Use of Radiation Therapy for the Treatment of Breast Cancer in 2019 vs. 2020

Abstract

Purpose/Objective(s)The COVID-19 pandemic disrupted medical care and reduced access to elective procedures. While prior claims-based research has shown that patients received more conservative care, little is known about how radiation therapy (RT) ordering behavior changed during the pandemic. This study examines whether the rate at which orders for lumpectomy were followed by orders for RT changed from 2019 to 2020, and whether there were changes in the percentage of RT orders that were for hypofractionated (HF) RT, rather than conventional (CF) RT.Materials/MethodsPrior authorization order data pertaining to patients from one national organization's commercial and Medicare Advantage health plans were used to perform the analysis. Included patients were females, aged 18 to 89, who had an order for a lumpectomy in 2019 or 2020. Patients were excluded if they were not continuously enrolled in their health plan for 90 days following lumpectomy. Orders were reviewed to determine whether patients had an order for RT in the 90 days following lumpectomy. Orders were classified as HF if they were for 5 to 21 fractions, CF if they were for 28 or more fractions, and as neither if they were for other numbers of fractions. Univariate analyses were conducted using Chi-square tests, and adjusted analyses were conducted using multivariate logistic regression, controlling for patient age, urbanicity, local median income (<$40,000, $40,000-$80,000, or >$80,000), region (top four CMS regions by enrollment versus all other regions), if the designated lumpectomy facility's name implied an academic affiliation, and if the designated lumpectomy facility was a hospital.ResultsThere were 4,689 patients meeting inclusion criteria in 2019 and 4,383 in 2020, for a total of 9,072. In 2019, 47.1% (2,208/4,689) of patients had an RT order following lumpectomy, versus 44.6% (1,953/4,383) in 2020, a significant difference (P=0.02). Of the patients receiving RT orders meeting the definition of HF or CF, 76.3% (1,475/1,933) of orders in 2019 were for HF, and 80.5% (1,383/1,719) of orders in 2020 were for HF, a significant difference (P<0.01). Adjusted analysis found that patients in 2020 were at significantly reduced odds (OR: 0.91; 95% CI: 0.83-0.99) of receiving an order for RT following lumpectomy, and among orders meeting the definition of HF or CF, there were significantly increased odds that the order was for HF (OR: 1.29; 95% CI: 1.10-1.52). Patient age, region, and receipt of an order for treatment at an academic facility were significantly associated with receipt of an order for RT. Patient age, local median income, and region were all significantly associated with whether CF versus HF RT was ordered.ConclusionIn the population examined, physicians were less likely to order RT following lumpectomy in 2020 than in 2019, and if they did, were more likely to order HF in 2020 than in 2019. This suggests that physician ordering became more conservative in response to the pandemic.