The Royal Australian and New Zealand College of Radiologists
Recommendations from the Royal Australian and New Zealand College of Radiologists on imaging for ankle trauma, deep venous thrombosis (DVT), pulmonary embolism, low back pain, whole breast radiation therapy, prostate cancer, bone metastases, brain radiation therapy & locoregional therapy. 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.
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
- 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.
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 7-12 (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 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.
- 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 ≥50y 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 extended fractionation schemes (>10 fractions) for palliation of bone metastases.
- 10 Don't routinely add adjuvant whole-brain radiation therapy to stereotactic radiosurgery for limited brain metastases.
- 11 Don’t routinely use extensive locoregional therapy in most cancer situations where there is metastatic disease and minimal symptoms attributable to the primary tumour.