ASCO Perspective
Don S. Dizon, MD, ASCO Expert in Breast Cancer
“There are many factors in determining high-quality, high-value care for our patients, including clinical benefit and costs. This study suggests that the tailored use of radiation therapy (including when not to use it) based on clinical evidence represent high quality cancer care, particularly in women 50 years and older who undergo lumpectomy. At the same time, this study demonstrates that this evidence-based approach to treatment also reduces the associated costs. This study further emphasizes the importance of the shared decision-making process between physicians and patients.”

A new study demonstrates that the use of less radiation therapy (RT) for breast cancer patients who have undergone lumpectomy does not negatively impact patient outcomes, and could result in significant reductions in health care costs. These findings, which examine patient eligibility for evidence-based radiation therapies or no RT in the National Cancer Database (NCDB), were published online today in the Journal of Oncology Practice. People living with breast cancer often receive lumpectomy followed by RT instead of a full mastectomy because research has demonstrated that there is no difference in disease-specific or overall survival.

“This study is an important reminder that there are treatment strategies that can retain high quality cancer care, while reducing health care costs,” said study author Rachel Greenup MD, MPH, Director of Breast Fellowship and Assistant Professor of Surgery at Duke University School of Medicine. “There are opportunities in cancer care to align high value care, patient preferences and societal benefits of reduced health care spending.”

About the Study
Researchers accessed the NCDB, a database of clinical and demographic data from tumor registries capturing approximately 70% of all newly diagnosed cancers in the U.S., to identify more than 43,000 women with invasive breast cancers who had received a lumpectomy in 2011. Through analysis, the patients were determined to be candidates for two types of RT or no RT:

Conventional fractionated whole-breast irradiation (a 5-6 week therapy where RT is applied to the whole breast for the first 4-5 weeks and then followed by more focused treatment on the tumor)
Shorter course whole-breast irradiation (accelerated or hypofractionated courses delivered in a 3-4 week therapy by using a higher daily dose of RT to the breast)
No RT at all
The study authors then determined national RT patterns and estimated RT costs using the Medicare Physician Fee Schedule.

Key Findings
Since 2002, numerous studies have been published suggesting that hypofractionated RT regimens with fewer treatments and higher doses of radiation were a safe alternative in carefully selected patients. In 2013, the American Society of Radiation Oncology through the Choosing Wisely campaign recommended considering shorter RT regimens among women with breast cancer who are 50 years and older. Guided by that evidence base, the study authors found:

Within the 43,247 patient cohort, 64% received conventional RT, 14.4% received accelerated or hypofractionated RT and 21.6% received no RT.
The estimated costs for all RT treatments for all 43,247 patients in 2011 were approximately $420.2 million.
Of the patients who were eligible for shorter RT or no RT, 57% underwent treatment with longer, costlier regimens.
Had these patients received the other RT therapies for which they were safely eligible, the overall estimated treatment costs in 2011 would have been $256.2 million.
This shows a potential savings of $164 million or 39% reduction in cost of care for patients.
This analysis is the largest study to date to examine a strategic radiation approach and the potential implications on cost savings.

Next Steps
The authors reported that the study was limited by the fact that the NCDB may not fully capture the experience of patients who elect to receive RT in a different practice than where they received the lumpectomy. In addition, clinical decisions made by patients and physicians are often based on factors that are not fully captured in a large database.

Dr. Greenup also noted that the findings emphasize that that there are “win-win” scenarios in cancer treatment.

“High-quality care is the priority in cancer treatment, but our study suggests that utilization of evidence-based radiation treatment can translate into reductions in health care spending without sacrificing quality,” said Dr. Greenup. “When patients can receive excellent cancer care that reduces the treatment burden and translates into decreased health care costs, that’s high-quality, high-value care.”

The researchers state that patient preference is best maintained when all treatment options are discussed. Dr. Greenup is currently evaluating how costs of cancer care might become part of the shared decision-making process between patients and physicians as women choose treatment for breast cancer.

The study received funding support from the NIH Building Interdisciplinary Research in Women’s Health award.