INSOMNIACS place to talk in the wee hours

Under construction Make no assumptions on final product. I'll be using these notes to put together a final product for Nettie

Below is the link to the current ASCO guidelines. The first link, I have cut and pasted for  linkage to the the full page. 

The paragraph that starts "In January 2010" starts to describe when and why imaging guidelines were changed. It is taken from the middle of the article.  It is included here to give a historical continuity to the question at hand. 

The section below the first break has a link to the full list of treatments and tests that the TOP FIVE list identified in ASCO's Cost of Care Task Force. Of the Top Five list, #3 and #4 were specifically related to Nettie's questions regarding why her doc didn't do imaging. They are placed here, so, as I gather the rest of the information, I can easily refer to them.  I will use them in the final discussion with Nettie. Believe it or not this is an easy way to do this. 

http://jco.ascopubs.org/content/30/14/1715.full?ij...

• © 2012 by American Society of Clinical Oncology
American Society of Clinical Oncology Identifies Five Key Opportunities to Improve Care and Reduce Costs: The Top Five List for Oncology

In January 2010, Howard Brody, MD, challenged the organized medical community at large to address the problem of waste and inefficiency in the delivery of health care by suggesting that each specialty identify the top five practices that are costly, widely used, and for which no evidence exists to support their value.⁵ ASCO's Cost of Care Task Force found this to be a compelling suggestion and undertook an initiative to identify diagnostic tests or treatment interventions that are commonly ordered, expensive, and of unproven clinical benefit.

Taking its cue from the “Top Five” challenge, in 2011 the American Board of Internal Medicine Foundation began to organize a national effort to promote awareness about the importance of stewardship of health care resources. The effort, entitled, “Choosing Wisely ®: The Five Things Physicians and Patients Should Question,” is intended to promote conversations between physicians and patients about using the most appropriate tests and treatments, as well as avoiding care that is unnecessary or whose harm may outweigh the benefits. ASCO, along with other medical specialty organizations, agreed to participate in this effort and has taken its guidance from the Cost of Care Task Force in developing its list.

After careful consideration by experienced oncologists, ASCO highlights five practices that are in common use despite the absence of evidence supporting their clinical value (Table 1).^10–24 It is understood that the Top Five list discussed in this article is no substitute for the individualized decision making that is the essence of the doctor-patient relationship. Furthermore, the elements of the Top Five list may not be appropriate in certain situations, as could be the case when a patient is enrolled in a clinical trial that demands tests or interventions that are not part of the standard of care.

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http://jco.ascopubs.org/content/30/14/1715/T1.expa...

"The American Society of Clinical Oncology (ASCO) is a medical professional oncology society committed to conquering cancer through research, education, prevention and delivery of high-quality patient care. ASCO recognizes the importance of evidence-based cancer care and making wise choices in the diagnosis and management of patients with cancer. After careful consideration by experienced oncologists, ASCO highlights five categories of tests, procedures and/or treatments whose common use and clinical value are not supported by available evidence. These test and treatment options should not be administered unless the physician and patient have carefully considered if their use is appropriate in the individual case. As an example, when a patient is enrolled in a clinical trial, these tests, treatments, and procedures may be part of the trial protocol and therefore deemed necessary for the patient's participation in the trial."

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#3 of 5 on the "Top Five List for Oncology"

Don't perform PET, CT and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.

Imaging with PET, CT or radionuclide bone scans can be useful in the staging of specific cancer types. However, these tests are often used in the staging evaluation of low-risk cancers, despite a lack of evidence suggesting they improve detection of metastatic disease or survival.

In breast cancer, for example, there is a lack of evidence demonstrating a benefit for the use of PET, CT or radionuclide bone scans in asymptomatic individuals with newly identified DCIS, or clinical stage I or II disease.

Unnecessary imaging can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.

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#4 of 5 on the "Top Five List for Oncology"

Don't perform surveillance testing (biomarkers) or imaging (PET, CT and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.^12,20–23

• Surveillance testing with serum tumor markers or imaging has been shown to have clinical value for certain cancers (e.g. colorectal). However, for breast cancer that has been treated with curative intent, several studies have shown there is no benefit from routine imaging or serial measurement of serum tumor markers in asymptomatic patients.
• False-positive tests can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.

