Patient Care and Research

2014 Choosing Wisely List

  1.  Don't recommend radiation following hysterectomy for endometrial cancer patients with low risk disease.
    • Patients with low risk endometrial cancer including no residual disease in hysterectomy despite positive biopsy, grade 1 or 2 with <50% myometrial invasion and no additional high risk features such as age >60, lymphovascular space invasion or cervical involvement have a very low risk of recurrence following surgery.
    • Meta-analysis studies of RT for low risk endometrial cancer demonstrate increased side effects with no benefit in overall survival compared with surgery alone. 


  1. Don't routinely offer radiation therapy for patients who have resected non-small-cell lung cancer (NSCLC) negative margins N0-1 disease.
    • Patients with early stage NSCLC have several management options following surgery. These options include: observation, chemotherapy and radiotherapy
    • Two meta-analysis studies of post-operative radiotherapy in early NSCLC with node negative or N1 disease suggest increased side effects with no benefit for disease free survival or overall survival compared to observation.
    • Patients with positive margins following surgery may benefit from post-operative radiotherapy to improve local control regardless of status of their nodal disease. 


  1. Don't initiate non-curative radiation therapy without defining the goals of treatment with the patient and considering palliative care referral.
    • 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 anti-cancer therapies.
    • Early palliative care intervention may improve patient outcomes, including survival. 


  1. Do not routinely recommend follow up mammograms more often than annually for women who have had radiotherapy following breast conserving surgery.
    • Studies indicate that annual mammograms are the appropriate frequency for surveillance of breast cancer patients who have had breast conserving surgery and radiation therapy with no clear advantage to shorter interval imaging.
    • Patients should wait 6 – 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. 


  1. Don't routinely add adjuvant whole brain radiation therapy to stereotactic radiosurgery for limited brain metastases.
    • Primary analyses of randomized studies have demonstrated no overall survival benefit from the addition of adjuvant whole brain radiation therapy (WBRT) to stereotactic radiosurgery (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. These results are consistent with the worsened self-reported cognitive function and diminished verbal skills observed in randomized studies of prophylactic cranial irradiation for small cell or non-small cell lung cancer.
    • 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. Patients should discuss these options with their radiation oncologist. 


References for Item 1:

  • Diavolitsis V, Rademaker A, Lurain J, Hoekstra A, Strauss J, Small W, Jr. Clinical outcomes in international federation of gynecology and obstetrics stage IA endometrial cancer with myometrial invasion treated with or without postoperative vaginal brachytherapy. Int J Radiat Oncol Biol Phys. 2012 Oct 1;84(2):415-419.
  • Johnson N, Cornes P. Survival and recurrent disease after postoperative radiotherapy for early endometrial cancer: systematic review and meta-analysis. BJOG. 2007 Nov;114(11):1313-1320.
  • Kong A, Johnson N, Kitchener HC, Lawrie TA. Adjuvant radiotherapy for stage I endometrial cancer: an updated Cochrane systematic review and meta-analysis. J Natl Cancer Inst. 2012 Nov 7;104(21):1625-1634.
  • Creutzberg CL, Nout RA. The role of radiotherapy in endometrial cancer: current evidence and trends. Curr Oncol Rep. 2011 Dec;13(6):472-478.
  • Klopp A, Smith BD, Alektiar K, Cabrera A, Damato AL, et al. The role of postoperative radiation therapy for endometrial cancer: Executive Summary of an American Society for Radiation Oncology evidence-based guideline. Pract Radiat Oncol. 2014 May-Jun;4(3):137-144. 

References for Item 2:

  • Perry MC. A phase III study of surgical resection and paclitaxel/carboplatin chemotherapy with or without adjuvant radiation therapy for resected stage III non-small-cell lung cancer: Cancer and Leukemia Group B 9734. Clin Lung Cancer. 2007 Jan; 8(4):268-72.
  • Trodella L, Granone P, Valente S, et al. Adjuvant radiotherapy in non-small cell lung cancer with pathological stage I: definitive results of a phase III randomized trial. Radiother Oncol. 2002 Jan;62(1):11–19.
  • Keller SM, Adak S, Wagner H, et al. A randomized trial of postoperative adjuvant therapy in patients with completely resected stage II or IIIA non-small-cell lung cancer. Eastern Cooperative Oncology Group. N Engl J Med 2000;343:1217–1222.
  • Feng QF, Wang M, Wang LJ, et al. A study of postoperative radiotherapy in patients with non-small-cell lung cancer: a randomized trial.  Int J Radiat Oncol Biol Phys. 2000 Jul 1;47(4):925–929.
  • Mayer R, Smolle-Juettner FM, Szolar D, et al. Postoperative radiotherapy in radically resected non-small cell lung cancer. Chest. 1997;112:954-959.
  • Rodrigues G, Choy H, Bradley J, et al. Adjuvant radiation therapy in locally advanced non-small cell lung cancer: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based clinical practice guideline. Pract Radiat Oncol. 2015 May-June;5(3):149-55. 

