Dr. Michael Steinberg,
chairman of ASTRO's board of directors
giving an update on Choosing Wisely
at ASTRO 2013

ASTRO announces 5 treatments that may be unnecessary

September 24, 2013
by Nancy Ryerson, Staff Writer
ASTRO released a list of five radiation oncology treatments for providers to question using, as part of the nationwide "Choosing Wisely" campaign. The campaign seeks to encourage conversations between physicians and patients about potentially unnecessary tests.

The society's recommendations are:

Don’t routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry.

ASTRO came down on the debate around using proton therapy for prostate cancer, determining that there is "no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy." The society recommended that proton beam therapy only be used for prostate cancer in a prospective clinical trial or registry.

The National Association for Proton Therapy released a statement in response to the guidelines.

"Patients and physicians have a number of options when approaching prostate cancer," says Leonard Arzt, Executive Director of the National Association for Proton Therapy (NAPT). "We believe that all options, including proton therapy, should be available through an informed decision making process. The choice of treatment will have an enormous impact on the patient's health and ability to enjoy his life. Patients have a right to know what is available to them."

The statement noted that in 2011 an expert panel from the American College of Radiology concluded that proton therapy is equally appropriate and as beneficial as IMRT, 3-D conformal X-ray therapy and brachytherapy in treating Stages T1 and T2 prostate cancer.

Don’t initiate whole breast radiotherapy as a part of breast conservation therapy in women ages 50 and younger with early stage invasive breast cancer without considering shorter treatment schedules.

Most breast radiotherapy treatments have included five to six weeks of therapy followed by one to two weeks of boost therapy. But recent studies have shown equivalent tumor control in cosmetic results in certain patient populations in only four weeks of therapy.

Don’t initiate management of low-risk prostate cancer without discussing active surveillance.

PSA screenings for prostate cancer often detect cancers that may never cause a problem for the patient, a finding that led the U.S. Preventive Task Force to recommend against the screenings in 2011. Since then, medical societies and radiation oncologists have urged providers to monitor some cases of cancer rather than jumping right into radiation therapy.

“There are multiple treatments for prostate cancer, which we’ve already known, but we’re reinforcing the shared decision model between patient and physician by including this on our list,” said Steinberg.

Don’t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases.

Studies have suggested an equivalent pain relief following 30 Gy in 10 fractions, 20 Gy in 5 fractions or a single 8 Gy fraction. While a single treatment is more convenient, it may be associated with a slightly higher rate of re-treatment to the same site, making it a choice physicians should consider for patients with transportation difficulties or an unpromising prognosis.

“This data has existed for a while but has been slow on the uptake, not entirely because of financial reasons, but also based on past training,” said Steinberg. “We’re reemphasizing the existence of evidence in an effort to move the needle.”

Don’t routinely use intensity modulated radiation therapy (IMRT) to deliver whole breast radiotherapy as part of breast conservation therapy.

The final recommendation comes in response to observed confusion regarding to the term IMRT. In clinical trials, the term “IMRT” was applied to describe methods that should be defined as “field-in-field 3-D conformal radiotherapy.”

While 3-D conformal treatments have been linked to lower rates of skin toxicity, IMRT itself is better used for special breast cancer treatments involving unusual anatomy, but in general, its routine use has not shown significant clinical advantage.