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

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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.

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).

Higher score indicates better quality

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 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 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 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'

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.

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.

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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

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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, or bone scan ordered by someone other than reporting clinician)

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

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