Study: Cost savings associated with a shorter course or omission of radiation treatment for early-stage breast cancer

IN-DEPTH REVIEW OF RESEARCH

Study background:

Previous work suggested that radiation regimens with fewer treatments and higher radiation amounts were safe. Patients who received whole-breast irradiation consisting of 42.5 Gy (Gray or Gy is a measure of the dose of irradiation or the amount of energy being transferred) in 16 treatments over 22 days had similar survival rates compared to patients who received traditional whole breast irradiation consisting of 50 Gy in 25 treatments over 35 days. Additionally, some clinical trial data suggests that some carefully selected patients may avoid radiation treatment entirely after lumpectomy.

As recently as 2014 patients were commonly treated with the conventional 5-7 week radiation therapy. The American Society for Radiation Oncology (ASTRO) and other professional groups have issued guidelines for use of HF-WBI in patients: women with small (≤3 cm), node-negative breast cancers with negative surgical margins, patients who are at least 50 years old, and patients who have non-invasive disease.

The choice of radiation treatment, as well as identification of patients who can be managed without radiation, can impact health care spending. Rachel Greenup and colleagues from Duke University Medical Center and other institutions published work in the Journal of Oncology Practice to estimate cost savings if early-stage breast cancer patients received the least costly radiation treatment for which they were safely eligible based on the criteria in this study. It is important to remember that for individual patients, the criteria is complex and must be made between the patient and her care team. Furthermore, recurrence rates with different types of radiation therapy should be carefully considered.

Researchers of this study wanted to know:

What are the potential health care cost savings if early-stage breast cancer patients received the least expensive radiation regimen for which they were safely eligible?

Population(s) looked at in the study:

This study analyzed data from the American College of Surgeons National Cancer Database (NCDB).  Women who had node-negative, early-stage invasive breast cancers and were treated with lumpectomy during 2011 were the study group because of the availability of cost data. Cost data for the following radiation treatment regimens was collected:

• Lumpectomy and conventionally fractionated whole-breast external-beam irradiation (CF-WBI) or traditional RT (27,697 women; 64%)
  • Estimated radiation cost $13,358
• Lumpectomy and hypofractionated whole-breast irradiation (HF-WBI) (5724 women; 13%)
  • Estimated radiation cost $8,328
• Lumpectomy without radiation treatment (9,349 women; 21.6%)
  • Estimated radiation cost $0

Study findings: 

1. About 57% of early-stage breast cancer patients in 2011 were safely eligible for a shorter radiation treatment or no radiation treatment compared to the treatment that they received.
2. The study authors concluded that if these patients had received the least expensive radiation regimens that they were safely eligible for, estimated costs would have been $252.2 million compared to the $420.2 million that was spent in 2011 for a cost savings of almost $170 million.

Limitations:

• One of the biggest limitations of this study is that it generalizes breast cancer patient care without considering specific individual issues. Regardless of the results of this study, the final treatment decision should be made by a patient and her health care providers. 
• This study used data from 2011 and radiation treatment regimens have changed. It is likely that today more patients are being offered a shorter course of radiation for treatment of early breast cancer.
• In addition, this was a retrospective study, meaning the authors used data from previously documented records of past patients instead of collecting patient data specifically for this study. This means that other factors that were unknown to the study authors may have affected the results. 
• Additionally, the authors were unable to estimate the costs of breast cancer recurrence when comparing the different radiation treatment regimens because the database they used did not include recurrence rates or data on treatment after recurrence.
• Finally, the study authors stated that “It is important to acknowledge the risk of perceived overtreatment within this study when women may have in fact received appropriate care. Clinical decisions made by the treating team are often based on patient factors and features of the disease that are not captured within large national databases…”                     

Conclusions:

This study suggests that health care costs associated with radiation treatment could be reduced if patients received the least expensive radiation regimen for which they were safely eligible. However, this study does not capture all the factors that go into a treatment decision. Individuals who are genetically predisposed to breast cancer should know that recurrence rates are higher for mutation carriers who undergo lumpectomy and radiation therapy. Women should continue to work with their health care providers to determine the treatment that is best for them.

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Posted 6/20/17