Choosing Wisely Canada

Five Things Physicians and Patients Should Question

• Don’t order a routine bone scan and CT scan of the pelvis in men with low-risk prostate cancer. ShowTopic 1

  Low-risk patients (defined by D’Amico criteria and National Comprehensive Cancer Network guidelines) are unlikely to have metastatic disease. Accordingly, imaging is generally unnecessary in patients with newly diagnosed prostate cancer who have a PSA <20.0 ng/mL and a Gleason score 6 or less unless the patient’s history or clinical examination suggests distant disease.  Metastases are much more likely in high-grade disease that is characterized by fast and aggressive growth into surrounding areas such as bones or lymph nodes.

   

  Sources:

  American Urological Association. Prostate-Specific Antigen Best Practice Statement [Internet]. Linthicum (MD): AUA; 2013 [cited 2017 May 5].

  National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology [Internet]. 2017 [cited 2017 May 5].

   

  Related Resources:

  Patient Pamphlet: Low-Risk Prostate Cancer: Don’t rush to get treatment

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• Don’t order serum testosterone in men without symptoms of hypogonadism. ShowTopic 2

  In the evaluation of men with erectile dysfunction, testosterone should only be ordered if there are signs and/or symptoms of hypogonadism.

   

  Sources:

  American Urological Association. Management of Erectile Dysfunction Clinical Practice Guideline [Internet]. Linthicum (MD): AUA; 2011 [cited 2017 May 5].

  The Endocrine Society. Testosterone Therapy in Adult Men with Androgen Deficiency Syndromes: An Endocrinology Society Clinical Practice Guideline [Internet]. 2010 [cited 2017 May 5].

   

  Related Resources:

  Patient Pamphlet: Treatment for Erection Problems: When you need testosterone treatment and when you don’t

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• Don’t prescribe testosterone to men with erectile dysfunction who have normal testosterone levels. ShowTopic 3

  While testosterone treatment may increase sexual interest, there appears to be no significant influence on erectile function in men with normal testosterone levels.

   

  Sources:

  American Urological Association. Management of Erectile Dysfunction Clinical Practice Guideline [Internet]. Linthicum (MD): AUA; 2011 [cited 2017 May 5].

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• Don’t use antimicrobials to treat asymptomatic bacteriuria in the elderly. ShowTopic 4

  Studies suggest that asymptomatic bacteriuria in the elderly does not carry significant risk of morbidity if left untreated. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and show increased adverse antimicrobial effects. Consensus criteria has been developed to characterize the specific clinical symptoms that, when associated with bacteriuria, define urinary tract infection. Screening for and treatment of asymptomatic bacteriuria is recommended before urologic procedures for which mucosal bleeding is anticipated.

   

  Sources:

  Juthani-Mehta M. Asymptomatic bacteriuria and urinary tract infection in older adults. Clin Geriatr Med. 2007 Aug;23(3):585–94, vii. PMID: 17631235.

  Nordenstam GR, et al. Bacteriuria and mortality in an elderly population. N Engl J Med. 1986 May 1;314(18):1152-6. PMID: 3960089.

  Nicolle LE, et al. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med. 1987 Jul;83(1):27-33. PMID: 3300325.

  Nicolle LE, et al. Infectious Diseases Society of America Guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1;40(5):643-54. PMID: 15714408.

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• Don’t perform an ultrasound in children with undescended testes. ShowTopic 5

  Ultrasound is of minimal value in localizing the position or existence of testes that cannot be felt through physical examination. Studies have shown that there remained a significant chance that testes were present even after a negative ultrasound result. The likelihood of locating testes is low when using ultrasound.

   

  Sources:

  Tasian G et al. Diagnostic performance of ultrasound in Nonpalpable Cryptorchidism: A systematic review and meta-analysis. Pediatrics. 2011 Jan;127(1):119-28. PMID: 21149435.

  National Advisory Committee on Blood and Blood Products (NAC). Prothrombin Complex Concentrates [Internet]. 2014 May [cited 2017 May 5].

  Scottish Intercollegiate Guidelines Network (SIGN). Sign 129: Antithrombotics: Indications and Management [Internet]. 2013 Jun [cited 2017 May 5].

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• How the list was created ShowTopic 1

  The Canadian Urological Association (CUA) utilized its guidelines committee to review evidence from the association’s guidelines and the suggestions put forward by the American Urological Association (AUA) to identify potential topics for nomination to the CUA’s Choosing Wisely Canada list. The general membership had the opportunity to put forward suggestions after being notified of the process via email. The committee reviewed a number of recommendations and through a consensus process identified the five tests or procedures that should be questioned. These recommendations were reviewed and approved by the CUA guidelines committee. Recommendations 1, 3 and 5 were adopted with permission from the Five Things Physicians and Patients Should Question, © 2013 American Urological Association. Recommendation 4 was adopted with permission from the Ten Things Physicians and Patients Should Question, © 2015 American Geriatrics Society, New York, New York. Reprinted with permission. www.americangeriatrics.org.