Use of Shorter Radiation Regimen Triples, but Still Underused Experts Say

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A study found that more U.S. women diagnosed with early-stage breast cancer were treated after lumpectomy with a whole-breast radiation schedule that was shorter than the conventional regimen, but that this shorter schedule still wasn’t prescribed as often as it could be.

The research was published in the Dec. 17, 2014 issue of the Journal of the American Medical Association. Read the abstract of “Uptake and Costs of Hypofractionated vs Conventional Whole Breast Irradiation After Breast Conserving Surgery in the United States, 2008-2013.”

After lumpectomy to remove early-stage breast cancer, radiation therapy often is used to reduce the risk of recurrence. Whole-breast radiation therapy after breast cancer surgery is usually given as one treatment per day, 5 days a week, for 5 to 7 weeks. A Gray is the way radiation oncologists measure the dose of radiation therapy; if you’re on a 5-week treatment schedule, 50 Gray is the usual amount given during the 5 weeks (2 Gray at each treatment). A supplemental “boost” dose may be included at the end of the regimen that targets the area where the cancer was.

Radiation treatment schedules have been developed based on research results. But a 5- to 7-week nearly daily commitment may be difficult for some women, especially if they live far away from a treatment center.

Doctors have studied a new radiation therapy schedule that involves fewer treatments with higher doses of radiation at each treatment, but the same total radiation dose. So the new schedule puts the same radiation dose into a 3- to 5-week schedule. Giving the traditional amount of radiation in a shorter time period is called hypofractionated whole-breast radiation.

A hypofractionated whole-breast radiation schedule is appealing to doctors and people getting radiation for several reasons:

  • convenience: arranging daily trips to get treatment can be a problem for some women; fewer treatment days or a shorter period of time may be easier to schedule
  • if radiation is more convenient to schedule, it’s probably easier for women to get all the recommended radiation therapy

In 2011, the American Society for Radiation Oncology (ASTRO) released guidelines on hypofractionated whole-breast radiation (PDF) and said the technique was as safe and effective as conventional whole-breast radiation for early-stage breast cancer after lumpectomy for women who meet the four criteria below:

  • age 50 or older when diagnosed with breast cancer
  • the cancer is stage T1 to T2, no cancer cells have been found in the lymph nodes, and the cancer has been removed with lumpectomy
  • the cancer hasn’t been treated with chemotherapy
  • the minimum and maximum doses of radiation are plus or minus 7% of the prescription dose

The guidelines also say that hypofractionated whole-breast radiation could be a good option for other women who don’t meet all four of the criteria, especially younger women. But since the studies the ASTRO experts looked at to write the guidelines included smaller numbers of younger women, the experts weren’t comfortable including younger women in the guidelines.

So researchers wanted to know how widely used hypofractionated whole-breast radiation was in the United States, as well as whether the shorter schedule reduced costs.

In this study, the researchers looked at information from the HealthCore Integrated Research Database, which includes medical and pharmacy information from 14 commercial insurance plans across the United States, covering 9.2 million women (about 7.4% of all U.S. women). From the claims to the health insurance companies, the researcher could see how many women diagnosed with breast cancer treated with lumpectomy had hypofractionated whole-breast radiation and how many had traditional whole-breast radiation. The researchers divided the women into two groups:

  • women who met the four criteria for hypofractionated radiation therapy (8,924 women)
  • women diagnosed with early-stage breast cancer who were younger than 50, or had been treated with chemotherapy, or who had cancer cells in their lymph nodes (6,719 women)

While the women in the second group didn’t meet all four of the criteria for hypofractionated whole-breast radiation, the ASTRO guidelines suggest that the shorter schedule would be acceptable for them.

The researchers found that hypofractionated whole-breast radiation therapy use more than tripled from 2008 to 2013 -- from 10.6% in 2008 to 34.5% in 2013 -- for women in the first group who met all four of the ASTRO criteria.

For women in the second group, the use of hypofractionated whole-breast radiation therapy also went up during the same time period, but not by as much -- from 8.1% in 2008 to 21.2% in 2013.

In the first year after diagnosis, the cost for hypofractionated whole-breast radiation was $28,747 and the cost for traditional whole-breast radiation was $31,641 for women in the first group.

For women in the second group, the cost for hypofractionated whole-breast radiation was $64,273 and the cost for traditional whole breast radiation was $72,860 in the first year after diagnosis.

When the researchers talked to radiation specialists about why they stuck with a traditional whole-breast radiation schedule, even for women who met all four criteria for hypofractionated whole-breast radiation, the specialists said they were concerned about side effects when compressing the same radiation dose into a 3- to 5-week schedule.

Another reason that hypofractionated whole-breast radiation therapy isn’t used as often as it could be may be because the ASTRO guidelines stop short of recommending the shorter schedule as a standard of care that can be used in place of traditional whole-breast radiation. This lack of a clear recommendation may be contributing to the shorter schedule being underused.

If you’ve been diagnosed with early-stage breast cancer that has been removed with lumpectomy and radiation therapy will be part of your treatment plan, you may want to talk to your doctor about hypofractionated whole-breast radiation therapy and whether it makes sense for you and your unique situation. Be sure to talk about your scheduling needs and ask your doctor whether you meet the criteria for hypofractionated whole-breast radiation.

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