ASTRO releases list of five radiation oncology treatments to question as part of national Choosing Wisely® campaign

Atlanta, September 23, 2013 – The American Society for Radiation Oncology (ASTRO) today 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:

  • 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 5-6 weeks, often followed by 1-2 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). Patients and their physicians should review these options to determine the most appropriate course of therapy.

  • 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. 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.

  • 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 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.

“We are proud to be a part of the Choosing Wisely campaign and to issue our list of radiation oncology treatments we recommend for detailed conversation and evaluation by physicians and patients. We are committed to assuring that treatment options align with individual patient needs and patient expectations and that our patients have the information they need to make wise health care decisions,” said Michael L. Steinberg, MD, FASTRO, chairman of ASTRO’s Board of Directors. “The five items on ASTRO’s list represent important treatments that we believe need careful consideration; the list should serve as a starting point for detailed physician-patient conversations to ensure the optimal level of patient-centered care—a core principle of ASTRO.”

ASTRO’s Choosing Wisely list was developed after several months of careful consideration and thorough review, using the most current evidence about management and treatment options. A survey was sent to ASTRO’s Health Policy Council, Health Policy Committee, Clinical Affairs and Quality Committee, the Guidelines Subcommittee, Best Practices Subcommittee, Measures Subcommittee and disease-site resource panels in order to identify potential items for inclusion in the list. A seven-member work group was formed, with representation from ASTRO’s Clinical Affairs and Quality, Health Policy and Government Relations councils, and each work group member chose their top eight items from the total of 34 topics that had been suggested in the initial survey. The results were tabulated and a list of the highest scoring items created a short list of 13 draft items. Three conference calls were subsequently held to further refine the list and finalize the wording of the items based on input from ASTRO’s Board of Directors. An extensive literature review was conducted for each topic, and the work groups drafted the text and selected references for each topic. The final items for submission were approved by ASTRO’s Board of Directors.

“ASTRO has shown tremendous leadership by releasing its list of tests and procedures they say are commonly done in radiation oncology, but aren’t always necessary,” said Richard J. Baron, MD, president and CEO of the ABIM Foundation. “The content of this list and all of the others developed through this effort are helping physicians and patients across the country engage in conversations about what care they need, and what we can do to reduce waste and overuse in our health care system.”

Over the next year, more than 30 other specialty society partners will release Choosing Wisely lists, including:

  • September 4, 2013 – AMDA – Dedicated to Long Term Care Medicine
  • September 4, 2013 – American College of Surgeons
  • September 4, 2013 – Commission on Cancer—a multidisciplinary program of the American College of Surgeons
  • September 11, 2013 – American Academy of Orthopaedic Surgeons
  • September 12, 2013 – Society of General Internal Medicine
  • September 20, 2013 – American Psychiatric Association
  • September 24, 2013 – American Academy of Family Physicians**
  • September 26, 2013 – American Association of Clinical Toxicology/American College of Medical Toxicology
  • October 8, 2013 – American Association for Pediatric Ophthalmology and Strabismus
  • October 9, 2013 – North American Spine Society
  • October 14, 2013 – American College of Emergency Physicians
  • October 15, 2013 – American Association of Clinical Endocrinology/The Endocrine Society
  • October 27, 2013 – American College of Chest Physicians/American Thoracic Society (Pulmonary)
  • October 27, 2013 – American College of Rheumatology*
  • October 29, 2013 – American Academy of Dermatology
  • October 29, 2013 – American Society of Clinical Oncology*
  • October 31, 2013 – Society of Gynecologic Oncology
  • November 21, 2013 – American Headache Society
  • December 4, 2013 – American Society of Hematology
  • January 11, 2014 – American College of Chest Physicians/Society of Critical Care (Critical Care)
  • February 3, 2014 – Society for Maternal-Fetal Medicine
  • February 10, 2014 – Heart Rhythm Society
  • February 24, 2014 – American College of Occupational and Environmental Medicine
  • February 27, 2014 – American Geriatrics Society*
  • February 28, 2014 – American Academy of Allergy, Asthma & Immunology
  • TBD – American Association of Neurological Surgeons
  • TBD – American Society of Anesthesiologists
  • TBD – American Society of Colon and Rectal Surgeons
  • TBD – Society for Cardiovascular Magnetic Resonance

* Releasing a second list
** Releasing a third list

To date, more than 80 national and state medical specialty societies, regional health collaboratives and consumer partners have joined the Choosing Wisely campaign to promote conversations about appropriate care. With the release of these new lists, the campaign will have covered more than 250 tests and procedures that the specialty society partners say are potentially overused and inappropriate, and that physicians and patients should discuss.

The campaign also continues to reach millions of consumers nationwide through a stable of consumer and advocacy partners, led by Consumer Reports—the world’s largest independent product-testing organization—which has worked with the ABIM Foundation to distribute patient-friendly resources for consumers and physicians to engage in these important conversations.

Choosing Wisely consumer partners include:

  • AARP
  • Alliance Health Networks
  • Midwest Business Group on Health
  • Minnesota Health Action Group
  • National Business Coalition on Health
  • National Business Group on Health
  • National Center for Farmworker Health
  • National Hospice and Palliative Care Organization
  • National Partnership for Women & Families
  • Pacific Business Group on Health
  • SEIU
  • The Leapfrog Group
  • Union Plus
  • Wikipedia

To speak with Dr. Steinberg, contact Michelle Kirkwood on September 22-25, 2013, in the ASTRO Press Office at the Georgia World Congress Center in Atlanta at 404-222-5303 or 404-222-5304, or email To learn more about Choosing Wisely and to view the complete lists and additional detail about the recommendations and evidence supporting them, visit

ASTRO’s 55th Annual Meeting, held in Atlanta, September 22-25, 2013, is the premier scientific meeting in radiation oncology and brings together more than 11,000 attendees including oncologists from all disciplines, medical physicists, dosimetrists, radiation therapists, radiation oncology nurses and nurse practitioners, biologists, physician assistants, practice administrators, industry representatives and other health care professionals from around the world. The theme of the 2013 meeting is “Patients: Hope • Guide • Heal” and will focus on patient-centered care and the importance of the physician’s role in improving patient-reported outcomes and the quality and safety of patient care. The four-day scientific meeting includes presentation of four plenary papers, 363 oral presentations, 1,460 posters and 144 digital posters in 70 educational sessions and scientific panels for 19 disease sites/tracks. Keynote and featured speakers include: William B. Munier, director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality; Darrell G. Kirch, MD, president and CEO of the Association of American Medical Colleges; James Cosgrove, PhD, director of the U.S. Government Accountability Office; Otis W. Brawley, MD, chief medical officer of the American Cancer Society; and Peter Friedl, MD, PhD, of St. Radboud University Nijmegen Medical Centre at the University of Nijmegen and MD Anderson Cancer Center.