Uptake and Costs of Hypofractionated vs Conventional Whole Breast Irradiation After Breast Conserving Surgery in the United States, 2008–2013

Abstract

IMPORTANCE Based on randomized evidence, expert guidelines in 2011 endorsed shorter, hypofractionated whole breast irradiation (WBI) for selected patients with early-stage breast cancer and permitted hypofractionated WBI for other patients. OBJECTIVES To examine the uptake and costs of hypofractionated WBI among commercially insured patients in the United States. DESIGN, SETTING, AND PARTICIPANTS Retrospective, observational cohort study, using administrative claims data from 14 commercial health care plans covering 7.4%of US adult women in 2013, we classified patients with incident early-stage breast cancer treated with lumpectomy and WBI from 2008 and 2013 into 2 cohorts: (1) the hypofractionation-endorsed cohort (n = 8924) included patients aged 50 years or older without prior chemotherapy or axillary lymph node involvement and (2) the hypofractionation-permitted cohort (n = 6719) included patients younger than 50 years or those with prior chemotherapy or axillary lymph node involvement. EXPOSURES Hypofractionated WBI (3–5 weeks of treatment) vs conventional WBI (5–7 weeks of treatment). MAIN OUTCOMES AND MEASURES Use of hypofractionated and conventional WBI, total and radiotherapy-related health care expenditures, and patient out-of-pocket expenses. Patient and clinical characteristics included year of treatment, age, comorbid disease, prior chemotherapy, axillary lymph node involvement, intensity-modulated radiotherapy, practice setting, and other contextual variables. RESULTS Hypofractionated WBI increased from 10.6%(95%CI, 8.8%–12.5%) in 2008 to 34.5%(95%CI, 32.2%–36.8%) in 2013 in the hypofractionation-endorsed cohort and from 8.1% (95%CI, 6.0%–10.2%) in 2008 to 21.2%(95%CI, 18.9%–23.6%) in 2013 in the hypofractionation-permitted cohort. Adjusted mean total health care expenditures in the 1 year after diagnosis were $28 747 for hypofractionated and $31 641 for conventional WBI in the hypofractionation-endorsed cohort (difference, $2894; 95%CI, $1610–$4234; P < .001) and $64 273 for hypofractionated and $72 860 for conventional WBI in the hypofractionation-permitted cohort (difference, $8587; 95%CI, $5316–$12 017; P < .001). Adjusted mean total 1-year patient out-of-pocket expenses were not significantly different between hypofractionated vs conventional WBI in either cohort. CONCLUSIONS AND RELEVANCE Hypofractionated WBI after breast conserving surgery increased among women with early-stage breast cancer in 14 US commercial health care plans between 2008 and 2013. However, only 34.5%of patients with hypofractionation-endorsed and 21.2%with hypofractionation-permitted early-stage breast cancer received hypofractionated WBI in 2013.

The Impact of Radiation Oncologists on the Early Adoption of Hypofractionated Radiation Therapy for Early-Stage Breast Cancer

“…Owing to wide variations in the patterns of care surrounding fractionation (7,8), multiple randomized trials directly comparing hypofractionation with standard radiation were initiated, with recent long-term results confirming equivalence (9-13). However, despite the development of clinical guidelines by the American Society for Radiation Oncology in 2011 (14) followed by the American Board of Internal Medicine's Choosing Wisely campaign in 2013 (7), the uptake of hypofractionation in the United States has been slow (15,16), with evidence that practice patterns vary widely based on geography (15,17).…”

“…Data suggest that tumor-related factors such as tumor size, histologic grade, and laterality do not affect the receipt of hypofractionation, although several patient-related factors do increase the likelihood of receiving hypofractionation, namely, older age, greater comorbidity, lower median household income (16), and lower level of education (15). Limited practice-related factors have also been investigated, with treatment in a hospital-based clinic and higher density of radiation oncologists increasing the likelihood of receiving hypofractionation (16,17), whereas overall population density had no impact (15).…”

“…Limited practice-related factors have also been investigated, with treatment in a hospital-based clinic and higher density of radiation oncologists increasing the likelihood of receiving hypofractionation (16,17), whereas overall population density had no impact (15). The impact of providerspecific data, however, is limited to data from a single-state multi-institution study (21).…”

General Overview and Treatment Recommendations for Young Women with Breast Cancer

“…Moderately hypofractionated radiotherapy schedules of breast/chest wall and/or lymph node areas with higher dose per fraction (> 2 Gy) and shortened overall treatment time are increasingly gaining popularity around the globe including in patients younger than 50 years [85][86][87][88] . Shortened treatment schedules demonstrated equivalent local control and similar or lower toxicity rates, regardless of the patient's age 87,89 .…”

Longitudinal Analysis of Patient-Reported Outcomes and Cosmesis in a Randomized Trial of Conventionally Fractionated Versus Hypofractionated Whole-Breast Irradiation

“…However, to the best of our knowledge, the adoption of HF-WBI in the United States has been more limited (6), perhaps owing to skepticism regarding the applicability of these results to the practice of radiation oncology in the United States, in which a tumor bed boost is frequently used and obesity, with its attendant dosimetric challenges, is common (7)(8)(9)(10)(11).…”