Use Of Hypofractionated Radiation Therapy Research Articles

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

PurposeThe COVID-19 pandemic disrupted medical care. Little is known about how radiation therapy (RT) ordering behavior changed during the pandemic. This study examined: 1. whether there was a change in the rate at which orders for lumpectomy were followed by orders for RT, and 2. whether there was a change in the percentage of RT orders that were for hypofractionated (HF) RT, rather than conventionally fractionated (CF) RT. Materials and MethodsPrior authorization order data from 2019 and 2020, pertaining to patients with commercial and Medicare Advantage health plans were reviewed to determine whether patients had an order for RT in the 90 days following lumpectomy, and if it was for CF or HF RT. 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, region, if the lumpectomy facility was academic, and if the lumpectomy facility was a hospital. ResultsIn 2019, 47.7% (2,200/4,610) of included lumpectomy orders were followed by an RT order within 90 days, in contrast to 45.6% (1,944/4,263) in 2020 (P=0.048). Of the RT orders meeting this study's definition of CF or HF, 75.3% (1,387/1,843) of orders placed in 2019 and 79.0% (1,261/1,597) of orders placed in 2020 were for HF (P=0.011). Adjusted analysis found patients receiving a lumpectomy order in the 1st quarter of 2020 had significantly reduced odds (OR: 0.84; 95% CI: 0.71-0.99) of receiving an order for RT following lumpectomy relative to those with orders placed in the 1st quarter of 2019. Adjusted analysis likewise found significant evidence of increased use of HF RT during the pandemic. 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 RT.

Evaluation of Hypofractionated Radiation Therapy Use and Patient-Reported Outcomes in Men With Nonmetastatic Prostate Cancer in Australia and New Zealand

Randomized clinical trials in prostate cancer have reported noninferior outcomes for hypofractionated radiation therapy (HRT) compared with conventional RT (CRT); however, uptake of HRT across jurisdictions is variable. To evaluate the use of HRT vs CRT in men with nonmetastatic prostate cancer and compare patient-reported outcomes (PROs) at a population level. Registry-based cohort study from the Australian and New Zealand Prostate Cancer Outcomes Registry (PCOR-ANZ). Participants were men with nonmetastatic prostate cancer treated with primary RT (excluding brachytherapy) from January 2016 to December 2019. Data were analyzed in March 2021. HRT defined as 2.5 to 3.3 Gy and CRT defined as 1.7 to 2.3 Gy per fraction. Temporal trends and institutional, clinicopathological, and sociodemographic factors associated with use of HRT were analyzed. PROs were assessed 12 months following RT using the Expanded Prostate Cancer Index Composite (EPIC)-26 Short Form questionnaire. Differences in PROs were analyzed by adjusting for age and National Comprehensive Cancer Network risk category. Of 8305 men identified as receiving primary RT, 6368 met the inclusion criteria for CRT (n = 4482) and HRT (n = 1886). The median age was 73.1 years (IQR, 68.2-77.3 years), 2.6% (168) had low risk, 45.7% (2911) had intermediate risk, 44.5% (2836) had high-/very high-risk, and 7.1% (453) had regional nodal disease. Use of HRT increased from 2.1% (9 of 435) in the first half of 2016 to 52.7% (539 of 1023) in the second half of 2019, with lower uptake in the high-/very high-risk (1.9% [4 of 215] to 42.4% [181 of 427]) compared with the intermediate-risk group (2.2% [4 of 185] to 67.6% [325 of 481]) (odds ratio, 0.26; 95% CI, 0.15-0.45). Substantial variability in the use of HRT for intermediate-risk disease remained at the institutional level (median 53.3%; range, 0%-100%) and clinician level (median 57.9%; range, 0%-100%) in the last 2 years of the study period. There were no clinically significant differences across EPIC-26 urinary and bowel functional domains or bother scores. In this cohort study, use of HRT for prostate cancer increased substantially from 2016. This population-level data demonstrated clinically equivalent PROs and supports the continued implementation of HRT into routine practice. The wide variation in practice observed at the jurisdictional, institutional, and clinician level provides stakeholders with information that may be useful in targeting implementation strategies and benchmarking services.

