Abstract
Efficacy of hypofractionated (HF) radiotherapy (RT) in breast cancer has recently been established by randomized trials. We report patterns of care in Utah to identify how patient, tumor, and treatment characteristics may influence prescription patterns. Data from 1,588 patients from nine facilities with 18 providers were retrospectively collected. Conventionally fractionated (CF) RT was defined as >19 fractions with fractions < 200cGy; HF was defined as <19 fractions with fractions >200cGy. Partial breast irradiation (PBI) was defined as external beam RT to 3850cGy in 10 fractions. Patients considered eligible for HF were >45 years with breast separation <25 cm and tumor size <2cm with negative nodes and margins. Analysis utilized Wilcoxon Rank Sum Tests and logistic regression. Of all patients, 83.2% received CF, 12% received HF, and 4.7% received PBI. Based on recent published guidelines, 53.5% of patients were eligible for HF. There were no significant differences with respect to laterality, tissue separation, or medical comorbidities. Calculated odds ratios (OR) for increased use of HF included age (OR 1.05, p<0.001) and lower cancer stage (OR 3.75, p=0.002). Use of HF strongly correlated with increased age, number of miles traveled to clinic (47.8 vs. 21), lower grade, less aggressive surgery, and less chemotherapy. HF RT utilization is increasing over time but only in a segment of eligible patients. We report on changes in practice patterns after recent publication of randomized trial data in an effort to bring awareness to underutilization of HF, and intend to track how this changes over time.
Highlights
1.1 BackgroundConventionally fractionated (CF) whole breast radiotherapy, which typically involves five to six-and-a-half weeks of once daily, radiotherapy, has been a standard of care after lumpectomy since the publication of major randomized trials showing efficacy of breast conserving surgery plus radiotherapy to mastectomy
This study examines patient, facility, disease characteristics and patterns of care amongst the majority of radiation oncology facilities within the state of Utah over the formative years after major randomized trials have published in an effort to help guide quality improvement measures in the future
1,588 women treated with radiotherapy for breast cancer were identified from 2007-2010 in nine radiation facilities across Utah staffed by 15 providers
Summary
Fractionated (CF) whole breast radiotherapy, which typically involves five to six-and-a-half weeks of once daily, (five days a week) radiotherapy, has been a standard of care after lumpectomy since the publication of major randomized trials showing efficacy of breast conserving surgery plus radiotherapy to mastectomy. The problem with five to six and a half weeks of once daily radiotherapy is the burden of cost, emotional distress, and fatigue to patients undergoing prolonged daily treatment. Some reports reveal that an average of 20-30% of North American women forego radiotherapy after receiving lumpectomy (Chuba & Simon, 1997; Malin, Schuster, Kahn, & Brook, 2002), or choose mastectomy over breast preservation (Tuttle, Habermann, Grund, Morris, & Virnig, 2007) due to several factors, including age, psychological distress, quality of life concerns, and cost of undergoing prolonged daily radiotherapy (Dwyer, Hickey, Burmeister, & Burmeister, 2010). The women undergoing the HF regimen reported less anxiety, less transient weight change, and less depression compared to the CF group
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