March 10, 2016
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Choosing Wisely endorsements give ASH opportunity to ‘make a difference’ beyond hematology

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More than 70 medical specialty societies participate in the American Board of Internal Medicine Foundation’s Choosing Wisely campaign, designed to reduce unnecessary expenses without sacrificing quality care.

The past 2 years, ASH representatives identified common procedures or tests unique to their field that they believed should be questioned, given that the costs and potential harms might outweigh the benefits.

This year, ASH took a different approach, endorsing five recommendations proposed by other specialties.

“The reality of medical care is that we do not exist in silos,” Lisa Hicks, MD, MSc, FRCPC, assistant professor of medicine at University of Toronto, hematologist at St. Michael’s Hospital and chair of the ASH Choosing Wisely Task Force, told HemOnc Today. “There is overlapping expertise and shared care models throughout medicine. We really felt that the way for us to crack the nut of overutilization was through collaboration. We wanted to leverage the work that had been done by others and share it with our community.”

ASH reviewed and endorsed Choosing Wisely recommendations made by other societies to capitalize on overlapping expertise, according to Lisa Hicks, MD, MSc, FRCPC.
ASH reviewed and endorsed Choosing Wisely recommendations made by other societies to capitalize on overlapping expertise, according to Lisa Hicks, MD, MSc, FRCPC. “We really felt that the way for us to crack the nut of overutilization was through collaboration,” she said. “We wanted to leverage the work that had been done by others and share it with our community.”

Photo by St. Michael’s Hospital

The ASH-endorsed recommendations, released in December at the ASH Annual Meeting and Exposition, are:

  • Do not image for suspected pulmonary embolism without moderate or high pretest probability of PE;
  • Do not routinely order thrombophilia testing for patients undergoing a routine infertility evaluation;
  • Do not perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability;
  • Do not transfuse red blood cells for iron deficiency without hemodynamic instability; and
  • Avoid using PET or PET/CT scanning as part of routine follow-up care to monitor for cancer recurrence in asymptomatic patients who finished initial treatment unless there is high-level evidence that such imaging will change the outcome.
  • “We chose these items because of their impact to our patients and to the hematology field,” Hicks said during a presentation. “Many of us are more distally involved when some of these decisions are made. However, people do look to hematologists as experts in these areas, so this is an opportunity for us to make a difference and show leadership in changing the practices we all know are not in our patients’ best interests.”

    HemOnc Today spoke with experts in the field of value-based health care about the need to reduce the incidence of redundant, costly and potentially harmful medical practices; the process through which these recommendations are made; and the overall impact of the Choosing Wisely campaign.

    Imaging for PE

    Approximately $750 billion is wasted every year in the U.S. health care system, according to a 2012 estimate from the Institute of Medicine. Of that figure, $210 billion is spent on unnecessary care.

    The Choosing Wisely campaign, launched in 2012, is designed to spark physician–patient dialogue about the costs, benefits and potential harms of specific practices. ASH, ASCO, the American Society for Radiation Oncology and the Society of Gynecologic Oncology are among the participants.

    When ASH decided to endorse existing recommendations rather than propose new ones, members of its task force reviewed all 380 Choosing Wisely recommendations from other societies. They started with a list of 50 relevant recommendations, ultimately narrowing it to the five announced in December.

    The task force conducted its review “from the lens of importance and specifically considered the potential for avoiding harm to patients, the evidence base, aggregate cost, frequency, relevance and impact,” Hicks said.

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    The first recommendation — avoid imaging suspected PE in low-risk patients — originally was released by the American College of Radiology. This practice is costly, time consuming and ineffective, according to Michael A. Bettmann, MD, FACR, professor emeritus of radiology at Wake Forest University and chair of the American College of Radiology Committee on Appropriateness Criteria.

    Although deep vein thrombosis and PE are common, they rarely affect patients without easily observable risk factors, such as high blood D-dimer levels. Thus, clinicians should be able to identify patients at a greater risk for complications and limit imaging to this population.

    Data from Venkatesh and colleagues — published in Archives of Internal Medicine — showed 32% of imaging conducted for suspected PE in hospital EDs could have been avoided based on low pretest probability for PE. These patients either did not undergo a D-dimer test or received a negative D-dimer result. The occurrence of avoidable imaging due to not ordering a D-dimer test was associated with age (OR = 1.15 per decade; 95% CI, 1.1-1.21), whereas avoidable imaging due to negative D-dimer results appeared associated with inactive malignancy (OR = 1.66; 95% CI, 1.11-2.49).

