Intensity modulated radiation therapy following lumpectomy in early-stage breast cancer: Patterns of use and cost consequences among Medicare beneficiaries.

Lia M Halasz,Qin Sun,Joshua A Roth,Jean A Mcdougall,Catherine Fedorenko,Shilpen A Patel,Bernardo H L Goulart,Eugenio Paci

doi:10.1371/journal.pone.0222904

Abstract

PurposeIn 2013, the American Society for Radiation Oncology (ASTRO) issued a Choosing Wisely recommendation against the routine use of intensity modulated radiotherapy (IMRT) for whole breast irradiation. We evaluated IMRT use and subsequent impact on Medicare expenditure in the period immediately preceding this recommendation to provide a baseline measure of IMRT use and associated cost consequences.Methods and materialsSEER records for women ≥66 years with first primary diagnosis of Stage I/II breast cancer (2008–2011) were linked with Medicare claims (2007–2012). Eligibility criteria included lumpectomy within 6 months of diagnosis and radiotherapy within 6 months of lumpectomy. We evaluated IMRT versus conventional radiotherapy (cRT) use overall and by SEER registry (12 sites). We used generalized estimating equations logit models to explore adjusted odds ratios (OR) for associations between clinical, sociodemographic, and health services characteristics and IMRT use. Mean costs were calculated from Medicare allowable costs in the year after diagnosis.ResultsAmong 13,037 women, mean age was 74.4, 50.5% had left-sided breast cancer, and 19.8% received IMRT. IMRT use varied from 0% to 52% across SEER registries. In multivariable analysis, left-sided breast cancer (OR 1.75), living in a big metropolitan area (OR 2.39), living in a census tract with ≤$90,000 median income (OR 1.75), neutral or favorable local coverage determination (OR 3.86, 1.72, respectively), and free-standing treatment facility (OR 3.49) were associated with receipt of IMRT (p<0.001). Mean expenditure in the year after diagnosis was $8,499 greater (p<0.001) among women receiving IMRT versus cRT.ConclusionWe found highly variable use of IMRT and higher expenditure in the year after diagnosis among women treated with IMRT (vs. cRT) with early-stage breast cancer and Medicare insurance. Our findings suggest a considerable opportunity to reduce treatment variation and cost of care while improving alignment between practice and clinical guidelines.

Highlights

The annual cost of cancer care in the United States is projected to reach approximately $175 billion by 2020, a 40% increase from 2010.[1]
Reports on the increasing use of intensity modulated radiation therapy (IMRT) for breast cancer were published leading up to the American Society for Radiation Oncology (ASTRO) Choosing Wisely’ (CW) recommendation in 2013.[16,17,18,19] several Medicare carriers discontinued local coverage decisions (LCDs) that covered IMRT for breast cancer or changed LCDs to only allow IMRT in specific situations around 2008–2009.[20]. Given these changes, the primary objectives of this study were to determine the baseline utilization of IMRT prior to the CW recommendation in 2013, to identify factors associated with CW recommendation adherence, and to estimate the impacts of IMRT use on breast cancer direct medical expenditure
Our findings clearly demonstrate the need for the 2013 CW recommendation, as well how much room for improvement there is in reducing practice variation around IMRT after lumpectomy

Summary

Introduction

The annual cost of cancer care in the United States is projected to reach approximately $175 billion by 2020, a 40% increase from 2010.[1]. High costs impact the ability for patients to receive recommended care and may increase their risk of death.[2] To slow the rising costs of cancer care, there is consensus across the cancer community that the value of cancer care should be considered.[3] This includes assessing the value of new technologies in regard to their marginal benefits, harms, and costs. These types of analyses are relatively common for pharmaceutical interventions, but are less frequently conducted in the case of radiation oncology interventions. In 2013, ASTRO issued a CW recommendation against the routine use of intensity modulated radiation therapy (IMRT) for whole breast radiation therapy

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