It’s not easy doing the right thing. But when ASTRO released its contribution to the Choosing Wisely campaign, I was proud that my professional organization declared itself in favor of integrity and science.
It would have been easy to come up with platitudes. Instead, the leadership of the American Society for Radiation Oncology came up with evidence-based, substantive recommendations that will change how many radiation oncologists practice. Those changes are likely to help decrease the costs of cancer care without compromising quality. Here are the five areas that ASTRO shines the light upon:
1. Breast cancer radiation, historically 5-6.5 weeks, may be able to be shortened to 4 weeks or less in women 50 years or older.
The most common daily treatment courses have been giving whole breast radiation followed by a focused boost. The concern was for more problems with cosmetic appearance after treatment if the daily dose was too high. Now randomized trials support shortening treatment in appropriate patients with no concerns about cosmetic outcome. There are some caveats about tumor grade, how the radiation is delivered, use of chemotherapy but I have increasingly used the ‘Canadian fractionation’ schedule of 16 fractions for the breast sometimes with a boost afterward since 2010.
2. Don’t treat men with low risk prostate cancer without discussing active surveillance.
Many men with prostate cancer will never develop symptoms from it or have any serious health risk after diagnosis. There has been a tendency among urologists and radiation oncologists to suffer from “hammer-nail” syndrome and focus on offering treatment when it may not be needed in very low risk patients. Supporting active surveillance is the right thing to do for many men based upon other competing health issues, which may be more important. Informed, shared decision-making is critical and often it’s helpful to include primary care physicians in that conversation. I’ve worked out a good relationship with urologists at my hospital to see many low-risk patients at diagnosis to give them all their options before going on active surveillance. In my opinion it’s better to give good advice than rush to treatment and have patients regret it later.
3. Don’t use routinely prolonged courses of treatment for bone metastases.
I’m not a health policy expert but apparently some doctors use very long courses of treatment for cancer that’s spread to the bone. The main situation where I find longer courses are worth considering is women with limited ER+ bone metastases, usually spine, often showing up years after initial diagnosis. I’ve been trending down from ten treatments to anywhere from 1-5 depending upon what else is going on. Palliative care is very challenging but the evidence definitely supports a ‘less is more’ approach.
4. Don’t recommend proton therapy for prostate cancer off of a clinical trial or registry.
The beauty of high technology is not an end unto itself. Proton therapy does have great potential but is very expensive with no better outcomes for prostate cancer, the main financial driver for developing very expensive treatment centers. I see no reason why proton therapy shouldn’t be able to reimburse equally with photon therapy, but it doesn’t deserve a premium.
5. Don’t routinely use intensity modulated radiation therapy (IMRT) for breast cancer.
Even with less treatments (point 1), breast cancer care can be very expensive if one considers some technical tweaks, called field in field, to be an more complex process called IMRT. Supposedly the skin reaction is less, but when I’ve tried it I can’t say that it necessarily made much difference. There are rare complex cases that IMRT works well for, but that’s the exception to the rule.
All of these changes in practice will have a negative effect on income but a more important positive effect: as a professional radiation oncology takes evidence seriously and does what’s right for patients. This integrity will serve us much better by reassuring patients, colleagues, insurers, and the government that we are trustworthy.
My hope is that ASTRO’s commitment to quality care is recognized and appreciated widely. But just in case it isn’t, I can still speak for myself.