Choosing Wisely? “It’s Complicated!”

Abstract

Larry, age 62 years, presented with muscle-invasive bladder cancer and a suspicious lesion within his iliac bone. We treated him with induction chemotherapy followed by concurrent chemoradiation therapy to the pelvic disease. Three months after his treatment, Larry’s life was getting back to normal, and his restaging was unremarkable. Two months later, experiencing headaches, nausea, vomiting, vertigo, and falls, he underwent a craniotomy to evacuate a single hemorrhagic posterior fossa brain metastasis and recovered with only some mild residual ataxia. In the past, decisions for what should happen next for patients like Larry were simple: add postoperative whole brain radiation therapy (WBRT) with an expectation of improved intracranial control.1 We would counsel the patient about possible long-term neurologic-neurocognitive impairments; however, such risks seemed remote in Larry’s case.2 If Facebook had existed in those days, then the status of WBRT’s relationship with radiation oncology would have read, “Married.” Since then, however, with data evolving, the relationship between WBRT and radiation oncology has been changing.3,4 Progress is reflected in the American Society for Radiation Oncology’s “Choosing Wisely” statement: “Don’t routinely add adjuvant whole brain radiation therapy to stereotactic radiosurgery for limited brain metastases.”5 The guideline concludes, “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