    Avoidable imaging leads to unnecessary costs and potential health risks associated with ionizing radiation and IV contrast.

    “For any test that is ordered, doctors have to do an assessment of the risk-to-benefit ratio,” Bettmann said during the ASH presentation. “Some tests can cause more harm than good.”

    The American College of Radiology based its recommendation largely on data from the ADJUST-PE study by Righini and colleagues. Results, published in 2014 in JAMA, showed that — compared with a fixed D-dimer cutoff of 500 g/L — a combined pretest clinical probability assessment and age-adjusted D-dimer cutoff better identified patients for whom PE could be considered highly unlikely.

    Thus, patients considered at moderate to high risk for PE should be defined and recommended for imaging if necessary, whereas patients at low risk should be spared, Bettmann said.

    “It is not that low-risk patients will never have PE or DVT,” Bettmann said. “However, the risk for radiation and unexpected findings, coupled with the cost, exceeds the potential benefits.”

    Thrombophilia testing

    ASH endorsed the American Society for Reproductive Medicine’s recommendation against routine thrombophilia testing for patients undergoing an infertility evaluation.

    Because thrombophilia can cause implantation failure, miscarriages, preeclampsia and other complications, testing is commonly recommended for women who experience unexplained infertility, according to Shannon M. Bates, MD, MSc, associate professor in the division of hematology and thromboembolism at McMaster University in Hamilton, Ontario.

    However, there is no indication for testing women who do not have a history of bleeding or abnormal clotting.

    Downsides include false results due to inappropriate timing, misinterpretation of results, emotional distress and the possibility of genetic discrimination, Stevens and colleagues wrote in a guideline published this year in Journal of Thrombosis and Thrombolysis.

    Casadei and colleagues conducted a study to evaluate whether the prevalence of genetic mutations linked to increased thrombophilia risk differed between infertile and fertile women. Results, published in Fertility and Sterility, showed no significant differences between 100 women who experienced unexplained infertility and 200 fertile women with no history of infertility.

    “In order for thrombophilia testing to be included in a diagnostic workup, you would need at least minimum evidence of a clear and consistent association between thrombophilia and infertility or failure of assisted reproduction,” Bates said during a presentation. “The recommended treatment of prophylactic low–molecular-weight heparin [LMWH] can have serious drawbacks.”

    Rodger and colleagues evaluated whether antepartum LMWH with dalteparin (Fragmin, Pfizer) reduced complications in pregnant women with thrombophilia. The results, published in 2014 in The Lancet, showed the occurrence of severe or early-onset preeclampsia, small-for-gestational-age infant (birthweight < 10th percentile), pregnancy loss or venous thromboembolism appeared comparable among women who did and did not receive dalteparin (17.1% vs. 18.9%). Minor bleeding appeared more common among women who received dalteparin (19.6% vs. 9.2%).

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    Further, case–control studies indicate recommendations for in vitro fertilization have been comparable between women with and without thrombophilia, including women with unexplained infertility, Bates said.

    Another study of women who underwent thrombophilia testing after at least one cycle of assisted reproduction showed the incidence of live birth increased from 2% to 18% after thrombophilia testing, but the increase was not restricted to women with thrombophilia or women assigned prophylactic LMWH.

    “[Studies show] thrombophilia status is not important to determine which patients will benefit from intervention,” Bates said. “Good supportive care on its own can improve outcomes. These are not entirely benign procedures, and they have important drawbacks.”

    Complete blood counts

    The Society for Hospital Medicine–Adult Hospital Medicine recommended against repetitive complete blood count and chemistry testing in patients with clinical and lab stability.

    The performance of complete blood count and chemistry testing is based more in dogma and tradition than on verifiable outcomes or patient benefit, according to Christopher Moriates, MD, assistant clinical professor in the division of hospital medicine at University of California, San Francisco.

    Christopher Moriates, MD
    Christopher Moriates

    “Thirty percent to 50% of tests performed on hospitalized patients are unnecessary,” Moriates told HemOnc Today. “This is a habit. Morning labs are a ritual in residency training. Like stirring milk into coffee, it is a ritual [clinicians] do habitually but only half consciously.”

