Patient Care and Research

2013 Choosing Wisely List

  1. Don’t initiate whole breast radiotherapy as a part of breast conservation therapy in women with early-stage invasive breast cancer without considering shorter treatment schedules.
    • Whole breast radiotherapy decreases local recurrence and improves survival of women with invasive breast cancer treated with breast conservation therapy. Most studies have utilized "conventionally fractionated" schedules that deliver therapy over 5-6 weeks, often followed by 1-2 weeks of boost therapy.
    • Recent studies, however, have demonstrated equivalent tumor control and cosmetic outcome in specific patient populations with shorter courses of therapy (∼4 weeks). Patients and their physicians should review these options to determine the most appropriate course of therapy. 


  1. Don’t initiate management of low risk prostate cancer without discussing active surveillance.
    • Patients with prostate cancer have a number of reasonable management options. These include surgery and radiation, as well as conservative monitoring without therapy in appropriate patients.
    • Shared decision making between the patient and the physician can lead to better alignment of patient goals with treatment and more efficient care delivery.
    • ASTRO has published patient-directed written decision aids concerning prostate cancer and numerous other types of cancer. These types of instruments can give patients confidence about their choices, improving compliance with therapy. 


  1. Don’t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases.
    • Studies suggest equivalent pain relief following 30 Gy in 10 fractions, 20 Gy in 5 fractions, or a single 8 Gy fraction.
    • A single treatment is more convenient but may be associated with a slightly higher rate of retreatment to the same site.
    • Strong consideration should be given to a single 8 Gy fraction for patients with a limited prognosis or with transportation difficulties. 


  1. Don’t routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry.
    • There is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy. 


  1. Don’t routinely use intensity modulated radiotherapy (IMRT) to deliver whole breast radiotherapy as part of breast conservation therapy.
    • Clinical trials have suggested lower rates of skin toxicity after using modern 3-D conformal techniques relative to older methods of 2-D planning
    • In these trials, the term "IMRT" has generally been applied to describe methods that are more accurately defined as field-in-field 3-D conformal radiotherapy.
    • While IMRT may be of benefit in select cases where the anatomy is unusual, its routine use has not been demonstrated to provide significant clinical advantage. 


How the list was developed

ASTRO’s Choosing Wisely list was developed after several months of careful consideration and thorough review, using the most current evidence about management and treatment options. A survey was sent to ASTRO’s Health Policy Council, Health Policy Committee, Clinical Affairs and Quality Committee, the Guidelines Subcommittee, Best Practices Subcommittee, Measures Subcommittee and disease-site resource panels in order to identify potential items for inclusion in the list. A seven-member work group was formed, with representation from ASTRO’s Clinical Affairs and Quality, Health Policy and Government Relations councils, and each work group member chose their top eight items from the total of 34 topics that had been suggested in the initial survey. The results were tabulated and a list of the highest scoring items created a short list of 13 draft items. Three conference calls were subsequently held to further refine the list and finalize the wording of the items based on input from ASTRO’s Board of Directors. An extensive literature review was conducted for each topic, and the work groups drafted the text and selected references for each topic. The final items for submission were approved by ASTRO’s Board of Directors. 

References for Item 1:

  • Clarke M, Collins R, Darby S, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005; 366(9503):2087-2106.
  • Smith BD, Bellon JR, Blitzblau R, et al. Radiation therapy for the whole breast: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Pract Radiat Oncol. 2018 May - Jun;8(3):145-152.
  • Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), Darby S, McGale P, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet. 2011;378(9804):1707-1716.
  • Haviland JS, Owen JR, Dewar JA, et al. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol. 2013 Oct;14(11):1086-94. 

References for Item 2:

  • Dahabreh IJ, Chung M, Balk EM, et al. Active surveillance in men with localized prostate cancer: a systematic review. Ann Intern Med. 2012;156(8):582-590.
  • Wilt TJ, Brawer MK, Jones KM, et al. Radical Prostatectomy versus Observation for Localized Prostate Cancer. N Engl J Med. 2012;367(3):203–213.
  • Bill-Axelson A, Holmberg L, Ruutu M, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2011;364(18):1708-1717.
  • Klotz L, Zhang L, Lam A, et al. Clinical Results of Long-Term Follow-Up of a Large, Active Surveillance Cohort With Localized Prostate Cancer. JCO. 2010;28(1):126-131.
  • Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2011;10:CD001431-CD001431.
  • Hamdy FC, Donovan JL, Lane JA, et al. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. N Engl J Med. 2016; 13:375(15):1415-1424.
  • Donovan JL, Hamdy FC, Lane JA, et al. Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med. 2016:375(15):1425-1437.
  • Sanda MG, Chen RC, Crispino T, et al. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. 2017. http://www.auanet.org/Documents/education/clinical-guidance/Clinically-Localized-Prostate-Cancer.pdf.

References for Item 3:

  • Lutz S, Berk L, Chang E, et al. Palliative Radiotherapy for Bone Metastases: An ASTRO Evidence-Based Guideline. Int J Radiat Oncol Biol Phys. 2011;79(5):965-976.
  • Lutz ST, Lo SS, Chang EL, et al. ACR Appropriateness Criteria® non-spine bone metastases. J Palliat Med. 2012;15(5):521-526.
  • Chow E, Zheng L, Salvo N et al. Update on the systematic review of palliative radiotherapy trials for bone metastases. Clin Oncol (R Coll Radiol). 2012;24(2):112-124.
  • Lutz S, Balboni T, Jones J, et al. Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline. Pract Radiat Oncol. 2017;7(1):4-12.

References for Item 4:

  • Mohler JL, Armstrong AJ, Bahnson RR, et al. NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer. Version 3.2012.
  • Sheets NC, Goldin GH, Meyer AM, et al. Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer. JAMA. 2012;307(15):1611-20.
  • Yu JB, Soulos PR, Herrin J, et al. Proton Versus Intensity-Modulated Radiotherapy for Prostate Cancer: Patterns of Care and Early Toxicity. J Natl Cancer Inst. 2013;105(1):25-32.
  • Coen JJ, Zietman AL, Rossi CJ, et al. Comparison of High-Dose Proton Radiotherapy and Brachytherapy in Localized Prostate Cancer: A Case-Matched Analysis. Int J Radiat Oncol Biol Phys. 2012;82(1): e25-e31. 

References for Item 5:

  • Barnett GC, Wilkinson JS, Moody AM, et al. Randomized controlled trial of forward-planned intensity modulated radiotherapy for early breast cancer: interim results at 2 years. Int J Radiat Oncol Biol Phys. 2012;82(2):715-723.
  • Donovan E, Bleakley N, Denholm E, et al. Randomised trial of standard 2D radiotherapy (RT) versus intensity modulated radiotherapy (IMRT) in patients prescribed breast radiotherapy. Radiother Oncol. 2007;82(3):254-264.
  • Pignol JP, Olivotto I, Rakovitch E, et al. A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol. 2008;26(13): 2085-2092.
  • Smith BD, Bellon JR, Blitzblau R, et al. Radiation therapy for the whole breast: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Pract Radiat Oncol. 2018 May - Jun;8(3):145-152.