Limitations

Limitations of the current study include the small sample size and its retrospective nature. Our institution is an NCCN member that establishes institutional guidelines across three national sites and may, therefore, stand as an outlier among national RT providers. There are additional scenarios beyond the scope of this paper, including longer treatment schedules using 1.8 Gy/fraction or lumpectomy cavity boost, or both, which add time, fractions, and expenses. Our institution uses the Radiation Therapy Oncology Group 1005 indications for lumpectomy cavity boost as a guideline, which spares many patients’ additional fractions. Additional studies have evaluated even shorter regimens, delivering five fractions once weekly33 or five fractions in 1 week.34 We understand that practice patterns may vary nationally and have only presented the direct medical costs associated with the four WBRT regimens most applicable to our discussion.


Continue Reading

CONCLUSION

Overall, the data presented show that it is possible for RT practice patterns to rapidly change in response to new level I evidence. We demonstrate evidence-based practice and adherence to national expert recommendations for the population of women aged ≥50 years with hormone receptor-positive, early-stage breast cancer. Millions of potential savings in the health care system could be achieved by practicing evidence-based medicine and following national guidelines for RT in early-stage breast cancer. More importantly, shorter treatment schedules and omission of WBRT in selected patients do not compromise oncologic outcomes and have the immeasurable benefit of avoiding weeks of potentially unnecessary RT to patients.

Acknowledgments

We are deeply grateful to Sally Eggleston, MBA, BSRT(T) of Revenue Cycle, Inc (Austin, Texas, USA) for her assistance with our cost assessment. Portions of this manuscript have been published in abstract form: Int J Radiat Oncol Biol Phys. 2015;93(3 Suppl):E12.

Disclosure

The authors report no conflicts of interest in this work.

References

1. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347(16):1233–1241.

2. Veronesi U, Luini A, Del Vecchio M, et al. Radiotherapy after breast-preserving surgery in women with localized cancer of the breast. N Engl J Med. 1993;328(22):1587–1591.

3. Fowler JF. The linear-quadratic formula and progress in fractionated radiotherapy. Br J Radiol. 1989;62(740):679–694.

4. Olivotto IA, Weir LM, Kim-Sing C, et al. Late cosmetic results of short fractionation for breast conservation.Radiother Oncol. 1996;41(1):7–13.

5. Yarnold J, Ashton A, Bliss J, et al. Fractionation sensitivity and dose response of late adverse effects in the breast after radiotherapy for early breast cancer: long-term results of a randomised trial. Radiother Oncol. 2005;75(1):9–17.

6. Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med. 2010;362(6):513–520.

7. Group ST, Bentzen SM, Agrawal RK, et al. The UK Standardisation of Breast Radiotherapy (START) Trial A of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet Oncol. 2008;9(4):331–341.

8. Group ST, Bentzen SM, Agrawal RK, et al. The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet. 2008;371(9618):1098–1107.

9. Haviland JS, Owen JR, Dewar JA, et al. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol. 2013;14(11):1086–1094.

10. Harnett A. Fewer fractions of adjuvant external beam radiotherapy for early breast cancer are safe and effective and can now be the standard of care: why the UK’s NICE accepts fewer fractions as the standard of care for adjuvant radiotherapy in early breast cancer. Breast. 2010;19(3):159–162.

11. Smith BD, Bentzen SM, Correa CR, et al. Fractionation for whole breast irradiation: an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Int J Radiat Oncol Biol Phys. 2011;81(1):59–68.

12. Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 2013;31(19):2382–2387.

13. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Breast cancer. Available from: https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed December 14, 2017.

14. Suh WW, Pierce LJ, Vicini FA, Hayman JA. A cost comparison analysis of partial versus whole-breast irradiation after breast-conserving surgery for early-stage breast cancer. Int J Radiat Oncol Biol Phys. 2005;62(3):790–796.

15. Donovan E, Bleakley N, Denholm E, et al. Randomised trial of standard 2D radiotherapy (RT) versus intensity modulated radiotherapy (IMRT) in patients prescribed breast radiotherapy. Radiother Oncol. 2007;82(3):254–264.

16. Pignol JP, Olivotto I, Rakovitch E, et al. A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol. 2008;26(13):2085–2092.

17. Pignol JP, Truong P, Rakovitch E, Sattler MG, Whelan TJ, Olivotto IA. Ten years results of the Canadian breast intensity modulated radiation therapy (IMRT) randomized controlled trial. Radiother Oncol. 2016;121(3):414–419.