    These tests remain common, even when their benefit is not necessarily clear.

    “Traditionally, patients get a complete blood count and chemistry every morning that they are in the hospital, and I would say that is still the rule,” Moriates said. “The norm is that every single day, people get at least one draw. However, the literature has shown that it would be safe to eliminate some of this testing because it is overused.”

    Onuoha and colleagues evaluated the use of unindicated preoperative testing in an academic ambulatory center. Results — published in 2015 in Perioperative Medicine — showed 52.9% of patients who underwent ambulatory surgery received at least one unindicated laboratory test. Seventy-three percent of complete blood counts appeared unindicated, and they affected 51% of the study population.

    “The sicker patients are, the more blood we are likely to take,” Moriates said. “This past year, a study of patients undergoing cardiac surgery — arguably, a group of patients who really need their blood — found that they often had up to 500 mLs drawn.”

    Excessive phlebotomy can cause hospital-induced anemia, which can be detrimental to critically ill patients. A study by Thavendiranathan and colleagues showed phlebotomy contributed to significant decreases in hemoglobin (mean change, 7.9 g/L) and hematocrit (mean change, 2.1%; P < .0001 for both) during hospitalization.

    “If you think about the downstream effects, you realize that critically ill patients do not have the reserves to compensate [for the loss of blood],” Moriates said. “Transfusions can become necessary, but transfusions can lead to poorer outcomes.”

    Phlebotomy should occur only when the test being performed is a diagnostic necessity, Moriates said.

    Further, doctors at teaching hospitals believe laboratory testing is a cornerstone of education for young physicians; thus, more tests often are ordered than are necessary.

    However, a decrease in the five most frequently ordered phlebotomy tests did not lead to poorer patient outcomes, according to a study conducted by May and colleagues at San Francisco General Hospital.

    Rather, according to the researchers, it allowed senior clinicians to redirect the efforts of phlebotomists to the hospital’s “understaffed outpatient phlebotomy service.”

    “San Francisco General Hospital reduced lab testing by up to 72,000 tests in a 1-year period,” Moriates said. “That decreased phlebotomy rates by up to 21%. Guess what: Nothing bad happened.”

    This Choosing Wisely recommendation may reflect the reality that many long-held hematologic practices are no longer widely useful, Hicks said.

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    “There has been a real evolution in the tone of our Choosing Wisely sessions,” Hicks said. “The first time we talked about Choosing Wisely at ASH, the tone was that of surprise and perhaps some pushback. Some of the community seemed very ready to embrace it, but it was still a challenge to talk about the idea of significant overutilization and unnecessary care to parts of the community.

    “By the second year, that wasn’t the tone at all — the tone was one of interest and of education,” Hicks added. “This year, my impression of the tone was more of a, ‘How do we do this?’ It was all about how things can change.”

    Iron deficiency

    Iron deficiency has remained a common and largely nonfatal issue.

    “Somewhere between 4% and 18% of the nonhospitalized, nonsick population is iron deficient,” Jeannie Callum, MD, FRCPC, associate scientist at Sunnybrook Research Institute and director of transfusion medicine and tissue banks at Sunnybrook Health Sciences Centre in Toronto, said during a presentation. “Common habits — such as vegetarian diets or those low in red meat, as well as exercise and the demand for blood donation — can lead to iron deficiency.”

    However, the frequency of iron deficiency has led to a surge of treatment with blood transfusions.

    “In the clinic, we must look for iron deficiency because it is so common,” Callum said. “However, iron deficiency is something that can be easily managed.”

    Despite the development of safer and more cost-effective strategies — such as oral or IV iron — blood transfusion has remained the standard treatment option for patients with iron deficiency, Callum said. Thus, ASH endorsed the American Association of Blood Banks’ Choosing Wisely recommendation against transfusing red blood cells for iron deficiency in patients without hemodynamic instability.

    “Transfusion is prescribed in about half of the patients seen with iron deficiency,” Callum said. “More iron is clearly effective for the half of patients who can tolerate this form of therapy. Recent studies show that oral iron can be clearly effective and as effective as transfused iron after 6 weeks.”

    In a systematic review published in Transfusion Medicine Reviews, Lin and colleagues observed that erythropoietin, as well as IV iron, appeared safe and effective for treating iron deficiency in patients who may have otherwise been recommended for blood transfusion. A short regimen of erythropoietin, or a single dose of erythropoietin plus IV iron, significantly reduced transfusion rates in patients with preoperative iron deficiency.

