• Don’t recommend radiation following hysterectomy for endometrial cancer patients with low-risk disease.
Patients with low-risk endometrial cancer, including no residual disease in hysterectomy despite positive biopsy, grade 1 or 2 with <50 percent myometrial invasion and no additional high-risk features such as age >60, lymphovascular space invasion or cervical involvement have a very low risk of recurrence following surgery. Meta-analysis studies of radiation therapy for low-risk endometrial cancer demonstrate increased side effects with no benefit in overall survival compared with surgery alone.
• Don’t routinely offer radiation therapy for patients who have resected non-small cell lung cancer (NSCLC), negative margins, N0-1 disease.
Patients with early-stage NSCLC have several management options following surgery. These options include observation, chemotherapy and radiotherapy. Two meta-analysis studies of post-operative radiotherapy in early NSCLC with node negative or N1 disease suggest increased side effects with no benefit for disease-free survival or overall survival compared to observation. Patients with positive margins following surgery may benefit from post-operative radiotherapy to improve local control regardless of status of their nodal disease.
• Don’t initiate non-curative radiation therapy without defining the goals of treatment with the patient and considering palliative care referral.
Well-defined goals of therapy are associated with improved quality of life and better understanding on the part of patients and their caregivers. Palliative care can be delivered concurrently with anti-cancer therapies. Early palliative care intervention may improve patient outcomes including survival.
• Don’t routinely recommend follow-up mammograms more often than annually for women who have had radiotherapy following breast conserving surgery.
Studies indicate that annual mammograms are the appropriate frequency for surveillance of breast cancer patients who have had breast conserving surgery and radiation therapy with no clear advantage to shorter interval imaging. Patients should wait six to 12 months after the completion of radiation therapy to begin their annual mammogram surveillance. Suspicious findings on physical examination or surveillance imaging might warrant a shorter interval between mammograms.
• Don’t routinely add adjuvant whole brain radiation therapy to stereotactic radiosurgery for limited brain metastases.
Randomized studies have demonstrated no overall survival benefit from the addition of adjuvant whole brain radiation therapy (WBRT) to stereotactic radiosurgery (SRS) in the management of selected patients with good performance status and brain metastases from solid tumors. The addition of WBRT to SRS is associated with diminished cognitive function and worse patient-reported fatigue and quality of life. These results are consistent with the worsened, self-reported cognitive function and diminished verbal skills observed in randomized studies of prophylactic cranial irradiation for small cell or non-small cell lung cancer. Patients treated with radiosurgery for brain metastases can develop metastases elsewhere in the brain. Careful surveillance and the judicious use of salvage therapy at the time of brain relapse allow appropriate patients to enjoy the highest quality of life without a detriment in overall survival. Patients should discuss these options with their radiation oncologist.
“We are proud to continue our commitment to the Choosing Wisely® campaign and to release our second list of five radiation oncology treatments that we recommend physicians and patients discuss in more detail prior to treatment,” said Colleen A.F. Lawton, MD, FASTRO, chair of ASTRO’s Board of Directors. “ASTRO is dedicated to supporting a strong doctor-patient relationship to ensure that patients are able to make sound and informed health care decisions. Both of ASTRO’s lists provide evidence-based recommendations that will foster detailed conversations so that patients receive appropriate, high-quality radiation oncology care.”
ASTRO’s Choosing Wisely® list was developed after several months of careful consideration and thorough review, using the most current evidence about management and treatment options. In January 2014, ASTRO formed a work group to develop the second Choosing Wisely® list with representatives from health policy, government relations, and clinical affairs and quality. The work group narrowed a list of 28 topics to nine potential items. A survey was sent to ASTRO’s members to rate the value and relevancy of each item. The survey also included an open response option for members to comment on the nine suggested items and to provide additional ideas for the Choosing Wisely® list. Using the survey results, the work group submitted a list of eight items to ASTRO’s Board of Directors, from which the final list of five items was selected. An extensive literature review was conducted for each topic, and the work group drafted the text and selected references for each topic. The final items for submission were approved by ASTRO’s Board of Directors.
