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Walk the evidence base by book and chapter — the raw source passages that ground Ask, Differential, and the rest.
11 passages
Do not use PET-CT routinely to monitor response in patients receiving palliative chemotherapy. Setting: patient on palliative-intent chemotherapy for advanced cancer, being monitored for response Why: Routine PET-CT to monitor palliative chemotherapy adds substantial cost without improving outcomes or altering the palliative treatment plan. Consider instead: clinical assessment and conventional imaging as indicated Source: National Cancer Grid of India (Choosing Wisely, IN, 2019).
Do not delay or avoid palliative care for a patient with metastatic cancer because they are pursuing disease-directed treatment. Setting: patient with metastatic cancer who is receiving or pursuing disease-directed treatment (chemotherapy or radiotherapy) Why: Randomised trials show early palliative care improves pain and symptom control, family satisfaction, and quality of life, reduces cost, and increases survival in selected populations; it can enhance the benefits of cancer-directed treatment. Consider instead: integrate early palliative care alongside disease-directed treatment Source: National Cancer Grid of India (Choosing Wisely, IN, 2019).
Avoid chemotherapy and instead focus on symptom relief and palliative care for patients with advanced cancer unlikely to benefit from chemotherapy. Setting: advanced solid-organ cancer with one or more of: performance status 3 or 4, no benefit from previous evidence-based interventions, not suitable for a clinical trial, and no evidence supporting further anticancer treatment Why: Cancer-directed therapies are unlikely to be effective for markedly debilitated patients (performance status 3-4); appropriate symptom control and palliative care substantially improve quality of life. Consider instead: symptom relief and palliative care Source: National Cancer Grid of India (Choosing Wisely, IN, 2019).
Do not order tests to detect recurrent cancer in asymptomatic patients if there is not a realistic expectation that early detection of recurrence can improve survival or quality of life. Setting: asymptomatic patient on follow-up where early detection of recurrence is not expected to improve survival or quality of life (most solid tumours) Why: For most solid tumours there is no evidence that earlier detection of recurrence improves outcomes; the value of biomarkers, PET/CT and CT scans, endoscopy, and radionuclide scans must be balanced against the harm and anxiety of extensive follow-up testing. Consider instead: symptom-directed follow-up; reserve surveillance testing for cancers where early recurrence detection changes outcomes Source: National Cancer Grid of India (Choosing Wisely, IN, 2019).
Do not order PET/CT scans to monitor response to palliative chemotherapy. Setting: patient on palliative-intent chemotherapy for advanced cancer, being monitored for treatment response Why: Existing evidence does not support PET/CT to monitor response to palliative chemotherapy; no reliable evidence shows it improves survival or quality of life, so it should not be used outside a clinical trial. Consider instead: clinical assessment and conventional imaging as indicated; use PET/CT only within a clinical trial Source: National Cancer Grid of India (Choosing Wisely, IN, 2019).
Do not decide treatment for potentially curable cancers without inputs from a multidisciplinary oncology team. Setting: potentially curable cancer requiring multimodality therapy (e.g. oral cavity, cervix, lung) Why: Multidisciplinary team care improves staging accuracy, processes of care, and guideline concordance; the stakes are especially high for potentially curable disease. Consider instead: present the case to a multidisciplinary tumour board or clinic before deciding treatment Source: National Cancer Grid of India (Choosing Wisely, IN, 2019).
Do not treat patients with advanced metastatic cancer in the intensive care unit unless there is an acutely reversible event. Setting: advanced metastatic cancer with life expectancy under 1 year and no acutely reversible cause for deterioration Why: Prognosis is poor and ICU care is likely futile unless the cause of admission is reversible; international groups recommend against ICU admission for advanced metastatic cancer with life expectancy under 1 year. Consider instead: goals-of-care discussion and palliative management outside the ICU Source: National Cancer Grid of India (Choosing Wisely, IN, 2019).
Do not use advanced radiation techniques where conventional radiation can be just as effective. Setting: radiotherapy where conventional technique is equally effective and no level-1 evidence supports the advanced technique's superiority for that site Why: Conventional radiotherapy costs a fraction of advanced therapy (especially out-of-pocket); no level-1 evidence shows advanced techniques improve overall survival in general, though they help selected sites. Consider instead: conventional radiotherapy; reserve advanced techniques for scenarios with clear evidence of superiority Source: National Cancer Grid of India (Choosing Wisely, IN, 2019).
Do not deliver care in a high-cost setting when it could be delivered just as effectively in a lower-cost setting. Setting: routine or low-risk cancer care and follow-up that could be delivered closer to home at a lower-cost local or regional facility Why: Surveillance and routine care after definitive treatment can be delivered equally well locally and is more patient-centred; patients often travel vast distances for care that could be delivered closer to home. Consider instead: a hub-and-spoke model: routine/low-risk care closer to home, complex cases referred to tertiary centres Source: National Cancer Grid of India (Choosing Wisely, IN, 2019).
Do not initiate whole breast radiotherapy in 25 fractions as part of breast conservation therapy in women aged 50 years and older with early-stage invasive breast cancer without considering shorter treatment schedules. Setting: woman aged 50 years or older with early-stage invasive breast cancer undergoing whole-breast radiotherapy after breast conservation surgery Why: Evidence shows equivalent tumour control and cosmetic outcome with shorter (~3-4 week) hypofractionated schedules in specific populations; patients and physicians should consider these before a 25-fraction course. Consider instead: consider hypofractionated schedules (approximately 3-4 weeks), which show equivalent tumour control and cosmesis Source: National Cancer Grid of India (Choosing Wisely, IN, 2019).
Do not use white-cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20% risk for this complication. Setting: chemotherapy regimen with less than approximately 20% risk of febrile neutropenia, with effective alternative regimens available and no patient-specific high-risk features (age, medical history, disease characteristics) Why: International guidelines recommend white-cell stimulating factors when febrile-neutropenia risk is approximately 20% and no effective alternative regimen exists; below that threshold, routine primary prophylaxis is low-value unless patient-specific high-risk features are present. Consider instead: reserve G-CSF primary prophylaxis for regimens with ~20% or greater febrile-neutropenia risk, or for high-risk patients Source: National Cancer Grid of India (Choosing Wisely, IN, 2019).