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Oncology High Value Care Recommendations The American College of Physicians, in collaboration with ¢ Second-look laparotomy to assess pathologic response multiple other organizations, is engaged in a worldwide following chemotherapy of ovarian cancer should not be initiative to promote the practice of High Value Care performed. (HVC). The goals of the HVC initiative are to improve e Annual cervical or vaginal cytology should be done on all health care outcomes by providing care of proven benefit cervical cancer survivors; additional surveillance imaging and reducing costs by avoiding unnecessary and even and laboratory studies for cervical cancer survivors are harmful interventions. The initiative comprises several recommended only if there are signs or symptoms sug- programs that integrate the important concept of health gestive of recurrence. care value (balancing clinical benefit with costs and PET scans should not be used for preoperative staging or harms) for a given intervention into a broad range of postoperative surveillance in colorectal cancer. educational materials to address the needs of trainees, PET scans do not add value in the staging of pancreatic practicing physicians, and patients. cancer and are not part of standard management. Well-differentiated neuroendocrine tumors are indolent HVC content has been integrated into MKSAP 19 in sev- and often initially only require observation and serial eral important ways. MKSAP 19 includes HVC-identified imaging. key points in the text, HVC-focused multiple-choice ques- e Anal cancer is often curable with combined irradiation tions, and, in MKSAP Digital, an HVC custom quiz. From and chemotherapy; surgery is typically not indicated the text and questions, we have generated the following (see Item 22). list of HVC recommendations that meet the definition Patients with poor performance status and advanced below of high value care and bring us closer to our goal non-small cell lung cancer without a driver mutation do of improving patient outcomes while conserving finite not benefit from chemotherapy nor immunotherapy and resources. are best served with supportive care (see Item 25). High Value Care Recommendation: A recommendation to e Routine imaging for head and neck cancer after a nega- choose diagnostic and management strategies for patients tive posttreatment scan is not indicated unless signs and in specific clinical situations that balance clinical benefit symptoms suggest recurrent disease. with cost and harms with the goal of improving patient Although patients who receive radiation therapy that outcomes. includes the thyroid bed are at increased risk of thyroid cancer, screening thyroid ultrasonography is not Below are the High Value Care Recommendations for the indicated. Oncology section of MKSAP 19. In men with low-risk prostate cancer, active surveillance e Imaging studies such as PET, CT, or bone scan for staging is a reasonable strategy because some men will never are not recommended in asymptomatic patients with require treatment, and outcomes are no worse if men newly diagnosed stage 0 to II breast cancer. with low-grade cancer are treated at the time of progres- ¢ Surveillance blood tests and other imaging tests for breast sion rather than when first diagnosed (see Item 38). cancer should not be routinely performed and should be Patients with prostate-specific antigen-only recurrence guided by a patient’s symptoms or findings on examina- of prostate cancer may be treated with androgen depri- tion that raise concern for recurrence. vation therapy, although observation is also a reasonable e Neither radiation therapy nor hormonal therapy provides choice. benefit after bilateral mastectomy for patients with ductal Patients with CT findings pathognomonic for renal cell carcinoma in situ (see Item 70). ; carcinoma do not need a biopsy to confirm the diagnosis. ¢ Multigene recurrence assays or gene expression profiles ¢ Chronic lymphocytic leukemia is typically an indolent have dramatically improved the ability to avoid chemo- disease, and many patients require no therapy for many therapy for patients at low risk of recurrence who will years (see Item 49). not benefit from chemotherapy and to identify patients e Physical examination and PET/CT are used to stage at greater risk who do benefit from chemotherapy (see patients with Hodgkin lymphoma; laparotomy and Item 45). splenectomy are no longer performed. ¢ Consensus guidelines indicate that pregnancy after breast ¢ Chemotherapy without irradiation is a treatment option cancer should not be discouraged (see Item 16). for early-stage Hodgkin lymphoma after a complete

