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Radiation Oncology Group Questions Five Treatments

Recommendations encourage more detailed physician–patient conversations

The American Society for Radiation Oncology (ASTRO) has released its second list of five radiation-oncology-specific treatments that are commonly ordered but may not always be appropriate. The list is part of the national Choosing Wisely campaign, an initiative of the ABIM Foundation.

The list identifies five targeted treatment options that ASTRO recommends should be subject to detailed patient–physician discussion before being prescribed. ASTRO released its first list of five recommendations in September 2013.

The five recommendations are as follows:

For patients with low-risk endometrial cancer, radiation is not recommended after hysterectomy. Patients with low-risk endometrial cancer — including no residual disease in hysterectomy despite positive biopsy; grade 1 or 2 with less than 50% myometrial invasion; and no additional high-risk features, such as age greater than 60 years, invasion of the lymphovascular space, or cervical involvement — have a very low risk of recurrence after surgery. Meta-analyses of radiation therapy for low-risk endometrial cancer have demonstrated increased side effects with no benefit in overall survival (OS) compared with surgery alone.

Radiation therapy should not be routinely offered to patients with resected non–small-cell lung cancer (NSCLC) with negative margins and N0-1 disease. Patients with early-stage NSCLC have several management options after surgery. These options include observation, chemotherapy, and radiotherapy. Two meta-analysis studies of postoperative radiotherapy in early NSCLC with node-negative or N1 disease suggested increased side effects with no benefit for disease-free survival or OS compared with observation. Patients with positive margins after surgery may benefit from postoperative radiotherapy to improve local control regardless of the status of their nodal disease.

Noncurative radiation therapy should not be initiated without defining treatment goals with the patient and considering referral to palliative care. Well-defined goals of therapy are associated with improved quality of life and better understanding on the part of patients and their caregivers. Palliative care can be delivered concurrently with anticancer therapies. Early palliative-care intervention may improve patient outcomes, including survival.

Follow-up mammograms should not be routinely recommended more often than once a year for women who have had radiotherapy after breast conservation therapy. Studies indicate that once a year is the appropriate frequency for mammograms for the surveillance of breast cancer patients who have had breast-conserving surgery and radiation therapy; there is no clear advantage to shorter-interval imaging. Patients should wait 6 to 12 months after the completion of radiation therapy to begin their annual mammogram surveillance. Suspicious findings on physical examination or surveillance imaging might warrant a shorter interval between mammograms.

For limited brain metastases, adjuvant whole-brain radiation therapy (WBRT) should not be routinely added to stereotactic radiosurgery (SRS). Randomized studies have demonstrated no OS benefit from the addition of adjuvant WBRT to SRS in the management of selected patients with good performance status and brain metastases from solid tumors. The addition of WBRT to SRS is associated with diminished cognitive function and worse patient-reported fatigue and quality of life. Patients treated with radiosurgery for brain metastases can develop metastases elsewhere in the brain. Careful surveillance and the judicious use of salvage therapy at the time of brain relapse allow appropriate patients to enjoy the highest quality of life without a detriment in overall survival.

Sources: Medical Xpress; September 18, 2014; and ASTRO; September 14, 2014.

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