Oncology
Canadian Association of Medical Oncologists
Canadian Association of Radiation Oncology
Canadian Partnership Against Cancer
Canadian Society for Surgical Oncology
Last updated: May 2024
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In some specific situations, the early detection of cancer recurrence (local and/or distant) may increase the likelihood of successful subsequent curative treatment. However, in many circumstances, earlier knowledge of recurrence does not improve outcome. As such, it is important to balance the information that can come from advanced testing with what is best for the individual patient. Specifically, the need for patient reassurance should be balanced against the anxiety and uncertainty provoked by extensive follow-up testing when there is not a realistic expectation that the early identification of recurrence may improve survival or quality of life.
Sources:
BC Cancer Agency. Cancer Management Guidelines. Gastrointestinal, Colon [Internet]. 2014 Feb 1 [cited 2014 Sep 23].
Earle C, et al. Follow-up care, surveillance protocol, and secondary prevention measures for survivors of colorectal cancer [Internet]. 2012 Feb 3 [cited 2014 Sep 23].
Fahy BN. Follow-up after curative resection of colorectal cancer. Ann Surg Oncol. 2014 Mar;21(3):738-46. PMID: 24271157.
Grunfeld E, et al. Routine follow up of breast cancer in primary care: randomised trial. BMJ. 1996 Sep 14;313(7058):665-9. PMID: 8811760.
Khatcheressian J, et al. Breast cancer follow-up in the adjuvant setting. Curr Oncol Rep. 2008 Jan;10(1):38-46. PMID: 18366959.
Meyerhardt JA, et al. Follow-up care, surveillance protocol, and secondary prevention measures for survivors of colorectal cancer: American Society of Clinical Oncology clinical practice guideline endorsement. J Clin Oncol. 2013 Dec 10;31(35):4465-70. PMID: 24220554.
National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: colon cancer [Internet]. 2014 [cited 2014 Sep 23].
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Screening for cancer can be lifesaving in otherwise healthy at-risk patients. While screening tests lead to a mortality benefit which emerges years after the test is performed, they expose patients to immediate potential harms. In general, patients with metastatic cancer have competing mortality risks that would outweigh the mortality benefits of screening as demonstrated in healthy patients. In fact, patients with metastatic disease may be more likely to experience harm since patients with limited life expectancy are more likely to be frail and more susceptible to complications of testing and treatments. Therefore, the balance of potential benefits and harms does not favor recommending screening for a new asymptomatic primary malignancy in most patients with metastatic disease. Screening may be considered in a very small subgroup of patients where metastatic disease is relatively indolent, or its treatment is expected to result in prolonged survival.
Sources:
Fisher DA, et al. Inappropriate colorectal cancer screening: findings and implications. Am J Gastroenterol. 2005 Nov;100(11):2526-30. PMID: 16279910.
Lee SJ, et al. Time lag to benefit after screening for breast and colorectal cancer: meta-analysis of survival data from the United States, Sweden, United Kingdom, and Denmark. BMJ. 2013 Jan 8;346:e8441. PMID: 23299842.
Moyer VA. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 Jul 17;157(2):120-34. PMID: 22801674.
Schroder FH, et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med. 2012 Mar 15;366(11):981-90. PMID: 22417251.
Whitlock EP, et al. Screening for colorectal cancer: a targeted, updated systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008 Nov 4;149(9):638-58. PMID: 18838718.
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Studies show that, in general, cancer directed treatments are likely to be ineffective for patients with solid organ tumours who are markedly debilitated by their cancer (i.e., performance status 3 or 4). Exceptions may include patients with functional limitations due to other conditions resulting in a low performance status, or selected patients with specific disease types (e.g., germ cell cancer) or characteristics (e.g., mutations) that suggest a high likelihood of response to therapy. It has also been shown that appropriate symptom control and palliative care can significantly improve quality of life.
Sources:
Azzoli CG, et al. 2011 Focused Update of 2009 American Society of Clinical Oncology Clinical Practice Guideline Update on Chemotherapy for Stage IV Non-Small-Cell Lung Cancer. J Clin Oncol. 2011 Oct 1;29(28):3825-31. PMID: 21900105.
Carlson RW, et al. Breast cancer. Clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2009 Feb;7(2):122-92. PMID: 19200416.
