Shorter Radiation Schedule Less Likely for Black Cancer Patients
As part of breast cancer or prostate cancer treatment, Black people were less likely to receive a shorter, or hypofractionated, schedule of radiation than white people, according to a study.
The research was published in the Feb. 1, 2023, issue of the journal JCO Oncology Practice. Read the abstract of “Shorter Radiation Regimens and Treatment Noncompletion Among Patients With Breast and Prostate Cancer in the United States: An Analysis of Racial Disparities in Access and Quality.”
What is hypofractionated radiation?
A traditional external whole-breast radiation schedule includes about 25 treatments — one treatment five days a week for five to seven weeks.
Radiation oncologists measure the dose of radiation therapy in Gray. People on traditional radiation therapy schedules receive 45 to 50 Gray in a five- to seven-week period — 1.8 to 2 Gray during each treatment.
But a five- to seven-week nearly daily commitment is difficult for many people, especially if they live far away from a treatment center.
So doctors developed a radiation therapy schedule that involves fewer treatments that deliver higher doses of radiation during each treatment. This shorter schedule — called an accelerated or a hypofractionated schedule — allows people to receive about the same radiation dose in a three- to five-week schedule.
Both the National Comprehensive Cancer Network (NCCN) and the American Society for Radiation Oncology (ASTRO) say that a hypofractionated schedule should be the standard of care for whole-breast radiation therapy. The preferred hypofractionated schedule is 40 Gray in 15 treatments or 42.5 Gray in 16 treatments.
About the study
Research shows that hypofractionated radiation schedules offer the same breast and prostate cancer outcomes as traditional radiation schedules and may increase the number of people who complete the recommended full course of radiation.
When people don’t complete the full course of a prescribed treatment, doctors call it treatment non-compliance.
Studies strongly suggest that the length and cost of radiation treatment were part of the reason some women decided not to have radiation therapy after lumpectomy for breast cancer.
Still, other studies suggest that Black people are less likely to be prescribed hypofractionated radiation to treat breast or prostate cancer.
In this study, the researchers looked at the type of radiation schedule used to treat breast and prostate cancer in people diagnosed between 2004 and 2017, as well as rates of radiation therapy treatment non-compliance.
The researchers used information in the National Cancer Database to identify 306,846 women diagnosed with non-metastatic breast cancer and 170,386 men diagnosed with non-metastatic prostate cancer.
The National Cancer Database is a U.S. registry of cancer cases, sponsored by the American Cancer Society and the American College of Surgeons. About 70% of new cancer diagnoses are included in the database.
Metastatic cancer is cancer that has spread from the organ where it started to other places in the body, such as the bones or liver. Non-metastatic cancer is cancer that has not spread beyond the organ where it started or lymph nodes around the organ.
Among the women diagnosed with breast cancer:
269,193 (87.7%) were white
37,653 (12.3%) were Black
half were younger than 61 and half were older
17.36% were diagnosed with DCIS, which is non-invasive breast cancer
42.99% were diagnosed with stage I breast cancer
26.47% were diagnosed with stage II breast cancer
13.16% were diagnosed with stage III breast cancer
all had mastectomy or lumpectomy, followed by radiation therapy
69.7% received hormonal therapy
Overall, 14.7% of the women received radiation on a hypofractionated schedule after surgery, and 85.3% of the women received radiation on a traditional schedule after surgery. By race:
84.7% of the white women received radiation on a traditional schedule
15.3% of the white women received radiation on a hypofractionated schedule
89.62% of the Black women received radiation on a traditional schedule
10.38% of the Black women received radiation on a hypofractionated schedule
Although use of hypofractionated radiation schedules increased from 2004 to 2017 — from 0.8% in 2004 to 35.6% in 2017 — Black women were less likely to receive a hypofractionated schedule than white women: 15.3% versus 10.38%. This difference was statistically significant, which means that it was likely due to the difference in race and not just because of chance.
And even as hypofractionated radiation to treat breast cancer became more common, the disparity between its use in Black and white women got wider during the study period. In other words, the increase in hypofractionated radiation was greater among white women than Black women.
The researchers’ analysis found that women who received hypofractionated radiation were more likely to complete the full course of treatment than women who received radiation on a traditional schedule.
Among the men diagnosed with prostate cancer:
140,656 (82.5%) were white
29,730 (17.5%) were Black
19.4% had low-risk disease
47.4% had intermediate-risk disease
33.2% had high-risk disease
91.9% received radiation on a traditional schedule
5.8% received stereotactic body radiotherapy, a type of radiation that uses special equipment to position the person and precisely to deliver radiation to the cancer tumor
2.3% — 2.33% of white men and 2.24% of Black men — received radiation on a moderate hypofractionated schedule
Black men were less likely to complete the full course of radiation treatment than white men and also were less likely to receive radiation on a modified hypofractionated schedule than white men. Men who received radiation on a modified hypofractionated schedule were more likely to complete the full course of treatment.
“Black patients were consistently less likely to receive hypofractionated radiation for prostate cancer or breast cancer, despite evidence suggesting that shorter regimens may lower rates of treatment non-completion with similar oncologic outcomes,” the researchers wrote. “Our findings underscore the need to identify and meaningfully address barriers to successful treatment with high-quality radiotherapy as part of larger efforts to combat racial bias and inequities in access to cost-effective cancer care.”
What this means for you
The results of this study are concerning. Research strongly suggests that women who receive radiation for breast cancer on a shorter, hypofractionated schedule are more likely to complete the full course of treatment. Hypofractionated radiation to treat early-stage breast cancer is the standard of care, according to the NCCN and ASTRO.
Still, shorter radiation schedules are not equally prescribed.
All people — no matter their race, ethnicity, gender identity, sexual orientation, age, economic status, or other health conditions — deserve the best breast cancer care possible.
If your doctor recommends radiation therapy after surgery for early-stage breast cancer but doesn’t recommend a hypofractionated schedule, it makes sense to be your own advocate and ask why. You also may want to bring up the results of this study.
Learn more about whole-breast radiation therapy.
— Last updated on February 28, 2023 at 8:38 PM