Shorter-duration whole breast irradiation may be underutilized

1. Analysis of health care claims data demonstrated significantly reduced hypofractionated whole breast irradiation (WBI) utilization in the United States compared to Canada and the United Kingdom.

2. Hypofractionated WBI was associated with significantly decreased total health care expenditure compared to conventional WBI.

Evidence Rating Level: 3 (Average)

Study Rundown: The current standard of care of early-stage breast cancer (ESBC) is breast conservation surgery followed by whole-breast irradiation (WBI).  Recently, randomized controlled trials completed in Canada and the United Kingdom demonstrated that a shorter, 3-5 week regimen of radiation was equivalent to the conventional 5-7 weeks of WBI.  In 2011, the American Society for Radiation Oncology (ASTRO) recommended the use of this shorter-course, or hypofractionated WBI for women with ESBC 50 or older who meet criteria and permitted hypofractionated WBI for women 50 or younger with ESBC. The purpose of this study is to determine the uptake of hypofractionated WBI since this recommendation. Claims and eligibility data from 14 commercial health plans in the United States were retrospectively reviewed for use of hypofractionated versus conventional WBI in women with ESBC as well as total costs expenditures for these two modalities. At the conclusion of the study, the authors demonstrated that the use of the hypofractionated regimen increased from 10.6% in 2008 to 34.5% in 2013. However, the rate of uptake was significantly less compared to the rate of hypofractionated WBI use in both Canada and the United Kingdom, suggesting that hypofractionated WBI may be underutilized in the United States. Furthermore, hypofractionated WBI was associated with a significant reduction in total health care expenditure for patients of either age group compared to conventional WBI. The main limitation of this study was the retrospective methodology, which may be subject to misclassification error and bias. Future prospective trials on patterns of hypofractionated WBI use are required to validate the uptake trend of this hypofractionated WBI.

Click to read the study in JAMA

Relevant Reading: Long-Term Results of Hypofractionated Radiation Therapy for Breast Cancer

In-Depth [retrospective cohort]: This study retrospectively analyzed the administrative claims data from 14 commercial health care plans, representing 9.2 million US women, for use of hypofractionated versus conventional WBI in patients with ESBC from 2008 to 2013. This dataset included data from Medicare Advantage enrollees as well as commercial payers. Overall, the study cohort included 8924 ESBC patients met all ASTRO criteria to endorse hypofractionation as well as 6719 ESBC patients considered to be in a “hypofractionation-permitted” cohort.  In the hypofractionation-endorsed cohort, hypofractionation rates increased from 10.6% (95% CI: 8.8%-12.5%) in 2008 to 34.5% (95% CI: 32.2%-36.8%) in 2014. In the hypofractionation-permitted cohort, rates increased from 8.1% (95% CI: 6.0%-10.2%) in 2008 to 21.2% (95% CI: 18.9%-23.6%) in 2014. Total health-related expenditures were $2894 lower for patients receiving hypofractionated WBI compared to conventional WBI (95% CI: $1610-$4234; P<0.001) in the endorsed cohort while that difference was $8585 (95% CI: $5316-$12,017; P<0.001) in the permitted cohort. The percentage of patients that received conventional WBI (>30 fractions) was significantly increased in the United States compared to Ontario, Canada (52.7% vs 6.3%).

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