On the medical stuff you do have a reason to talk with your doc's ABSOLUTELY supported by ASCO guidelines and the info from Spine -Health.

ASCO sections in the boxes say that scanning is not appropriate if the patient is asymptomatic. -------your very symptomatic. You have pre treatment back pain that got worse after treatment. The MO sent you back to PCP. PCP has dropped the ball big time. You have a lifelong spine problem. No radiograph evidence of change. Please, review Spine-Health link. You are at high risk for Facet Syndrome. I didn't put a link to that, but put that phrase into the search box on Spine-health web page and it'll bring it up.

The chiropractic therapy could actually aggravate your spinal problems if your spine has changed. The long distant past films that the chiro doc did, doesn't tell the story of what your spine is like in 2014. The fact that you can't even remember when the films were done tells me they are very old.

Chiro's in order to get paid have to have done films. The bad part is they can take films and use them for a basis for payment for years and years.. The insurance company doesn't demand recent evidence. Your films could be 10 years old(whatever age). Not good. Particularly when you have a change in symptoms.

The definitive test for your spinal evaluation is the MRI. Adding that you may ask for with and without contrast. It'd be astretch to get a bone scan or PET. Your care at this point has put you at futher risk of spinal injury.

Hope this helps------------- coping this section to your box, original sent by PM

Edit to add:

Nettie if you somehow can get you to the spine center in Plano or Fort Worth. Their going to know the best how to evaluate you. I'll compare it to my thyroid treatment. The area docs did okay, but the BIGWIG doc at Moffit had a complete different evaluation method and treatment protocol. EVERYTHING was different with BIGWIG doc. You will be more satisfied overall by going to the spine centers that manage scoliosis everyday. Your PCP has already demonstrated she doesn't have a clue. You would be battling to get her to respond.

The diagnostic imaging departments at the big centers will even take better films. Way better films. They will likely identify each level with very fine measurements.for evidence of spinal nerve impingement. Identifying width of spinal canal. Which would identify any cord impingement. Lastly, how the spine impacts the thoracic cage and heart.

Edit to add

Nettie, I just came back to the computer. I'm going to write the response on the board.

hate it when I write a response on a pm in it is blocked. Won't know if this is blocked till I hit submit.

I have a new thought--YAY It's cool. By going to the spine center. The docs have the EXTREME expertise in the musculoskeletal system.

They will give your spine a proper look see because your spine needs to have a proper baseline exam. Remember you are going to need it to be in great shape when you get old.

You, also, can express your concern about METS. They are the pro's on skeleton. I can really see that they would be much more cooperative on covering all bases. It's there business. No stone on turned.

Yes, I'm trying to get your hopes up. You have a right to have your concerns listened to and evaluated by a doc.

You have an underlying medical condition scoliosis that affects the whole body. The spine spinning as yours did was stablized as a young one. What wasn't communicated to you was that as an aging adult your condition could change. When you read the S-H.com pages. RE: Adult Scoliosis , you will read things can deteriorate. I am familiar with Facet syndrome b/c of when I worked in the surg center that also housed pain management. When the scoliosis pages described the adult scoliosis deterioration the problem of Facet Syndrome(FS) is included in the description. It was an "NO SHIT" moment. FS can only be properly evaluated by the inclusion of MRI studies.

A symptom that is associated with scoliosis changes in the adult is PAIN. The adolescent patients don't experience pain ( that was new for me--looks painful).

Your pain got worse after treatment--pretty sure you had rads. If the rads table was not body friendly. You had to get on a step stool. Think- about the body mechanics of the stepping, twisting to turn to sit on the table, laying on a very hard surface, Then all the mechanics getting off the table with a spine that would be prone to have a problem.

Look you are near an answer. I know you want a break from docs, but you need that back in good shape for your old age. Give yourself the best present you can. An answer.

I use Spine Health as a learning/teaching site. I even recommended it to DS the lawyer, to use it for his law purposes b/c it is so good.

But when I plugged in scoliosis into google the spine centers in Plano and Fort Worth came up in the top pull of info. But there's something wrong with their web page it wouldn't load right. But they had Scoliosis in their name. Pretty specific to what the practice focuses on.

AND your in Texas.

Hope this goes through, but will post on the board to be safe.

AH-Hah the link to Baylor Scoliosis Center

http://baylorscoliosiscenter.calls.net/PhysiciansL...