has been the incorporation of immune check-
point inhibitors into the standard treatment of many malig
nancies. These agents, although not directly attacking the
patient's cancer, deactivate checkpoints that would other
wise suppress the immune system, and so facilitate the
patient's own immune surveillance efforts to destroy the
cancer. Another major advance includes the expanded role of
molecular profiling and precision therapeutics. Current
techniques allow for genomic profiling of tumor tissue,
cither from fresh biopsies from archived, paraffin-embedded
specimens, or from blood-based tumor mutation profiting,
With the knowledge of the mutational profile, oncologists
‘can make more informed decisions in the selection and
rejection of different therapeutic options and inclusion of
so-called targeted therapies that are designed to Inhibit a
particular molecular mutation or aberration. However, many
traditional aspects of oncology, including the use of histologic
diagnosis and clinical staging, as well as extensive use of
cytotoxic chemotherapy, radiation therapy, and surgery,
remain central to current oncologic practice. The cancer care
continuum Is now recognized to include not only diagnosis
and treatment but also supportive/palliative care, survivor
ship care, and end-of-life care.
Careful clinical evaluation and staging, understanding
and communicating realistic goals of care, and recognizing
‘and promoting patient preferences remain central to the prac
tice of oncology. Meaningful progress has been made in many
types of cancer, However, most cancers, once metastasized,
although treatable with substantial potential for improve
‘ments in overall survival and quality of life, are still incurable.
Supportive management of adverse effects has also Improved:
however, the adverse effects of cancer chemotherapy remain,
problematic for many patients, and sensitivity t0 the risks
‘versus benefits must be considered when discussing treatment
‘options with patients. Burdensome increases in the cost of
new oncology drugs has become a focus of concern, Some of
these high-cost drugs are highly active and offer substantial
benefits, whereas others result in survival advantages meas-
tured in months or even weeks that, although statistically sig-
rlficant, are of debatable clinical relevance. The impact of
financial toxicity has become an important consideration in,
‘oncologic care.
Staging
To plan a treatment strategy a clinilan must fst determine
thestage, or extent, ofthe cancer. arly stage cancersar often
«aired by local therapy, such as surgery or tradiaton, whereas
‘more advanced-stage cancers require a systemic approach.
Solld tumors are staged using the TNM system. In the TNM
system, T(TI-T4) refers to thesize or extent of local invasion of
the primary tumor, N (NO-N3) indicates locoreyional Iymph
node involvement, and M indicates th absence (MO) or pres-
ence (MI) of distant metastases. Some hematologle (liquid)
tumors have unique tumor-specific staging systems.
Approprtate Imaging techniques depend on the expected
behavior pattern of each cancer type and differ from one
tumor type to the next. Therefore, a proper cancer evaluation
requites knowledge of the specific disease ently so that the
necessary tests can be done and unnecessary tests avoided.
“Tests with very low yield should not be ordered in te absence
‘of specific directing symptoms. For example, bone and brain
Imaging 1s appropriate Inthe staging of patients with lung
cancer because bone and braln metastases are common and
‘may be asymptomatic, However, in patients with presumed
locoregional colorectal cancer, asymptomatic bone or brain
‘metastases are exceedingly rare; consequently routine imag-
{ng of these sites is not warranted, Staging ina patient with
cancer is generally the most accurate indicator of prognosis
and largely dictates the therapeutic strategy
REYES NTS ET
‘+ Most sold tumors are staged using the TM cancer staging
system, In which T represents the siz or extent of local
invasion ofthe primary tumor (T1-T4), N indicates locore-
sional lymph node involvement (NO-N3), and M indicates
the absence (MO) or presence (MI) of distant metastases.
‘Appropriate cancer-staging imaging techniques depend
‘on the expected behavior pattern of each cancer type;
‘therefore, proper cancer evaluation requires knowledge
‘of the specific disease entity so that the necessary tests
ccan be done and unnecessary tests avoided,
‘+ Within a particular type of cancer, staging is generally
the most accurate prognostic indicator and largely dic
tates the therapeutic strategy.
Performance Status
Performance status is a means of quantifying how medically
‘At a patient Is. A good performance status predicts favorable
1 Issues in Oncology
{olerance and response to treatment. Patients with a poor per~
formance status are muuch more likely to experience serious oF
life-threatening toxicity and much less likely to benefit from
treatment.
Is important to differentiate patients with a poor perfor:
‘mance status who are debilitated due to chronic comorbidities
from patients who would otherwise be medically fit but are
acutely debilitated by thelr cancer. The latter situation may
‘warrant an attempt at aggressive treatment because reversing
the cancer is the only strategy that will improve the patient's
‘overall condition, whereas the former may need to be treated
‘with less aggressive treatment or possibly no specific antican-
cer treatment. Cancer drug approvals are based on clinical
trials, virtually all of which limit participants to patients with,
‘good performance status, so the degree to which the results of
these trials are relevant to patients with poor performance
status is limited,
Age alone should not bea reason to avold aggressive treat-
‘ment. Elderly patients who are otherwise medically fit and
healthy and have a good performance status may tolerate
aggressive therapy well.
‘The two most commonly used performance status sales
are the Karnofsky Performance Seale and the Fastern
(Cooperative Oncology Group/ World Health Organization sys-
tem (also called the Zubrod scale). These are outlined and
contrasted in Table 1
POINT RITES
+ Patients with poor performance status may be divided
into two groups: patients who are debilitated by chronic
comorbidities and may need less aggressive treatment
‘and those who are debilitated by the cancer but are oth-
cerwise medically fit and might benefit from aggressive
treatment.
