September 15, 2014 — The American Society for Radiation Oncology (ASTRO) released its second list of five radiation oncology-specific treatments that are commonly ordered but may not always be appropriate, as part of the national Choosing Wisely campaign, an initiative of the ABIM Foundation. The list identifies five targeted treatment options that ASTRO recommends for detailed patient-physician discussion before being prescribed. ASTRO released its first list of five recommendations on Sept. 23, 2013.
ASTRO’s 2014 list of five recommendations are:
- 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, M.D., 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 healthcare 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.