18. American Society for Radiation Oncology. ASTRO releases list of five radiation oncology treatments to question as part of national Choosing Wisely campaign. 2013. Available from: http://www.choosingwisely.org/astro-releases-list-of-five-radiation-oncology-treatments-to-question-as-part-of-national-choosing-wisely-campaign. Accessed December 14, 2017.

19. Centers for Medicare and Medicaid Services. Physician fee schedule. Available from:https://www.cms.gov/apps/physician-fee-schedule/. Accessed August 29, 2016.

20. Centers for Medicare and Medicaid Services. Hospital outpatient prospective payment system. Available from: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/. Accessed August 29, 2016.

21. Jagsi R, Falchook AD, Hendrix LH, Curry H, Chen RC. Adoption of hypofractionated radiation therapy for breast cancer after publication of randomized trials. Int J Radiat Oncol Biol Phys. 2014;90(5):1001–1009.

22. Wang EH, Mougalian SS, Soulos PR, et al. Adoption of hypofractionated whole-breast irradiation for early-stage breast cancer: a National Cancer Data Base analysis. Int J Radiat Oncol Biol Phys. 2014;90(5):993–1000.

23. Jagsi R, Griffith KA, Heimburger D, et al. Choosing wisely? Patterns and correlates of the use of hypofractionated whole-breast radiation therapy in the state of Michigan. Int J Radiat Oncol Biol Phys. 2014;90(5):1010–1016.

24. Bekelman JE, Sylwestrzak G, Barron J, et al. Uptake and costs of hypofractionated vs conventional whole breast irradiation after breast conserving surgery in the United States, 2008-2013. JAMA. 2014;312(23):2542–2550.

25. Palta M, Palta P, Bhavsar NA, Horton JK, Blitzblau RC. The use of adjuvant radiotherapy in elderly patients with early-stage breast cancer: changes in practice patterns after publication of Cancer and Leukemia Group B 9343.Cancer. 2015;121(2):188–193.

26. Kunkler IH, Williams LJ, Jack WJ, Cameron DA, Dixon JM; PRIME II Investigators. Breast-conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II): a randomised controlled trial. Lancet Oncol. 2015;16(3):266–273.

27. University of Michigan Cancer Center. The IDEA Study (Individualized Decisions for Endocrine Therapy Alone). Available from: https://clinicaltrials.gov/ct2/show/NCT02400190. Accessed December 14, 2017.

28. Dana-Farber Cancer Institute. The PRECISION Trial (Profiling Early Breast Cancer for Radiotherapy Omission): A Phase II Study of Breast-Conserving Surgery Without Adjuvant Radiotherapy for Favorable-Risk Breast Cancer. Available from: https://clinicaltrials.gov/ct2/show/NCT02653755. Accessed December 14, 2017.

29. Breast Cancer Trials, Australia and New Zealand. EXamining PErsonalised Radiation Therapy for Low-risk Early Breast Cancer (EXPERT). Available from: https://clinicaltrials.gov/ct2/show/NCT02889874. Accessed December 14, 2017.

30. Hannan R, Thompson RF, Chen Y, et al. Hypofractionated whole-breast radiation therapy: does breast size matter? Int J Radiat Oncol Biol Phys. 2012;84(4):894–901.

31. Al-Rahbi ZS, Al Mandhari Z, Ravichandran R, et al. Dosimetric comparison of intensity modulated radiotherapy isocentric field plans and field in field (FIF) forward plans in the treatment of breast cancer. J Med Phys. 2013;38(1):22–29.

32. Mitchell JM. Urologists’ use of intensity-modulated radiation therapy for prostate cancer. N Engl J Med. 2013;369(17):1629–1637.

33. Dragun AE, Quillo AR, Riley EC, et al. A phase 2 trial of once-weekly hypofractionated breast irradiation: first report of acute toxicity, feasibility, and patient satisfaction. Int J Radiat Oncol Biol Phys. 2013;85(3):e123–e128.

34. Brunt AM, Wheatley D, Yarnold J, et al; FAST-Forward Trial Management Group. Acute skin toxicity associated with a 1-week schedule of whole breast radiotherapy compared with a standard 3-week regimen delivered in the UK FAST-Forward Trial. Radiother Oncol. 2016;120(1):114–118.

Source: Breast Cancer: Targets and Therapy.
Originally published February 9, 2018.