References for Item 3:

  • World Health Organization: WHO Definition of Palliative Care, 2011. Available from:http://www.who.int/cancer/palliative/definition/en/
  • Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: The Project ENABLE II randomized controlled trial. JAMA 2009;302:741-749.
  • Higginson IJ, Evans CJ. What is the evidence that palliative care teams improve outcomes for cancer patients and their families? Cancer J. 2010;16:423-435.
  • Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-742.
  • Smith T, Temin S, Alesi E, et al: American Society of Clinical Oncology Provisional Clinical Opinion: The Integration of Palliative Care Into Standard Oncology Care. J Clin Oncol 2012;30:880-887. 

References for Item 4:

  • Khatcheressian JL, Hurley P, Bantug E, et al. Breast Cancer Follow-Up and Management After Primary Treatment: An American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2013 Mar 1;31(7):961-965.
  • Grunfeld E, Dhesy-Thind S, Levine M, et al. Cancer practice guidelines for the care and treatment of breast cancer: follow-up after treatment for breast cancer (summary of the 2005 update). CMAJ. 2005 May 10;172(10):1319-1320.
  • Gradishar WJ, Anderson BO, Blair SL, et al. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. Version 3.2014.
  • Rojas MP, Telaro E, Russo A, et al. Follow-up strategies for women treated with early breast cancer. Cochrane Database Syst Rev. 2005;1: CD001768.
  • McNaul D, Darke M, Garg M, Dale P. An evaluation of post-lumpectomy recurrence rates: is follow-up every 6 months for 2 years needed? J Surg Oncol. 2013;107(6):597-601. 
  • Allen A, Cauthen A, Vaughan J, Dale P. The Clinical Utility and Cost of Postoperative Mammography Completed within One Year of Breast Conserving Therapy: Is It Worth It? Am Surg. 2017;83:871-874.
  • Hasan S, Abel S, Simpson-Camp L, et al. Short-Term Follow-Up Mammography in Breast Conservation Therapy Likely Leads to Unnecessary Downstream Workup: A Longitudinal Study. Int J Radiat Oncol Biol Phys. 2017. [Epub ahead of print] 

References for Item 5:

  • Soffietti R, Kocher M, Abacioqlu UM, et al. A European organisation for research and treatment of cancer phase III trial of adjuvant whole-brain radiotherapy versus observation in patients with one to three brain metastases from solid tumors after surgical resection or radiosurgery: quality-of-life results. J Clin Oncol. 2013 Jan 1;31(1):65-72.
  • Chang EL, Wefel JS, Hess KR, et al. Neurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomized controlled trial. Lancet. 2009 Nov;10(11):1036-44.
  • Aoyama H, Shirato H, Tago M, et al. Stereotectic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA. 2006 Dec 7;295(21):2483-91.
  • Kocher M, Soffietti R, Abacioglu U, et al. Adjuvant whole-brain radiotherapy versus observation after radiosurgery or surgical resection of one to three cerebal mestastases: Results of the EORTC 22952-26001 study. J Clin Oncol. 2011 Jan 10;29(2):134-41.
  • Gondi V, Paulus R, Bruner DW, et al. Decline in tested and self-reported cognitive functioning after prophylactic cranial irradiation for lung cancer: Pooled secondary analysis of Radiation Therapy Oncology Group randomized trials 0212 and 0214. Int J Radiat Oncol Biol Phys. 2013 Jul 15;86(4):656-64. 
  • Brown PD, Jaeckle K, Ballman KV, et al. Effect of Radiosurgery Alone vs Radiosurgery With Whole Brain Radiation Therapy on Cognitive Function in Patients with 1 to 3 Brain Metastases: A Randomized Clinical Trial. JAMA. 2016;316(4):401-409.