Choosing wisely after publication of level I evidence in breast cancer radiotherapy

Joshua R. Niska, Sameer R. Keole, Barbara A Pockaj, Michele Y. Halyard, Samir H. Patel, Donald W Northfelt, Richard J. Gray, Nabil Wasif, Carlos E. Vargas, William W. Wong

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

Background: Recent trials in early-stage breast cancer support hypofractionated whole-breast radiotherapy (WBRT) as part of breast-conserving therapy (BCT). Evidence also suggests that radiotherapy (RT) omission may be reasonable for some patients over 70 years. Among radiation-delivery techniques, intensity-modulated RT (IMRT) is more expensive than 3-dimensional conformal RT (3DCRT). Based on this evidence, in 2013, the American Society for Radiation Oncology (ASTRO) recommended hypofractionated schedules for women aged ≥50 years with early-stage breast cancer and avoiding routine use of IMRT for WBRT. To assess response to level I evidence and adherence to ASTRO recommendations, we evaluated the pattern of RT use for early-stage breast cancer at our National Comprehensive Cancer Network institution from 2006 to 2008 and 2011 to 2013 and compared the results with national trends. Methods: Data from a prospective database were extracted to include patients treated with BCT, aged ≥50 years, with histologic findings of invasive ductal carcinoma, stage T1-T2N0M0, estrogen receptor-positive, and HER2 normal. We retrospectively reviewed the medical records and estimated costs based on 2016 Hospital Outpatient Prospective Payment System (technical fees) and Medicare Physician Fee Schedule (professional fees). Results: Among 55 cases from 2006 to 2008, treatment regimens were 11% hypofractionated, 69% traditional schedule, and 20% RT omission (29% of patients were aged >70 years). Among 83 cases from 2011 to 2013, treatment regimens were 54% hypofractionated, 19% traditional schedule, and 27% RT omission (48% of patients were aged >70 years). 3DCRT was used for all WBRT treatments. Direct medical cost estimates were as follows: 15 fractions 3DCRT, $7,197.87; 15 fractions IMRT, $11,232.33; 25 fractions 3DCRT, $9,731.39; and 25 fractions IMRT, $16,877.45. Conclusion: Despite apparent resistance to shorter radiation schedules in the United States, we demonstrate that rapid practice change in response to level I evidence is feasible. Wider adoption of evidence-based guidelines in early-stage breast cancer may substantially lower health care costs and improve convenience for patients without sacrificing oncologic outcomes.

Original languageEnglish (US)
Pages (from-to)31-37
Number of pages7
JournalBreast Cancer: Targets and Therapy
Volume10
DOIs
StatePublished - Feb 9 2018

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Publications
Radiotherapy
Breast Neoplasms
Breast
Appointments and Schedules
Radiation Oncology
Fees and Charges
Fee Schedules
Prospective Payment System
Radiation
Conformal Radiotherapy
Therapeutics
Costs and Cost Analysis
Intensity-Modulated Radiotherapy
Ductal Carcinoma
Medicare
Estrogen Receptors
Health Care Costs
Medical Records
Outpatients

Keywords

  • Breast cancer
  • CALGB
  • Choosing wisely
  • Hypofractionation
  • Omission
  • UK START

ASJC Scopus subject areas

  • Oncology

Cite this

Choosing wisely after publication of level I evidence in breast cancer radiotherapy. / Niska, Joshua R.; Keole, Sameer R.; Pockaj, Barbara A; Halyard, Michele Y.; Patel, Samir H.; Northfelt, Donald W; Gray, Richard J.; Wasif, Nabil; Vargas, Carlos E.; Wong, William W.

In: Breast Cancer: Targets and Therapy, Vol. 10, 09.02.2018, p. 31-37.

Research output: Contribution to journalArticle

Niska, Joshua R. ; Keole, Sameer R. ; Pockaj, Barbara A ; Halyard, Michele Y. ; Patel, Samir H. ; Northfelt, Donald W ; Gray, Richard J. ; Wasif, Nabil ; Vargas, Carlos E. ; Wong, William W. / Choosing wisely after publication of level I evidence in breast cancer radiotherapy. In: Breast Cancer: Targets and Therapy. 2018 ; Vol. 10. pp. 31-37.
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abstract = "Background: Recent trials in early-stage breast cancer support hypofractionated whole-breast radiotherapy (WBRT) as part of breast-conserving therapy (BCT). Evidence also suggests that radiotherapy (RT) omission may be reasonable for some patients over 70 years. Among radiation-delivery techniques, intensity-modulated RT (IMRT) is more expensive than 3-dimensional conformal RT (3DCRT). Based on this evidence, in 2013, the American Society for Radiation Oncology (ASTRO) recommended hypofractionated schedules for women aged ≥50 years with early-stage breast cancer and avoiding routine use of IMRT for WBRT. To assess response to level I evidence and adherence to ASTRO recommendations, we evaluated the pattern of RT use for early-stage breast cancer at our National Comprehensive Cancer Network institution from 2006 to 2008 and 2011 to 2013 and compared the results with national trends. Methods: Data from a prospective database were extracted to include patients treated with BCT, aged ≥50 years, with histologic findings of invasive ductal carcinoma, stage T1-T2N0M0, estrogen receptor-positive, and HER2 normal. We retrospectively reviewed the medical records and estimated costs based on 2016 Hospital Outpatient Prospective Payment System (technical fees) and Medicare Physician Fee Schedule (professional fees). Results: Among 55 cases from 2006 to 2008, treatment regimens were 11{\%} hypofractionated, 69{\%} traditional schedule, and 20{\%} RT omission (29{\%} of patients were aged >70 years). Among 83 cases from 2011 to 2013, treatment regimens were 54{\%} hypofractionated, 19{\%} traditional schedule, and 27{\%} RT omission (48{\%} of patients were aged >70 years). 3DCRT was used for all WBRT treatments. Direct medical cost estimates were as follows: 15 fractions 3DCRT, $7,197.87; 15 fractions IMRT, $11,232.33; 25 fractions 3DCRT, $9,731.39; and 25 fractions IMRT, $16,877.45. Conclusion: Despite apparent resistance to shorter radiation schedules in the United States, we demonstrate that rapid practice change in response to level I evidence is feasible. Wider adoption of evidence-based guidelines in early-stage breast cancer may substantially lower health care costs and improve convenience for patients without sacrificing oncologic outcomes.",
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