Adoption of hypofractionated radiation therapy for early breast cancer in private practice: the GenesisCare experience 2014–2106

Abstract

Introduction: Cancer Australia guidelines recommend that hypofractionation should be considered for women over the age of 50 years with early breast cancer. GenesisCare is the largest provider of radiation therapy services in Australia. This study aimed to investigate variation in hypofractionation across 4 states encompassing the period when the most recent guidelines had been released. Methods: Patients with T1 N0 and T2 N0 breast cancer who received radiation therapy as adjuvant therapy after breast conservation surgery between 2014 and 2016 were reviewed. Patient, treatment and disease-related variables were included in the univariate and multivariate models together with other potential explanatory variables such as the state, in which the patient was treated, radiation oncologist and distance from the treatment centre. Results: Of 3374 patients included, 44% received a hypofractionated schedule. There was an increase in the use of hypofractionation from 32% in 2014 to 56% in 2016. Older patients were more likely to receive a hypofractionated treatment schedule -75% for patients 80 years and over. Multivariate modelling revealed older age, year of treatment, higher T stage and grade, chemotherapy and the individual radiation oncologist (and state) as independent predictors of the use of hypofractionation. There was no difference in hypofractionation based on laterality. Conclusions: Guidelines from Cancer Australia may impact clinician behaviour. The influence of the individual radiation oncologist remains paramount, and their practice is affected by their immediate colleagues. Subsequent analysis of hypofractionation rates after presentation of these data has resulted in a significant increase in its use.The doctor who treated the most patients in each state was selected for comparison. ‡ All patients in these cohorts received hypofractionation.

Variation in the use of radiotherapy fractionation for breast cancer: Survival outcome and cost implications

“…Our study identified that the residence LHD influenced the use of hypofractionation reflecting variation between facilities, and previous studies have identified prescribing radiation oncologist as a factor [9] , [12] , [24] . Prades et al [24] suggested two reasons for understanding clinicians’ reluctance to adopt hypofractionation regimens; (1) some clinicians perceived newer treatment techniques as ‘another layer of complexity’ that seemed to slow adoption of hypofractionation, (2) quality of evidence is a necessary but not a sufficient condition determining clinician’s behaviour towards hypofractionation including clinical management factors, such as the role of the department head.…”

“…Previous studies in NSW have also identified age, laterality, year, and treating facility as factors that correlated significantly with hypofractionation use in patients with early breast cancer [9,12]. Although our study and previous published studies [8,9,12] showed increase in hypofractionation use over time, this rate of increase is very slow.…”

“…Factors that correlated with increased use of hypofractionation in breast alone included increasing age, laterality (right-sided), later year of treatment (2013), early stage, lower SES, and inner/outer regional areas of residence. Previous studies in NSW have also identified age, laterality, year, and treating facility as factors that correlated significantly with hypofractionation use in patients with early breast cancer [9] , [12] . Although our study and previous published studies [8] , [9] , [12] showed increase in hypofractionation use over time, this rate of increase is very slow.…”

“…There is urgency for improving evidence-based practice because of increasing demand for services from an ageing population, medical science developments and cost escalators [7] . Substantial variation in the adoption of hypofractionation for early stage breast cancer has been observed in Australia and internationally [8] , [9] , [10] , [11] , [12] despite the availability of consensus guidelines. These studies are limited to when the breast alone is treated.…”