To speak with Dr. Lawton, please call Michelle Kirkwood on September 14 – 17, 2014, in the ASTRO Press Office at the Moscone Center in San Francisco Center at 415-978-3503 or 415-978-3504, or contact her by email: [email protected]. To learn more about the national Choosing Wisely® initiative and to view the complete lists and additional details about the recommendations and evidence supporting them, visit www.ChoosingWisely.org.
ASTRO’s 56th Annual Meeting, to be held at the Moscone Center in San Francisco, September 14-17, 2014, is the nation’s premier scientific meeting in radiation oncology. The 2014 Annual Meeting is expected to attract more than 11,000 attendees including oncologists from all disciplines, medical physicists, dosimetrists, radiation therapists, radiation oncology nurses and nurse practitioners, biologists, physician assistants, practice administrators, industry representatives and other health care professionals from around the world. Led by ASTRO President Bruce G. Haffty, MD, FASTRO, a radiation oncologist specializing in breast cancer, the theme of the 2014 Meeting is “Targeting Cancer: Technology and Biology,” and the Presidential Symposium, “Local-regional Management of Breast Cancer: A Changing Paradigm,” will feature Jay R. Harris, MD, FASTRO, and Thomas A. Buchholz, MD, FASTRO, to highlight recent practice-changing, landmark studies and current developments in the local-regional management of breast cancer. ASTRO’s four-day scientific meeting includes presentation of four plenary papers, 360 oral presentations, 1,862 posters and 144 digital posters in more than 50 educational sessions and scientific panels for 20 disease-site tracks. Three keynote speakers will address a range of topics including oncologic imaging, biology and targeting in oncology, and human error and safety concerns: Hedvig Hricak, MD, PhD, Chair of the Department of Radiology and the Carroll and Milton Petrie Chair at Memorial Sloan Kettering Cancer Center; Frank McCormick, PhD, FRS, DSc (hon), Professor Emeritus and the David A. Wood Distinguished Professor of Tumor Biology and Cancer Research of the University of California at San Francisco Helen Diller Family Comprehensive Cancer Center; and Sidney Dekker, PhD, MA, MSc, Professor and Director of the Safety Science Innovation Lab at Griffith University, Brisbane, Australia.
ABOUT ASTROASTRO is the premier radiation oncology society in the world, with more than 10,000 members who are physicians, nurses, biologists, physicists, radiation therapists, dosimetrists and other health care professionals that specialize in treating patients with radiation therapies. As the leading organization in radiation oncology, the Society is dedicated to improving patient care through professional education and training, support for clinical practice and health policy standards, advancement of science and research, and advocacy. ASTRO publishes two medical journals, International Journal of Radiation Oncology • Biology • Physics (www.redjournal.org) and Practical Radiation Oncology (www.practicalradonc.org); developed and maintains an extensive patient website, www.rtanswers.org; and created the Radiation Oncology Institute (www.roinstitute.org), a non-profit foundation to support research and education efforts around the world that enhance and confirm the critical role of radiation therapy in improving cancer treatment. To learn more about ASTRO, visit www.astro.org.
ABOUT Choosing WiselyChoosing Wisely is an initiative of the American Board of Internal Medicine Foundation that aims to promote conversations between providers and patients by helping patients choose care that is supported by evidence; not duplicative of other tests or procedures already received; free from harm; and truly necessary. In response to this challenge, national organizations representing medical specialists have asked its providers to “choose wisely” through the identification of tests or procedures commonly used in their field, whose necessity should be questioned and discussed. The resulting lists of “Things Providers and Patients Should Question” will spark discussion about the need—or lack thereof—for many frequently ordered tests or treatments. The concept was originally conceived and piloted by the National Physicians Alliance, which, through an ABIM Foundation Putting the Charter into Practice grant, created a set of three lists of specific steps physicians in internal medicine, family medicine and pediatrics could take in their practices to promote the more effective use of health care resources. These lists were first published in Archives of Internal Medicine. Recognizing that patients need better information about what care they truly need in order to have these conversations with their providers, Consumer Reports is developing patient-friendly materials and is working with consumer groups to disseminate them widely. Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.###
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