Engstrom PF, et al. Colon cancer clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2005 Jul;3(4):468-91. PMID: 16038639.
Ettinger DS, et al. Non-small cell lung cancer. J Natl Compr Canc Netw. 2010 Jul;8(7):740-801. PMID: 20679538.
Peppercorn JM, et al. American society of clinical oncology statement: toward individualized care for patients with advanced cancer. J Clin Oncol. 2011 Feb 20;29(6):755-60. PMID: 21263086.
Smith TJ, et al. Bending the cost curve in cancer care. N Engl J Med. 2011 May 26;364(21):2060-5. PMID: 21612477.
Temel JS, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010 Aug 19;363(8):733-42. PMID: 20818875.
Related Resources:
Patient Pamphlet: Care at the End of Life for Advanced Cancer Patients: When to stop cancer treatment
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Studies have shown clearly that, in the absence of heredity syndromes, the progression from polyp to cancer (adenoma carcinoma sequence) occurs over many years. Thus, the timing of a follow-up surveillance colonoscopy should be determined based on the results of a previous high-quality colonoscopy. Typical colonoscopic surveillance following colon cancer surgery consists of a colonoscopy at one year; thereafter it should not typically exceed every 3 years following detection of an advanced polyp, or every 5 years following a normal exam or one showing small polyps. In Canada, there is both evidence of overuse of surveillance colonoscopy following colon cancer resection and, in areas, a limited availability of endoscopy resources.
Sources:
BC Cancer Agency. Cancer Management Guidelines. Gastrointestinal, Colon [Internet]. 2014 Feb 1 [cited 2014 Sep 23].
Hill MJ, et al. Aetiology of adenoma–carcinoma sequence in large bowel. Lancet. 1978 Feb 4;1(8058):245-7. PMID: 74668.
Leddin D, et al. Colorectal cancer surveillance after index colonoscopy: guidance from the Canadian Association of Gastroenterology. Can J Gastroenterol. 2013 Apr;27(4):224-8. PMID: 23616961.
Levin B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology. 2008 May;134(5):1570-95. PMID: 18384785.
Urquhart R, et al. Population-based longitudinal study of follow-up care for patients with colorectal cancer in Nova Scotia. J Oncol Pract. 2012 Jul;8(4):246-52. PMID: 23180991.
van Kooten H, et al. Awareness of postpolypectomy surveillance guidelines: a nationwide survey of colonoscopists in Canada. Can. J. Gastroenterol. Feb 2012;26(2):79-84. PMID: 22312606.
Related Resources:
Patient Pamphlet: Colonoscopy: When you need it and when you don’t
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Numerous studies—including randomized trials—show that palliative care improves pain and symptom control, improves family satisfaction with care, and reduces costs. Palliative care does not accelerate death, and may prolong life in selected populations. The benefits of disease-directed treatment (e.g., chemotherapy or radiation) can be enhanced by early consideration of palliative care.
Sources:
Delgado-Guay MO, et al. Symptom distress, interventions, and outcomes of intensive care unit cancer patients referred to a palliative care consult team. Cancer. 2009 Jan 15;115(2):437-45. PMID: 19107768.
Elsayem A, et al. Impact of a palliative care service on in-hospital mortality in a comprehensive cancer center. J Palliat Med. 2006 Aug;9(4):894-902. PMID: 16910804.
Elsayem A, et al. Palliative care inpatient service in a comprehensive cancer center: clinical and financial outcomes. J Clin Oncol. 2004 May 15;22(10):2008-14. PMID: 15143094.
Gelfman LP, et al. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage. 2008 Jul;36(1):22-8. PMID: 18411019.
Higginson IJ, et al. Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers? J Pain Symptom Manage. 2003 Feb;25(2):150-68. PMID: 12590031.
Jordhøy MS, et al. A palliative-care intervention and death at home: a cluster randomised trial. Lancet. 2000 Sep 9;356(9233):888-93. PMID: 11036893.
London MR, et al. Evaluation of a Comprehensive, Adaptable, Life- Affirming, Longitudinal (CALL) palliative care project. J Palliat Med. 2005 Dec;8(6):1214-25. PMID: 16351535.
Temel JS, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. J Clin Oncol. 2011 Jun 10;29(17):2319-26. PMID: 21555700.
Zimmermann C, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014 May 17;383(9930):1721-30. PMID: 24559581.
