Intensity modulated radiation therapy following lumpectomy in early-stage breast cancer: Patterns of use and cost consequences among Medicare beneficiaries

Abstract

PurposeIn 2013, the American Society for Radiation Oncology (ASTRO) issued a Choosing Wisely recommendation against the routine use of intensity modulated radiotherapy (IMRT) for whole breast irradiation. We evaluated IMRT use and subsequent impact on Medicare expenditure in the period immediately preceding this recommendation to provide a baseline measure of IMRT use and associated cost consequences.Methods and materialsSEER records for women ≥66 years with first primary diagnosis of Stage I/II breast cancer (2008–2011) were linked with Medicare claims (2007–2012). Eligibility criteria included lumpectomy within 6 months of diagnosis and radiotherapy within 6 months of lumpectomy. We evaluated IMRT versus conventional radiotherapy (cRT) use overall and by SEER registry (12 sites). We used generalized estimating equations logit models to explore adjusted odds ratios (OR) for associations between clinical, sociodemographic, and health services characteristics and IMRT use. Mean costs were calculated from Medicare allowable costs in the year after diagnosis.ResultsAmong 13,037 women, mean age was 74.4, 50.5% had left-sided breast cancer, and 19.8% received IMRT. IMRT use varied from 0% to 52% across SEER registries. In multivariable analysis, left-sided breast cancer (OR 1.75), living in a big metropolitan area (OR 2.39), living in a census tract with ≤$90,000 median income (OR 1.75), neutral or favorable local coverage determination (OR 3.86, 1.72, respectively), and free-standing treatment facility (OR 3.49) were associated with receipt of IMRT (p<0.001). Mean expenditure in the year after diagnosis was $8,499 greater (p<0.001) among women receiving IMRT versus cRT.ConclusionWe found highly variable use of IMRT and higher expenditure in the year after diagnosis among women treated with IMRT (vs. cRT) with early-stage breast cancer and Medicare insurance. Our findings suggest a considerable opportunity to reduce treatment variation and cost of care while improving alignment between practice and clinical guidelines.

Breast size and dose to cardiac substructures in adjuvant three-dimensional conformal radiotherapy compared to tangential intensity modulated radiotherapy

“…Bull's eye diagrams of the left ventricle and segment models of the coronary arteries with reported median D mean distributions in three-dimensional conformal radiotherapy plans, divided in groups according to clinical target volume size. Contouring segments of left ventricle consisted of anterior (segments 1 and 7), apical (segments 13-17), inferior (segments 4 and 10), lateral (segments 5,6,11,12) and septal regions (segments 2, 3, 8, 9). CTV = clinical target volume; Gy = Gray; LADCA = left anterior descending artery; LCX = left circumflex artery; LMCA = left main coronary artery; RCA = right coronary artery Despite the low MWHD for the whole group, our study confirms that apical and anterior parts of LV and mid or distal LADCA segments in both 3D-CRT and t-IMRT techniques receive disproportionately higher D mean radiation doses.…”

“…3,5,10 In many recent publications, authors favor the use of intensity modulated techniques over threedimensional conformal radiotherapy (3D-CRT) in node negative breast cancer adjuvant RT, arguing for lower MWHD, decreased skin toxicity and more homogeneous dose distribution in the target volume. [11][12][13] Besides the RT technique used, MWHD depends on the position of the patient's heart relative to the irradiated breast and the shape of their chest wall. 14 Different simple anatomical measures were evaluated to predict increased MWHD and subsequently for the need to use one of the heartsparing techniques, namely deep inspiration breath hold technique (DIBH).…”

A scoping review characterizing "Choosing Wisely®" recommendations for breast cancer management

“…The remaining 49 publications were excluded, as they did not specifically present official CW® recommendations, address CW®, or have the original full text available. The excluded citations from this review are listed in the reference list [23,24,. The gray literature search identified 22 recommendations in total from 10 campaigns which are summarized in Table 1.…”

“…To date, it appears that CW® recommendations have resulted in limited [20,[22][23][24][25] alterations in oncology practice. Whether the simple observation of this variability in practice and its publication will lead to sustained changes in practice remains to be seen.…”

Two-Level Factorial Pre-TomoBreast Pilot Study of Tomotherapy and Conventional Radiotherapy in Breast Cancer: Post Hoc Utility of a Mean Absolute Dose Deviation Penalty Score

“… 8 Despite the contradicting observation, 9 complex IMRT is still considered inappropriate, and < 20% of patients undergoing lumpectomy received IMRT based on surveys of Medicare beneficiaries. 10 , 11 In Australia and New Zealand, where patients with breast cancer represent the largest population receiving curative RT, IGRT has been seldom applied; 2-dimensional portal imaging was the predominant imaging mode for breast cancer (82% and 86%, respectively). 12 , 13 To further compound the disease burden, reimbursement of IP-IMRT/V-IGRT is denied to most patients with breast cancer in several western countries.…”