Nick Mulcahy

September 16, 2014

SAN FRANCISCO ― A list of 5 common radiation oncology practices that should not be routinely employed has been released by the American Society for Radiation Oncology (ASTRO).

The practice "don'ts" are the second time that ASTRO has issued a set of recommendations that are aimed at curbing practices that are not evidence based. In 2013, the organization released its initial list of 5.

Both lists are part of ASTRO's participation in the Choosing Wisely campaign. The multispecialty initiative is devoted to removing "waste" from US medical practice and is an initiative of the American Board of Internal Medicine (ABIM) Foundation.

"We want to make sure that care is truly necessary," said Carol Hahn, MD, of Duke University Medical Center in Durham, North Carolina, during her oral presentation.

She presented the new list at the ASTRO annual meeting here to an audience of about 250 during a session on, ironically, payment reform; financial incentives are known drivers of overuse of oncology practices.

The recommendations involve a variety of cancers, including endometrial, breast, non–small-cell lung, and metastases in the brain.

However, the new recommendation about palliative care is the "most impactful," Dr. Hahn told Medscape Medical News in an interview.

"Every radiation oncologist delivers palliative care," she said.

The ASTRO recommendation reads: "Don't initiate non-curative radiation therapy without defining the goals of treatment with the patient and considering palliative care referral."

Dr. Hahn reworded the advice to add emphasis: "Define the goals of treatment."

In other words, explicitly state whether or not there is a chance for cure.

If a patient is not going to be cured, "then the goals of treatment will be different," said Dr. Hahn, who is the former chair of the ASTRO guidelines committee and a current member of palliative care work group.

Three of the other recommendations were cancer-specific and, like the palliative care recommendation, begin with the word "don't."

"Don't recommend radiation following hysterectomy for endometrial cancer patients with low-risk disease," reads the ASTRO document.

"This group of patients has a very low risk of recurrence," said Dr. Hahn.

Low-risk endometrial cancer patients are defined as having the following: no residual disease in hysterectomy despite positive biopsy; grade 1 or 2 with <50% myometrial invasion; and no additional high-risk features, such as age older than 60 years, lymphovascular space invasion, or cervical involvement.

Meta-analyses of radiation therapy for low-risk endometrial cancer have shown no benefit in overall survival ― but increased side effects ― 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," the document states.

Two meta-analyses of postoperative radiotherapy in early NSCLC with node-negative or minimal (N1) disease suggest increased side effects with no benefit for disease-free survival or overall survival compared with observation.

"These recommendations are not proscriptive," added Dr. Hahn, explaining that in certain cases, they can be bypassed.

"Don't routinely recommend follow-up mammograms more often than annually for women who have had radiotherapy following breast conserving surgery," reads the next item.

Mammograms often are done, "for reasons that are unclear," more frequently than once a year, said Bruce Haffty, MD, president of ASTRO. He is from the Robert Wood Johnson Medical School– University of Medicine and Dentistry of New Jersey, New Brunswick. He spoke at a press conference about the Choosing Wisely list.

But Dr. Hahn hinted at a possible motivator. "Imaging is something that radiation oncologists own," she said, suggesting a profit motive.

There is "no clear advantage to shorter interval imaging," according to ASTRO. However, suspicious findings on physical examination or surveillance imaging might warrant a shorter interval than the recommended 1 year between mammograms.

"Don't routinely add adjuvant whole brain radiation therapy to stereotactic radiosurgery for limited brain metastases," reads the final recommendation.

For patients with brain metastases from solid tumors who have good performance status, data from randomized studies show no overall survival benefit from the addition of adjuvant whole-brain radiation therapy (WBRT) to stereotactic radiosurgery (SRS), but this addition of WBRT to SRS is associated with diminished cognitive function and worse patient-reported fatigue and quality of life.

"Adding whole-brain radiation does not add to quality of life," Dr. Haffty commented. This recommendation is an effort to decrease the cost, inconvenience, and toxicity of cancer treatment, he observed, and commented that it is already being acted upon.

"This is an area where I have seen significant pattern changes in care," said Dr. Hahn.

For 2014, ASTRO developed an initial list of 28 topics and then winnowed that down to 9 potential items, which, in turn, were sent out to ASTRO members to rate. The ASTRO work group and board of directors then arrived at the final 5 for this year.

American Society for Radiation Oncology (ASTRO) 56th Annual Meeting. Panel 03. Presented Sept. 14, 2014.


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