American Society of Clinical Oncology Choosing Wisely; Last Reviewed 2021
ASCO's 2021 Top Five List in Oncology
The American Society of Clinical Oncology (ASCO) is a medical professional oncology society committed to conquering cancer through research, education, prevention, and delivery of high-quality patient care. ASCO recognizes the importance of evidence-based cancer care and making wise choices in the diagnosis and management of patients with cancer. After careful consideration by experienced oncologists, ASCO highlights ten categories of tests, procedures, and/or treatments whose common use and clinical value are not supported by available evidence. These test and treatment options should not be administered unless the physician and patient have carefully considered if their use is appropriate in the individual case. As an example, when a patient is enrolled in a clinical trial, these tests, treatments, and procedures may be part of the trial protocol and therefore deemed necessary for the patient’s participation in the trial.
These items are provided solely for informational purposes and are not intended to replace a medical professional’s independent judgment or as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their health care provider. New evidence may emerge following the development of these items. ASCO is not responsible for any injury or damage arising out of or related to any use of these items or to any errors or omissions.
Five Things Patients and Physicians Should Question (2012)
1. |
Don’t use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, and no strong evidence supporting the clinical value of further anti-cancer treatment. |
|
|
||
2. |
Don’t perform PET, CT, and radionuclide bone scans, or newer imaging scans in the staging of early prostate cancer at low risk for metastasis. |
|
|
||
3. |
Don’t perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis. |
|
|
||
4. |
Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent. |
|
|
||
5. |
Don’t use prophylactic white cell stimulating factors unless the expected risk of febrile neutropenia associated with a chemotherapy agent or regimen is equal to or greater than 20%. |
|
|
Five More Things Patients and Physicians Should Question (2013)
6. |
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 of causing nausea and vomiting. |
|
|
||
7. |
Don’t use combination cytotoxic chemotherapy (multiple drugs) instead of chemotherapy with one drug when treating an individual for metastatic breast cancer unless the patient needs a rapid response to relieve tumor-related symptoms. |
|
|
||
8. |
Avoid using PET or PET-CT scanning as part of routine follow-up care to monitor for a cancer recurrence in asymptomatic patients who have finished initial treatment to eliminate the cancer unless there is high-level evidence that such imaging will change the outcome. |
|
|
||
9. |
Don’t routinely perform PSA testing for prostate cancer screening in men with no symptoms of the disease. |
|
|
||
10. |
The original Choosing Wisely Statement #10 recommended against using a targeted therapy intended for use against a specific genetic aberration unless a patient’s tumor cells have a specific biomarker that predicts an effective response to the targeted therapy. While this statement continues to hold true, it is also currently being incorporated into a forthcoming ASCO Choosing Wisely 2021, which will update the currency and provide further context for this recommendation. |
|
|
Abbreviations
CT, computed tomography; DCIS, ductal carcinoma in situ; PET, positron emission tomography; PSA, prostate-specific antigen.
How This List Was Created (1–5)
In response to the 2010 New England Journal of Medicine article by Howard Brody, MD, “Medicine’s Ethical Responsibility for Health Care Reform – the Top Five List,” a subcommittee of ASCO’s Cost of Cancer Care Task Force began work to identify practices in oncology that were common and lacked sufficient evidence to support widespread use. Upon joining the Choosing Wisely campaign, the members of the subcommittee conducted a literature search to ensure the proposed list of items was supported by available evidence in oncology; ultimately the proposed Top Five list was approved by the full Task Force. The initial draft list was then presented to the ASCO Clinical Practice Committee, a group composed of community-based oncologists as well as the presidents of the 48 state/regional oncology societies in the United States. Advocacy groups were also asked to weigh in to ensure the recommendations would achieve the dual purpose of increasing physician-patient communication and changing practice patterns. A plurality of more than 200 clinical oncologists reviewed, provided input, and supported the list. The final Top Five list in oncology was then presented to, discussed, and approved by the Executive Committee of the ASCO Board of Directors and published in the Journal of Clinical Oncology. ASCO’s disclosure and conflict of interest policies can be found at www.asco.org.
How This List Was Created (6–10)
To guide ASCO in developing this list, suggestions were elicited from current ASCO committee members (approximately 700 individuals); 115 suggestions were received. After removing duplicates, researching the literature, and discussing practice patterns, the Value in Cancer Care Task Force culled the list to 11 items, which comprised an ASCO Top Five voting slate that was sent back to the membership of all standing committees. Approximately 140 oncologists from its leadership cadre voted, providing ASCO with an adequate sample size and perspective on what oncologists find to be of little value. The list was reviewed and finalized by the Value in Cancer Care Task Force and ultimately reviewed and approved by the ASCO Board of Directors and published in the Journal of Clinical Oncology. ASCO’s disclosure and conflict of interest policies can be found at www.asco.org.
How This List Was Updated (1-10)
A survey was distributed to gather the opinions of the original authors of ASCO’s Choosing Wisely on the ongoing relevance of the 2012-2013 statements. For the most part, responses indicated that the statements continue to be relevant. The exception was ASCO’s statement #10, which the group agreed continues to hold true, but would benefit from additional updating and context. Thus, it was decided that a new version of this statement will be included in a forthcoming ASCO Choosing Wisely Five Things. In addition, some modifications were made to the original wording of the recommendations and accompanying bullet points in order to reflect current context.