Many breast cancer patients do not receive shorter radiation treatment

Although the use of a radiation treatment that is shorter in duration and less costly has increased among women with early stage breast cancer who underwent breast conserving surgery, most patients who meet guidelines to receive this treatment do not, according to a study that appeared in JAMA (2014; doi:10.1001/jama.2014.16616). The study was released to coincide with the San Antonio Breast Cancer Symposium.

Breast cancer accounts for the largest portion of national expenditures on cancer care, estimated to reach $158 billion in 2020. Breast conservation therapy is the most common treatment for early stage breast cancer.

Whole breast irradiation (WBI), recommended for most women after breast conserving surgery, reduces local recurrence and improves overall survival. Conventional WBI, comprising 5 to 7 weeks of daily radiation fractions (ie, treatments), has been the mainstay of treatment in the United States.

Hypofractionated WBI is a shorter duration treatment alternative to conventional WBI, comprising fewer but higher-dose fractions generally delivered over 3 weeks. Based on high quality evidence from clinical trials, expert guidelines in 2011 endorsed hypofractionated WBI for selected patients with early stage breast cancer and permitted hypofractionated WBI for other patients, according to background information in the article.

"Hypofractionated WBI increases convenience, reduces treatment burden, and lowers health care costs while offering similar cancer control and cosmesis to conventional WBI. Furthermore, patients prefer shorter radiation treatment regimens," the authors wrote.

Justin E. Bekelman, MD, of the University of Pennsylvania Perelman School of Medicine, Philadelphia, and colleagues examined the usage and costs of hypofractionated WBI between 2008 and 2013, which was before and after the publication of key clinical trials and updated practice guidelines.

The researchers used administrative claims data from 14 commercial health care plans covering 7.4% of US adult women in 2013, and classified patients with incident early stage breast cancer treated with lumpectomy and WBI from 2008 and 2013 into two groups: the hypofractionation- endorsed cohort (n = 8,924) and the hypofractionation-permitted cohort (n = 6,719). For this analysis, hypofractionated WBI was 3 to 5 weeks of treatment; conventional WBI was 5 to 7 weeks.

The researchers found that hypofractionated WBI increased from 10.6% in 2008 to 34.5% in 2013 in the hypofractionation-endorsed group and from 8.1% in 2008 to 21.2% in 2013 in the hypofractionation-permitted group.

Adjusted average total health care expenditures in the 1 year after diagnosis were $28,747 for hypofractionated and $31,641 for conventional WBI in the hypofractionation-endorsed group (difference, $2,894) and $64,273 for hypofractionated and $72,860 for conventional WBI in the hypofractionation-permitted group (difference, $8,587).

Adjusted average total 1-year patient out-of-pocket expenses were not significantly different between hypofractionated vs conventional WBI in either group.

"In the United States, the absence of a clear recommendation may have contributed to slower uptake of hypofractionation in the United States than in other countries. In 2013, we observed more pronounced uptake of hypofractionation; evaluation of future treatment patterns will be important to document whether or not this trend reflects the beginning of more widespread adoption," the authors wrote.

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