Latest Cancer TreatmentsDr. Mohammadreza Dabiri
Dr. Mohammadreza Dabiriفارسی
Physician lesson

15 things to stop doing in cancer care

A "Choosing Wisely" list for oncology and haematology, with the evidence for each item

Updated: 28 October 20261 min read17 references

Key points

  • This list is a decision aid, not a rule; every item has exceptions. But each of these practices has shown harm or futility in studies or guidelines.
  • Most harm comes from "keeping old habits": chemotherapy that has been replaced by a targeted drug, or tests that do not change the outcome.

Treatment

  1. 1

    1. First-line chemoimmunotherapy (FCR, BR or chlorambucil) in CLL, especially with disrupted TP53 or unmutated IGHV

    Ibrutinib-rituximab had better progression-free and overall survival than FCR [4], and venetoclax-obinutuzumab (± ibrutinib) was superior to chemoimmunotherapy [5]. With disrupted TP53, chemotherapy is almost ineffective [16]. (More)

  2. 2

    2. Delaying ATRA when you suspect APL

    Start ATRA at the first clinical suspicion (pancytopenia, coagulopathy, promyelocytes on the smear) and before genetic confirmation; most deaths in the first days are from bleeding [6].

  3. 3

    3. Chemotherapy (instead of ATRA and arsenic) in low-risk APL

    ATRA with arsenic trioxide gave better event-free survival and less toxicity than ATRA with chemotherapy [7].

  4. 4

    4. First-line chemotherapy or immunotherapy in EGFR-mutated lung cancer

    First-line osimertinib increased progression-free and overall survival compared with older TKIs [8]; immunotherapy has little benefit in these patients. Know the EGFR and ALK status before treatment [17].

  5. 5

    5. A targeted drug without testing for the target

    Drugs such as cetuximab (without RAS wild type), trastuzumab (without HER2) or lung cancer TKIs (without a mutation) have no benefit and only add toxicity [2, 17].

  6. 6

    6. Chemotherapy in solid tumours with poor performance status (ECOG 3 to 4) without evidence of benefit

    In these patients, prioritise supportive and palliative care, unless the disease is highly treatment-sensitive (for example lymphoma, germ cell tumours, small cell lung cancer) or the weakness is caused by the cancer itself and is reversible [1].

Tests and imaging

  1. 1

    7. PET, CT or bone scan for staging early breast cancer (stage 0 to 2) or low-risk prostate cancer

    The chance of finding metastases is very low, and false findings lead to biopsies and delays [1].

  2. 2

    8. Tumour markers and routine imaging in the follow-up of treated breast cancer without symptoms

    Finding an asymptomatic recurrence earlier has not improved survival; examination and yearly mammography are enough [1].

  3. 3

    9. Starting rituximab or chemotherapy without testing for hepatitis B

    Check HBsAg, anti-HBc and anti-HBs before treatment; hepatitis B reactivation can be fatal and is preventable with antiviral prophylaxis [9].

  4. 4

    10. Starting a fluoropyrimidine without considering DPYD testing

    DPD deficiency causes fatal toxicity; genotype-guided dosing reduces this risk [10]. (Pharmacogenomics lesson)

Supportive care

  1. 1

    11. Primary G-CSF prophylaxis with low-risk regimens (below 20%) without risk factors

    It has no benefit and adds cost and bone pain [1, 11]. (G-CSF tool)

  2. 2

    12. Strong antiemetics (NK1) for low-emetogenic chemotherapy and multi-day dexamethasone without reason

    Prevention should match the emetogenicity of the regimen; too much dexamethasone has side effects [2, 12]. (Antiemetic tool)

  3. 3

    13. Transfusing at a haemoglobin above 7 to 8 in a stable patient without symptoms

    A restrictive threshold (7 g/dL; 8 in heart disease or orthopaedic surgery) is safe in most admitted patients [15]; give one unit at a time and reassess [3].

  4. 4

    14. Treating asymptomatic CLL or smouldering myeloma just because of a laboratory number

    In CLL, treatment starts only with the iwCLL criteria for active disease, not because of the lymphocyte count [16].

  5. 5

    15. Delaying referral to palliative care until the last days

    Early palliative care in advanced lung cancer improved quality of life, reduced depression and even prolonged survival [13]; ASCO recommends it for all patients with advanced disease from the first weeks [14].

For patients and families

If you have been offered a treatment that is on this list, ask why; sometimes there is a good reason. A simple version: Targeted therapy or chemotherapy?

References

17 references
Show all references, 9 with a study cardClose the reference list

Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.