Related Resources:
Patient Pamphlet: Care at the End of Life for Advanced Cancer Patients: When to stop cancer treatment
Patient Pamphlet: Palliative Care: Support at any time during a serious illness
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Randomized trials have established that single-fraction radiation to a previously unirradiated, uncomplicated peripheral bone or vertebral metastasis provides comparable pain relief and morbidity compared to multiple-fraction regimens, while optimizing patient and caregiver convenience. Although it results in a higher incidence of retreatment at a later date (20% vs. 8 % for multi-fraction regimens), the decreased patient burden usually outweighs any considerations of long-term effectiveness for those with a limited life expectancy.
Sources:
Fairchild A, et al. International patterns of practice in palliative radiotherapy for painful bone metastases: evidence-based practice? Int J Radiat Oncol Biol Phys. 2009 Dec 1;75(5):1501-10. PMID: 19464820.
Lutz S, et al. Palliative radiotherapy for bone metastases: an ASTRO evidence-based guideline. Int J Radiat Oncol Biol Phys. 2011 Mar 15;79(4):965-76. PMID: 21277118.
Popovic M, et al. Review of international patterns of practice for the treatment of painful bone metastases with palliative radiotherapy from 1993 to 2013. Radiother Oncol. 2014 Apr;111(1):11-7. PMID: 24560750.
Zimmermann C, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014 May 17;383(9930):1721-30. PMID: 24559581.
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Patients with localized prostate cancer have a number of reasonable management options. These include surgery, radiation, as well as conservative monitoring without therapy in appropriate patients. Shared decision-making between the patient and the physician can lead to better alignment of patient goals with treatment and more efficient care delivery. The use of patient-directed written decision aids concerning prostate cancer can give patients confidence about their choices, and improve compliance with therapy. Discussion regarding active surveillance should include both the elements and timing of such surveillance, and emphasize the need for compliance.
Sources:
Bill-Axelson A, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2011 May 5;364(18):1708-17. PMID: 21542742.
Dahabreh IJ, et al. Active surveillance in men with localized prostate cancer: a systematic review. Ann Intern Med. 2012 Apr 17;156(8):582-90. PMID: 22351515.
Klotz L. Active surveillance for prostate cancer: overview and update. Curr Treat Options Oncol. 2013 Mar;14(1):97-108. PMID: 23318986.
Klotz L, et al. Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. J Clin Oncol. 2010 Jan 1;28(1):126-31. PMID: 19917860.
Stacey D, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017 Apr 12;4:CD001431. PMID: 28402085.
Thompson I, et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol. 2007 Jun;177(6):2106-31. PMID: 17509297.
Wilt TJ, et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med. 2012 Jul 19;367(3):203-13. PMID: 22808955.
Related Resources:
Patient Pamphlet: Low-Risk Prostate Cancer: Don’t rush to get treatment
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Whole breast radiotherapy is beneficial for most women with invasive breast cancer treated with breast conservation therapy. Many studies have utilized “conventionally fractionated” schedules that deliver therapy over 5 to 6 weeks, often followed by 1 to 2 weeks of boost therapy. However, more recent evidence (including a major study from Canada) has demonstrated equivalent tumour control and cosmetic outcome in specific patient populations with shorter courses of therapy (approximately 3 to 4 weeks). Patients and their physicians should review these options to determine the most appropriate course of therapy.
Sources:
Clarke M, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005 Dec 17;366(9503):2087-106. PMID: 16360786.
Darby S, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet. 2011 Nov 12;378(9804):1707-16. PMID: 22019144.
Smith BD, et al. Fractionation for whole breast irradiation: an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Int J Radiat Oncol Biol Phys. 2011 Sep 1;81(1):59-68. PMID: 20638191.
Whelan TJ, et al. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med. 2010 Feb 11;362(6):513-20. PMID: 20147717.
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Several studies (including randomized clinical trials) have demonstrated that surveillance following definitive cancer therapy can be performed equally well, and in a more patient-centered fashion, within a primary care setting. With the substantial increase in cancer survivors, the traditional practice of providing routine follow-up care through specialist cancer centres is placing rising demands and competing with other care delivery functions of such centres. Primary care providers are both willing to provide follow-up cancer care and have repeatedly assumed such responsibility. Despite this, the transition to primary care in Canada has been both variable and incomplete.
