JAMA: Although the use of a type of radiation treatment that is shorter in
duration and less costly has increased among women with early-stage
breast cancer who had breast conserving surgery, most patients who meet
guidelines to receive this treatment do not, according to a study
appearing in JAMA. The study is being 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 (i.e., 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 [cosmetic outcomes] to conventional WBI.
Furthermore, patients prefer shorter radiation treatment regimens,” the
authors write.
Justin E. Bekelman, M.D., of the University of Pennsylvania Perelman
School of Medicine, Philadelphia, and colleagues examined the usage and
costs of hypofractionated WBI between 2008 and 2013—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 percent of U.S. adult women in 2013, and
classified patients with incident early-stage breast cancer treated with
lumpectomy and WBI from 2008 and 2013 into 2 groups: (1) the
hypofractionation- endorsed cohort (n = 8,924) included patients 50
years of age or older without prior chemotherapy or axillary lymph node
involvement and (2) the hypofractionation-permitted cohort (n = 6,719)
included patients younger than 50 years or those with prior chemotherapy
or axillary lymph node involvement. For this analysis, hypofractionated
WBI was 3-5 weeks of treatment; conventional WBI was 5-7 weeks.
The researchers found that hypofractionated WBI increased from 10.6
percent in 2008 to 34.5 percent in 2013 in the
hypofractionation-endorsed group and from 8.1 percent in 2008 to 21.2
percent 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, although the 2011 practice guidelines
concluded that hypofractionated and conventional WBI were ‘equally
effective for in-breast tumor control and comparable in long-term side
effects’ for selected women, the guidelines stopped short of
recommending hypofractionated WBI as a care standard to be used in place
of conventional WBI. 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 write.
(doi:10.1001/jama.2014.16616; Available pre-embargo to the media at http://media.jamanetwork.com)
Editor’s Note:
Dr. Bekelman received support from a grant from the National Cancer
Institute. WellPoint provided funds to support research at HealthCore, a
wholly-owned WellPoint subsidiary. Please see the article for
additional information, including other authors, author contributions
and affiliations, financial disclosures, etc.