Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

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 2020 PCPI(R) Foundation. All Rights Reserved.

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, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. 

Commercial uses of the Measure require a license agreement between the user and the PCPI(R) Foundation (PCPI[R]). Neither the PCPI, nor the American Medical Association (AMA), nor the former AMA-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI), nor their members shall be responsible for any use of the Measure.

The PCPI encourages use of the Measure by other health care professionals, where appropriate.

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

Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, the PCPI and its members and former members of the AMA-PCPI disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications. 

CPT(R) contained in the Measure specifications is copyright 2004-2019 American Medical Association. LOINC(R) is copyright 2004-2019 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2019 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2019 World Health Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R].

None

None

None

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 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 SEER-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, 2017). 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.

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 and T2 disease with PSA over 10 ng/mL, high- or very-high risk disease; or symptomatic disease (National Comprehensive Cancer Network, 2019) (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).

A routine bone scan is unnecessary in men with low-risk prostate cancer. 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, 2017).

Higher score indicates better quality

American Urological Association. (2017). A routine bone scan is unnecessary in men with 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).

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.auanet.org/guidelines/prostate-cancer-clinically-localized-(2017)

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

National Comprehensive Cancer Network. (2019). Clinical Practice Guidelines in Oncology: Prostate Cancer. Version 4.209. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf

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 (3D-CRT), intensity modulated radiation therapy (IMRT), stereotactic body radiotherapy (SBRT), 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.

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.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

All patients, regardless of age, with a diagnosis of prostate cancer

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

None

Patients who did not have a bone scan performed at any time since diagnosis of prostate cancer

Not Applicable

Documentation of reason(s) for performing a bone scan (including documented pain, salvage therapy, other medical reasons, bone scan ordered by someone other than reporting physician)

For every patient evaluated by this measure also identify payer, race, ethnicity and sex