Sources:
Del Giudice ME, et al. Primary Care physician willingness to provide follow-up care for adult cancer survivors. J Clin Oncol. 2007 Jun:25(18 suppl);6562.
Ristovski-Slijepcevic S. Environmental scan of cancer survivorship in Canada: Conceptualization, practice & research. Vancouver (BC): BC Cancer Agency; 2008.
Erikson C, et al. Future supply and demand for oncologists: challenges to assuring access to oncology services. J Oncol Pract. 2007 Mar;3(2):79-86. PMID: 20859376.
Grunfeld E. Looking beyond survival: how are we looking at survivorship? J Clin Oncol. 2006 Nov 10;24(32):5166-9. PMID: 17093281.
Grunfeld E, et al. Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care. J Clin Oncol. 2006 Feb 20;24(6):848-55. PMID: 16418496.
Grunfeld E, et al. Routine follow up of breast cancer in primary care: randomised trial. BMJ. 1996 Sep 14;313(7058):665-9. PMID: 8811760.
Murchie P, et al. Patient satisfaction with GP-led melanoma follow-up: a randomised controlled trial. Br. J. Cancer. May 11 2010;102(10):1447-1455. PMID: 20461089.
Wattchow DA, et al. General practice vs surgical-based follow-up for patients with colon cancer: randomised controlled trial. Br J Cancer. 2006 Apr 24;94(8):1116-21. PMID: 16622437.
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In the past, extensive local regional therapies (e.g., surgery) were often provided in patients with metastatic disease, regardless of the symptomatology of the primary tumour. However, recent evidence has suggested that in many cases these therapies do not improve outcome and, at times, delay the more important treatment of metastatic disease (e.g., chemotherapy). In general, patients with metastatic disease from solid organ malignancies and a relatively asymptomatic primary tumour should be considered for systemic therapy as a priority; the delay in systemic therapy and potential additional morbidity arising from extensive locoregional therapies should be avoided in these patients.
Sources:
Badwe, R. Surgical removal of primary tumor and axillary lymph nodes in women with metastatic breast cancer at first presentation: A randomized controlled trial. San Antonio Breast Conference; 2013.
Kleespies A, et al. Determinants of morbidity and survival after elective non-curative resection of stage IV colon and rectal cancer. Int J Colorectal Dis. 2009 Sep;24(9):1097-109. PMID: 19495779.
National Comprehensive Cancer Network. NCCN Guidelines for Colon Cancer Version 3 [Internet]. 2014 [cited 2014 April].
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Intracranial metastases are a source of neurologic morbidity and mortality. For several decades, whole brain radiation therapy (WBRT) remained the standard of care, but the development of advanced radiation techniques such as stereotactic radiosurgery (SRS) allows treatment of limited brain metastases in less time and while largely sparring surrounding brain. Several randomized trials have compared SRS alone to SRS plus WBRT or local therapy alone (SRS or surgery) to local therapy plus WBRT. These trials allowed up to 4 lesions and including patients with good performance status (Karnofsky performance status >= 70 or Eastern Cooperative Oncology Group 0 to 2). These trials showed that adding WBRT to SRS alone did not improve survival and that there was worse neurocognitive deterioration and quality of life in patients treated with WBRT plus SRS. Several national international guidelines now recommend the use of SRS for patients with good performance status and up to 4 brain metastases.
Sources:
Kocher M, Soffietti R, Abacioglu U et al. Adjuvant whole-brain radiotherapy versus observation after radiosurgery or surgical resection of one to three cerebral metastases: results of the EORTC 22952-26001 study. J Clin Oncol. 2011;29(2):134-41. PMID: 21041710.
Brown PD, Jaeckle K, Ballman KV et al. Effect of Radiosurgery Alone vs Radiosurgery With Whole Brain Radiation Therapy on Cognitive Function in Patients With 1 to 3 Brain Metastases: A Randomized Clinical Trial. JAMA. 2016;316(4):401-409. PMID: 27458945.
Chang EL, Wefel JS, Hess KR et al. Neurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomised controlled trial. Lancet Oncol. 2009;10(11):1037-44. PMID: 19801201.
Gondi V, Bauman G, Bradfield L et al. Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol. 2022;12(4):265-282. PMID: 35534352.
Vogelbaum MA, Brown PD, Messersmith H, et al. Treatment for Brain Metastases: ASCO-SNO-ASTRO Guideline. J Clin Oncol. 2022;40(5):492-516. PMID: 34932393.
