Choosing Wisely: Constructing a Top-Five List in Oncology

Apr 16, 2012

ASCO has joined the American Board of Internal Medicine (ABIM) Foundation and eight other medical specialty societies to take a collective stand in improving patient care and addressing rising health care costs. As part of the ABIM Foundation’s Choosing Wisely® campaign, ASCO—backed by the expertise of more than 30,000 member oncologists—has developed a “Top Five” list of tests and procedures in oncology whose frequent use should be questioned because they do not add clinical value.

The list identifies practices that are expensive, widely employed, and not supported by clinical evidence. When used unnecessarily, these procedures may contribute to increasing costs, without improving outcomes for patients. In many cases, they may actually do more harm than good, by leading to unnecessary procedures, misdiagnosis, and anxiety among patients.

“As oncologists, it is our personal and professional responsibility both to provide the highest quality of care to our patients and to help rein in the rising costs of cancer care,” said ASCO President Michael P. Link, MD. “We hope that ASCO’s participation in this campaign helps to create a culture of self-examination in our field, so that every intervention our patients receive provides meaningful benefit.”

The development of the list for oncology was led by ASCO’s Cost of Care Task Force, a multidisciplinary group of expert oncologists committed to addressing the underlying issues contributing to the rising cost of cancer care. Selections were based on a comprehensive review of published studies and current guidelines from ASCO and other organizations. The final list also reflects input from more than 200 oncologists, including those on the Society’s Clinical Practice Committee, the leadership of the state/regional oncology societies, as well as other leading oncologists and patient advocates.

“By working together to reduce the overuse of these procedures, the oncology field can help improve the care of our patients, while achieving substantial cost savings,” said Lowell E. Schnipper, MD, ASCO’s Cost of Care Task Force Chair. “This list will help oncologists and their patients make more informed decisions about their care.”

ASCO’s top-five list makes the following recommendations:

1. For patients with advanced solid-tumor cancers who are unlikely to benefit, avoid unnecessary anticancer therapy and focus on symptom relief and palliative care instead.
Overtreatment near the end of life is common. Data have shown that a significant number of patients with cancer received chemotherapy in the last two weeks of life. Such treatment does little to improve survival or quality of life. It has the unintended consequence of increasing costs. It may also delay patients’ access to supportive care that could maximize their comfort at this extremely difficult moment.

ASCO recommends eliminating treatment that is unlikely to be effective in patients who meet all of the following criteria: Patients with low performance status (3 or 4); who have not benefited from prior standard therapy; who have no further standard treatment options for their disease; and who are not eligible for a clinical trial. For these patients, emphasis should be placed on palliative and supportive care, which evidence has shown can increase quality of life and, in some cases, increase survival.

“When treatment is no longer likely to work, our chief responsibility as physicians is to help our patients live in comfort and dignity,” Dr. Link said. “Oncologists should not feel compelled to provide an intervention when there is no evidence that it will result in meaningful benefit to the patient, especially if it might limit their quality of life.”

2. Do not use PET, CT, and radionuclide bone scans in the staging of early breast cancer that is at low risk of spreading.

3. Do not use PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk of spreading.

For patients with these early-stage cancers, use of expensive PET, CT, or radionuclide bone scans to search for further spread has not been shown to improve detection of metastatic disease or result in greater survival. These tests are also known to increase the risk of misdiagnosis, which can lead to unnecessary invasive procedures and over-treatment or incorrect treatment. ASCO recommends against the use of these imaging modalities for patients with newly identified ductal carcinoma in situ (DCIS), stage I or II breast cancer, as well as newly diagnosed low-grade prostate cancer that is unlikely to have macrometastases.

4. For individuals who have completed curative breast cancer treatment and have no symptoms of cancer recurrence, routine blood tests for certain biomarkers (e.g., CEA, CA 15-3, CA 27-29) and advanced imaging tests (PET, CT, and radionuclide bone scans) should not be used to screen for cancer recurrences.
Although these types of tests have been shown to have clinical value for certain cancers, such as colorectal cancer, for women with breast cancer that has been treated with curative intent, these tests have not been shown to improve survival. Moreover, false-positive results can lead to invasive procedures, over-treatment, and misdiagnosis that can severely impact an individual’s quality of life. ASCO guidelines continue to emphasize that routine physical exams and mammography are safe and effective for detecting recurrences.

5. Avoid administering white-cell stimulating factors to patients undergoing chemotherapy who have less than a 20% risk for febrile neutropenia.
ASCO guidelines recommend these treatments only when the risk of febrile neutropenia (FN) from chemotherapy is greater than 20% and effective alternative therapies are unavailable. However, research shows that use varies widely across the United States, and that many low-risk patients receive the drugs.

“There is growing evidence that these drugs are overused, likely costing the U.S. health system tens of millions of dollars,” said Dr. Schnipper. “Myeloid growth factors have been proven essential in the delivery of dose-dense chemotherapy for ER-negative, node-positive women with breast cancer.1 Yet this regimen has demonstrated minimal benefit for the ER-positive patient over standard regimens with lower risk of FN.2–3 In spite of this evidence, dose-dense chemotherapy remains a widely accepted and recommended standard for all women with breast cancer in the adjuvant setting,” he added.

ASCO recognizes that there are exceptions to this recommendation, such as for patients at higher risk for chemotherapy-related febrile neutropenia because of other complications including age, medical history, or disease characteristics.

Over the coming months, ASCO will work with its members and other partners in the cancer community to help implement these recommendations in practice. ASCO is developing additional tools and publications for physicians, together with new resources to help patients have informed discussions with their physicians.

For more information on ASCO’s cost of cancer care efforts and the Choosing Wisely campaign, visit

1. Citron ML, Berry DA, Cirrincione C, Hudis C, et al. J Clin Oncol. 2003; 21:1431–9.
2. Berry DA, Cirrincione C, Henderson IC, et al. JAMA. 2006; 295:1658–67.
3. Bonilla L, Ben-Ahron I, Vidal L, et al. J Natl Cancer Inst. 2010; 102:1845–54.


Ahmed M. Elzawawy, MD, PhD

Apr, 17 2012 9:55 AM

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Kindest regards,
Ahmed Elzawawy

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