Breast Cancer: Utilization of Hypofractionated Regimens for Treatment of Breast Cancer in an Insured Population Before and After Initiation of ASTRO's "Choosing Wisely" Campaign

Author: Reporting Author: Lindsay Brown, MD
Content Contributor: The Abramson Cancer Center of the University of Pennsylvania
Last Reviewed: September 18, 2014

Presenting Author: Heather Curry, MD
Presenting Author Affiliation: Eviti, Inc.

Breast cancer remains the most common malignancy in women, and radiation often plays a role in the treatment of this disease. Traditionally, women undergoing lumpectomy for breast cancer were treated with 5-6 weeks of daily radiation after surgery. "Hypofractionated" regimens are shorter courses of radiation, in which a slightly larger dose of radiation is given per day, allowing radiation to be delivered in a shorter period of time, most commonly in 3-4 weeks. In the past 10 years, multiple large, well-designed trials have shown that hypofractionated radiation following lumpectomy is equivalent to the longer, conventional treatment regimens used in the past for appropriately selected patients. These trials have also shown no difference in side effects and cosmesis (appearance) of the treated breast between the two radiation courses.

Shorter course, hypofractionated, radiation has the benefit of increased convenience for women and lower cost to the insurer and the patient. Despite the high-quality data supporting the efficacy and safety of shorter course radiation for breast cancer after lumpectomy and the benefits of such a regimen, hypofractionated breast radiotherapy has not been widely adopted in the United States.

In 2013, a list of 5 recommendations to improve the efficacy and value of radiation therapy use in the United States was released, as part of a national "Choosing Wisely" campaign. One of the 5 recommendations was "Don't initiate whole breast radiotherapy as a part of breast conservation therapy in women age 50 years or greater with early stage invasive breast cancer without considering shorter treatment schedules."

Dr. Curry and her coauthors were interested in patterns of hypofractionated regimen use over time, and whether the "Choosing Wisely" recommendation had resulted in increased utilization of hypofractionated breast radiation for patients receiving whole breast radiation after lumpectomy. Dr. Curry analyzed patterns of radiation plans for patients with early stage breast cancer that were submitted for insurance authorization through a particular web-based service from June 2011 through June 2014. This service is used by 9 insurers, and represents approximately 1 million patients in the United States. The authors analyzed patterns of hypofractionation use for all women treated with radiation after lumpectomy and also for those women who met the specific criteria laid out in the recommendation.

During the study period, 949 plans for whole breast radiation after lumpectomy were submitted, 389 of which were for patients who would have been eligible for hypofractionation according to the Choosing Wisely definition. There was a significant increase in the number of eligible patients treated with short course radiation before versus after the release of Choosing Wisely (9.7 v. 21.3%). There also was a trend towards increased use of hypofractionation over time when analyzed by year. Similar trends were seen when all patients receiving radiation to the whole breast after lumpectomy were considered.

In summary, the authors demonstrate that use of hypofractionated whole breast radiation is increasing over time. There was a significant increase in utilization after release of the "Choosing Wisely" campaign. It is important to note that these findings may not be generalizable across the United States, as this study analyzed only a subset of the population. Nonetheless, these data suggest that awareness campaigns are of value and may result in appropriate change in practice patterns.

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