Treatments to Question ASTRO SEPT 2013

ASTRO Releases List of Five Radiation Treatments to Question

As part of national Choosing Wisely campaign, list encourages more detailed physician-patient conversations

September 26, 2013

The American Society for Radiation Oncology (ASTRO) released its 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’s five recommendations are:

Do not initiate whole breast radiotherapy as a part of breast conservation therapy in women age ≥50 with early stage invasive breast cancer without considering shorter treatment schedules. Whole breast radiotherapy decreases local recurrence and improves survival of women with invasive breast cancer treated with breast conservation therapy. Most studies have utilized “conventionally fractionated” schedules that deliver therapy over five to six weeks, often followed by one to two weeks of boost therapy. Recent studies, however, have demonstrated equivalent tumor control and cosmetic outcome in specific patient populations with shorter courses of therapy (approximately four weeks). Patients and their physicians should review these options to determine the most appropriate course of therapy.

· Do not initiate management of low-risk prostate cancer without discussing active surveillance. Patients with prostate cancer have a number of reasonable management options. These include surgery and radiation, as well as conservative monitoring without therapy in appropriate patients. Shared decision-making between the patient and the physician can lead to better alignment of patient goals with treatment and more efficient care delivery. ASTRO has published patient-directed written decision aids concerning prostate cancer and numerous other types of cancer. These types of instruments can give patients confidence about their choices, improving compliance with therapy.

· Do not routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases. Studies suggest equivalent pain relief following 30 Gy in 10 fractions, 20 Gy in 5 fractions, or a single 8 Gy fraction. A single treatment is more convenient but may be associated with a slightly higher rate of retreatment to the same site. Strong consideration should be given to a single 8 Gy fraction for patients with a limited prognosis or with transportation difficulties.

· Do not routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry. There is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy.

· Do not routinely use intensity modulated radiation therapy (IMRT) to deliver whole breast radiotherapy as part of breast conservation therapy. Clinical trials have suggested lower rates of skin toxicity after using modern 3-D conformal techniques relative to older methods of 2-D planning. In these trials, the term “IMRT” has generally been applied to describe methods that are more accurately defined as field-in-field 3-D conformal radiotherapy. 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.