University of Michigan. US: Findings reveal slow adoption of patient-preferred and less costly hypofractionated radiation therapy. Two-thirds of women treated for early-stage breast cancer in the U.S. receive longer radiation therapy than necessary,
according to a new study published in JAMA this week from Penn Medicine researchers Ezekiel J. Emanuel, MD, PhD, and Justin E. Bekelman, MD.
Their findings reveal that the vast majority of women after breast
conserving surgery receive six to seven weeks of radiation therapy,
despite multiple randomized trials and professional society guidelines
showing that three weeks of radiation – called hypofractionated whole
breast radiation – is just as clinically effective, more convenient,
and less costly.
“Hypofractionated radiation is infrequently used for women with
early-stage breast cancer, even though it’s high-quality,
patient-centric cancer care at lower cost,” said lead author Bekelman,
an assistant professor of Radiation Oncology, Medical Ethics and Health
Policy at the University of Pennsylvania’s Perelman School of Medicine and Abramson Cancer Center.
“It is clinically equivalent to longer duration radiation in curing
breast cancer, has similar side effects, is more convenient for
patients, and allows patients to return to work or home sooner.”
Shown to reduce local recurrence and improve overall survival after
breast conserving surgery, conventional whole breast radiation, given
daily over five to seven weeks, has been the mainstay of treatment in
the U.S. for women for decades. The use of hypofractionated whole
breast radiation, which involves higher doses of radiation given over
just three to four weeks, is supported by four randomized trials and
2011 practice guidelines from the American Society for Radiation
Oncology (ASTRO).
The researchers found that in 2013, 34.5 percent of women over 50
years old received hypofractionated therapy, up from 10.6 percent in
2008. Among younger women and those with more advanced cancers, 21.1
percent of women received hypofractionated therapy in 2013, up from 8.1
percent in 2008.
The researchers also found that using hypofractionated radiation therapy lowered total health care costs paid
by insurers in the first year after diagnosis of breast cancer by 10
percent. While patients’ out-of-pocket costs were not significantly
different between the two therapies, likely because patients had
reached their deductible and co-payment maximums, patients who receive
hypofractionated therapy are able to reduce time away from work and home
because of less time spent in daily radiation treatment, resulting in
direct economic and quality-of-life benefits, the authors say.
“Hypofractionated radiation is high-value care and high-quality
breast cancer treatment that saves the health care system money. It’s a
win-win. And yet, only a third or fewer women are getting it in the
U.S., while in other countries over 70 percent of women receive
hypofractionated treatment,” said senior author Emanuel, chairman of
Penn’s Department of Medical Ethics and Health Policy and a breast
oncologist.
The findings also highlight big differences in international care
for patients with early-stage breast cancer. In Canada, more than 70
percent of women received hypofractionated therapy vs conventional in
2008; that percentage is even greater in the United Kingdom, where the
National Institute of Health and Clinical Excellence released guidance
recommending it as standard of care in 2009.
In the study, the researchers analyzed insurance claims data
provided by Anthem, Inc., a health benefits company (formerly
WellPoint, Inc.), and its health outcomes subsidiary, HealthCore, from
14 commercial healthcare plans covering nine million women (7.4 percent
of the U.S. female population). The research spanned the period from
2008 through 2013, before and after the publication of the supportive
randomized trials and endorsement by ASTRO.
“Everything out there says we ought to be treating more women with
hypofractionated therapy, and it’s only a matter of how we make that
happen,” said Bekelman.
Said Emanuel: “The current payment structure is the biggest
hurdle—there is no financial incentive to recommend shorter duration
treatment. We need to properly align payment with health care quality
in order to reduce low-value cancer care.”
In the U.S., experts strongly encouraged patients to discuss with
their physicians the option of using hypofractionated radiation, naming
it among the Top 5 Choosing Wisely initiatives for radiation oncology in 2013.
“This is solid, actionable information for health plans to have
because it helps in collaborating with providers to develop different
approaches to payment, such as flat fee schedules or bundled payments,
that can improve patient experience while potentially reducing costs
and maintaining the same or better health outcomes,” said Jennifer
Malin, MD, Anthem’s oncology medical director.
Co-authors of the study include Andrew J. Epstein, PhD, and Gary
Freedman, MD, from Penn Medicine, Dr. Malin, from Anthem, and Gosia
Sylwestrzak, MS, John Barron, PharmD, and Jinan Liu, PhD from
HealthCore.
The study was supported by Anthem, Inc., and grants from the National Cancer Institute (K07-CA163616).