ASTRO Offers Five Recommendations as Part of Choosing Wisely Campaign


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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 American Board of Internal Medicine Foundation. ASTRO recommends detailed patient-physician discussion before these five treatment options are  prescribed.

  • Don’t 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 5 to 6 weeks, often followed by 1 to 2 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 4 weeks).

  • Don’t 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.

  • Don’t 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.

  • Don’t 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.

  • Don’t 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 3D conformal techniques relative to older methods of 2D planning. In these trials, the term “IMRT” has generally been applied to describe methods that are more accurately defined as field-in-field 3D 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. ■


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