    Oral iron is very affordable and can be administered more easily than transfusion, Callum said.

    “It is pennies per pill,” she said. “Once-daily dosing in older patients in randomized controlled trials has been shown as effective as transfusion. In pregnancy, a single low oral dose has appeared sufficient.”

    Ethical issues surrounding blood transfusion also exist.

    “One in five blood donors are iron deficient,” Callum said. “So, you take iron from one person who is already deficient and move it to another person who is slightly more iron deficient. It is better to just leave the iron in the donor.”

    Open communication could result in fewer transfusions and higher incidence of oral iron use among noncritical patients.

    “The problem is that family physicians are sending patients to the ED with hemoglobin under 100 and a prescription for a blood transfusion,” Callum said. “Usually, the patient’s only symptoms are that they are tired and pale, and they have a low test result. Something to do is perhaps to send an email to the ED saying, ‘If you have a young woman with a hemoglobin level of 55 and a prescription for a blood transfusion, are we actually going to transfuse them?’ I guarantee that the answer is that the patient will be transfused when she could have been treated with oral iron instead.”

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    PET/CT scans

    PET and PET/CT scans frequently are used to diagnose, stage and monitor disease. However, evidence has shown that repeat scans do not improve outcomes in recurrent disease.

    Thus, in its 2013 Choosing Wisely effort, ASCO recommended against the use of these scans as routine follow-up to monitor for recurrence in asymptomatic patients.

    “Concerns [in this setting] include false-positive results, radiation exposure, misdiagnosis and overtreatment,” Gary H. Lyman, MD, MPH, professor of medicine at University of Washington and co-director of Hutchinson Institute for Cancer Outcomes Research at Fred Hutchinson Cancer Research Center in Seattle, said during a presentation. “A high level of evidence suggests that routine surveillance with these high-level techniques does not promote well-being.”

    Other medical societies have issued similar guidelines. ASH previously recommended against performing surveillance CT on asymptomatic patients with aggressive lymphoma following treatment with a curative intent, as well as baseline or routine CT in patients with asymptomatic early-stage chronic lymphocytic leukemia.

    ASCO based its recommendation in part on a CMS decision memo regarding PET scanning for solid tumors, which indicated that up to three PET scans should be covered for patients at risk for relapse following initial antitumor treatment. However, additional PET scans have to be deemed clinically relevant rather than investigatory.

    Further, ASCO cited clinical practice guidelines issued by the European Society for Medical Oncology for the diagnosis, adjuvant treatment and follow-up of primary colon cancer. The researchers recommended annual or biannual CT scanning for patients considered at high risk for relapse, but not those at lower risk.

    “The procedure is costly and has not demonstrated an association with survival,” Lyman said. “Physicians are encouraged to anticipate the benefit of posttreatment CT against the potential harm for exposure. Due to the decreased risk for recurrence over time, scanning more than 2 years following treatment with a curative intent is rarely advisable.”

    The first step

    Choosing Wisely recommendations do not necessarily lead to immediate practice changes, Hicks said. Rather, they are used to start discussions about appropriate use and value-based care in practice.

    “There are some isolated examples where you can suggest that [Choosing Wisely] has led to actual on-the-ground changes,” Hicks said. “But honestly, I would not expect an education campaign to do that yet — this is just the first step. You need dedicated change and implementation strategies to see how to change a practice, and that is the next chapter.”

    Moriates agreed.

    “The goal of the Choosing Wisely campaign was to spark a conversation, and that is very clearly what has happened,” Moriates said. “Choosing Wisely has been remarkably successful and effective, especially in having recruited more than 70 specialty societies to make these lists.

    “They also have moved on from including only physicians by reaching out to nursing associations and physician assistants,” Moriates said. “By the standards of having created a movement, opening up conversations and raising the issue of overuse and unnecessary use, Choosing Wisely has absolutely been successful.”

    Strategies exist for practicing clinicians to implement the recommendations they consider most useful.

    “The simplest thing to do is to change your own practice,” Hicks said. “Beyond that, I would encourage people to start thinking about specific implementation projects that they can undertake. Some hematologists are very well positioned to do this due to leadership positions in hospitals, in labs, or in situations where they can influence policy and introduce strategies for change. We have to remember that implementation is rarely easy.” – by Cameron Kelsall

    References:

    The ASH Choosing Wisely Campaign: Top 5 non-ASH Choosing Wisely recommendations of relevance to hematology. Presented at: ASH Annual Meeting and Exposition; Dec. 5-8, 2015; Orlando, Fla.

