The Royal College of Pathologists of Australasia: tests, treatments and procedures clinicians and consumers should question

Asymptomatic bacteriuria is a common finding in all ages and in association with other comorbidities. Treatment of asymptomatic bacteriuria is recommended in pregnancy but not in other clinical situations. Prophylaxis against development of symptoms prior to simple cystoscopy and prosthetic joint replacement is not recommended. Extensive guidelines from the Infectious Diseases Society of America (IDSA) are available for this condition and asymptomatic bacteriuria in catheterised patients. The use of chemical screening strips in asymptomatic patients may lead to unnecessary urine cultures when positive results are obtained. Increasing antibiotic resistance in urinary pathogens may be a consequence of unnecessary treatment.

Supporting evidence

  • Nicolle LE. Asymptomatic bacteriuria. Current Opinion in Infectious Diseases 2014;27(1):90-6.
  • Nicolle LE, Bradley S, Colgan S, et al. Infectious Diseases Society of America Guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clinical Infectious Diseases 2005;40(5):643-54.
  • Gupta K, Hooton TM, Naber KG, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases 2011;52(5):e103-20.
  • Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases 2010;50(5):625-63.

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Prostate cancer causes significant mortality and morbidity and all patients with concerns about their risks of having the disease and/or their prognosis if diagnosed, including the role of prostate specific antigen (PSA) testing, should discuss these with their doctor. Since any mortality benefit from early diagnosis of prostate cancer due to PSA testing is not seen within less than 6–7 years from testing, PSA testing is not recommended for men who are unlikely to live another 7 years.

Supporting evidence

  • Bergdahl AG, Holmberg E, Moss S, et al. Incidence of prostate cancer after termination of screening in a populationbased randomised screening trial. Eur Urol 2013;64(5):703-9.
  • Hugosson J, Carlsson S, Aus G et al. Mortality results from the Goteborg randomised population-based prostate-cancer screening trial. Lancet Oncol 2010;11(8):725-32.
  • Roobol MJ, Kranse R, Bangma CH et al. Screening for prostate cancer: Results of the Rotterdam section of the European randomized study of screening for prostate cancer. Eur Urol 2013;64(4):530-9.
  • Schroder FH, Hugosson J, Roobol MJ et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012;366(11):981-90.

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The quality of the evidence for the health benefits of an adequate vitamin D status is highly variable. As the main source of vitamin D is UVB sunlight exposure, vitamin D status as assessed by the measurement of 25 hydroxyvitamin D (25OH-D) is correlated with time spent outdoors, exercise and other aspects of a healthy lifestyle including body weight. Vitamin D insufficiency is associated with low levels of exercise, obesity and/or reduced sun light exposure, such as occur more commonly in the elderly, the overweight, the frail and unwell or institutionalised and where there are occupational, racial or cultural reasons. In individuals at risk of vitamin D deficiency, measurement of 25OH-D is an appropriate, case-finding strategy. Routine screening of healthy infants, children and adults (including pregnant women) for vitamin D deficiency is currently not recommended.

Supporting evidence

  • Ajuria-Morentin I, Mar-Medina C, Bereciartua-Urbieta E et al. Lack of transferability between different immunoassays and LC-MS/MS for total 25-hydroxyvitamin D measurement and disagreement defining deficiency. Scand J Clin Lab Invest 2013;73(1):82-6.
  • Autier P, Boniol M, Pizot C, et al. Vitamin D status and ill health: a systematic review. The Lancet Diabetes & Endocrinology 2014;(2):76-89.
  • Bolland MJ, Grey A, Gamble GD et al. The effect of vitamin D supplementation on skeletal, vascular, or cancer outcomes: a trial sequential meta-analysis. The Lancet Diabetes & Endocrinology 2014;2(4):307-20.
  • Cavalier E, Lukas P, Crine Y, et al. Evaluation of automated immunoassays for 25(OH)-vitamin D determination in different critical populations before and after standardization of the assays. Clin Chim Acta 2014;(431):60-5.
  • Glendenning P, Chew GT. Controversies and consensus regarding vitamin D deficiency in 2014: whom to test and whom to treat? Med J Aust 2015;202(9):470-1.
  • Meyer HE, Holvik K, Lips P. Should vitamin D supplements be recommended to prevent chronic diseases. BMJ 2015;(350):321.
  • Schleicher RL, Sternberg MR, Lacher DA, et al. The vitamin D status of the US population from 1988 to 2010 using standardized serum concentrations of 25-hydroxyvitamin D shows recent modest increases. Am J Clin Nutr 2016;104(2):454-61.
  • Theodoratou E, Tzoulaki I, Zgaga L, et al. Vitamin D and multiple health outcomes: umbrella review of systematic reviews and meta-analyses of observational studies and randomised trials. BMJ 2014;348:g2035.

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The measurement of levels of certain tumour biomarkers is known to be helpful in monitoring the progress of specific cancers in response to treatment or in detecting changes in cancer activity or secondary or recurring cancer. In some circumstances they are helpful adjuncts in detecting specific cancers, where there is a strong known underlying predisposition or suspicion, such as in detecting liver cancer in patients with chronic hepatitis C and cirrhosis. However, the testing for a broad range of biomarkers in patients with non-specific symptoms in the hope of finding an undetected cancer is not supported by the evidence from numerous systematic reviews. Tumour markers generally should not be used in the initial diagnostic pathway and are rarely diagnostic due to low sensitivity and specificity.

Supporting evidence

  • Association for Clinical Biochemistry & Laboratory Medicine. Recommendations as a result of the ACB national audit on tumour marker service provision. 2013. Recommendation Document. Available at http://www.acb.org.uk/docs/defaultsource/guidelines/tumour-marker-guidelines.pdf.
  • Duffy MJ, McGing P. Guidelines for the use of tumour markers. Association of Clinical Biochemists in Ireland 2010. Available at: www.acbi.ie/Downloads/Guideline-tumour-markets-4th.pdf.
  • National Institute of Health and Care Excellence. Diagnosis and management of metastatic malignant disease of unknown primary origin. NICE Clinical Guideline 104. National Collaborating Centre for Cancer 2010. Available at www.nice.org.uk/guidance/cg104.
  • Sturgeon CM, Duffy MJ, Stenman UH, et al. National Academy of Clinical Biochemistry laboratory medicine practice guidelines for use of tumor markers in testicular, prostate, colorectal, breast, and ovarian cancers. Clin Chem 2008;54(12):e11-79.
  • Sturgeon CM, Hoffman BR, Chan DW, et al. Laboratory Medicine Practice Guidelines for use of tumor markers in clinical practice: quality requirements. National Academy of Clinical Biochemistry 2008. Available at https://www.aacc.org/science-and-research/practice-guidelines/tumor-markers-quality-requirements.

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Measurement of lipid levels is part of absolute risk assessment for the prevention of cardiovascular disease. Age is a predominant risk factor in the elderly, so absolute risk calculators accommodate this by fixing 75 years as the maximum age that can be included in the calculation. Clinicians need to consider whether or not the assessment and treatment of risk factors beyond this age in the very elderly is likely to yield clinical benefit within the patient’s remaining life expectancy. On rare occasions lipid testing may provide relevant information in other life threatening diseases, such as pancreatitis, but in most critical illnesses lipid measurement for prevention of chronic disease will no longer be a priority.

Supporting evidence

  • National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. 2012.

A list of ten items was compiled after reviewing international literature associated with the Choosing Wisely campaign in Northern America. The College’s advisory committees were canvassed for further relevant evidence based literature and their expert opinions were sought.

The ten items were then adopted as a College Position Statement titled ‘Inappropriate Pathology Requesting’. This list was then sent to RCPA Fellows and Trainees based in Australia to rank the top five tests to include in the Australian Choosing Wisely initiative. The five items selected were approved by both the RCPA's Board of Professional Practice and Quality and the RCPA Board of Directors.

Last reviewed 22 April 2015

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