eMeasure Title

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

eMeasure Identifier (Measure Authoring Tool) 129 eMeasure Version number 7.0.000
NQF Number 0389 GUID 1635c14d-e612-4fa6-96cd-285361aa7f7b
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward PCPI(R) Foundation (PCPI[R])
Measure Developer American Medical Association (AMA)
Measure Developer PCPI(R) Foundation (PCPI[R])
Endorsed By National Quality Forum
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, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer
Copyright
Copyright 2017 PCPI(R) Foundation and American Medical Association. All Rights Reserved.
Disclaimer
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CPT(R) contained in the Measure specifications is copyright 2004-2016 American Medical Association. LOINC(R) is copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED CLINICAL TERMS (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation (IHTSDO). ICD-10 is copyright 2016 World Health Organization. All Rights Reserved.

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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 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, 2013). 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
Routine use of a bone scan is not required for staging asymptomatic men with clinically localized prostate cancer when their PSA level is equal to or less than 20.0 ng/mL. (AUA, 2013)

For symptomatic patients and/or those with a life expectancy of greater than 5 years, a bone scan is appropriate for patients with any of the following: 1) T1 disease with PSA over 20 ng/mL or T2 disease with PSA over 10 ng/mL; 2) Gleason score 8 or higher; 3) T3 to T4 disease; or 4) symptomatic disease. (NCCN, 2016) (Category 2A)
Improvement Notation
Higher score indicates better quality
Reference
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). doi:10.1200/jop.2014.001818
Reference
American Urological Association. A routine bone scan is unnecessary in men with low-risk prostate cancer. Choosing Wisely Initiative. Released February 21, 2013. Available at:  http://www.choosingwisely.org/societies/american-urological-association.  Accessed February 25, 2016.
Reference
American Urological Association Education and Research, Inc. PSA testing for the pretreatment staging and posttreatment management of prostate cancer: 2013 Revision of 2009 Best Practice Statement. Linthicum, MD: American Urological Association Education and Research, Inc. 2013. Available at: https://www.auanet.org/common/pdf/education/clinical-guidance/Prostate-Specific-Antigen.pdf
Reference
National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology: Prostate Cancer. Version 3.2016. Available at www.nccn.org
Definition
Risk Strata Definitions: Very Low, Low, Intermediate, High, or Very High- 
Very Low Risk - PSA < 10 ng/mL; AND Gleason score 6 or less; AND clinical stage T1c; AND presence of disease in fewer than 3 biopsy cores; AND <= 50% prostate cancer involvement in any core; AND PSA density < 0.15 ng/mL/g. 
Low Risk - PSA < 10 ng/mL; AND Gleason score 6; AND clinical stage T1 to T2a. 
Intermediate Risk - PSA 10 to 20 ng/mL; OR Gleason score 7; OR clinical stage T2b to T2c. Note: Patients with multiple adverse factors may be shifted into the high risk category. 
High Risk - PSA > 20 ng/mL; OR Gleason score 8 to 10; OR clinically localized stage T3a. Note: Patients with multiple adverse factors may be shifted into the very high risk category. 
Very High Risk - Clinical stage T3b to T4; OR primary Gleason pattern 5; OR more than 4 cores with Gleason score 8 to 10. (NCCN, 2016)

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.
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.
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, OR cryotherapy
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, bone scan ordered by someone other than reporting physician)
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Table of Contents


Population Criteria

Data Criteria (QDM Variables)

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables


Measure Set
None