Utilization trend and regimens of hypofractionated whole breast radiation therapy in the United States

Abstract

Purpose We aimed to evaluate the adoption of hypofractionated whole breast irradiation (HF-WBI) over time and factors related to its adoption for patients undergoing lumpectomy. We also examined whether HF-WBI can increase the overall use of radiotherapy. Methods Using data from the National Cancer Database between 2004 and 2013, we identified 528,051 invasive and 190,431 ductal carcinoma in situ (DCIS) patients who underwent lumpectomy. HF-WBI was defined as 2.5-3.33 Gy/fraction to the breast, whereas conventional therapy (CF-WBI) was defined as 1.8-2.0 Gy/fraction. Results The usage of HF-WBI among invasive cancer patients increased from 0.7% in 2004 to 15.6% in 2013 and among DCIS patients, HF-WBI increased from 0.4% in 2004 to 13.4% in 2013. However, these changes only leaded to a slight increase in the overall use of radiotherapy. Interestingly, for DCIS patients who lived ≥50 miles from hospitals, the uptake of HF-WBI translated to a moderate increase in the overall use of radiotherapy (58% in 2004 to 63% in 2013). Multivariable logistic regression showed that older age, node negative or smaller tumor, living in mountain states, rural area or ≥50 miles from hospitals, and treated in large or academic cancer centers were associated with elevated HF-WBI use. The median duration of finishing radiotherapy for HF-WBI was 26 days, compared to 47 days for CF-WBI. Conclusions Although HF-WBI can save 3 weeks of patient time, its adoption remained low in the US. There was only a slight increase in the overall use of radiotherapy among patients undergoing lumpectomy.

Fractionation in adjuvant radiotherapy for invasive breast cancer and ductal carcinoma in situ in Ontario, Canada from 2009 to 2015

“…A study by Prades et al (n = 34 859) reported 6.7% of patients received HFRT in 2005 compared with 29.0% in 2015 in all breast cancer patients in Catalonia. In a study by Hasan et al (n = 528 051), HFRT in the United States for post‐BCS early‐stage invasive breast cancer patients was only 15.6% in 2013, although a substantial increase from 0.7% in 2004. The use of HFRT in this patient population can still be considered low.…”

“…In the present study, use of HFRT in 2015 for post‐BCS DCIS patients (73.4%) parallels that of invasive breast cancer patients (74.6%). In the United States, a study by Stokes et al (n = 101 615) reported trends of increased HFRT use in patients with DCIS from 4.3% in 2004 to 33.0% in 2014 and a study by Hasan et al (n = 190 431) reported increasing use of HFRT from 0.4% in 2004 to 13.4% in 2013. Current evidence suggests that HFRT use in patients with DCIS is safe; however phase III randomized trials such as the Trans‐Tasman Radiation Oncology Group (TROG) DCIS trial which has not yet been published may strengthen the level of evidence supporting this practice and potentially lead to increased HFRT use.…”

Three-Year Outcomes With Hypofractionated Versus Conventionally Fractionated Whole-Breast Irradiation: Results of a Randomized, Noninferiority Clinical Trial

“…Since 2013, the ASTRO Choosing Wisely Campaign has endorsed considering HF-WBI for such women, 5 but adoption has been slow in the United States. [6][7][8][9] Reticence to embrace HF-WBI has included concerns about the effect of this treatment regimen on cosmesis, particularly when used with a tumor bed boost or in patients who receive chemotherapy or with larger breast size.…”

Radiation Boost After Adjuvant Whole Breast Radiotherapy: Does Evidence Support Practice for Close Margin and Altered Fractionation?

“…Returning to the patterns-of-practice data, an important caveat to interpreting the results previously discussed is that patient characteristics may not have be similar between the groups treated with hypofractionated vs. conventional radiation. Using the same National Cancer Database (NCDB) as Stokes et al ( 16 ) and Zhong et al ( 18 ), Hasan et al ( 42 ) found that hypofractionation was used more commonly in older patients (2.6% age <40 vs. 19.5% age >80; RR 8.40, 95% CI 5.01–14.09), those with node-negative disease (9.8% pN0 vs. 3.3% pN1; RR 0.38, 0.36–0.40), smaller tumors (9.5% ≤ 2.0 cm vs. 5.9% 2.1–5.0 cm; RR 0.78, 0.75–0.81), and lower-grade cancers [10.9% Grade 1 vs. 9.1% Grade 2 (RR 0.87, 0.85–0.90) vs. 5.8% Grade 3 (RR 0.79, 0.76–0.83)]. However, a survey of 2,150 randomly selected members of the American Society for Radiation Oncology suggests that the decision to forgo boost may still be made solely on the basis of WBI fractionation schedule.…”