Doing more, expecting nothing for it

Sometimes I feel like a broken record on breast cancer. But this is important, and I’m not going to ignore it. “Uptake and Costs of Hypofractionated vs Conventional Whole Breast Irradiation After Breast Conserving Surgery in the United States, 2008–2013“:

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.

Here’s the deal. There are RCTs looking at using shorter, more intense radiation treatments for many early-stage and other types of breast cancer. It works just as well, has similar side effects, but it takes less time and it costs less. In 2011, the American Society for Radiation Oncology endorsed it. In 2013, Choosing Wisely encouraged it.

And, hooray, the use of hypofractionated WBI increased from 11% to 35% in 2013 in the “endorsed” cohort. It went from 8% to 21% in the “permitted cohort”. Hypofractionated WBI cost, on average, about $2900 less in the “endorsed” cohort and about $8600 less in the “permitted” cohort.

Why? Without breaking a sweat, it’s possible to point out the fact that in a fee-for-service system, many on the health care delivery side make more money if you do more treatments. Shortening the treatment length cuts into their revenue. So if you have a fee-for-service system, then it’s going to be hard to change provider behavior.

The authors point out the fact that in Canada, 6% of patients who received WBI without regional lymph node irradiation got the longer therapy. In the US, 72% did. In Canada, 53% of patients under age 50 without regional lymph node involvement received hypofractionated WBI; in the US, 13.0% did.

I can already hear the cries of “rationing”! Evidently radiation oncologists are concerned about “the possibility of long-term toxic effects associated with shortened treatment schedules.” This is in spite of the fact that twice as many women want hypfractionated WBI over conventional therapy. And it’s in spite of this:

Research supports benefits to patients with the use of hypofractionated WBI. Four randomized trials, each with at least 10 years’ follow-up, have demonstrated similar cancer control and breast cosmetic outcomes between hypofractionated and conventional WBI.

Yet only half of radiation oncologists offer hypofractionated WBI. So much about our system is broken. There’s so much work to do.


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