Nurse practitioner Adele M. Caruso, MSN, CRNP, discusses appropriate timing of follow-up and ponders related health insurance coverage and cancer survivorship issues.
What is the right amount when it comes to patient follow-up for treated renal cancers? What are advanced practice providers and physicians really doing around the country? Is there consistency? What are the guidelines? In this blog post, I will provide an overview of current practices in renal cancer follow-up and also look at related health insurance coverage and cancer survivorship issues.
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Post-treatment renal cancer follow-up. What is the right amount? In recent years, we have seen a considerable stage shift in renal cell carcinoma. Smaller treated masses can have a more protracted or indolent history. Additionally, with renal-sparing surgery, there is less worry of renal deterioration and a lower need for constant short-term monitoring. Also, during this time we have gained further information on the long-term outcomes of larger masses that have been successfully treated. Late recurrences in multiple sites can be more common than previously thought.
Not too much. Standard schedules and techniques for monitoring have been rethought as our concerns for excessive radiation exposure and contrast media toxicity have grown. Additionally, the natural history of small renal masses allows for a thorough yet longer interval period between evaluations.
Not too little. As we become comfortable with longer periods between evaluation and less intensive evaluation, it is important not to let this lapse into a program more similar to watchful waiting. This is especially true since patients are often non-compliant with obtaining follow-up studies. It would be inappropriate for large time periods to lapse between studies.
Just right. In 2013 , the AUA created evidence-based guidelines for follow-up of treated renal cancers with surgery or renal ablative procedures. Additionally, these guidelines address surveillance of clinically localized renal cancers-both biopsy-proven untreated and biopsy-unproven renal masses treated with renal ablative procedures or surveillance. The guideline statements are based on the best available evidence and expert opinion.
Next: The AUA's stance
AUA stance. Low-risk patients (pT1, N0, Nx). The AUA guidelines for nephron-sparing surgery in low-risk patients require baseline computed tomography (CT) or magnetic resonance imaging (MRI), and for radical nephrectomy require a baseline scan of either retroperitoneal ultrasound (US), CT, or MRI, from 3 to 12 months following surgery. Additional imaging may be performed if the initial imaging is negative and may be performed annually for 3 years. Chest x-ray (CXR) is recommended annually for 3 years and beyond if clinically indicated.
Moderate to high-risk patients (pT2-4N0, Nx, or N+). The AUA panel recommends that moderate- to high-risk patients undergo a baseline chest and abdominal scan (CT or MRI) within 3 to 6 months after treatment and then imaging (US, CT, or MRI and CXR) every 6 months for 3 years, then annually to year five. Additional imaging beyond year five is at the discretion of the provider.
Health insurance coverage. I know I am not alone when I say that peer-to-peer reviews for imaging authorizations are requested so regularly that they are almost an everyday occurrence in clinical practice. Is there really a consensus regarding the guidelines and best practices? The “discretion of the provider” is frequently called into question. Is this reflected in the authorization for insurance coverage? Is there consistency?
GU cancer survivorship. Cancer survivorship for adults is focused on monitoring for cancer recurrence and treatment effects, identification of secondary tumors, and prevention and treatment of new cancers. Care is also inclusive of the physiologic and psychological aspects.
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A recent study showed results from a web-based survey that identified that the lack of time/resources and practice guidelines were considered the two most important barriers to survivorship care by 31% and 30% of participants (Urology Practice 2016; 3:62-69). Practice guidelines and advocacy groups that are web based were selected as the most important. The conclusions were evident. Professional societies and advocacy groups should educate their members to the consensus best practices and guidelines.
Next: "I urge you to stay up to date with the current guidelines and best practices."
Educate. I urge you to stay up to date with the current guidelines and best practices. It is ideal for both providers and nursing staff to be familiar with the recommendations when interacting with patients. Patient should naturally be knowledgeable regarding their care. Often, patients are baffled when imaging is not authorized by their insurance carrier, and it is advantageous for them to be informed.
In my practice, I regularly refer to the above-mentioned AUA guideline. I have made some changes since 2013 and have adapted my current practice to the recommendations according to the guideline changes, specifically in regard to low-risk patients and the imaging time interval. I also regularly use discretion based on a patient’s particular situation, especially for moderate- to high-risk patients. Please feel free to share your practice patterns and perspectives.
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