American Society of Clinical Oncology
View all recommendations from this societyReleased April 4, 2012; Updated July 26, 2021
Don’t use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, and no strong evidence supporting the clinical value of further anti-cancer treatment.
- Cancer directed treatments are likely to be ineffective and more toxic for solid tumor patients who meet the above stated criteria.
- Exceptions may include when disease characteristics (e.g., an extremely chemosensitive tumor, or a sensitive and targetable alteration in the tumor) suggest a high likelihood of a response to therapy that may reverse functional limitations related to the cancer.
- While this Choosing Wisely statement originally referred to cytotoxic chemotherapy, it also applies to novel, purportedly less-toxic treatments such as immunotherapy and off-label targeted therapy in patients who meet the above stated criteria.
The American Society of Clinical Oncology (ASCO) is a medical professional oncology society committed to conquering cancer through research, education, prevention and delivery of high-quality patient care. ASCO recognizes the importance of evidence-based cancer care and making wise choices in the diagnosis and management of patients with cancer. After careful consideration by experienced oncologists, ASCO highlights 10 categories of tests, procedures and/or treatments whose common use and clinical value are not supported by available evidence. These test and treatment options should not be administered unless the physician and patient have carefully considered if their use is appropriate in the individual case. As an example, when a patient is enrolled in a clinical trial, these tests, treatments and procedures may be part of the trial protocol and therefore deemed necessary for the patient’s participation in the trial. These items are provided solely for informational purposes and are not intended to replace a medical professional’s independent judgment or as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their health care provider. New evidence may emerge following the development of these items. ASCO is not responsible for any injury or damage arising out of or related to any use of these items or to any errors or omissions.
How The List Was Created
1–5: The American Society of Clinical Oncology (ASCO) has had a standing Cost of Cancer Care Task Force since 2007. The role of the Task Force is to assess the magnitude of rising costs of cancer care and develop strategies to address these challenges. In response to the 2010 New England Journal of Medicine article by Howard Brody, MD, “Medicine’s Ethical Responsibility for Health Care Reform – the Top Five List,” a subcommittee of the Cost of Cancer Care Task Force began work to identify common practices in oncology that were both common as well as lacking sufficient evidence for widespread use. Upon joining the Choosing Wiselycampaign, the members of the subcommittee conducted a literature search to ensure the proposed list of items were supported by available evidence in oncology; ultimately the proposed Top Five list was approved by the full Task Force. The initial draft list was then presented to the ASCO Clinical Practice Committee, a group composed of community-based oncologists as well as the presidents of the 48 state/regional oncology societies in the United States. Advocacy groups were also asked to weigh in to ensure the recommendations would achieve the dual purpose of increasing physician-patient communication and changing practice patterns. A plurality of more than 200 clinical oncologists reviewed, provided input and supported the list. The final Top Five list in oncology was then presented to, discussed and approved by the Executive Committee of the ASCO Board of Directors and published in the Journal of Clinical Oncology.
6–10: To guide ASCO in developing this list, suggestions were elicited from current ASCO committee members (approximately 700 individuals); 115 suggestions were received. After removing duplicates, researching the literature and discussing practice patterns, the Value in Cancer Care Task Force culled the list to 11 items, which comprised an ASCO Top Five voting slate that was sent back to the membership of all standing committees. Approximately 140 oncologists from its leadership cadre voted, providing ASCO with an adequate sample size and perspective on what oncologists find to be of little value. The list was reviewed and finalized by the Value in Cancer Care Task Force and ultimately reviewed and approved by the ASCO Board of Directors and published in the Journal of Clinical Oncology.
How This List Was Updated (1–10): A survey was distributed to gather the opinions of the original authors of ASCO’s Choosing Wisely on the ongoing relevance of the 2012–2013 statements. For the most part, responses indicated that the statements continue to be relevant. The exception was ASCO’s statement #10, which the group agreed continues to hold true, but would benefit from additional updating and context. Thus, it was decided that a new version of this statement will be included in a forthcoming ASCO Choosing Wisely Five Things. In addition, some modifications were made to the original wording of the recommendations and accompanying bullet points in order to reflect current context.
ASCO’s disclosure and conflict of interest policies can be found at www.asco.org.
Sources
Azzoli CG, Temin S, Aliff T, et al: 2011 focused update of 2009 American Society of Oncology clinical practice guideline update on chemotherapy for stage IV non–small cell lung cancer. J Clin Oncol 29:3825–3831, 2011
Ettinger DS, Akerley W, Bepler G, et al: Non-small cell lung cancer. J Natl Compr Canc Netw 8:740–801, 2010
Carlson RW, Allred DC, Anderson BO, et al: Breast cancer. J Natl Compr Canc Netw 7:122–192, 2009
Engstrom PF, Benson AB 3rd, Chen YJ, et al: Colon cancer clinical practice guidelines. J Natl Compr Canc Netw 3:468–491, 2005
Smith TJ, Hillner BE: Bending the cost curve in cancer care. N Engl J Med 364:2060–2065, 2011
Peppercorn JM, Smith TJ, Helft PR, et al: American Society of Clinical Oncology statement: Toward individualized care for patients with advanced cancer. J Clin Oncol 29:755–760, 2011