    Baglin T, et al. Br J Haematol. 2010;doi:10.1111/j.1365-2141.2009.08022.x.

    Labianca R, et al. Ann Oncol. 2010;doi:10.1093/annonc/mdq168.

    Lin DM, et al. Transfus Med Rev. 2013;doi:10.1016/j.tmrv.2013.09.001.

    PAGE BREAK

    May TA, et al. A J Clin Pathol. 2006;doi:10.1309.WP59YM73L6CEGX2F.

    Onuoha OC, et al. Periop Med (London). 2015;doi:10.1186/s13741-015-0023-y.

    Phurrough S, et al. CMS. Decision memo for positron emission tomography (FDG) for solid tumors (CAG–00181R4). Available at: www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=263. Accessed Feb. 9, 2016.

    Righini M, et al. JAMA. 2014;doi:10.1001/jama.2014.2135.

    Rodger MA, et al. Lancet. 2014;doi:10.1016/S0140-6736(14)60793-5.

    Stevens SM, et al. J Thromb Thrombolysis. 2016;doi:10.1007/s11239-015-1316-1.

    Thavendiranathan P, et al. J Gen Intern Med. 2005;doi:10.1111/j.1525-1497.2005.0094.x.

    Torbicki A, et al. Eur Heart J. 2008;doi:10.1093/eurheartj/ehn310.

    For more information:

    Shannon M. Bates, MD, MSc, can be reached at batessm@mcmaster.ca.

    Michael A. Bettmann, MD, FACR, can be reached at mabettmann@gmail.com.

    Jeannie Callum, MD, FRCPC, can be reached at jeannie.callum@sunnybrook.ca.

    Lisa Hicks, MD, MSc, FRCPC, can be reached at hicksl@smh.ca.

    Gary H. Lyman, MD, MPH, can be reached at glyman@fredhutch.org.

    Christopher Moriates, MD, can be reached at christopher.moriates@ucsf.edu.

    Disclosure: Bates, Bettman, Callum, Hicks, Lyman and Moriates report no relevant financial disclosures.

     

    POINTCOUNTER 

    Should select patients undergo PET/CT surveillance during remission for localized disease?

    POINT

    Some patients may benefit from additional screening during remission.

    Although routine surveillance scans for lymphoma are discouraged due to lack of evidence to support a survival benefit for patients, there are certain caveats to consider.

    Nadia Khan, MD
    Nadia Khan

    Clinical judgment — including laboratory assessment and physical exam — remain the mainstay of disease evaluation after induction chemotherapy. In patients with aggressive lymphomas who may be eligible for curative therapies and who are deemed at very high risk for relapse, a considered approach for individual cases may be warranted.

    For example, for patients with multiply relapsed disease, undergoing successive therapeutic interventions with curative intent, surveillance scans are often employed. Successive, intensive therapeutic interventions may leave patients physically debilitated and bone marrow suppressed, blurring aspects of clinical signs of relapse.

    Another example of patients who may warrant heightened vigilance are those patients with genetic hallmarks of the most chemotherapy-refractory diffuse large B-cell lymphoma (DLBCL): the double- and triple-hit subtypes. Absent prospective data regarding these most aggressive subtypes of DLBCL, the double- and triple-hit subtypes, repeating PET/CT scans within the first 2 years after induction is not inappropriate in select cases.

    Until conclusive data suggest otherwise, most clinicians would surveil with PET/CT at intervals in young patients eligible for curative therapy who are deemed to be at very high risk for relapse.

     

    Nadia Khan, MD, is assistant professor of hematology and oncology at Fox Chase Cancer Center. She can be reached at nadia_khan@fccc.edu. Disclosure: Khan reports no relevant financial disclosures.

    COUNTER

    Surveillance after remission does not benefit patients.

    18Ffluorodeoxyglucose PET (FDG-PET) has become the standard of care for pretreatment staging evaluation in many locally advanced aerodigestive malignancies, including lung, head and neck, esophageal and gastric cancers. The role of FDG-PET in routine surveillance of locally advanced diseases treated definitively with radiation and chemotherapy, however, remains controversial.

