Hypofractionated Radiation Therapy for Early Stage Breast Cancer: Outcomes, Toxicities, and Cost Analysis

Abstract

A French prospective randomized trial comparing whole breast radiotherapy with 45 Gy in 25 fractions versus 23 Gy in four fractions demonstrated equivalent 5-year local control and survival. On the basis of this data, we offer the hypofractionated regimen to women who refuse to undergo standard radiotherapy. We report our outcomes and a cost analysis. Between 2000 and 2012, 84 patients participated in this IRB-approved study and underwent whole breast radiation to 23 Gy in four fractions. Local control and survival were analyzed using the Kaplan-Meier method. Acute toxicities and overall long-term cosmetic results were assessed. Costs were estimated from 2012 Medicare reimbursement data and compared to costs from standard courses of 25 and 16 fractions. All 84 patients are included in this report. Median age was 83 (range 42-98). Most patients had stage I (80%), hormone receptor positive (90%) breast cancer. Fifty-eight patients (69%) were treated prone and 26 (31%) supine. At a median follow-up of 3 years, one local recurrence has occurred, of ductal carcinoma in situ histology. Among the 13 patients deceased, two died of metastatic breast cancer. Five-year actuarial local control is 99%, breast cancer-specific survival is 98%, and overall survival is 79%. Toxicities were limited to grade 1 dermatitis in 32 patients (38%) and grade 2 fatigue in three (4%). Sixty-three patients (75%) reported good or excellent cosmetic outcome at their last follow-up. Collected Medicare reimbursement was $4,798 for the hypofractionated course. Compared to the projected reimbursement of standard regimens, $10,372 for 25 fractions and $8,382 for 16 fractions, it resulted in a difference of $5,574 and $3,584, respectively. At a follow-up of 3 years, this hypofractionated regimen appears to be a promising approach, primarily for elderly women who are unable to undergo longer treatment courses but have indications for whole breast radiotherapy.

Cost‐containment in hypofractionated radiation therapy: a literature review

“…Hypofractionation in breast cancer is seen to provide promising local control rates and good cosmetic outcomes . Published data from the UK START trials confirm the safety and efficacy of hypofractionated breast radiation therapy, negating prior concerns of long‐term (cardiac) post‐treatment management .…”

Évolution des pratiques médicales d’hypofractionnement en radiothérapie pour cancer du sein et impact économique

“…Économiquement, l'hypofractionnement est clairement rentable pour le système de santé, comme cela a déjà été démontré [20]. Il est important de noter que l'oncologue radiothérapeute est le prescripteur du nombre des séances, ainsi que par corolaire des transports et que selon l'article L. 162-2-1 du Code de la sécurité sociale le prescripteur est tenu d'observer la « plus stricte économie compatible avec la qualité, la sécurité et l'efficacité des soins ».…”

“…Notre étude a aussi montré que 20 % des patientes pourraient être candidates pour un hypofractionnement. Une comparaison des coûts avec ceux estimés par Min et al montre que notre système de santé est proche du système américain [20]. Ils ont effectivement estimé une réduction de 221 $ (environ 175 D ) par séance, (sans coût de transport) contre 170,77 D .…”

The impact of radiotherapy costs on clinical outcomes in breast cancer

“…Therefore, longer courses of radiation and the use more advanced technology such as IMRT further increases payments relative to simpler or shorter techniques of radiation delivery [5,26,27]. Multiple randomized trials in breast cancer have demonstrated no clinical difference between shorter courses (hypofractionated) and longer courses of radiation in terms of toxicity or tumor control[28,29].…”