Medical Oncology Group of Australia

For some patients with advanced cancer, chemotherapy is no longer effective. Symptom relief and palliative care should become the primary modes of care. The Eastern Cooperative Oncology Group (ECOG) performance status is a valid predictor of poor survival, reduced response, and worsened toxicity from chemotherapy. Patients with advanced solid tumours, with an ECOG performance status of 3 or 4, generally exhibit a poor response to chemotherapy. There are well known exceptions to this. These are generally patients with untreated highly chemo-sensitive malignancies, and who have recently declined from a good performance status.

Supporting evidence

  • Baldotto CS, Cronemberger EH, de Biasi P, et al. Palliative care in poor-performance status small cell lung cancer patients: is there a mandatory role for chemotherapy? Support Care Cancer. 2012;20(11):2721–7.
  • Gridelli C, Ardizzoni A, Le Chevalier T, et al. Treatment of advanced non-small-cell lung cancer patients with ECOG performance status 2: results of a European Experts Panel. Ann Oncol 2004;15(3):419–26.
  • Kenmotsu H, Goto K, Kubota K, et al. Clinical significance of chemotherapy for small cell lung cancer (SCLC) with ECOG performance status (PS) 3–4. Journal of Clinical Oncology 2008 26:15_suppl, 19123-19123.
  • Prigerson HG, Bao Y, Shah MA3, et al. Chemotherapy Use, Performance Status, and Quality of Life at the End of Life. JAMA Oncol. 2015;1(6):778–84.
  • Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010; 363:733–42.

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For patients with metastatic cancer (particularly but not restricted to those with life expectancy of less than five years), screening for new primary cancers is of little value and may even cause harm.

Reductions in mortality due to earlier detection and management of cancer due to various forms of screening (e.g. breast, colorectal, and prostate) typically take approximately ten years to accrue. Also, patients who have suspected cancers detected after screening may need to undergo further tests (such as prostate biopsies) and treatments. Patients with metastatic disease are more susceptible to complications arising from such tests and treatments given that they are already in frail health.

Supporting evidence

  • Ilic D, Neuberger MM, Djulbegovic M, Dahm P. Screening for prostate cancer. Cochrane Database Syst Rev. 2013;(1):CD004720.
  • Lee SJ, Boscardin WJ, Stijacic-Cenzer I, 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; 346:e8441.
  • Loeb S, Carter HB, Berndt SI, et al. Complications after prostate biopsy: data from SEER-Medicare. J Urol. 2011;186(5):1830–4.
  • Tang V, Boscardin WJ, Stijacic-Cenzer I, Lee SJ. Time to benefit for colorectal cancer screening: survival meta-analysis of flexible sigmoidoscopy trials. BMJ;350:h1662.
  • van Hees F, Zauber AG, Klabunde CN, et al. The appropriateness of more intensive colonoscopy screening than recommended in Medicare beneficiaries: a modelling study. JAMA Internal Medicine. 174(10):1568–76.

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Some biomarker and imaging tests are effective in staging cancers. For instance, flourodeoxyglucose (FDG) PETs are most effective at staging NSCLC (non-small-cell lung cancer), restaging HL (Hodgkin lymphoma), staging/restaging colorectal cancer, and detection of SPN (solitary pulmonary nodule). However, the clinical impacts of these tests for surveillance of asymptomatic patients are unclear, particularly in cases where early detection of recurrence is unlikely to improve clinical outcomes.

Moreover, despite more recent evidence that PET-CT scanning and serial measurement of serum tumour markers can be helpful for some asymptomatic patients by leading to appropriate treatment modifications, there are alternatives to these intensive approaches for detecting recurrence (e.g. surveillance mammography and clinical breast examination in the case of breast cancer).

Supporting evidence

  • Champion L, Brain E, Giraudet AL, et al. Breast cancer recurrence diagnosis suspected on tumor marker rising. Cancer 2011; 117: 1621–29.
  • Di Gioia D, Stieber P, Schmidt GP, et al. Early detection of metastatic disease in asymptomatic breast cancer patients with whole-body imaging and defined tumour marker increase. Br J Cancer. 2015;112(5):809–18.
  • Facey K, Bradbury I, Laking G, Payne E. Overview of the clinical effectiveness of positron emission tomography imaging in selected cancers. Health Technol Assess. 2007;11(44).
  • Moschetti I, Cinquini M, Lambertini M, et al. Follow-up strategies for women treated for early breast cancer. Cochrane Database Syst Rev. 2016;(5):CD001768.
  • Patel K, Hadar N, Lee J, et al. The Lack of Evidence for PET or PET-CT Surveillance of Patients with Treated Lymphoma, Colorectal Cancer, and Head and Neck Cancer: A Systematic Review. Journal of Nuclear Medicine: official publication, Society of Nuclear Medicine. 2013;54(9):1518–27.

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In patients with non-specific symptoms, testing for a panel of tumour markers to try and diagnose an underlying cancer is not supported by evidence given the low sensitivity and specificity of these tests. An exception is in cases of suspected, strong underlying predisposition of specific cancers, in which case testing may prove a useful adjunct or in specific contexts where biomarkers may be useful such as CA-125 for suspected ovarian cancer and the use of PSA to detect prostate cancer in men with lower urinary tract symptoms (LUTS).

The appropriate use of tumour biomarker testing is otherwise to monitor the progress of specific cancers under treatment or to detect changes in cancer activity or a secondary or recurring cancer.

Supporting evidence

  • Buys SS, Partridge E, Black A, et al. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. JAMA 2011; 305(22):2295–303.
  • Cramer DW, Bast RC Jr, Berg CD, et al. Ovarian cancer biomarker performance in prostate, lung, colorectal, and ovarian cancer screening trial specimens. Cancer Prevention Research 2011; 4(3):365–74.
  • Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine 2009; 360(13):1320–8.
  • Shimada H, Noie T, Ohashi M, et al. Clinical significance of serum tumor markers for gastric cancer: a systematic review of literature by the Task Force of the Japanese Gastric Cancer Association. Gastric Cancer. 2014;17(1):26–33.

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Patients receiving oncological treatment are at higher risk of thromboembolic disease and hence may require anticoagulant treatment. While there is some evidence that some of these treatments significantly reduce the risk of venous thromboembolic (VTE) events, this benefit must be weighed against the risk of haemorrhagic complications.

Pharmacological VTE prophylaxis should not, therefore, be routinely offered to ambulant oncology patients. Exceptions may apply to high-risk cases, such as patients with multiple myeloma receiving antiangiogenesis agents, with chemotherapy and/or dexamethasone.

Supporting evidence

  • Di Nisio M, Porreca E, Candeloro M, et al. Primary prophylaxis for venous thromboembolism in ambulatory cancer patients receiving chemotherapy. Cochrane Database Syst Rev. 2016;12:CD008500.
  • Lyman GH, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2013; 31: 2189–204.
  • NICE Guidance, Venous thromboembolism: reducing the risk for patients in hospital, last updated 2015.

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Last reviewed 29 April 2019