eCQM Title | # Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
eCQM Identifier (Measure Authoring Tool) | 129 | eCQM Version Number | 13.0.000
NQF Number | Not Applicable | GUID | 1635c14d-e612-4fa6-96cd-285361aa7f7b
Measurement Period | January 1, 20XX through December 31, 20XX
Measure Steward | Centers for Medicare & Medicaid Services (CMS)
Measure Developer | Mathematica
Measure Developer | American Medical Association (AMA)
Measure Developer | PCPI(R) Foundation (PCPI[R])
Endorsed By | None
Description |
    Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy who did not have a bone scan performed at any time since diagnosis of prostate cancer
Copyright |
    Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets.

    The PCPI’s and American Medical Association's (AMA) significant past efforts and contributions to the development and updating of the Measure is acknowledged.

    CPT(R) contained in the Measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) is copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2022 World Health Organization. All Rights Reserved.
Disclaimer |
    The Measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications.

    THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

    Due to technical limitations, registered trademarks are indicated by (R) or [R].
Measure Scoring | Proportion
Measure Type | Process
Stratification |
    None
Risk Adjustment |
    None
Rate Aggregation |
    None
Rationale |
    Multiple studies have indicated that a bone scan is not clinically necessary for staging prostate cancer in men with a low (or very low) risk of recurrence and receiving primary therapy. For patients who are categorized as low-risk, bone scans are unlikely to identify their disease. Furthermore, bone scans are not necessary for low-risk patients who have no history of bony involvement or if the clinical examination suggests no bony involvement. Less than 1% of low-risk patients are at risk of metastatic disease.

    While clinical practice guidelines do not recommend bone scans in low-risk prostate cancer patients, overuse is still common. An analysis of prostate cancer patients in the Surveillance, Epidemiology and End Results Medicare database diagnosed from 2004-2007 found that 43% of patients for whom a bone scan was not recommended received it (Falchook, Hendrix, & Chen, 2015). The analysis also found that the use of bone scans in low-risk patients leads to an annual cost of $4 million dollars to Medicare. The overuse of bone scan imaging for low-risk prostate cancer patients is a concept included on the American Urological Association's (AUA) list in the Choosing Wisely Initiative as a means to promote adherence to evidence-based imaging practices and to reduce health care dollars wasted (AUA, 2019). This measure is intended to promote adherence to evidence-based imaging practices, lessen the financial burden of unnecessary imaging, and ultimately to improve the quality of care for prostate cancer patients in the United States.
Clinical Recommendation Statement |
    For symptomatic patients and/or those with a life expectancy of greater than 5 years, bone imaging is appropriate for patients with unfavorable intermediate-risk prostate cancer, high-risk and very-high-risk prostate cancer (National Comprehensive Cancer Network, 2022) (Evidence Level: Category 2A).

    Clinicians should not perform routine bone scans in the staging of asymptomatic very low- or low-risk localized prostate cancer patients (AUA, American Society for Radiation Oncology, & Society of Urologic Oncology, 2017) (Strong Recommendation; Evidence Level: Grade C).

