ASCO’s “Choosing Wisely” Top 5 List: Inappropriate Tests, Imaging, and Targeted Therapies

San Diego, CA—Unnecessary treatment, imaging, and testing all came into focus in the American Society of Clinical Oncology (ASCO)’s 2013 choices for the Choosing Wisely campaign to eliminate the overuse and misuse of medical care resources.

At the 2013 ASCO Quality Care Symposium, Lowell E. Schnipper, MD, Medical Director, Beth Israel Deaconess Medical Center Cancer Center, Boston, Chair of ASCO’s Cost of Cancer Care Task Force, cited inappropriate use of antiemetics, combination chemotherapy for metastatic breast cancer, routine follow-up imaging with positron-emission tomography (PET) or PET–computed tomography (CT), prostate-specific antigen (PSA) testing, and targeted therapies.

2012 Top 5 List
ASCO released its first “Top Five” list in 2012 and received considerable positive feedback from the oncology community, said the task force.
“The exercise we went through to identify the top five items was viewed by our professional colleagues in ASCO as very, very helpful to them, because [the recommendations] all were quite evidence-based,” said Dr Schnipper. “They provided substantial support in difficult conversations the doctors might have been having with their patients as they were negotiating management plans with them.”

Initiated by the American Board of Internal Medicine Foundation, the Choosing Wisely campaign has provided a vehicle for leading medical organizations to identify and publicize practices that are widely used but have no supporting evidence and likely add nothing to aid clinical care. The 2012 inappropriate practices included:

• Use of cancer therapy in poor performance
• Poor-prognosis patients
• PET, CT, or radionuclide bone scans for staging low-risk early prostate cancer
• PET, CT, or radionuclide bone scans for staging low-risk early breast cancer
•  Surveillance tests or imaging for asymptomatic patients with breast cancer treated with curative intent
• Use of growth factors for the pri­mary prevention of febrile neutropenia in patients at low risk of the complication.

2013 Top 5 List
Dr Schnipper reviewed the 2013 Top Five and discussed the rationale for the choices:

1. Antiemetics designed to reduce the risk of nausea and vomiting associated with highly emetogenic chemotherapy regimens in patients treated with regimens that have a low or moderate risk of nausea or vomiting.
   
   The agents are extremely effective when given with highly emetogenic regimens, but also are “phenomenally expensive.”
   
   “We thought it very important to emphasize that antiemetic use guidelines—guidelines that ASCO itself has promulgated—suggesting ways in which antinausea drugs be utilized, should be adhered to,” said Dr Schnipper.
   
   Agents developed for use with highly emetogenic regimens should be given to patients treated with those regimens, recognizing the high cost, he added. On the other hand, ASCO encourages the use of lower cost but effective antiemetics in association with regimens that have a moderate or low emetogenic potential.
2. Do not use combination chemotherapy instead of a single drug in patients with metastatic breast cancer, except when a rapid response is required to relieve tumor-related symptoms.
   
   “The concept at the outset of clinical trials that have utilized combination chemotherapy agents is that more is better,” said Dr Schnipper. “It turns out that, when we look at the outcome, bringing multiple drugs together, for the majority of women who have metastatic breast cancer, does not add to their survival and sometimes, because of the side effects or toxicities, actually detracts from the quality of their life.”
   
   Single-agent therapy, even when used sequentially, also saves money, Dr Schnipper added. However, the judicious use of single agents serves to support the primacy of the patient and is a time-tested, effective approach for most patients with metastatic breast cancer.
    
3. Avoid PET or PET-CT imaging for routine follow-up of asymptomatic patients who have finished curative therapy, except when high-level evidence suggests that the imaging will change the outcome.
   
   “We do not believe there is any evidence to say that routine use of CT scans or PET scans or PET-CT scans provides any strong evidence that we can keep patients alive longer or maintain their health better,” said Dr Schnipper. “In fact, the concern we have is that too much testing will uncover abnormalities that are not related to cancer, that don’t even need to be identified because they are harmless.”
    
4. Do not perform screening PSA tests in asymptomatic men who have a life expectancy of less than 10 years.
   “Studies have been done looking at the impact of prostate cancer diagnosis in men, particularly men over 70, and the majority of studies do not show that treating this prostate cancer affects their mortality at all,” said Dr Schnipper. “There is a very small increase over time in mortality related to prostate cancer in these individuals, but overall mortality is not affected at all.”
   
   Members of the task force were quite affected by the impact of therapy for localized prostate cancer, Dr Schnipper added. Surgery, radiation therapy, and hormonal therapy all can substantially and adversely affect a man’s quality of life.
    
5. Do not use targeted therapy unless a patient’s tumor produces a biomarker that predicts response to the therapy.
   “If the biomarker predicts response to the drug, we suggest strongly that that is the only circumstance in which that particular targeted therapy should be utilized. We think that will control the use of these expensive, but very valuable, target agents and restrict them to the indicated population, assuming this is an adhered to element without promiscuous use in populations of patients who are not likely to derive benefit.”

These Top Five are not intended as “legislated dicta. They are evidence-based suggestions that are presented as a foundation for discussion between the doctor and the patient,” Dr Schnipper concluded. “Of course, there will be individual circumstances in which patients and their doctors may decide in ways that would not be consistent with the guidelines….What we are trying to do is make recommendations that adhere to evidence and encourage our colleagues to do so.”

The list was published simultaneously online (Schnipper LE, et al. J Clin Oncol. Epub 2013 October 29).