+ Most clinical trials used to determine treatment efficacy
and safety are based on patients with good performance
status; the results of such trials should generally not be
expected in patients with poor performance status.
Goals of Therapy
Clear and candid communication between clinicians and
pitients is essential for good oncologic are. When communt-
cating treatment options and recommendations, clintians
‘must work to establish realistic treatment goals. When a cure
{snot realistically possible, goals such as lengthening survival,
shrinking a tumor, controlling disease growth, palliation or
preventing disease-related symptoms, and maintaining qual-
ity of fe should be discussed. The potential benefits of treat
‘ment must be weighed and considered against thetr risks and.
toxicities. Patients with incurable eancer face choices of more
aggressive therapy designed to prolong their life, associated
ECOG/WHO Performance Status"
(0- Fully active; no resticlions on actives
11-Unable to do strenuous atiitos, But able to carry outofice work, ight housework, or sedentary activites
2-Able towalk and manage self-care, but unable to work; outof bed or chair >50% of waking hours
3-Confined to bed or chair>50% of waking hours; capable of limited self-care |
‘4-Moribund. Fully confined toa bed or chair unable to do any self-care
5-Death
Karnofzky Performance Status
[7100-Normal: ne symptoms or evidence of disease
90- Minor symptoms, butable to caeryon normal activities
| 80- Some symptoms; normal activity requires fort
| 70- Unable to cary on normal activities, but able to care for self
40 - Disabled: needs special care and assistance
30- Severely disabled; hospitalized
| 20-Veryil significant supportive care isneeded
10 Actively dying
0-Death
{60- Needs frequent care for most noeds; some occasional assistance with cocare
50- Needs considerable assistance with self-care and frequent medical care with more unpleasant and potentially dangerous adverse
effects. Similarly, more aggressive initial therapy may result in
prolonged remission or disease-free survival but may not nec-
essarily change overall survival. All patients will have a unique
perspective on how they interpret this equation.
‘A cancer diagnosis has been shown to be a leading cause
of personal bankruptcy, and studies show financial worries
contribute to patients’ anxiety. Inability to meet copays or cotn-
surance requirements, especially for expensive oral anticancer
‘medications, is a leading cause of failure to properly receive
‘therapy: A clear understanding ofthe goals of care and the tox
ies, including financial toxicity, is necessary for patients and
physicians to make informed choices in treatment options. This,
concept of financial toxicity goes beyond individual patients in
affecting the overall health care economy. Quantifying the
‘overall benefit of extending a patients life by relatwely short
periods (less than 2 months’ median benefit) and contrasting
‘that benefit by the financial cost of care require complex ethi-
cal, economic, and public health decisions.
Early-stage cancers often havea high chance of cure. With
‘nereasing cancer stage, the possibility of cure diminishes. Most
‘metastatic cancers are treatable but not curable. The risks of
treatment are higher and may outweigh the benefit in patients,
‘with poor performance status due to chronie medical comor-
bldities or those who have not been able to tolerate initial treat-
‘ment attempts, For such patients or for those who have
cechausted standard treatment options, supportive, comfort-
oriented care may be most appropriate, Use of adequate anal-
fgesia, as well as involving supportive care specialist, is
Important throughout the continuum of care but particularly,
so in patients with pain or with symptoms from either disease
‘or therapy, Studies suggest that such supportive care, when
instituted early in conjunction with anticancer therapy, helps
patients better tolerate their cancer care and should not be
delayed to the point at which no more active cancer therapy is,
considered.
RINSE
‘© The potential benefits of treatment must be weighed
and discussed along with its risks and toxicities, includ~
ing financial toxicity, because the costs of anticancer
treatments have increased substantially
‘Palliative care shouldbe instituted early in the manage-
‘ment of patients with cancer and not reserved only for the
‘time when they are no longer receiving cancer therapy.
Understanding Cancer
Terminology
‘A clear understanding of cancer terminology is necessary to
foelitate informed discussions and develop realistic treatment
souls.
‘The one pure and simple term Is cure. Cure means that
the cancer is gone, no further treatment is required, and the
patient can be expected to live out his or her life without
Issues in Oncology
seeing that cancer again. Cure should not be confused with the
term overall survival, which is defined as the amount of time
from the start of treatment until death. Overall survival soften,
misunderstood by patients to be synonymous with cure.
‘Median survival outcomes that are reported in studies are too
often explained to patlents as indicating how long they will
live, but it must be understood and explained that medians
‘dentify the center of an often-broad, bell-shaped curve, and
‘may be meaningful for populations, but cannot predict an
‘outcome for any one individual patient,
Patient expectations can be further confused by the
frequent use of the phrase significant improvement in sur
vival, in which significant refers to the statistical certainty
of the finding but is often misinterpreted as a substantial
improvement in survival. Many drugs have been approved
with significant improvements in median survival that are
limited to less than 2 or 3 months, a quantity that most
‘would agree is not substantial. Furthermore, one must be
‘cautious about interpreting nonrandomized comparisons of
folder versus newer survival data. Randomized controlled
trials are the only reliable means of comparing one treat-
‘ment with another.
One of the most misrepresented and misunderstood
terms is progression-free survival. Itis the time from when a
treatment is started until that treatment is no longer control
ling the cancer. The word survival was initially included in the
term because the duration of progression-free survival is,
defined by either growth ofthe cancer (progression) or patient
