ATLANTA—The American Society for Radiation Oncology has released its list of five radiation oncology-specific treatments that are commonly ordered but that may not always be appropriate—as part of the American Board of Internal Medicine Foundation's Choosing Wisely campaign. The first reactions here at the 55th Annual American Society for Radiation Oncology Annual Meeting were both supportive of the items on the list, and more notably, supportive of ASTRO's participation in the effort.
“Choosing Wisely may be the most extraordinary thing we're doing as specialties,” Darrell G. Kirch, MD, President and CEO of the Association of American Medical Colleges, said during the first keynote address of the meeting. All specialties need to step back and do this, he added. “It advises us to take ownership—you should be proud.”
ASTRO's five recommendations are:
- Don't initiate whole breast radiotherapy as part of breast conservation therapy in women older than 50 with early stage invasive breast cancer without considering shorter treatment schedules;
- Don't initiate management of low-risk prostate cancer without discussing active surveillance;
- Don't routinely use extended fractionation schemes (more than 10 fractions) for palliation of bone metastases;
- Don't routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry; and
- Don't routinely use intensity modulated radiation therapy (IMRT) to deliver whole breast radiotherapy as part of breast conservation therapy.
The first reactions from members attending the session during which the list was released were both supportive and critical—not necessarily of the items on the list, but rather that the recommendations were not stringent enough.
“It seems several of your recommendations are really really cautious,” James Martenson Jr., MD, Professor of Oncology at the Mayo Clinic, commented during the session. Specifically, he noted: Recommendation 3 on fractionation schemes, a topic where data have shown shorter fractionation schemes to be superior given that they are less toxic.
The next comment came from David Brizel, MD, Professor of Radiation Oncology and in Surgery at Duke Cancer Institute: “Words like ‘consider’ are kind of wishy-washy, in my opinion, and give people the opportunity to wiggle out. How does ASTRO plan to see what the radiation oncology community is actually doing to execute these recommendations? Are we going to take action?”
The purpose behind the recommendations on the list is to begin to promulgate patterns of change—to begin the discussion of how to do that, the Chairman of ASTRO's Board of Directors, Michael L. Steinberg, MD, FASTRO, said in response. “We're evolving to an era where the questions will be asked: Do you have an understanding of the cost? We are in that transition right now.”
ASTRO followed the ABIM's process for developing these recommendations, Steinberg added in an interview after the session. “The process is not to define ‘never’ events. It's to highlight and spotlight particular interactions, treatments, and procedures that we do that need more discussion and introspection—both by the physician and by patients themselves.”
After initial input of several ASTRO subcommittees and the disease-site resource panels (by way of survey to identify potential items for inclusion on the list), an ASTRO work group created a short list of 13 items, which was shortened to five with the input of ASTRO's Board of Directors. The work group conducted a literature review for each topic and has cited references in its recommendations.
“I'm the medical director of the newest operating proton center in the United States—and you're probably expecting me to castigate Mike [Steinberg], but I want to applaud him. I totally agree with him,” commented George Laramore, MD, PhD, Professor in the Radiation Oncology Department at the University of Washington School of Medicine. “Trying to answer the question, if protons are good for prostate cancer, is an excellent one. In treating prostate cancer patients, I can say protons are an excellent form of treatment. But, long-term, I don't know if it's better than anything else we do.”
Also in support of the recommendations was Shaleen Kumar, Professor and Head of the Department of Radiotherapy at the Sanjay Gandhi Postgraduate Institute of Medical Sciences in Lucknow, India, who was attending ASTRO for the first time. He commented: “This is like a breath of fresh air and gives us renewed vigor to practice pragmatic radiotherapy.”
The complete list is now published on the Choosing Wisely website (www.choosingwisely.org/doctor-patient-lists/american-society-for-radiation-oncology). ASTRO does plan to start the process again to make additional recommendations for further Choosing Wisely lists (some professional organizations are now on their third such Top 5 lists), although he said he could not commit to a date of when that would be—“but soon,” he said. “We're not done.”