A recommendation to consider the use of single-drug chemotherapy in most women with metastatic breast cancer is one of five newly recommended changes issued in the second round of the Choosing Wisely campaign.
The recommendations advise reconsidering tests and treatments that are often seen as routine, yet add costs without necessarily benefitting patients.
The action items are meant as a guide, not a demand, Dr. Lowell Schnipper said during a press briefing announcing the recommendations in advance of their release at a symposium on quality care sponsored by the American Society of Clinical Oncology.
Dr. Lowell Schnipper
"This is an attempt to encourage physicians and patients to curb the use of certain tests and procedures that are not supported by clinical research," said Dr. Schnipper, clinical director of Beth Israel Deaconess Medical Center Cancer Center in New York. "They are not meant to be legislative dictums. They are evidence-based suggestions presented as a foundation for discussion between doctor and patient – but there may be individual circumstances when they may decide to do otherwise."
The goal of the Choosing Wisely campaign – led by the American Board of Internal Medicine Foundation and joined by much of organized medicine – is to promote conversations that help patients and physicians choose care that is evidence driven, does not replicate care already provided, is free from harm, and is truly necessary.
ASCO’s second list of recommendations as part of the Choosing Wisely campaign includes the following:
• Restrict the use of antiemetic drugs to patients who are on chemotherapy regimens with a high risk of inducing nausea.
"One of the most important and unpleasant side effects of cancer drugs is nausea and vomiting," Dr. Schnipper said. "Over the years there has been an enormous degree of progress in medications to reduce and sometimes completely negate this."
But some of these drugs are "phenomenally expensive," he said. They should be saved for use in regimens that have a high potential to produce severe or persistent nausea and vomiting.
• Consider the use of single-drug chemotherapy in metastatic breast cancer.
"How much treatment is the optimal amount for metastatic breast cancer?" Dr. Schnipper said. "The concept is that more is better, but if we look at the outcomes for the majority of women, multiple drugs don’t add to survival and sometimes, because of the toxicities, actually detract from quality of life."
ASCO suggests that single drugs be used consecutively – a regimen that that may improve quality of life, even if it does not extend life. Multiple-drug regimens "should only be used in exceptional circumstances when a very rapid response to severe symptoms or life-threatening complications is at hand," according to the recommendation. "In a patient with advanced breast cancer who is not heavily pretreated and in whom symptomatic visceral crisis is apparent and rapid tumor response necessary, short courses of multiple agent
chemotherapy may be useful. However, as a general rule,
administration of sequential single agents lowers the risk of adverse
effects, may improve a patient’s quality of life, and does not typically
compromise overall survival.
• Avoid PET or PET-CT scans as part of routine follow-up care to monitor for recurrence in asymptomatic patients.
For patients who have completed treatment and show no clinical signs of relapse or new disease, routine imaging may not be necessary, Dr. Schnipper said.
"When we look too hard we almost always find some abnormality that, because of the patient’s medical history, we feel compelled to pursue. We don’t believe there’s any evidence showing that routine surveillance with CT or PET imaging provides anything that helps us keep patients alive longer. We think we can care for patients better with fewer risks, avoiding the cost of expensive imaging, and not compromising the cancer care they have received."
The report noted that "the utility of PET or PET-CT scanning for surveillance of both solid tumors and lymphomas remains unproven. In addition to clinical and economic considerations, the specter of unnecessary interventions and associated morbidity is a concern in the routine use of this technology for post-treatment surveillance."
• Avoid PSA testing in men who have a life expectancy of 10 years or less.
Again, the issue is whether any benefit of treatment would be worth the risk. "It’s not uncommon for these men to have comorbid illnesses that are more threatening than a low-grade prostate cancer. Most studies don’t show that treating affects mortality at all," although it can confer problems that really detract from quality of life.
Reserve targeted therapies intended for use against tumors with a specific genetic blueprint unless the patient’s tumor cells are expected to respond.