Le Rhun E, Guckenberger M, Smits M et al. EANO-ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up of patients with brain metastasis from solid tumours. Ann Oncol. 2021;32(11):1332-1347. PMID: 34364998.
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Hypofractionated or shortened radiation regimens have been documented to attain similar efficacy and safety as conventional and longer radiation courses for multiple tumor sites. By reducing the number of treatments, patient travel and machine time are reduced, thereby decreasing carbon emissions and energy demands of radiotherapy.
Sources:
Canadian Association of Radiation Oncology
Brunt AM, et al. Hypofractionated breast radiotherapy for 1 week versus 3 weeks (FAST-Forward): 5-year efficacy and late normal tissue effects results from a multicentre, non-inferiority, randomised, phase 3 trial. Lancet. 2020 May 23;395(10237):1613-1626. PMID: 32580883.
Cheung R, et al. Evaluating the Short-term Environmental and Clinical Effects of a Radiation Oncology Department’s Response to the COVID-19 Pandemic. Int J Radiat Oncol Biol Phys. 2023 Jan 1;115(1):39-47. PMID: 36309074.
Lutz S, et al. Palliative radiotherapy for bone metastases: an ASTRO evidence-based guideline. Int J Radiat Oncol Biol Phys. 2011 Mar 15;79(4):965-76. PMID: 21277118.
Morgan SC, et al. Hypofractionated Radiation Therapy for Localized Prostate Cancer: Executive Summary of an ASTRO, ASCO and AUA Evidence-Based Guideline. J Urol. 2019 Mar;201(3):528-534. PMID: 30759696.
Tree AC, et al. Intensity-modulated radiotherapy versus stereotactic body radiotherapy for prostate cancer (PACE-B): 2-year toxicity results from an open-label, randomised, phase 3, non-inferiority trial. Lancet Oncol. 2022 Oct;23(10):1308-1320. PMID: 36113498.
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A major source of the carbon footprint in the delivery of radiotherapy stems from the travels of the patients and staff to the radiation centres. As Canadian radiation facilities are centralized within larger towns and cities, public transits are commonly available. Active transportation is associated with many co-health benefits. Health care centres should ensure facilities exist to support active commuting (ex. showers, secure bike storage). Public transport when available should be incentivized, and in communities lacking this resource, health centres should advocate for this service.
Sources:
Canadian Association of Radiation Oncology
Celis-Morale et al., Association between active commuting and incident cardiovascular disease, cancer, and mortality: prospective cohort study. BMJ 2017: 357:1-7. PMID: 28424154.
Cheung R, et al. Evaluating the Short-term Environmental and Clinical Effects of a Radiation Oncology Department’s Response to the COVID-19 Pandemic. Int J Radiat Oncol Biol Phys. 2023 Jan 1;115(1):39-47. PMID: 36309074.
Chuter, Robert. (2023). Could building more satellite centres reduce the carbon footprint of external beam radiotherapy. IPEM-Translation. 6-8. 100021. 10.1016/j.ipemt.2023.100021. 4.
Chuter R, et al. Towards estimating the carbon footprint of external beam radiotherapy. Phys Med. 2023 Aug;112:102652. PMID: 37552912.
Tennison I et al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health. 2021 Feb;5(2):e84-e92. PMID: 33581070.
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Medical imaging is estimated to account for 1% of global GHG emissions. For example, a single MRI abdomen is estimated to generate emissions equivalent to driving a motor vehicle almost 300km. The annual energy requirements and carbon emissions associated with commonly used investigations in increasing order are: ultrasound system (2500 kWh, 0.74 tCO2e), CT scanner (20 000 – 35 000 kWH, 5.9-10.4 tCO2e), PET-CT scanner (52 000 kWH, 15.4 tCO2e), and MRI scanner (80 000-170 000 kWh, 23.7-50.3 tCO2e). Data for onboard imaging and picture storage is currently limited but an active area of research.
Sources:
Canadian Association of Radiation Oncology
Chuter R et al. Towards estimating the carbon footprint of external beam radiotherapy. Phys Med. 2023 Aug;112:102652. PMID: 37552912.
Heye T, Knoerl R, Wehrle T, et al. The energy consumption of radiology: Energy- and cost-saving opportunities for CT and MRI operation. Radiology 2020;295:593–605. PMID: 32208096.