The Association Between Use of Hypofractionated Radiation Therapy for the Treatment of Prostate Cancer and Treatment Completion

While hypofractionated (HF) radiation therapy (RT) is recognized as a suitable treatment for low and intermediate risk prostate cancer, it is not yet the standard of care. As HF RT requires the patient to attend fewer appointments, it is potentially easier for patients to complete than conventional fractionation (CF) RT. Since noncompletion of RT has been shown to lead to inferior outcomes, use of HF RT may be a way to increase treatment adherence. This study examines whether there is a difference in treatment completion rates for HF RT versus CF RT in the context of prostate cancer.Radiation therapy order data from a prior authorization program and health plan claims data were extracted. The data related to patients belonging to commercial and Medicare Advantage health plans from a national organization. The patients included had early-stage prostate cancer, had not had prostatectomy, were not receiving palliative care, had no prior prostate cancer RT orders, and received their order for RT between July 1st, 2016 and September 30th, 2019. Orders were categorized as HF if they were authorized for 5 to 28 fractions of RT, and CF if they were authorized for 29 to 48 fractions. Each RT order was assigned a target date for completion, and completion was assessed on the basis of whether the patient had received the number of fractions authorized by that date. Patients with orders for 5 fractions were considered to have completed treatment if they received 3+ fractions, as these were stereotactic body RT regimens that are adjusted based upon treatment response. A Chi-square test was used to evaluate the association between the authorized regimen and completion. A multivariate logistic regression was used to assess the same, after controlling for age, urbanicity, the median income of the patient's home ZIP code, if the order was placed at a hospital, and if the ordering facility's name suggested an academic affiliation. Finally, a multivariate logistic regression was used to assess whether any of the control variables were associated with the authorization of a HF regimen.Of the 936 orders included, 309 (33.0%) were for HF and 627 (67.0%) were for CF. The completion rate significantly (P < 0.01) differed between the groups; 64.7% (200/309) for HF orders and 55.8% (350/627) for CF orders. Multivariate analysis found HF orders were significantly associated with treatment completion, relative to CF orders; 1.49 (95% CI: 1.12-1.99) adjusted odds. None of the other covariates were significantly associated with completion. Patients had significantly higher odds of having an order for HF if they came from a < $40,000 median income ZIP code (OR: 1.40; 95% CI: 1.01-1.93), or if the site of service at which the order was placed was a hospital (OR: 1.75; 95% CI: 1.26-2.42).Patients with orders for HF regimens completed their RT more frequently than patients with orders for CF regimens. The potential for greater treatment adherence should be considered as a possible benefit of HF.

Rate of Whole-Breast Hypofractionated Radiation Therapy Before Versus After Virtual Tumor Board Implementation.

The virtual tumor board (VTB) is a multidisciplinary group of specialist physicians who remotely educate the treating physician on the development of an evidence-based cancer treatment plan that will enhance patient outcomes according to the available literature. The use of hypofractionated (HF) radiation therapy (RT) is a preferred approach according to National Comprehensive Cancer Network guidelines and is encouraged by the VTB, when appropriate. An observational, cohort study using prior authorization and claims data were conducted to show how the relative use of HF and conventional fractionated (CF) RT changed after the implementation of the VTB. Orders and claims for qualifying patients from 1 year before launch (August 2016) to 1 year after launch (August 2018) of the VTB were extracted. Claims were examined to observe which patients received CF (28-35 fractions) versus HF (15-21 fractions) RT. χ2 tests were used to assess the association between time period and the ordering and use of HF RT. Logistic regressions were used to test the association, after adjusting for the patient's age, urbanicity, local average income, and the RT modality used. After implementation, we observed a significantly higher percentage of orders for HF RT (60.3% [n = 1,254 of 2,079] v 53.2% [n = 1,010 of 1,899]; P < .001) and claims for HF RT (71.5% [n = 1,143 of 1,598] v 59.0% [n = 941 of 1,595]; P < .001). Relative to before implementation, the adjusted odds of an order for HF RT was 1.35 (CI, 1.19 to 1.54), and the adjusted odds of a claim for HF RT was 1.76 (CI, 1.52 to 2.04). After the VTB was implemented, there was a significant increase in HF RT orders and claims.

Hypofractionated radiation treatment for breast cancer: The time is now.

While there is now Level I data with long-term follow-up supporting the routine use of hypofractionated (HF) whole-breast radiation therapy (WBRT) after breast-conserving surgery, its adoption has been slow and variable. This article will review the literature supporting the efficacy and safety of hypofractionated radiation for breast cancer, discuss the radiobiological rationale specific to breast tumors, and make an argument for justifying the routine adoption of shorter, HF-WBRT courses when delivering breast radiation. Data using HF with regional nodal irradiation and in the post-mastectomy setting will also be reviewed. The aim is to provide an in-depth understanding of the use of hypofractionated radiation therapy for breast cancer, its applicability, and topics warranting future research.

