The Royal Australian and New Zealand College of Radiologists – Faculty of Radiation Oncology

RANZCR is a non-profit association that delivers skills, knowledge, and insight to promote the science and practice of the medical specialties of clinical radiology (diagnostic and interventional) and radiation oncology.

1. Don’t initiate whole-breast radiation therapy as a part of breast conservation therapy in women age ≥50y with early-stage invasive breast cancer without considering shorter treatment schedules.

Whole-breast radiation therapy decreases local recurrence and improves survival of women with invasive breast cancer treated with breast conservation therapy. Most studies have utilised “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 tumour 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.
Recommendation released October 2016

Supporting Evidence
  • 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; 366:2087-106.
  • Smith BD, Bentzen SM, Correa CR, et al. Fractionation for Whole Breast Irradiation: An American Society for Radiation Oncology (ASTRO) Evidence-Based Guideline. Int J Radiation Oncology Biol Phys 2011;81(1):59-68.
  • Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), Darby S, McGale P, Correa C, 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;378:1707-16.
  • 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;14(11):1086-94.

2. 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.
Recommendation released October 2016

Supporting Evidence
  • 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):582-90.
  • Wilt TJ, Brawer MK, Jones KM, et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 2012;367(3):203-13.
  • 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):1708-17.
  • Thompson I, Thrasher JB, Aus G, et al. Guideline for the management of clinically localized prostate cancer. J Urol 2007;177(6):2106-31.
  • 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. J Clin Oncol 2010;28(1):126-31.
  • Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions (Review). Cochrane Database Syst Rev 2011;10:CD001431-CD001431.
  • Chen RC, Rumble B, Loblaw DA, at el. Active surveillance for the management of localized prostate cancer (Cancer Care Ontario Guideline): American Society of Clinical Oncology Clinical Practice Guideline Endorsement. J Clin Oncol 2016; DOI: 10.1200/JCO.2015.65.7759.
  • Tosoian JT, Mamawala M, Epstein JI, et al. Intermediate and longer-term outcomes from a prospective active-surveillance program for favourable-risk prostate cancer. J Clin Oncol 2015;33(30):3379-85.
  • Preston MA, Feldman AS, Coen JJ, et al. Active surveillance for low-risk prostate cancer: need for intervention and survival at 10 years. Urologic Oncology: Seminars and Original Investigations 2015; 33(9):383.e9-16.
  • Morash C, Tey R, Agbassi C, et al. Active surveillance for the management of localized prostate cancer: Guideline recommendations. Can Urol Assoc J 2015;9(5-6):171-8.
  • Bul M, Zhu X, Valdagni R, et al. Active surveillance for low-risk prostate cancer worldwide: The PRIAS study. Eur Urol 2013;63:597-603.
  • Weerakoon M, Papa N, Lawrentschuk N, et al. The current use of active surveillance in an Australian cohort of men: a pattern of care analysis from the Victorian Prostate Cancer Registry. BJU Int 2015 Apr;115,Suppl 5:50-6.

3. 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.
Recommendation released October 2016

Supporting Evidence
  • 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(4):965-76.
  • Expert Panel on Radiation Oncology-Bone Metastases: Lutz ST, Lo SSM, Chang EL, et al. ACR Appropriateness Criteria® non-spine bone metastases. J Palliat Med 2012;15(5):521-26.
  • Chow E, Zheng L, Salvo N et al. Update on the systematic review of palliative radiotherapy trials for bone metastases. Clin Oncol 2012;24(2):112-24.

4. Don’t routinely add adjuvant whole-brain radiation therapy to stereotactic radiosurgery for limited brain metastases.

Randomised 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 tumours. 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 randomised studies of prophylactic cranial irradiation for small cell or non-small cell lung cancer. Patients treated with radiosurgery for brain metastases are at higher risk of developing 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. Radiation oncologists should discuss these options with patients, including participation in appropriate clinical trials.
Recommendation released October 2016

Supporting Evidence
  • 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 tumours after surgical resection or radiosurgery: quality-of-life results. J Clin Oncol 2013;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 Oncol 2009;10(11):1037-44.
  • Aoyama H, Shirato H, Tago M, et al. Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA 2006;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 cerebral metastases: results of the EORTC 22952-26001 study. J Clin Oncol 2011;29:134-41.
  • 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;86(4):656-64.
  • Brown PD, Asher AL, Ballman KV, et al. NCCTG N0574 (Alliance): A phase III randomized trial of whole brain radiation therapy (WBRT) in addition to radiosurgery (SRS) in patients with 1 to 3 brain metastases. J Clin Oncol 2015;33(18): suppl LBA4.

5. Don’t routinely use extensive locoregional therapy in most cancer situations where there is metastatic disease and minimal symptoms attributable to the primary tumour.

In the past, extensive local regional therapies (e.g., surgery) were often provided in patients with metastatic disease, regardless of the symptomatology of the primary tumour. However, recent evidence has suggested that in many cases these therapies do not improve outcome and, at times, delay the more important treatment of metastatic disease (e.g., chemotherapy). In general, patients with metastatic disease from solid organ malignancies and a relatively asymptomatic primary tumour should be considered for systemic therapy as a priority; the delay in systemic therapy and potential additional morbidity arising from extensive locoregional therapies should be avoided in these patients.
Recommendation released October 2016

Supporting Evidence
  • Kleespies A, Füessl KE, Seeliger H, et al. Determinants of morbidity and survival after elective non-curative resection of stage IV colon and rectal cancer. Int J Colorectal Dis 2009;24(9):1097-109.
  • National Comprehensive Cancer Network. NCCN Guidelines for Colon Cancer Version 3 [Internet]. 2014 [cited 2014 April]. Available from:
  • Badwe R, Parmar V, Hawaldar R, et al. Surgical removal of primary tumour and axillary lymph nodes in women with metastatic breast cancer at first presentation: A randomized controlled trial. Cancer Res 2013;73(24 Suppl): Abstract nr S2-02.
  • Choosing Wisely Canada. Oncology: Ten things physicians and patients should question. [Internet]. 2014 [cited 2016 March].
  • Available from:

Last reviewed October 2016

How was this list created?

Radiation oncology recommendations 1-5 (October 2016)

Recommendations relating to radiation oncology from the Choosing Wisely and Choosing Wisely Canada were circulated around the Faculty of Radiation Oncology Council to determine which recommendations were applicable to the Australian and New Zealand context. The selected recommendations were then put to the Quality Improvement Committee and the Economics and Workforce Committee, with each being asked to rank the recommendations.

The five highest ranked recommendations were then put to the radiation oncology membership for consultation prior to being formally approved by the Faculty of Radiation Oncology Council.

Recommendations 1-3 are adapted from the American Society for Radiation Oncology (ASTRO) 2013 and 2014 lists. Recommendation 4 is adapted from Choosing Wisely Canada’s Oncology list.  Each organisation was approached for—and subsequently granted—approval to adapt these recommendations as part of the Choosing Wisely New Zealand initiative.