by
Gus Iversen, Editor in Chief | December 22, 2014
Health care reform is all about achieving better outcomes faster, and at a lower cost. Yet when it comes to early-stage breast cancer, two-thirds of patients may be receiving a lengthier treatment than necessary; one that results in greater expenses and comparable outcomes.
WBI is recommended for most women after breast conserving surgery because it reduces the chance of recurrence while improving overall survival. The treatment has been used for decades, and the relatively recent development of hypofractionation builds upon that success model.
Hypofractionation means fewer fractions (treatments) at higher doses and is generally delivered over three weeks. Conventional WBI, on the other hand, typically takes five to seven weeks.
The benefits of hypofractionated whole breast irradiation (WBI) for cancer treatment are well documented. In 2011, ASTRO issued a guideline endorsing it as "equally effective for in-breast tumor control and comparable in long-term side effects" in relation to conventional WBI for many breast cancer patients. That effectiveness, coupled with the cost advantages and faster treatment times should make it very popular in today's health care climate – so what's the holdup?
Trends towards hypofractionation, but change is slow
The new study, (entitled, "Uptake and costs of hypofractionated versus conventional whole breast irradiation after breast conserving surgery in the United States, 2008-2013) was conducted by Penn Medicine and published by JAMA.
They took data claims from 14 commercial health care plans to assess the use of hypofractionated WBI in 2008 and 2013. Based on the ASTRO guideline, the study retroactively applied 15,643 patients into one of two candidacy groups: endorsed (8,924) and permitted (6,719). For the sake of their study, the researchers defined hypofractionated treatments as those spanning 11-24 fractions, and conventional as 25-40.
They found that 10.6 percent of the endorsed group received hypofractionated WBI in 2008, versus 34.5 percent in 2013. For the permitted group, hypofractionation increased from 8.1 percent to 21.2 percent.
In terms of cost, total health expenditures for the patients receiving hypofractionated WBI were an average of 10 percent lower, which is significant news, considering that breast cancer treatment accounts for the largest portion of cancer care expenditures nationwide.
In the U.K., most patients with early-stage breast cancer have received hypofractionated WBI since 2009, when a NICE guideline recommending it as a standard of care was published. The study authors note that ASTRO's endorsement stops short of declaring hypofractionated WBI a standard of care, and wonder if this could factor into slow adoption. The study also suggests some radiologists remain worried about the long term toxic effects of shortened treatments with higher doses.
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