Choosing Wisely? Patterns and Correlates of the Use of Hypofractionated Whole-Breast Radiation Therapy in the State of Michigan

Jagsi, Reshma; Griffith, Kent A.; Heimburger, D.K.; Walker, Eleanor M.; Grills, I.S.; Boike, Thomas; Feng, Mary; Moran, Jean M.; Hayman, James A.; Pierce, Lori J.

doi:10.1016/j.ijrobp.2014.09.027

Cited by 62 publications

(19 citation statements)

References 18 publications

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“…A recent observational cohort study from 14 commercial health care plans in the United States reported that only 34.5% of appropriate candidates for HF-WBI received this treatment in 2013, similar to the rate seen in a study examining practice patterns in Michigan between 2011 and 2013. [4, 6] In contrast, practice patterns in the United Kingdom and Canada have demonstrated much broader uptake of HF-WBI. [17–19] Limited adoption of HF-WBI in the United States has been attributed in part to concerns regarding the applicability of the available evidence to practice patterns in the United States, where use of a tumor bed boost is much more common and where higher prevalence of obesity may result in fewer patients meeting the dose homogeneity or central axis separation criteria applied in the randomized literature.…”

Section: Discussionmentioning

confidence: 99%

Acute and Short-term Toxic Effects of Conventionally Fractionated vs Hypofractionated Whole-Breast Irradiation

et al. 2015

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IMPORTANCE The most appropriate dose-fractionation for whole breast irradiation (WBI) remains uncertain. OBJECTIVE To assess acute and six-month toxicity and quality of life (QoL) with conventionally fractionated WBI (CF-WBI) versus hypofractionated WBI (HF-WBI). DESIGN Unblinded randomized trial of CF-WBI (n=149; 50 Gy/25 fractions + boost [10–14 Gy/5–7 fractions]) versus HF-WBI (n=138; 42.56 Gy/16 fractions + boost [10–12.5 Gy/4–5 fractions]). SETTING Community-based and academic cancer centers. PARTICIPANTS 287 women age ≥ 40 years with stage 0–II breast cancer treated with breast-conserving surgery for whom whole breast irradiation without addition of a third field was recommended. 76% (n=217) were overweight or obese. Patients were enrolled from February 2011 through February 2014. INTERVENTION(S) FOR CLINICAL TRIALS CF-WBI versus HF-WBI. MAIN OUTCOME MEASURES Physician-reported acute and six-month toxicities using NCICTCv4.0 and patient-reported QoL using the FACT-B version 4. All analyses were intention-to-treat, with outcomes compared using chi-square, Cochran-Armitage test, and ordinal logistic regression. Patients were followed for a minimum of 6 months. RESULTS Treatment arms were well-matched for baseline characteristics including FACT-B total score (P=0.46) and individual QoL items such as lack of energy (P=0.86) and trouble meeting family needs (P=0.54). Maximal physician-reported acute dermatitis (P<0.001), pruritus (P<0.001), breast pain (P=0.001), hyperpigmentation (P=0.002), and fatigue (P=0.02) during radiation were lower in patients randomized to HF-WBI. Overall grade ≥2 acute toxicity was less with HF-WBI vs. CF-WBI (47% vs. 78%; P<0.001). Six months after radiation, physicians reported less fatigue in patients randomized to HF-WBI (P=0.01), and patients randomized to HF-WBI reported less lack of energy (P<0.001) and less trouble meeting family needs (P=0.01). Multivariable regression confirmed the superiority of HF-WBI in terms of patient-reported lack of energy (OR 0.39, 95% CI 0.24–0.63) and trouble meeting family needs (OR 0.34, 95% CI 0.16–0.75). CONCLUSIONS AND RELEVANCE HF-WBI appears to yield less acute toxicity than CF-WBI, as well as less fatigue and trouble meeting family needs six months after completing radiation. These findings should be communicated to patients as part of shared decision-making. TRIAL REGISTRATION NCT01266642 (https://clinicaltrials.gov/ct2/show/NCT01266642)

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Section: Discussionmentioning

confidence: 99%

Acute and Short-term Toxic Effects of Conventionally Fractionated vs Hypofractionated Whole-Breast Irradiation

et al. 2015

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“…MROQC is an alliance of 24 academic and community practice centers in the state of Michigan funded by Blue Cross Blue Shield of Michigan, through which clinical, treatment, and outcomes related data is prospectively collected for patients undergoing thoracic irradiation. 14 Each participating site submits DVHs and DICOM-formatted files of actual treatment plans for each patient to MROQC. All patients undergoing definitive lung radiotherapy for stage I–III lung cancer were identified.…”

Section: Methodsmentioning

confidence: 99%

Lower Incidence of Esophagitis in the Elderly Undergoing Definitive Radiation Therapy for Lung Cancer

Soni

Boonstra

Schipper

et al. 2017

Journal of Thoracic Oncology

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Introduction The majority of lung cancer patients are elderly and poorly represented in randomized clinical trials. They are often undertreated due to concerns about their ability to tolerate aggressive treatment. We tested the hypothesis that elderly patients undergoing definitive lung radiation might tolerate treatment differently from younger patients. Methods 125 patients who underwent definitive lung radiotherapy were identified from a prospective institutional database (UM cohort). Logistic regression modelling was performed to assess the impact of age on esophagitis grade ≥3 or ≥2 and pneumonitis grade ≥3 or ≥2, adjusting for esophageal and lung dose respectively, chemotherapy utilization, smoking status, and performance status. The analysis was validated in a large cohort of 691 patients from the Michigan Radiation Oncology Quality Consortium (MROQC) registry, an independent statewide prospective database. Results In the UM Cohort, multivariable regression models revealed a significant inverse correlation between age and rate of esophagitis for both toxicity levels, (adjusted odds ratio=0.93 for both models, 95% confidence intervals of (0.88,0.98) and (0.87,0.99)), with AUC of 0.747 and 0.721, respectively, demonstrating good fit. This same association was noted in the MROQC cohort. There was no significant association between age and pneumonitis. Conclusions There is a lower incidence of esophagitis with increasing age even after adjusting for use of chemotherapy. This is a novel finding in thoracic oncology. No age dependence was noted for pulmonary toxicity. The elderly are able to tolerate definitive thoracic radiation well and should be offered this option when clinically warranted.

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“…As these and other studies mature it is incumbent on the profession of radiation oncology to ensure that these advances are appropriately translated into practice. Considerable recent attention has been devoted within both the Red Journal (27)(28)(29)(30) and other prominent publications (31,32) to the slow uptake of research advances, particularly with regard to hypofractionated whole breast radiation therapydan important example of the "less is more" approach. The lag in adoption of new evidence in clinical practice is an important concern, and initiatives that reduce the aggressiveness of therapy may be particularly difficult to disseminate.…”

Section: Resultsmentioning

confidence: 99%

Breast Radiation Therapy—Sometimes Less May Be More

Jagsi

Woodward

2015

International Journal of Radiation Oncology*Biology*Physics

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Choosing Wisely? Patterns and Correlates of the Use of Hypofractionated Whole-Breast Radiation Therapy in the State of Michigan

Cited by 62 publications

References 18 publications

Acute and Short-term Toxic Effects of Conventionally Fractionated vs Hypofractionated Whole-Breast Irradiation

Acute and Short-term Toxic Effects of Conventionally Fractionated vs Hypofractionated Whole-Breast Irradiation

Lower Incidence of Esophagitis in the Elderly Undergoing Definitive Radiation Therapy for Lung Cancer

Breast Radiation Therapy—Sometimes Less May Be More

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