    Very low-risk or low-risk patients are unlikely to have disease identified by bone scan. Accordingly, bone scans are generally unnecessary in patients with newly diagnosed prostate cancer who have a PSA <10.0 ng/mL and a Gleason score less than 7 unless the patient’s history or clinical examination suggests bony involvement. Progression to the bone is much more common in advanced local disease or in high-grade disease that is characterized by fast and aggressive growth into surrounding areas such as bones or lymph nodes (AUA, 2019).
Improvement Notation |
    Higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'American Urological Association. (2019). A routine bone scan is unnecessary in men with very low-risk or low-risk prostate cancer. Retrieved from http://www.choosingwisely.org/clinician-lists/american-urological-association-routine-bone-scans-with-low-risk-prostate-cancer/ (Original work published in 2013)'
Reference |
    Reference Type: CITATION
    Reference Text: 'American Urological Association, American Society for Radiation Oncology, & Society of Urologic Oncology. (2017). Clinically localized prostate cancer: AUA/ASTRO/SUO Guideline. Retrieved from https://www.astro.org/uploadedFiles/_MAIN_SITE/Patient_Care/Clinical_Practice_Statements/Content_Pieces/ClinicallyLocalizedProstateCancer.pdf'
Reference |
    Reference Type: CITATION
    Reference Text: 'Falchook, A. D., Hendrix, L. H., & Chen, R. C. (2015). Guideline-discordant use of imaging during work-up of newly diagnosed prostate cancer. Journal of Oncology Practice, 11(2), e239-e246. doi:10.1200/jop.2014.001818'
Reference |
    Reference Type: CITATION
    Reference Text: 'National Comprehensive Cancer Network. (2022). Clinical Practice Guidelines in Oncology: Prostate Cancer. Version 1.2023. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf'
Definition |
    Risk Strata Definitions: Very Low, Low, Intermediate, High, or Very High
    Very Low/Low Risk - PSA < 10 ng/mL; AND Gleason score 6 or less/Gleason grade group 1; AND clinical stage T1 to T2a.
    Intermediate Risk - PSA 10 to 20 ng/mL; OR Gleason score 7/Gleason grade group 2-3; OR clinical stage T2b to T2c.
    High/Very High Risk - PSA > 20 ng/mL; OR Gleason score 8 to 10/Gleason grade group 4-5; OR clinically localized stage T3 to T4 (adapted from the National Comprehensive Cancer Network, 2018).

    External beam radiotherapy - external beam radiotherapy refers to 3D conformal radiation therapy, intensity modulated radiation therapy, stereotactic body radiotherapy, and proton beam therapy.

    Bone scan - bone scan refers to the conventional technetium-99m-MDP bone scan as well as 18F-NaF PET (or PET/CT) scan.
Guidance |
    A higher score indicates appropriate treatment of patients with prostate cancer at low (or very low) risk of recurrence. Only patients with prostate cancer with low (or very low) risk of recurrence will be counted in the performance denominator of this measure.

    In 2022, the American Urological Association published guidance recommending that clinicians not perform bone scan in asymptomatic patients with low- or intermediate-risk prostate cancer. However, this quality measure remains focused on patients with low (or very low) risk of recurrence.

    This eCQM is a patient-based measure.

    Telehealth encounters are not eligible for this measure because the measure does not contain telehealth-eligible codes.

    This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.
Transmission Format |
    TBD
Initial Population |
    All patients, regardless of age, with a diagnosis of prostate cancer
Denominator |
    Equals Initial Population at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy
Denominator Exclusions |
    None
Numerator |
    Patients who did not have a bone scan performed at any time since diagnosis of prostate cancer
Numerator Exclusions |
    Not Applicable
Denominator Exceptions |
    Documentation of reason(s) for performing a bone scan (including documented pain, salvage therapy, other medical reasons, or bone scan ordered by someone other than reporting clinician)
Supplemental Data Elements |
    For every patient evaluated by this measure also identify payer, race, ethnicity and sex

## Table of Contents

- Population Criteria
- Definitions
- Functions
- Terminology
- Data Criteria (QDM Data Elements)
- Supplemental Data Elements
- Risk Adjustment Variables

### Population Criteria

- - Initial Population

    - -     exists "Prostate Cancer Diagnosis"

- - Denominator

    - -     "Initial Population"
              and "First Prostate Cancer Treatment during day of Measurement Period" is not null
              and "Most Recent Prostate Cancer Staging Tumor Size T1a to T2a" is not null
              and "Most Recent PSA Test Result is Low"
              and "Most Recent Gleason Score is Low"

- - Denominator Exclusions

    - -     None

- - Numerator

    - -     not exists "Bone Scan Study Performed"

- - Numerator Exclusions

    - -     None

- - Denominator Exceptions

    - -     "Has Diagnosis of Pain Related to Prostate Cancer"
              or "Has Salvage Therapy Performed After Prostate Cancer Diagnosis"
              or "Has Bone Scan Study Performed with Documented Reason"

- - Stratification

    - -     None

### Definitions

- - Bone Scan Study Performed

    - -     ["Diagnostic Study, Performed": "Bone Scan"] BoneScan
              with "Prostate Cancer Diagnosis" ActiveProstateCancer
                such that Global."NormalizeInterval" ( BoneScan.relevantDatetime, BoneScan.relevantPeriod ) starts after start of ActiveProstateCancer.prevalencePeriod

