ASCO: 5 More Cancer Practices Should Stop

Second List in 2 Years

Nick Mulcahy

October 30, 2013

The American Society of Clinical Oncology (ASCO) has released another list of oncology practices that should be stopped because they are either not supported by evidence or are wasteful.

The "top 5 list" of recommendations from ASCO is part of the Choosing Wisely campaign, an initiative of the American Board of Internal Medicine (ABIM) Foundation. A central aim of the Choosing Wisely campaign is to reduce wasteful healthcare expenditures.

Last year, ASCO became one of the first of 9 medical societies to join the campaign, noted Olatoyosi Odenike, MD, from the University of Chicago, who moderated a presscast on the new list. The list was unveiled as part of the 2013 Quality Care Symposium, which takes place later this week in San Diego, and is sponsored by ASCO.

The 2013 list addresses a wide range of practice issues: the use of antiemetic drugs; chemotherapy in metastatic breast cancer; advanced imaging in disease surveillance; prostate-specific antigen (PSA) testing in prostate cancer; and targeted therapies.

The ABIM Foundation asked ASCO to contribute a second list this year, said list lead author Lowell Schnipper, MD, from the Beth Israel Deaconess Medical Center in Boston.

The organization did so because the 2012 list was "well received" by oncologists and because "eliminating unnecessary testing or interventional procedures" is part of the mission of ASCO's Value in Cancer Care Task Force, he explained. "We felt it important to go further," Dr. Schnipper noted.

The list from Dr. Schnipper and his coauthors was published online October 29 in the Journal of Clinical Oncology.

The authors of the 2013 top 5 list had money on their minds. "The rising cost of healthcare continues to threaten the vigor of the US economy," they write in their opening sentence. Cancer care is only a "fraction" of healthcare costs in the United States, but oncology expenditures continue to rise, from $125 billion in 2010 to a projected $158 billion in 2020, they point out.

Approximately 700 ASCO committee members were asked what they would add to the list, and 115 suggestions were received. The Value in Cancer Care Task Force members selected 11 finalists, and 140 oncologists voted to select the top 5 list.

The list is comprised of "suggestions" that can serve as a "foundation of discussion" between physicians and patients, who will ultimately make their own choices, said Dr. Schnipper. "These top 5 are not meant to be legislative dicta to pass along to our professional colleagues," he said.

The ASCO 2013 Top 5 List in Oncology

Number 1
Appropriate antiemetics for patients on chemotherapy regimens should be based on the regimens' risk of causing nausea and vomiting


We should use "the right drug for the right circumstance," said Dr. Schnipper.

Oncologists customarily choose an antiemetic drug based on the likelihood (low, moderate, or high) that a particular chemotherapy program will cause nausea or vomiting, write the list authors.

But they are clearly concerned about the overuse of new, highly effective agents that are very expensive and unneeded with certain chemotherapy regimens that are either low or moderately emetogenic.

These drugs, known as 5-HT3 serotonin receptor antagonists, are appropriate for use with chemotherapy programs that "are almost certain to produce severe or persistent nausea or vomiting," say the authors.

Although Dr. Schnipper said that the guidelines do not focus on any one of these drugs, he singled out an agent during the presscast.

Palonosetron is an "excellent, excellent antiemetic" that "performs extremely well" with chemotherapy regimens that present a high risk of vomiting and nausea. It is also "very, very expensive," he added.

Palonosetron is more expensive than other agents in this class, such as granisetron or ondansetron, he said.

The list authors recommend that when adults receive highly emetogenic chemotherapy, they should receive the following antiemetic regimen: the 3-drug combination of an NK1 receptor antagonist (days 1 to 3 for oral aprepitant and day 1 only for intravenous aprepitant), a 5-HT3 receptor antagonist (day 1 only), and dexamethasone (days 1 to 3 or 1 to 4).

They also provide antiemetic regimen recommendations for low and moderately emetogenic chemotherapies.

Number 2
Use single-drug chemotherapy when treating an individual for metastatic breast cancer unless the patient needs urgent symptom relief


Single-agent chemotherapy is the "time-tested approach" for treating the "majority of patients with metastatic breast cancer," said Dr. Schnipper. Combination chemotherapy does not add to survival, and its toxicity can "detract" from quality of life, he added. It is also more expensive.

The authors point out that "combining multiple cytotoxic agents is clearly beneficial when chemotherapy is used as an adjunct to potentially curative breast surgery and radiation therapy. In the metastatic setting, this is not the case.

Number 3
Avoid using advanced imaging technologies — PET, CT, and radionuclide bone scans — to monitor for a cancer recurrence in patients who have finished initial treatment and have no signs or symptoms of cancer


PET and PET/CT, which are "expensive," have not been proven as surveillance tools to improve outcomes, said Dr. Schnipper.

"Until high-level evidence demonstrates that routine surveillance with PET or PET/CT scans helps prolong life or promote well-being after treatment for a specific type of cancer, this practice should not be done," according to an ASCO press statement on the top 5 list.

These scans can also give false-positive results, which can cause a patient to undergo additional unnecessary or invasive procedures or treatments or to be exposed to additional radiation, said Dr. Schnipper.

Number 4
Do not perform PSA testing for prostate cancer screening in men with no symptoms of the disease who are expected to live less than 10 years


Multiple studies have shown that men who are older than 70 years do not gain a survival benefit from prostate cancer treatment at this stage of life, said Dr. Schnipper.

The ASCO committee was "quite affected" when reviewing the many ways in which men of this age can have negative effects from treatment, he added.

For men with a life expectancy of more than 10 years, ASCO has previously recommended that physicians discuss with patients whether PSA testing for prostate cancer screening is appropriate. However, this recommendation is at odds with the highly publicized guidance from the US Preventative Services Task Force, which does not recommend the testing for men of any age who are otherwise healthy.

Number 5
Do not use a targeted therapy unless a patient's tumor cells have a specific biomarker that predicts a favorable response to that therapy


Targeted therapies are "phenomenally expensive medications," said Dr. Schnipper. The use of targeted therapy should be limited to patients who have an assay-verified tumor biomarker that provides a "red or green light" as to whether the tumor cells are susceptible to the therapy.

Specific cancers have genetic abnormalities that predict response to targeted therapies. For example, patients with non-small cell lung cancer (NSCLC) need to be tested for an EML4-ALK translocation before being treated with crizotinib, patients with metastatic NSCLC need to be tested for specific EGFR gene mutations before being treated with afatinib, and patients with melanoma need to be tested for BRAF V600E or V600K mutations before being treated with vemurafenib, dabrafenib, or trametinib.

Some of the list authors, including Dr. Schnipper, report financial relationships with industry, as detailed in the paper.

J Clin Oncol. Published online October 29, 2013. Abstract


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