  1. 1
    American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncologySchnipper LE, Smith TJ, Raghavan D, et al · J Clin Oncol · 2012;30:1715-24
    DOIPubMed Back to text: 1 2 3 4
  2. 2
    American Society of Clinical Oncology 2013 top five list in oncologySchnipper LE, Lyman GH, Blayney DW, et al · J Clin Oncol · 2013;31:4362-70
    DOIPubMed Back to text: 1 2
  3. 3
    The ASH Choosing Wisely® campaign: five hematologic tests and treatments to questionHicks LK, Bering H, Carson KR, et al · Blood · 2013;122:3879-83
    DOIPubMed Back to text
  4. 4
    Ibrutinib-Rituximab or Chemoimmunotherapy for Chronic Lymphocytic LeukemiaShanafelt TD, Wang XV, Kay NE, et al · N Engl J Med · 2019;381:432-443
    Study cardDOIPubMed Back to text
  5. 5
    First-Line Venetoclax Combinations in Chronic Lymphocytic LeukemiaEichhorst B, Niemann CU, Kater AP, et al · N Engl J Med · 2023;388:1739-1754
    DOIPubMed Back to text
  6. 6
    Management of acute promyelocytic leukemia: updated recommendations from an expert panel of the European LeukemiaNetSanz MA, Fenaux P, Tallman MS, et al · Blood · 2019;133:1630-1643
    DOIPubMed Back to text
  7. 7
    Retinoic acid and arsenic trioxide for acute promyelocytic leukemiaLo-Coco F, Avvisati G, Vignetti M, et al · N Engl J Med · 2013;369:111-21
    Study cardDOIPubMed Back to text
  8. 8
    Osimertinib in Untreated EGFR-Mutated Advanced Non-Small-Cell Lung CancerSoria JC, Ohe Y, Vansteenkiste J, et al · N Engl J Med · 2018;378:113-125
    Study cardDOIPubMed Back to text
  9. 9
    Hepatitis B Virus Screening and Management for Patients With Cancer Prior to Therapy: ASCO Provisional Clinical Opinion UpdateHwang JP, Feld JJ, Hammond SP, et al · J Clin Oncol · 2020;38:3698-3715
    DOIPubMed Back to text
  10. 10
    Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for Dihydropyrimidine Dehydrogenase Genotype and Fluoropyrimidine Dosing: 2017 UpdateAmstutz U, Henricks LM, Offer SM, et al · Clin Pharmacol Ther · 2018;103:210-216
    Study cardDOIPubMed Back to text
  11. 11
    Recommendations for the Use of WBC Growth Factors: American Society of Clinical Oncology Clinical Practice Guideline UpdateSmith TJ, Bohlke K, Lyman GH, et al · J Clin Oncol · 2015;33:3199-212
    Study cardDOIPubMed Back to text
  12. 12
    Antiemetics: ASCO Guideline UpdateHesketh PJ, Kris MG, Basch E, et al · J Clin Oncol · 2020;38:2782-2797
    Study cardDOIPubMed Back to text
  13. 13
    Early palliative care for patients with metastatic non-small-cell lung cancerTemel JS, Greer JA, Muzikansky A, et al · N Engl J Med · 2010;363:733-42
    Study cardDOIPubMed Back to text
  14. 14
    Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline UpdateFerrell BR, Temel JS, Temin S, et al · J Clin Oncol · 2017;35:96-112
    DOIPubMed Back to text
  15. 15
    Red Blood Cell Transfusion: 2023 AABB International GuidelinesCarson JL, Stanworth SJ, Guyatt G, et al · JAMA · 2023;330:1892-1902
    DOIPubMed Back to text
  16. 16
    iwCLL guidelines for diagnosis, indications for treatment, response assessment, and supportive management of CLLHallek M, Cheson BD, Catovsky D, et al · Blood · 2018;131:2745-2760
    Study cardDOIPubMed Back to text: 1 2
  17. 17
    Recommendations for the use of next-generation sequencing (NGS) for patients with advanced cancer in 2024: a report from the ESMO Precision Medicine Working GroupMosele MF, Westphalen CB, Stenzinger A, et al · Ann Oncol · 2024;35:588-606
    Study cardDOIPubMed Back to text: 1 2

This page is based on reputable scientific sources and was last updated on 28 October 2026. The content of this website is for educational and informational purposes only and does not replace consultation, diagnosis or treatment by a specialist physician. Consult your treating physician about any treatment decision.

Printed from the website; the full and up-to-date version: https://drdabiri.com/en/learn/stop-doing-oncology-choosing-wisely/

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