A new study published in JAMA reports that although they meet the guidelines, most women with early-stage breast cancer do not receive radiation treatment that is shorter and less costly.
Hypofractionated whole breast irradiation (WBI) is a treatment alternative with a shorter duration compared to conventional WBI. Conventional WBI consists of 5 to 7 weeks of daily radiation fractions, while hypofractionated WBI consists of fewer, but higher dose fractions received over about 3 weeks. As of 2011, expert guidelines endorse hypofractionated WBI for selected patients with early-stage breast cancer, saying both treatment methods were equally effective for in-breast tumor control and comparable in long-term side effects for selected women.
In the retrospective, observational study, led by Justin E. Bekelman, MD, of the University of Pennsylvania Perelman School of Medicine, researchers set out to examine the uptake and costs of hypofractionated WBI among insured US patients between 2008 and 2013. They used data from 14 commercial health care plans covering over 7 percent of US adult women in 2013. They classified patients with incident early-stage breast cancer treated with lumpectomy and WBI into 2 groups:
1) hypofractionation-endorsed group (almost 9,000 women) which included patients over 50 years of age without prior chemotherapy or axillary lymph node involvement
2) hypofractionation-permitted group (almost 7,000 women) which included patients who were permitted to have hypofractionated WBI, who were younger than 50 or who had prior chemotherapy or axillary lymph node involvement
The researchers found that although hypofractionated WBI among women increased over the study period, the increase was from 10.6% in 2008 to only 34.5% in 2013 in the hypofractionation-endorsed group, and from 8.1% in 2008 to only 21.2% in 2013 in the hypofractionation-permitted group. Adjusted mean total health care expenditures in the year after diagnosis were almost $29,000 for hypofractionated compared to almost $32,000 for conventional WBI in the endorsed group, and about $64,000 for hypofractionated and about $73,000 for conventional WBI in the permitted group.
The authors conclude by saying that although the updated practice guidelines in 2011 endorse hypofractionated WBI, they stopped short of recommending hypofractionated WBI as a care standard to be used in place of conventional WBI. They write, 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 continue, Radiation oncologists have expressed apprehension about the possibility of long-term toxic effects associated with shortened treatment schedules, however, Research supports benefits to patients with the use of hypofractionated WBI.
ACSH s Dr. Gil Ross added this perspective: When radiation oncologists express fear of long-term toxicity from WBI, contrary to the evidence, what they re really saying is, we won t take any chances with any newer approach, since first we ll have to do a lot of lengthy explaining to patients, and then if something does actually go in an unexpected direction, there ll be lawsuits to worry about. Sadly, that s the way medicine is often practiced these days.