Geographic Disparity in the Use of Hypofractionated Radiation Therapy Among Elderly Women Undergoing Breast Conservation for Invasive Breast Cancer

Abstract

PURPOSE Research demonstrates that the use of short-course (hypofractionated) radiotherapy (RT) breast cancer in the US has lagged behind other countries, despite evidence from randomized trials. This study evaluates geographic heterogeneity in the delivery of hypofractionated radiotherapy among Medicare beneficiaries across the US. METHODS We identified 190,193 patients from the Centers for Medicare and Medicaid Services (CMS) Chronic Conditions Warehouse. The study included patients over age 65 diagnosed with invasive breast cancer treated with breast conservation surgery followed by radiation diagnosed between 2000 and 2012. We analyzed data by hospital referral region based on patient residency zip code. The proportion of women who received hypofractionated RT within each region was analyzed over the study period. Multivariable logistic regression models identified predictors of hypofractionated RT. RESULTS Over the entire study period we found substantial geographic heterogeneity in the use of hypofractionated radiotherapy. The proportion of women receiving hypofractionated breast RT in individual hospital referral regions varied from 0% to 61%. We found no correlation between the use of hypofractionated RT and urban/rural setting or general geographic region. The proportion of hypofractionated RT increased in regions with higher density of radiation oncologists, as well as lower total Medicare reimbursements. CONCLUSIONS This study demonstrates substantial geographic heterogeneity in the use of hypofractionated radiotherapy among elderly women with invasive breast cancer treated with lumpectomy in the US. This heterogeneity persists despite clinical data from multiple randomized trials proving efficacy and safety compared to standard fractionation, and highlights possible inefficiency in healthcare delivery.

Hypofractionated radiation therapy for breast cancer: Preferences amongst radiation oncologists in Europe – Results from an international survey

“…Clinical management factors and financial issues also influence the inconsistent use of HFRT implementation. Healthcare environment, the strength of HFRT recommendations in institutional protocols, implementation of the clinical pathway or active advocacy for the shorter fractionation schedules, access to peer review, continuing medical education and existence of BC-dedicated ROs were all demonstrated as important factors in implementing new evidence-based recommendations [30,[46][47][48]. Similar patterns were reflected in our survey, as HF-WBI was more often preferred by ROs who worked in academic environments and dedicated !50% of their clinical time to patients with BC, thus demonstrating the importance of working context and professional experience.…”

The Impact of Radiation Oncologists on the Early Adoption of Hypofractionated Radiation Therapy for Early-Stage Breast Cancer

“…Owing to wide variations in the patterns of care surrounding fractionation (7,8), multiple randomized trials directly comparing hypofractionation with standard radiation were initiated, with recent long-term results confirming equivalence (9-13). However, despite the development of clinical guidelines by the American Society for Radiation Oncology in 2011 (14) followed by the American Board of Internal Medicine's Choosing Wisely campaign in 2013 (7), the uptake of hypofractionation in the United States has been slow (15,16), with evidence that practice patterns vary widely based on geography (15,17).…”

“…Limited practice-related factors have also been investigated, with treatment in a hospital-based clinic and higher density of radiation oncologists increasing the likelihood of receiving hypofractionation (16,17), whereas overall population density had no impact (15). The impact of providerspecific data, however, is limited to data from a single-state multi-institution study (21).…”

Extended Hypofractionated Cancer Radiation Therapy Against Aged and Non-aged Breast Carcinomas Patients

“…Lower paces of neighborhood repeat, and restricted radiation-actuated horribleness have been accounted for approaches [12]. Schedules utilized in these investigations went from 40 to 44 Gy given in 15 to 16 portions over a 21 days' time frame, with everyday parts of 2.5 to 2.7 Gy [13], [14].…”