Lichter KE et al. Transitioning to Environmentally Sustainable, Climate-Smart Radiation Oncology Care. Int J Radiat Oncol Biol Phys. 2022 Aug 1;113(5):915-924. PMID: 35841919.
Martin M, Mohnke A, Lewis GM, Dunnick NR, Keoleian G, Maturen KE. Environmental Impacts of Abdominal Imaging: A Pilot Investigation. J Am Coll Radiol 2018;15(10):1385–1393. PMID: 30158086.
Merkle E, Bamberg F, Vosshenrich J. The Impact of Modern Imaging Techniques on Carbon Footprints: Relevance and Outlook Eur Uro Focus. 2023. 9 (6): 891-893. PMID: 37758613.
Picano E, Mangia C, D’Andrea A. Climate Change, Carbon Dioxide Emissions, and Medical Imaging Contribution. J Clin Med 2022;12(1):215. PMID: 36615016.
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Hospital and clinic waste is transported to landfills or incinerated resulting in significant GHG emissions. Choosing reusable supplies (ex. Gowns, drapes) or recyclable products (ex. Masks, sterilization wraps) over products that are incinerated can significantly reduce carbon emissions. Proper disposal of medical waste (ex. not contaminating recyclables with biohazards) is critical. Health care providers are encouraged to support clinical waste audits in their departments.
Sources:
Canadian Association of Radiation Oncology
Lichter KE, et al. Environmentally sustainable brachytherapy care. Brachytherapy. 2022 Sep-Oct;21(5):712-717. PMID: 35794032.
Lichter KE et al. Transitioning to Environmentally Sustainable, Climate-Smart Radiation https://pubmed.ncbi.nlm.nih.gov/35841919/Oncology Care. Int J Radiat Oncol Biol Phys. 2022 Aug 1;113(5):915-924. PMID: 35841919.
Weadick CS et al. Climate toxicity: An increasingly relevant clinical issue in Cancer Care. J Cancer Policy. 2023 Mar;35:100410. PMID: 36773799.
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Several guidelines exist for the use of virtual care in oncology. These emphasize importance of calculated and appropriate triage, maximizing safety and equity. Transportation is currently the largest source of greenhouse gas (GHG) emissions. Cars emit an average of 206g of CO2 emissions per km. Virtual care can mitigate climate change by providing care from a distance and is also associated with substantial cost benefits and improved access. Various studies have shown that virtual visits are associated with a significant reduction in CO2 emissions as well as significant cost reductions to patients.
Sources:
Joint Recommendation: Canadian Association of Medical Oncologists, Canadian Association of Radiation Oncology, Canadian Society of Surgical Oncology
Cancer Care Ontario. Person-Centred Virtual Cancer Care Clinical Guidance Version: 2; 2022 Jan.
Clinical Oncology Society of Australia Teleoncology Guidelines Working Group. Clinical practice guidelines for teleoncology. Sydney: Clinical Oncological Society of Australia.
International Energy Agency. Fuel economy in major car markets: technology and policy drivers 2005-2017.
NICE. COVID-19 rapid guideline: Delivery of systemic anticancer treatments [NG161]; 2020 Mar 20. Updated: 2021 Feb 12. https://www.nice.org.uk/guidance/ng161. 5 Department of Transportation. Transportation Statistics Annual Report 2020. December 1, 2020. Accessed July 5, 2022.
Patel KB, Gonzalez BD, Turner K, Alishahi Tabriz A, Rollison DE, Robinson E, Naso C, Wang X, Spiess PE. Estimated Carbon Emissions Savings With Shifts From In-Person Visits to Telemedicine for Patients With Cancer. JAMA Netw Open. 2023 Jan 3;6(1):e2253788. PMID: 36719682.
Welk B, McArthur E, Zorzi AP. Association of Virtual Care Expansion With Environmental Sustainability and Reduced Patient Costs During the COVID-19 Pandemic in Ontario, Canada. JAMA Netw Open. 2022 Oct 3;5(10):e2237545. PMID: 36264577.
Zon RT, Kennedy EB, Adelson K, et al. Telehealth in Oncology: ASCO Standards and Practice Recommendations. JCO Oncol Pract. 09 2021; 17(9): 546-564. PMID: 34319760.
