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ASCO’s Latest “Top Five” List Details Cancer Tests and Treatments That Are Routinely Performed Despite Lack of Evidence


The American Society of Clinical Oncology has issued its second “Top Five” list of opportunities to improve the quality and value of cancer care. Published in the Journal of Clinical Oncology, the list was released as part of the ABIM Foundation’s Choosing Wisely campaign to encourage conver­sations between physicians and cancer survivors and is aimed at curbing the use of certain tests and procedures that are not supported by clinical research. The “Top Five” list includes the fol­lowing recommendations:

1 Don’t give a person starting on a chemotherapy regimen that has a low or moderate risk of causing nausea and vomiting antiemetic drugs intended for use with a regimen that has a high risk for this effect.

Different chemotherapy treatments produce side effects of variable sever­ity, including nausea and vomiting, and many medications have been developed to help control these side effects. When successful, these medications can help people avoid hospital visits, improve quality of life, and lead to fewer changes in the chemotherapy regimen.

In recent years, new drugs have been introduced to help manage the most severe and persistent cases of nausea and vomiting that result from certain chemotherapy regimens. ASCO recom­mends the use of these drugs be reserved only for people taking chemotherapy that has a high potential to produce severe or persistent nausea and vomit­ing, as they are very expensive and not without their own side effects. For people receiving chemotherapy that is less likely to cause nausea and vomit­ing, there are other effective antiemetic drugs available at a lower cost.

2 Don’t use combination chemo­therapy instead of single-drug chemotherapy when treating an individual for metastatic breast cancer unless that person needs urgent symptom relief.

While combination chemotherapy (chemotherapy with multiple drugs) has been shown to slow tumor growth in people with metastatic breast cancer, it has not been proven to improve sur­vival over single-drug chemotherapy, and it often produces more frequent and severe side effects, worsening a person’s quality of life. Therefore, as a general rule, ASCO recommends giving chemotherapy drugs one at a time in sequence, which may improve a person’s quality of life and does not typically compromise overall survival. Combination therapy may, however, be useful and worthwhile in situations where the cancer burden must be reduced quickly because it is accompanied by significant symptoms, such as pain and discomfort, or is immedi­ately life threatening.

3 Avoid using advanced imaging technologies – PET, CT, and radionuclide bone scans – to monitor for a cancer recurrence in people who have finished initial treat­ment and have no signs or symptoms of cancer.

Evidence shows that using PET or PET-CT to monitor for cancer recur­rence in individuals who have completed treatment and have no signs of disease does not improve outcomes or survival. These expensive tools can often lead to false positive results, which can cause a person to have additional unnecessary or invasive procedures or treatments or be exposed to additional radiation.

4 Don’t perform PSA testing for prostate cancer in men with no symptoms of the disease when they are expected to live less than 10 years.

Men with medical conditions or other chronic diseases that may limit their life expectancy to less than 10 years are unlikely to benefit from PSA screening. Studies have shown that in this population, PSA screening does not reduce the risk of dying from prostate cancer or of any cause. Furthermore, such testing could lead to unnecessary harm, including complications from unnecessary biopsy or treatment for cancers that may be slow-growing and not ultimately life threatening. How­ever, for men with a life expectancy of greater than 10 years, ASCO has previously recommended that physi­cians discuss with these men whether PSA testing for prostate cancer screen­ing is appropriate.

5 Don’t use a targeted therapy intended for use against a spe­cific genetic abnormality unless a person’s tumor cells have a specific biomarker that predicts a favorable response to the targeted therapy.

Targeted therapy can significantly benefit people with cancer because it can target specific pathways that can­cer cells use to grow and spread, while causing little or no harm to healthy cells. The individuals who are most likely to benefit from targeted therapy are those who have a specific biomarker in their tumor cells that indicates the presence or absence of a specific ab­normality that makes the tumor cells susceptible to the targeted agent.

Compared to chemotherapy, the cost of targeted therapy is generally higher, as these treatments are newer, more expensive to produce, and under patent protection. In addition, like all anticancer therapies, there are risks to using targeted agents when there is no evidence to support their use because of the potential for serious side effects or reduced efficacy compared with other treatment options.

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For more information on ASCO’s “Top Five” list and the Choosing Wisely campaign, visit

This article was published in Coping® with Cancer magazine, January/February 2014.