  - Denominator

    - -     "Initial Population"
              and "First Prostate Cancer Treatment during day of Measurement Period" is not null
              and "Most Recent Prostate Cancer Staging Tumor Size T1a to T2a" is not null
              and "Most Recent PSA Test Result is Low"
              and "Most Recent Gleason Score is Low"

  - Denominator Exceptions

    - -     "Has Diagnosis of Pain Related to Prostate Cancer"
              or "Has Salvage Therapy Performed After Prostate Cancer Diagnosis"
              or "Has Bone Scan Study Performed with Documented Reason"

  - First Prostate Cancer Treatment during day of Measurement Period

    - -     First(["Procedure, Performed": "Prostate Cancer Treatment"] ProstateCancerTreatment
                where Global."NormalizeInterval"(ProstateCancerTreatment.relevantDatetime, ProstateCancerTreatment.relevantPeriod)ends during day of "Measurement Period"
                sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
            )

  - Has Bone Scan Study Performed with Documented Reason

    - -     exists "Bone Scan Study Performed" BoneScanAfterDiagnosis
              where BoneScanAfterDiagnosis.reason ~ "Procedure reason record (record artifact)"

  - Has Diagnosis of Pain Related to Prostate Cancer

    - -     exists ["Diagnosis": "Pain Warranting Further Investigation for Prostate Cancer"] ProstateCancerPain
              with "Prostate Cancer Diagnosis" ActiveProstateCancer
                such that ProstateCancerPain.prevalencePeriod starts after start of ActiveProstateCancer.prevalencePeriod

  - Has Salvage Therapy Performed After Prostate Cancer Diagnosis

    - -     exists ["Procedure, Performed": "Salvage Therapy"] SalvageTherapy
              with "Prostate Cancer Diagnosis" ActiveProstateCancer
                such that Global."NormalizeInterval" ( SalvageTherapy.relevantDatetime, SalvageTherapy.relevantPeriod ) starts after start of ActiveProstateCancer.prevalencePeriod

  - Initial Population

    - -     exists "Prostate Cancer Diagnosis"

  - Most Recent Gleason Score is Low

    - -     ( Last(["Laboratory Test, Performed": "Gleason score in Specimen Qualitative"] GleasonScore
                with "First Prostate Cancer Treatment during day of Measurement Period" FirstProstateCancerTreatment
                  such that Global."NormalizeInterval"(GleasonScore.relevantDatetime, GleasonScore.relevantPeriod)starts before start of Global."NormalizeInterval"(FirstProstateCancerTreatment.relevantDatetime, FirstProstateCancerTreatment.relevantPeriod)
                sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
            )) LastGleasonScore
              return LastGleasonScore.result <= 6

  - Most Recent Prostate Cancer Staging Tumor Size T1a to T2a

    - -     ( Last(["Procedure, Performed": "Tumor staging (tumor staging)"] ProstateCancerStaging
                with "First Prostate Cancer Treatment during day of Measurement Period" FirstProstateCancerTreatment
                  such that Global."NormalizeInterval"(ProstateCancerStaging.relevantDatetime, ProstateCancerStaging.relevantPeriod)starts before start of Global."NormalizeInterval"(FirstProstateCancerTreatment.relevantDatetime, FirstProstateCancerTreatment.relevantPeriod)
                sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
            )) LastProstateCancerStaging
              where ( LastProstateCancerStaging.result ~ "T1a: Prostate tumor incidental histologic finding in 5 percent or less of tissue resected (finding)"
                  or LastProstateCancerStaging.result ~ "T1b: Prostate tumor incidental histologic finding in greater than 5 percent of tissue resected (finding)"
                  or LastProstateCancerStaging.result ~ "Neoplasm of prostate primary tumor staging category T1c: Tumor identified by needle biopsy (finding)"
                  or LastProstateCancerStaging.result ~ "Neoplasm of prostate primary tumor staging category T2a: Involves one-half of one lobe or less (finding)"
              )

  - Most Recent PSA Test Result is Low

    - -     ( Last(["Laboratory Test, Performed": "Prostate Specific Antigen Test"] PSATest
                with "Most Recent Prostate Cancer Staging Tumor Size T1a to T2a" MostRecentProstateCancerStaging
                  such that Global."NormalizeInterval"(PSATest.relevantDatetime, PSATest.relevantPeriod)starts before Global."NormalizeInterval"(MostRecentProstateCancerStaging.relevantDatetime, MostRecentProstateCancerStaging.relevantPeriod)
                sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
            )) LastPSATest
              return LastPSATest.result < 10 'ng/mL'