    Kristin A. Higgins, MD
    Kristin A. Higgins
    Walter J. Curran Jr., MD
    Walter J. Curran Jr.

    Specific to non–small cell lung cancer, FDG-PET has proven useful in detecting regional or distant metastatic disease and in defining gross tumor volumes in radiation planning. The value of surveillance FDG-PET after treatment remains unclear. Use of FDG-PET in the first 8 weeks to 14 weeks after treatment has been shown to have prognostic value in NSCLC. ACRIN 668/RTOG 0235 — a prospective study evaluating posttreatment FDG-PET approximately 14 weeks after platinum-based chemoradiotherapy for stage III NSCLC — demonstrated that a higher posttreatment primary tumor standardized uptake valuepeak (SUVpeak) or SUVmax is associated with worse survival, without a clear cutoff value. Retrospective studies have shown that surveillance with FDG-PET can detect disease progression earlier than standard surveillance with chest CT; however, earlier detection of recurrence has not been shown to improve survival outcomes.

    A prospective study from the Netherlands evaluated the utility of FDG-PET obtained 3 months after initiation of radiation with or without chemotherapy for stage I to stage III NSCLC. Twenty-four percent of patients had progressive disease after 3-month FDG-PET; however, only 3% were eligible for curative therapy.

    PAGE BREAK

    The data suggest that FDG-PET may be able to delineate “responders” from “nonresponders” and identify local and distant recurrence earlier than standard chest CT. Unfortunately, these findings have not translated into improved survival for patients. Rates of recurrence are high in the locally advanced NSCLC population, including a 30% risk for locoregional recurrence and a 40% risk for distant recurrence at 5 years. The lack of benefit in early detection of recurrent disease is likely due to a paucity of effective salvage treatments for recurrent NSCLC. Reirradiation for locally recurrent NSCLC yields a median survival of 3 months to 14 months, and few patients are considered for reirradiation due to concerns of normal tissue toxicity. However, with increasing use of stereotactic radiation for oligometastatic disease and locally recurrent disease, salvage rates could begin to improve over time. Additionally, with the success of immunotherapy in the second-line stage IV NSCLC setting, more successful systemic treatment for distant recurrence of locally advanced NSCLC may also be on the horizon.

    Currently, surveillance FDG-PET does not hold significant value over CT in locally advanced disease. Current National Comprehensive Cancer Network guidelines do not support the use of FDG-PET in routine surveillance, and recommendations are for chest CT contrast every 6 months to 12 months for 2 years, followed by annual chest CT. Further studies need to rigorously assess the cost-effectiveness of surveillance FDG-PET and yield a positive effect on clinical outcomes before FDG-PET replaces other clinically accepted modalities in routine surveillance care of patients with cancer.

     

    References:

    Auperin A, et al. J Clin Oncol. 2010;doi:10.1200/JCO.2009.26.2543.

    Bradley J, et al. Int J Radiat Oncol Biol Phys. 2010;doi:10.1016/j.ijrobp.2010.09.033.

    Curran WJ, et al. J Natl Cancer Inst. 2011;doi:10.1093/jnci/djr325.

    Jeremic B and Videtic GM. Int J Radiat Oncol Biol Phys. 2011;doi:10.1016/j.ijrobp.2011.01.069.

    Machtay M, et al. J Clin Oncol. 2013;doi:10.1200/JCO.2012.47.5947.

    MacManus MP, et al. Int J Radiat Oncol Biol Phys. 2001;doi:10.1016/j.ijrobp.2008.01.019.

    Pan Y, et al. Medicine (Baltimore). 2015;doi:10.1097/MD.0000000000001863.

    Van Loon J, et al. Eur J Cancer. 2009:10.1016/j.ejca.2008.10.017.

    Kristin A. Higgins, MD, is assistant professor and medical director of radiation oncology at Emory University and The Emory Clinic. She can be reached at khiggins@emory.edu. Disclosure: Higgins reports no relevant financial disclosures.

    Walter J. Curran Jr., MD, is executive director of Emory University’s Winship Cancer Institute and Lawrence W. Davis professor and chair of the department of radiation oncology at Emory University. He also serves as HemOnc Today’s associate editor for radiation oncology. He can be reached at wcurran@emory.edu. Disclosure: Curran reports no relevant financial disclosures.