Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
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| Measure Information | 2023 Performance Period | 2024 Performance Period | 2025 Performance Period |
|---|---|---|---|
| Title | Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients |
| CMS eCQM ID | CMS129v12 | CMS129v13 | CMS129v14 |
| CBE ID* | 0389e | Not Applicable | Not Applicable |
| MIPS Quality ID | 102 | 102 | 102 |
| Measure Steward | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) |
| 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 |
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 |
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 |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process | Process | Process |
| Stratification | *See CMS129v12.html |
None |
None |
| Risk Adjustment | *See CMS129v12.html |
None |
None |
| Rationale | *See CMS129v12.html |
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. |
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 | *See CMS129v12.html |
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). |
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 |
Higher score indicates better quality |
Higher score indicates better quality |
| Definition | *See CMS129v12.html |
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. |
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-methyl diphosphonate bone scan as well as 18F-sodium fluoride or prostate-specific membrane antigen (PSMA) 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. 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 QDM page for more information on the QDM. |
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 QDM page for more information on the QDM. |
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 favorable 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 QDM page for more information on the QDM. |
| Initial Population |
All patients, regardless of age, with a diagnosis of prostate cancer |
All patients, regardless of age, with a diagnosis of prostate cancer |
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 |
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 |
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 |
None |
None |
| Numerator |
Patients who did not have a bone scan performed at any time since diagnosis of prostate cancer |
Patients who did not have a bone scan performed at any time since diagnosis of prostate cancer |
Patients who did not have a bone scan performed after diagnosis of prostate cancer and before the end of the measurement period |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
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) |
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) |
Documentation of reason(s) for performing a bone scan (including documented pain, salvage therapy, or other medical reasons) |
| Telehealth Eligible | No | No | No |
| Next Version | No Version Available | ||
| Previous Version | No Version Available |
Additional Resources for CMS129v13
Header
Removed NQF number, re-endorsement was not pursued.
Measure Section: NQF Number
Source of Change: Measure Lead
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Revised wording in rationale for clarity and consistency with clinical recommendation statement.
Measure Section: Rationale
Source of Change: Measure Lead
Revised clinical recommendation statement to align with updated National Comprehensive Cancer Network guidelines.
Measure Section: Clinical Recommendation Statement
Source of Change: Measure Lead
Updated references.
Measure Section: Reference
Source of Change: Measure Lead
Updated grammar, wording, and/or formatting to improve readability and consistency.
Measure Section: Definition
Source of Change: Annual Update
Updated guidance to clarify the patient population in reference to an updated American Urological Association guideline.
Measure Section: Guidance
Source of Change: Measure Lead
Logic
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Definitions
Source of Change: Standards/Technical Update
Updated the timing precision in definitions by adding 'day of' to align with the measure intent.
Measure Section: Definitions
Source of Change: Measure Lead
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
Value set (2.16.840.1.113883.3.526.3.451): Renamed to Pain Warranting Further Investigation for Prostate Cancer based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Pain Warranting Further Investigation for Prostate Cancer (2.16.840.1.113883.3.526.3.451): Added 3 ICD-10-CM codes (M25.551, M25.552, M25.559) based on review by technical experts, SMEs, and/or public feedback. Added 1 SNOMED CT code (49218002) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead