Red flags in the medical record caused the NCH clinical review team to question a radiation oncologist's diagnosis of metastatic prostate cancer.
For NCH clinical oncology reviewers, preventing inappropriate utilization of drugs and therapies is all part of a day's work. There are occasions, however, when the details of a case raise serious concerns beyond the treatment regimen. One such case occurred recently, following an authorization request for a man with a history of prostate cancer.
Several years earlier, this patient had undergone a prostatectomy and had also received radiation to treat his prostate cancer. He had been on hormone therapy ever since. When a recent PET scan revealed several new areas concerning for cancer that had spread to lymph nodes both under his arms and in his pelvis, the radiation oncologist submitted a request to treat the pelvic lymph nodes through stereotactic radiotherapy (SBRT). SBRT is a treatment that delivers a precise dose of highly intense radiation to a very limited area.
Red flags in the medical record caused the NCH clinical review team to question the radiation oncologist's diagnosis of metastatic prostate cancer. First was the fact that the potentially cancerous sites had been discovered only in the lymph nodes. When prostate cancer metastasizes, it more commonly spreads to bones. Second, none of these new lymph nodes had been biopsied, which raised the real possibility that they contained a lymphoma or another malignancy. In addition, even if the diagnosis of metastatic prostate cancer had been correct, the choice of SBRT was not appropriate for a cancer that had spread so widely throughout this patient's body. SBRT is only an effective treatment for "spot-treating" cases when there are just a few, limited sites of metastatic disease. This patient, on the other hand, had diffusely involved lymph nodes in the upper and lower body. Systemic therapy, such as second-line hormone therapy or chemotherapy, would have been more effective.
NCH advised the radiation oncologist and the health plan's medical director that a biopsy was seriously needed to accurately diagnose and re-stage this patient. The NCH team's actions saved the patient from undergoing unnecessary SBRT treatment.