The American College of Physicians, in collaboration with ¢ Second-look laparotomy to assess pathologic response multiple other organizations, is engaged in a worldwide following chemotherapy of ovarian cancer should not be initiative to promote the practice of High Value Care performed. (HVC). The goals of the HVC initiative are to improve e Annual cervical or vaginal cytology should be done on all health care outcomes by providing care of proven benefit cervical cancer survivors; additional surveillance imaging and reducing costs by avoiding unnecessary and even and laboratory studies for cervical cancer survivors are harmful interventions. The initiative comprises several recommended only if there are signs or symptoms sug- programs that integrate the important concept of health gestive of recurrence. care value (balancing clinical benefit with costs and PET scans should not be used for preoperative staging or harms) for a given intervention into a broad range of postoperative surveillance in colorectal cancer. educational materials to address the needs of trainees, PET scans do not add value in the staging of pancreatic practicing physicians, and patients. cancer and are not part of standard management. Well-differentiated neuroendocrine tumors are indolent HVC content has been integrated into MKSAP 19 in sev- and often initially only require observation and serial eral important ways. MKSAP 19 includes HVC-identified imaging. key points in the text, HVC-focused multiple-choice ques- e Anal cancer is often curable with combined irradiation tions, and, in MKSAP Digital, an HVC custom quiz. From and chemotherapy; surgery is typically not indicated the text and questions, we have generated the following (see Item 22). list of HVC recommendations that meet the definition Patients with poor performance status and advanced below of high value care and bring us closer to our goal non-small cell lung cancer without a driver mutation do of improving patient outcomes while conserving finite not benefit from chemotherapy nor immunotherapy and resources. are best served with supportive care (see Item 25). High Value Care Recommendation: A recommendation to e Routine imaging for head and neck cancer after a nega- choose diagnostic and management strategies for patients tive posttreatment scan is not indicated unless signs and in specific clinical situations that balance clinical benefit symptoms suggest recurrent disease. with cost and harms with the goal of improving patient Although patients who receive radiation therapy that outcomes. includes the thyroid bed are at increased risk of thyroid cancer, screening thyroid ultrasonography is not Below are the High Value Care Recommendations for the indicated. Oncology section of MKSAP 19. In men with low-risk prostate cancer, active surveillance e Imaging studies such as PET, CT, or bone scan for staging is a reasonable strategy because some men will never are not recommended in asymptomatic patients with require treatment, and outcomes are no worse if men newly diagnosed stage 0 to II breast cancer. with low-grade cancer are treated at the time of progres- ¢ Surveillance blood tests and other imaging tests for breast sion rather than when first diagnosed (see Item 38). cancer should not be routinely performed and should be Patients with prostate-specific antigen-only recurrence guided by a patient’s symptoms or findings on examina- of prostate cancer may be treated with androgen depri- tion that raise concern for recurrence. vation therapy, although observation is also a reasonable e Neither radiation therapy nor hormonal therapy provides choice. benefit after bilateral mastectomy for patients with ductal Patients with CT findings pathognomonic for renal cell carcinoma in situ (see Item 70). ; carcinoma do not need a biopsy to confirm the diagnosis. ¢ Multigene recurrence assays or gene expression profiles ¢ Chronic lymphocytic leukemia is typically an indolent have dramatically improved the ability to avoid chemo- disease, and many patients require no therapy for many therapy for patients at low risk of recurrence who will years (see Item 49). not benefit from chemotherapy and to identify patients e Physical examination and PET/CT are used to stage at greater risk who do benefit from chemotherapy (see patients with Hodgkin lymphoma; laparotomy and Item 45). splenectomy are no longer performed. ¢ Consensus guidelines indicate that pregnancy after breast ¢ Chemotherapy without irradiation is a treatment option cancer should not be discouraged (see Item 16). for early-stage Hodgkin lymphoma after a complete xi

metabolic response assessed by interim PET/CT after two There is no better therapeutic success but rather an to three cycles of treatment (risk-adapted therapy) (see increased risk of toxicity from adding an aminoglycoside Item 36). to a broad-spectrum B-lactam in the treatment of febrile In patients with a metastatic cancer of unknown primary neutropenia (see Item 33). site, CT and histologic, endoscopic, and gender-specific Growth factors are not routinely used in the treatment cancer evaluations are reasonable; however, nonspecific of patients with neutropenic fever unless the patient has tumor markers, PET, and gene expression arrays should severe neutropenia (<100/yL [0.1 x 109/L]) expected to not be done. last more than 10 days or has other high-risk features. Palliative or hospice care is appropriate for patients with Loop diuretics are not indicated in the treatment of an unfavorable subtype of cancer of unknown primary hypercalcemia of malignancy unless kidney failure or site who have comorbidities and poor performance heart failure is present; in these circumstances, intrave- status. nous expansion of vascular volume should precede the Nodal metastases are uncommon in thin melanomas administration of loop diuretics (see Item 43). (Breslow depth less than 0.8 mm) and need not be Spinal cord compression from radiosensitive tumor assessed. types, such as leukemia, lymphoma, myeloma, and germ Most patients with neutropenic fever should be managed cell tumors, may not require initial surgical decompres- with monotherapy with an antipseudomonal B-lactam sion; instead, patients may be treated urgently with radi- agent. ation therapy alone (see Item 63). xii