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New ASCO Choosing Wisely® List Details Five Cancer Tests and Treatments Routinely Performed Despite Lack of Evidence

List provides immediate steps for physicians to improve quality and value in oncology care


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The American Society of Clinical Oncology (ASCO) has announced its second “Top Five” list of opportunities to improve the quality and value of cancer care. Published in the Journal of Clinical Oncology (JCO), ASCO’s second Top Five list was released as part of the Choosing Wisely® campaign, sponsored by the ABIM Foundation, to encourage conversations between physicians and patients aimed at curbing the use of certain tests and procedures that are not supported by clinical research. One of the first nine medical societies to join the Choosing Wisely campaign, ASCO issued its first Top Five list in April 2012.

“As physicians, we have a fundamental responsibility to provide high-quality, high-value cancer care for all of our patients,” said Lowell E. Schnipper, MD, lead author of the JCO article and chair of ASCO’s Value of Cancer Care Task Force. “That means eliminating screening and imaging tests where the risk of harm outweighs the benefits, and making sure that every choice of treatment reflects the best available evidence. By providing evidence-based care, we not only help our patients live better with cancer, we also assure they are getting high-quality care that will deliver the greatest possible benefit for the cost.”

ASCO’s New “Top Five” Choosing Wisely List

Thee following list was developed by ASCO’s Value of Cancer Care Task Force, which solicited ideas from the full ASCO membership, regional oncology societies and patient advocates. Each recommendation is based on a comprehensive review of current high-level clinical evidence (including published studies and guidelines from ASCO and other organizations), conducted by the Task Force.

1. Don't give patients 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 patients 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 patients taking chemotherapy that has a high potential to produce severe and/or persistent nausea and vomiting, as they are very expensive and not without their own side effects. For patients receiving chemotherapy that is less likely to cause nausea and vomiting, there are other effective anti-emetic drugs available at a lower cost.

2. Don’t use combination chemotherapy (multiple drugs) instead of single-drug chemotherapy when treating an individual for metastatic breast cancer unless the patient needs urgent symptom relief.

While combination chemotherapy has been shown to slow tumor growth in patients 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 patient’s quality of life. As a general rule, therefore, ASCO recommends giving chemotherapy drugs one at a time in sequence, which may improve a patient’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 causing significant symptoms (e.g., pain and discomfort) or is immediately life threatening.

3. Avoid using advanced imaging technologies -- positron emission tomography (PET), CT and radionuclide bone scans -- to monitor for a cancer recurrence in patients 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 asymptomatic patients who have completed cancer 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 patient to have additional unnecessary or invasive procedures or treatments or be exposed to additional radiation.

4. Don’t perform PSA testing for prostate cancer screening 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. For men with a life expectancy of greater than 10 years, however, ASCO has previously recommended that physicians discuss with patients 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 patient’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. Patients 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 anti‐cancer 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.

“All medical professionals should be accountable for both their patients’ well-being as well as their wise stewardship of health resources. High-value care not only benefits patients, but also reduces societal health care costs which should be a concern for everyone,” said Clifford A. Hudis, MD, FACP, President of ASCO. “At ASCO, we want to ensure that oncology providers have the skills and tools needed to assess the benefits of tests and treatments and to discuss options with their patients. These goals are not in conflict: the best care for patients is the best approach for society.”

To help members assess care in their practices based on ASCO’s Top Five lists, measures based on the Top Five recommendations are offered as test measures in ASCO’s Quality Oncology Practice Initiative (QOPI®) , a national program that helps practices assess and improve the quality of care they deliver through retrospective medical record abstraction and performance analysis. A team of clinicians and quality measurement experts are reviewing “Top Five” test performance based on more than 14,000 records (160 practices) and further refining the measures for future implementation.

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For more information on ASCO’s Top Five list and the Choosing Wisely campaign, visit asco.org/topfive.