over testing in cancer staging
TRANSCRIPT
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Jon Tilburt, MD General Internal Medicine
Mayo Clinic
“Over Testing in Cancer Staging”
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Too Big, Too Little Too Hot, Too Cold Too Soft, Too Firm
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“Just & Right Cancer Care”
Fair, sustainable and focused on individual needs
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Desire Hope
Fear
Suffering Progress
Technology
Disappointment
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Moral Danger of Cancer Care
“care” ≈ consumer goods Genuine concern ≈ more testing
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Objectives l What is cancer staging l Why is it important l What does it involve l Can “too much” ever be bad l What do the guidelines say for specific cancers
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Cancer Staging
l How far is it spread l What treatments are likely to work l State (0), 1, 2, 3, 4 l “T” – Tumor l “N” l “M” l “X”
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Staging Importance
l How do we balance ALL risks & benefits l Knowing approximate extent – always
important l If cancer is spread to other parts of body,
surgery may not benefit (harm>help) l Knowing exact extent varies (dynamics)
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Knowing Exactly Depends On
A. “Dynamics” B. How fast growing the tumor is C. How good our drugs are D. How toxic cutting would be to get them out
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Factors Influencing Doctors
l “Would it change my management?” l How well do doctors deal with uncertainty? l “What are my incentives?” l “What are my fears?”
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Staging: What does it involve?
l History & Physical l Blood tests l Biopsy review l Basic X-Rays/ CT scans l What else?
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PET Scan
Positron Emission Tomography • A type of imaging test • Uses a radioactive substance called a “tracer” to look for
disease in the body • Shows how organs and tissues use energy • A more precise test to find tumors
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Can Too Much Staging Be Bad?
l Little direct individual harm (from test) l Can cause timing delays l Can lead to “over-reacting,” but… l Can help avoid any unnecessary treatment
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What You Need to Know Exactly
l Likely an aggressive tumor has spread l Drugs are less effective l High risk surgery
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Lung Cancer
l Aggressive tumor l Drugs aren’t as effective l Surgery pretty rough l …need to know exact intent of spread
(Stages I-III)
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Breast Cancer
l Cancer aggressiveness, variable l Drugs are typically more effective, more
options for recurrences l Risk of surgery lower l …PET reserved for high risk
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Prostate Cancer
l Drugs can control & not cure l Risks of surgery are intermediate l Typically slower growing l …PET reserved for high risk
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Colon Cancer
l Drugs are pretty effective l Risks of surgery are intermediate l Metastatic disease curable l …PET not routinely needed
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The Data
l Minimal data on influence of intensity of staging on long term outcomes
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The Guidelines
l NCCN l Choosing Wisely
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Disparities & Overtesting
l “Haves” & “have nots” dynamic l Temptation for more l Fear l Consequence #1: Less aggressive treatment l Consequence #2: Overly aggressive,
outdated treatments
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Patient-Centered Cancer Care
l Help patients know they are “worth it” l Without counterproductive testing
Arthur Frank. Patient-Centered care as a Response to Medification. Wake Forest Law Review. Nov. 2010, p. 1453-1459