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To help create the cancer specific list for Choosing Wisely Canada, a Tri-Society Task Force was convened by the Canadian Partnership Against Cancer in late 2013. The Task Force included representatives from the Canadian Association of Radiation Oncology (CARO), Canadian Association of Medical Oncologists (CAMO) and Canadian Society of Surgical Oncology (CSSO). Through a multipronged consensus process of the Task Force, along with broader society member engagement, an initial list of 66 practices was generated. In addition, a framework for subsequent selection of low value/harmful practices was established and included the following elements: (1) the size of population to which practice is relevant; (2) the frequency of use of the practice in Canada; (3) the cost of the practice; (4) the evidence/degree of harm of practice; and (5) the potential for change in use of the practice. Based on this framework, and after an iterative adjudication and voting process, this list was first reduced to a long list of 41 practices, then to a short list of 19 practices, and subsequently to a final list of 10 low value, unnecessary, or harmful practices. Many practices were considered, including cancer-related practices previously identified in the U.S. Choosing Wisely® campaign. Recommendation 3 was adapted with permission from the Five Things Physicians and Patients Should Question, © 2014 American Society of Clinical Oncology. Recommendations 5 and 6 were adapted with permission from the Five Things Physicians and Patients Should Question, © 2013 American Academy of Hospice and Palliative Medicine. Recommendations 7 and 8 were adapted with permission from the Five Things Physicians and Patients Should Question, © 2013 American Society for Radiation Oncology.
Sources:
BC Cancer Agency. Cancer Management Guidelines. Gastrointestinal, Colon [Internet]. 2014 Feb 1 [cited 2014 Sep 23].
Earle C, et al. Follow-up care, surveillance protocol, and secondary prevention measures for survivors of colorectal cancer [Internet]. 2012 Feb 3 [cited 2014 Sep 23].
Fahy BN. Follow-up after curative resection of colorectal cancer. Ann Surg Oncol. 2014 Mar;21(3):738-46. PMID: 24271157.
Grunfeld E, et al. Routine follow up of breast cancer in primary care: randomised trial. BMJ. 1996 Sep 14;313(7058):665-9. PMID: 8811760.
Khatcheressian J, et al. Breast cancer follow-up in the adjuvant setting. Curr Oncol Rep. 2008 Jan;10(1):38-46. PMID: 18366959.
Meyerhardt JA, et al. Follow-up care, surveillance protocol, and secondary prevention measures for survivors of colorectal cancer: American Society of Clinical Oncology clinical practice guideline endorsement. J Clin Oncol. 2013 Dec 10;31(35):4465-70. PMID: 24220554.
National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: colon cancer [Internet]. 2014 [cited 2014 Sep 23].
Fisher DA, et al. Inappropriate colorectal cancer screening: findings and implications. Am J Gastroenterol. 2005 Nov;100(11):2526-30. PMID: 16279910.
Lee SJ, et al. Time lag to benefit after screening for breast and colorectal cancer: meta-analysis of survival data from the United States, Sweden, United Kingdom, and Denmark. BMJ. 2013 Jan 8;346:e8441. PMID: 23299842.
Moyer VA. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 Jul 17;157(2):120-34. PMID: 22801674.
Schroder FH, et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med. 2012 Mar 15;366(11):981-90. PMID: 22417251.
Whitlock EP, et al. Screening for colorectal cancer: a targeted, updated systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008 Nov 4;149(9):638-58. PMID: 18838718.
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Patient Pamphlet: Care at the End of Life for Advanced Cancer Patients: When to stop cancer treatment
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Patient Pamphlet: Colonoscopy: When you need it and when you don’t
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Related Resources:
Patient Pamphlet: Care at the End of Life for Advanced Cancer Patients: When to stop cancer treatment
Patient Pamphlet: Palliative Care: Support at any time during a serious illness
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Patient Pamphlet: Low-Risk Prostate Cancer: Don’t rush to get treatment
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About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
Email: info@choosingwiselycanada.org
Twitter: @ChooseWiselyCA
Facebook: /ChoosingWiselyCanada
Care at the End of Life for Advanced Cancer Patients
Deciding to stop cancer treatment.
Colonoscopy
When you need it and when you don’t.
Low-Risk Prostate Cancer
Don’t rush to get treatment.
Palliative Care
Support at any time during a serious illness.