ATLANTA, Georgia — Five radiation oncology practices should not be routinely used because they are not supported by evidence, according to the American Society for Radiation Oncology (ASTRO).
Perhaps most dramatically, the organization is calling for an end to the use of proton beam therapy for the treatment of prostate cancer — unless the therapy is in the context of a clinical trial.
ASTRO is also calling for radiation oncologists to discuss active surveillance with men who have low-risk prostate cancer before initiating any radiotherapy, said Michael Steinberg, MD, chairman of ASTRO's board of directors. He is from the University of California, Los Angeles, and spoke at a press conference today at the organization's annual meeting here.
The organization is also advising against routine use of extended fractionation schemes (>10 fractions) for palliation of bone metastases.
Additionally, ASTRO states that oncologists should not initiate whole breast radiotherapy as part of breast conservation therapy in women aged 50 years or older with early stage invasive breast cancer without considering shorter treatment schedules.
ASTRO also recommends against routine use of intensity modulated radiation therapy (IMRT) to deliver whole-breast radiotherapy as part of breast-conservation therapy.
The new recommendations from ASTRO have some teeth in them, observed Colleen Lawton, MD, in an interview with Medscape Medical News last week. She is president of ASTRO's board of directors and professor of radiation oncology at the Medical College of Wisconsin, in Milwaukee. "Some of the recommendations will result in less revenue for a practice," she said.
The final list of recommendations was whittled down from a larger list that was generated from a survey of ASTRO membership, Dr. Steinberg said.
"The process is not over," he added, saying that organization will eventually issue more recommendations.
The recommendations are part of the Choosing Wisely campaign, an initiative of the American Board of Internal Medicine (ABIM) Foundation.
"This campaign is about waste…the removal of waste" said Daniel Wolfson of the ABIM Foundation at the press conference. "Today is day one for increasing awareness among ASTRO members."
The campaign dates from 2010, when a prominent primary care clinician challenged each medical specialty to take a critical look at its field and identify practices that are commonly performed despite a lack of evidence (N Engl J Med. 2010;362:283-285).
A goal of the Choosing Wisely campaign is also to encourage patient-physician conversations about clinical choices.
The campaign also aims to reach consumers nationwide through a variety of partnerships, including one with Consumer Reports, which is issuing patient-friendly resources.
Prostate Cancer Controversies
The recommendation to stop routine use of proton therapy in men with prostate cancer is a blow to centers that advertise and employ the expensive treatment.
Proton therapy for prostate cancer should be now limited to clinical trials, says ASTRO.
An expert agreed. "I advocate that approach," said Michael Zelefsky, MD, a radiation oncologist specializing in genitourinary cancers at Memorial Sloan-Kettering Cancer Center, in New York City. "Studies are needed to elucidate the clinical benefit," he said. "There is no evidence of superiority over standard dose escalated photon therapy."
At the same time, Dr. Zelefsky emphasized that proton beam is not in its infancy as a technology. "I do not think it is experimental at this point," he told Medscape Medical News in a phone interview.
Earlier this year, ASTRO issued a statement that voiced support for the clinical trials and collection of data from patient registries that seek to inform best practices on the use of proton therapy for prostate cancer.
Dr. Steinberg said he has not yet received any "pushback" on the proton beam and prostate cancer recommendation. "But the day is young," he said with a smile.
The other ASTRO recommendation relating to prostate cancer calls for clinicians to present active surveillance as a management option for patients with low-risk disease before discussing radiation treatment.
The recommendation is no longer as controversial as it was in 2010 when the National Comprehensive Cancer Network first issued a guideline calling for active surveillance to be the only recommended optionfor very low-risk disease.
"Basically we re-emphasizing something we already know," Dr. Steinberg said about the active surveillance guidance.
Shorter Schedules in Breast Cancer
In the treatment of breast cancer, ASTRO reminds oncologists to consider shorter treatment schedules when thinking about radiotherapy as part of breast-conservation therapy in women aged 50 years or older with early stage, invasive breast cancer without considering shorter treatment schedules.
Recent studies have demonstrated that women aged 50 years or older with early stage breast cancer can have equivalent tumor control and cosmetic outcome with shorter courses of radiotherapy (approximately 4 weeks) as with longer courses, according to ASTRO press materials.
ASTRO points out that whole-breast radiotherapy decreases local recurrence and improves survival of women with invasive breast cancer treated with breast-conservation therapy.
Most studies that established this practice have utilized "conventionally fractionated" schedules that deliver therapy over 5 – 6 weeks, often followed by 1 – 2 weeks of boost therapy, the organization says.
But it is time to consider shorter schedules when determining, with patients, the appropriate course of action, said Dr. Steinberg.
Radiation oncologists also need to consider using simpler treatment schemes in patients with bone pain from the spread of a primary tumor, ASTRO says.
Clinicians should not routinely use extended fractionation schemes (>10 fractions) for palliation of these bone metastases, ASTRO says.
Studies suggest equivalent pain relief following 30 Gy in 10 fractions, 20 Gy in 5 fractions, or a even single 8 Gy fraction, summarized Dr. Steinberg.
A single treatment is more convenient but may be associated with a slightly higher rate of retreatment to the same site, according to ASTRO press materials. A single 8 Gy fraction should be strongly considered for patients with a limited prognosis or with transportation difficulties, says the organization.
These data have been "around for a while," but clinicians have been "slow on the uptake" for a variety of reasons, said Dr. Steinberg, including staying with established practices.
Finally, ASTRO advises against the routine use of IMRT to deliver whole-breast radiotherapy as part of breast conservation therapy.
Clinical trials have suggested lower rates of skin toxicity after using "very sophisticated" 3-D conformal techniques, Dr. Steinberg said.
While IMRT may be of benefit in select cases where the anatomy is unusual, its routine use has not been demonstrated to provide significant clinical advantage and it is substantially more expensive, he explained.
"We are calling out the issue of appropriate use of IMRT in breast cancer," Dr. Steinberg said.
Mr. Wolfson and Dr. Steinberg have disclosed no relevant financial relationships.
American Society for Radiation Oncology (ASTRO) 55th Annual Meeting: Press conference, September 23, 2013.
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.
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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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