  - Numerator

    - -     not exists "Bone Scan Study Performed"

  - Prostate Cancer Diagnosis

    - -     ["Diagnosis": "Prostate Cancer"] ProstateCancer
              where ProstateCancer.prevalencePeriod overlaps day of "Measurement Period"

  - SDE Ethnicity

    - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

  - SDE Payer

    - -     ["Patient Characteristic Payer": "Payer"]

  - SDE Race

    - -     ["Patient Characteristic Race": "Race"]

  - SDE Sex

    - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Functions

- - Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

    - -     if pointInTime is not null then Interval[pointInTime, pointInTime]
              else if period is not null then period
              else null as Interval<DateTime>

### Terminology

- code "Gleason score in Specimen Qualitative" ("LOINC Code (35266-6)")
- code "Neoplasm of prostate primary tumor staging category T1c: Tumor identified by needle biopsy (finding)" ("SNOMEDCT Code (433351000124101)")
- code "Neoplasm of prostate primary tumor staging category T2a: Involves one-half of one lobe or less (finding)" ("SNOMEDCT Code (433361000124104)")
- code "Procedure reason record (record artifact)" ("SNOMEDCT Code (433611000124109)")
- code "T1a: Prostate tumor incidental histologic finding in 5 percent or less of tissue resected (finding)" ("SNOMEDCT Code (369833007)")
- code "T1b: Prostate tumor incidental histologic finding in greater than 5 percent of tissue resected (finding)" ("SNOMEDCT Code (369834001)")
- code "Tumor staging (tumor staging)" ("SNOMEDCT Code (254292007)")
- valueset "Bone Scan" (2.16.840.1.113883.3.526.3.320)
- valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
- valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
- valueset "Pain Warranting Further Investigation for Prostate Cancer" (2.16.840.1.113883.3.526.3.451)
- valueset "Payer" (2.16.840.1.114222.4.11.3591)
- valueset "Prostate Cancer" (2.16.840.1.113883.3.526.3.319)
- valueset "Prostate Cancer Treatment" (2.16.840.1.113883.3.526.3.398)
- valueset "Prostate Specific Antigen Test" (2.16.840.1.113883.3.526.3.401)
- valueset "Race" (2.16.840.1.114222.4.11.836)
- valueset "Salvage Therapy" (2.16.840.1.113883.3.526.3.399)

### Data Criteria (QDM Data Elements)

- "Diagnosis: Pain Warranting Further Investigation for Prostate Cancer" using "Pain Warranting Further Investigation for Prostate Cancer (2.16.840.1.113883.3.526.3.451)"
- "Diagnosis: Prostate Cancer" using "Prostate Cancer (2.16.840.1.113883.3.526.3.319)"
- "Diagnostic Study, Performed: Bone Scan" using "Bone Scan (2.16.840.1.113883.3.526.3.320)"
- "Laboratory Test, Performed: Gleason score in Specimen Qualitative" using "Gleason score in Specimen Qualitative (LOINC Code 35266-6)"
- "Laboratory Test, Performed: Prostate Specific Antigen Test" using "Prostate Specific Antigen Test (2.16.840.1.113883.3.526.3.401)"
- "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
- "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
- "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
- "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
- "Procedure, Performed: Prostate Cancer Treatment" using "Prostate Cancer Treatment (2.16.840.1.113883.3.526.3.398)"
- "Procedure, Performed: Salvage Therapy" using "Salvage Therapy (2.16.840.1.113883.3.526.3.399)"
- "Procedure, Performed: Tumor staging (tumor staging)" using "Tumor staging (tumor staging) (SNOMEDCT Code 254292007)"

### Supplemental Data Elements

- SDE Ethnicity

  - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

- SDE Payer

  - -     ["Patient Characteristic Payer": "Payer"]

- SDE Race

  - -     ["Patient Characteristic Race": "Race"]

- SDE Sex

  - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Risk Adjustment Variables

- None

Measure Set |
    None