Breast Conservation and Hypofractionation in Women with Hereditary Breast Cancer

There is limited data on the use of breast conservation (BC) in women with non-BRCA related hereditary breast cancer (HBC) and on the use of hypofractionated radiation therapy (HRT) in women with HBC whether BRCA-related or not. This study examines the use of HRT as a component of BC in HBC with regard to outcomes and toxicity in women with germline DNA mutations that may confer increased risk of radio-sensitivity. From 2003-2015, 1303 patients were enrolled in 4 prospective protocols investigating HRT with a daily or weekly concomitant boost. Additional patients were identified through retrospective chart review. We identified patients who had genetic testing in this analysis and separated them into 2 groups: those with deleterious genetic mutations (MUT) and those with no mutation, benign variants, or variants of uncertain significance (NM). Overall survival (OS), Disease free survival (DFS), and Local recurrence free survival (LRFS) were estimated using the Kaplan Meier method. Patients with follow up <6 months were excluded for cosmetic endpoints. Clinician rated cosmesis, recorded on a scale from 1-4 (RTOG/Harvard scale) and patient rated cosmesis from 1-4 was collected. There were 329 patients with genetic testing, 300 with NM, and 29 with MUT. 98% of patients were enrolled on the prospective protocols. The MUT group included BRCA1 (21%), BRCA2 (28%), BRCA unclassified (10.3%), CHEK2 (17%), BRIP1 (7%), and 1 patient each (3%) with MUTYH, NF1, PALB2 and MUTYH, APC, and PMS2 mutations. There were no significant differences in baseline characteristics including race, stage, grade, estrogen or HER-2 receptor, or adjuvant therapy between the two groups with the exception of higher rates of progesterone receptor negativity in the MUT group and a higher frequency of a weekly concomitant boost (vs. daily concomitant boost) in the NM group. Median follow up was 90 months (mo) (MUT) and 74 mos for disease outcomes. There were no differences in OS, DFS, and LRFS. There was a higher rate of non-breast secondary cancer in the MUT group (21%) as compared to NM (4%) (p<0.001). With regard to clinician-rated cosmesis, rates of poor/fair cosmesis at a median follow up of 51 mo (MUT) and 48 mo (NM) were 13% (MUT) vs. 10% (NM) (p=0.09). Rates of patient rated cosmesis (median follow up 53 mo GM, 48 mo NM) of poor/fair were 13% (MUT) vs. 10% (NM) (p=0.81). There were no significant differences in the % grade ≥2 late toxicity in MUT vs NM: symmetry 11 vs. 7, edema 0 vs 1, skin thickening 0 vs 2, fibrosis 4 vs 3, retraction 15 vs 5, telangiectasia 4 vs 4, dimpling 0 vs 1, pigmentation changes 4 vs 1. There were no differences in disease-related outcomes, clinician and patient-rated cosmesis, or late toxicity between patients with known deleterious mutations and no mutations or benign variants. Though the numbers are small, this study provides preliminary data on the safety of hypofractionation in women with HBC.

Impact of Peer Review on Use of Hypofractionated Regimens for Early-Stage Breast Cancer for Patients at a Tertiary Care Academic Medical Center and Its Community-Based Affiliates.

Data have demonstrated that hypofractionated radiation therapy (HFRT) and conventionally fractionated radiation therapy regimens are equivalent with respect to outcomes. Efforts to increase HFRT use have had mixed success. We implemented a prospective peer review chart rounds integrating all practice sites and reviewed the use of HFRT in an attempt to identify potential predictors of use. Patients treated with whole-breast radiation therapy within our cancer care network from January 2016 to June 2017 were evaluated. Radiation courses with a dose per fraction of greater than 2 Gy were considered HFRT, whereas those with a dose per fraction of less than or equal to 2 Gy were considered as conventionally fractionated radiation therapy. Patient, provider, and tumor characteristics were categorized by use of HFRT and compared between groups using a χ2 test or two-tailed t test. A total of 349 consecutive patients were identified. All 120 patients treated at the main academic site received HFRT. There was significant variation in use of HFRT among community-based providers (28% to 100%; P < .001). There was increased use of HFRT after implementation of institution-wide prospective peer review (66% v 81% before and after implementation, respectively; P = .001). Age, tumor grade, chemotherapy receipt, surgeon type (academic v community), and treatment after implementation of peer review all correlated with HFRT use. On multivariable analysis, treatment after implementation of peer review ( P < .001) remained a significant predictor of HFRT use, as did age ( P = .005), tumor grade ( P = .013), and surgeon type ( P < .001). Significant variation persists in the use of HFRT among providers. Increased awareness and oversight through prospective peer review may be useful in improving compliance to HFRT. Expanding these efforts to include education of referring surgeons may be helpful.