The Royal Australian and New Zealand College of Radiologists
Recommendations from the Royal Australian and New Zealand College of Radiologists on early-stage breast cancer, low risk prostate cancer, palliation of bone metastases, and brain metastases. The Royal Australian and New Zealand College of Radiologists (RANZCR) is a not-for-profit association of members who deliver skills, knowledge, insight, time and commitments to promote the science and practice of the medical specialties of clinical radiology (diagnostic and interventional) and radiation oncology in Australia and New Zealand.
Do not proceed with any treatment for localised prostate cancer unless the man has been offered a consultation with a urologist and a radiation oncologist, and taken time to consider the advantages and disadvantages of each treatment option.
A recent randomised controlled trial has shown equivalent survival for both surgery and radiation therapy for prostate cancer (1). Yet, side effects (2) and costs – to patients and health services (3,4) can differ significantly. Guidelines emphasise informed choice for men with prostate cancer (5,6).
Evidence suggests men who miss out on this opportunity to discuss all options may suffer from stress and anxiety (7) or decision regret (8-10).
On the basis of current evidence, the position of RANZCR is that best practice should be that a man considering curative treatment for prostate cancer sees a urologist and a radiation oncologist to discuss his treatment options (11).
1. Hamdy FC, Donovan JL, Lane JA, Mason M, Metcalfe C, Holding P, et al. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. New England Journal of Medicine. 2016;375(15):1415-24.
2. Chen RC, Basak R, Meyer AM, Kuo TM, Carpenter WR, Agans RP, et al. Association Between Choice of Radical Prostatectomy, External Beam Radiotherapy, Brachytherapy, or Active Surveillance and Patient-Reported Quality of Life Among Men With Localized Prostate Cancer. Jama. 2017;317(11):1141-50.
3. Cronin P, Kirkbride B, Bang A, Parkinson B, Smith D, Haywood P. Long-term health care costs for patients with prostate cancer: a population-wide longitudinal study in New South Wales, Australia. Asia-Pacific journal of clinical oncology. 2017;13(3):160-71.
4. Royal Australasian College of Surgeons, Medibank. Surgical Variance Report: Urology: Royal Australasian College of Surgeons; 2016 [cited 2018 10 April]. Available from: https://www.surgeons.org/media/24417293/16046_RACS-Urology-Report_web_FA.PDF.
5. Sanda MG, Cadeddu JA, Kirkby E, Chen RC, Crispino T, Fontanarosa J, et al. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. Part I: Risk Stratification, Shared Decision Making, and Care Options. The Journal of urology. 2017.
6. EAU-ESTRO-ESUR-SIOG Prostate Cancer Guidelines Panel. Prostate Cancer and the John West Effect. European urology. 2017;72(1):7-9.
7. Kaplan AL, Crespi CM, Saucedo JD, Connor SE, Litwin MS, Saigal CS. Decisional conflict in economically disadvantaged men with newly diagnosed prostate cancer: baseline results from a shared decision-making trial. Cancer. 2014;120(17):2721-7.
8. Hu JC, Kwan L, Saigal CS, Litwin MS. Regret in men treated for localized prostate cancer. The Journal of urology. 2003;169(6):2279-83.
9. Aning JJ, Wassersug RJ, Goldenberg SL. Patient preference and the impact of decision-making aids on prostate cancer treatment choices and post-intervention regret. Current oncology (Toronto, Ont). 2012;19(Suppl 3):S37-44.
10. Shakespeare TP, Chin S, Manuel L, Wen S, Hoffman M, Wilcox SW, et al. Long-term decision regret after post-prostatectomy image-guided intensity-modulated radiotherapy. J Med Imaging Radiat Oncol. 2017;61(1):141-5.
11. RANZCR Informed Decision Making in the Management of Localised Prostate Cancer – A Patient Focused Perspective Position Statement V1. June 2018 [Available from https://www.ranzcr.com/documents-download/professional-documents/position-papers/4670-informed-decision-making-in-the-management-of-localised-prostate-cancer-position-paper]
Clinical radiology recommendations 1-6 (April 2015)
A team of five Lead Radiologists were nominated to guide RANZCR's Choosing Wisely contribution. These Lead Radiologists analysed previous work completed by RANZCR, in particular a series of Education Modules for Appropriate Imaging Referrals.
These modules had been developed from an extensive evidence base and with multiple stakeholder input. Using the evidence from the Education Modules, the Lead Radiologists developed a draft recommendations list, which was then further developed and endorsed by RANZCR's Quality and Safety Committee, before being circulated to the RANZCR membership for consultation with a request for alternative recommendations. Member feedback was reviewed by the Lead Radiologists prior to ratification of the final recommendations by the Faculty of Clinical Radiology Council. The final six items selected were those that were felt to meet the goals of Choosing Wisely, i.e. those which are frequently requested or which might expose patients to unnecessary radiation.
Due to the fundamental role of diagnostic imaging in supporting diagnosis across the healthcare system, RANZCR worked closely with other Colleges throughout the project via the Advisory Panel. Following identification of two common recommendations with the Australasian College for Emergency Medicine, it was agreed by both Colleges to present these items jointly.
Radiation oncology recommendations 7-10 (September 2021)
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 and Economics and Workforce Committees, 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 7-10 are adapted from the American Society for Radiation Oncology (ASTRO) 2013 and 2014 lists. Recommendation 11 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 Australia campaign.
This initial list has now been reviewed with recommendations 7, 8 & 10 remaining unchanged, recommendation 9 has been updated based on the advice of the Faculty of Radiation Oncology Quality Improvement Committee and Recommendation 11 has been replaced based on the feedback of the Quality Improvement Committee and the Policy and Advocacy team.
- 1 Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the Rules).
- 2 Don’t request duplex compression ultrasound for suspected lower limb deep venous thrombosis in ambulatory outpatients unless the Wells Score (deep venous thrombosis risk assessment score) is greater than 2, OR if less than 2, D dimer assay is positive.
Don’t request any diagnostic testing for suspected pulmonary embolism (PE) unless indicated by Wells Score (or Charlotte Rule) followed by PE Rule-out Criteria (in patients not pregnant). Low risk patients in whom diagnostic testing is indicated should have PE excluded by a negative D dimer, not imaging.
- 4 Don't perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain.
- 5 Don't request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
- 6 Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.
- 7 Don’t initiate whole-breast radiation therapy as a part of breast conservation therapy in women age ≥50 years with early-stage invasive breast cancer without considering shorter treatment schedules.
- 8 Don’t initiate management of low risk prostate cancer without discussing active surveillance.
- 9 Don’t routinely use more than one fraction for palliation of non-complex bone metastases.
- 10 Don't routinely add adjuvant whole-brain radiation therapy to stereotactic radiosurgery for limited brain metastases.
- 11 Do not proceed with any treatment for localised prostate cancer unless the man has been offered a consultation with a urologist and a radiation oncologist, and taken time to consider the advantages and disadvantages of each treatment option.