Incidence and Costs of Shorter Duration vs Conventional Irradiation After Breast Conserving Surgery

Bekelman et al in their study published in JAMA examined claims data from 14 commercial health care plans covering 7.4% of US adult women in 2013.   

They classified patients with early-stage breast cancer treated with lumpectomy and whole breast irradiation (WBI) from 2008 and 2013 into 2 cohorts: (1) the hypofractionation-endorsed cohort (n = 8924) that included patients aged 50 years or older without prior chemotherapy or axillary lymph node involvement and (2) the hypofractionation-permitted cohort (n = 6719) included patients younger than 50 years or those with prior chemotherapy or axillary lymph node involvement. Hypofractionated WBI (3-5 weeks of treatment) vs. conventional WBI (5-7 weeks of treatment).

Hypofractionated WBI increased from 10.6 in 2008 to 34.5% in 2013 in the hypofractionation-endorsed cohort and from 8.1% in 2008 to 21.2% in 2013 in the hypofractionation-permitted cohort. Adjusted mean total health care expenditures in the 1-year after diagnosis were $28747 for hypofractionated and $31641 for conventional WBI in the hypofractionation-endorsed cohort (difference, $2894; $1610-$4234; P < .001) and $64273 for hypofractionated and $72860 for conventional WBI in the hypofractionation-permitted cohort (difference, $8587; $5316-$12 017; P < .001). Adjusted mean total 1-year patient out-of-pocket expenses were not significantly different between hypofractionated vs. conventional WBI in either cohort.

They concluded that in spite the limitations of their study that they innumerate and discuss, hypofractionated WBI which is comparable in clinical efficacy, cosmesis, and toxicity after breast conserving surgery increased among women with early-stage breast cancer in 14 US commercial health care plans between 2008 and 2013. However, only 34.5% of patients with hypofractionation-endorsed and 21.2% with hypofractionation-permitted early-stage breast cancer received hypofractionated WBI in 2013.  Mean total health care expenditures for patients receiving hypofractionated WBI were about 10% less than for patients receiving conventional WBI.

Breast Conservation Therapy provides Better Survival for Early Stage Breast Cancer

Reseach by Agarwal S, et al published in JAMASurgery reports on an analysis of 132 149 patients who were followed between the years 1998 and 2008.  

Breast conservation therapy (lumpectomy and radiation therapy) was used to treat 70% of patients, mastectomy alone was used to treat 27% of patients, and mastectomy with radiation was used to treat 3% of patients. The 5-year breast cancer–specific survival rates of patients who underwent BCT, a mastectomy alone, or a mastectomy with radiation were 97%, 94%, and 90%, respectively (P < .001); the 10-year breast cancer–specific survival rates were 94%, 90%, and 83%, respectively (P < .001). Multivariate analysis showed that women undergoing BCT had a higher survival rate than those undergoing mastectomy alone (hazard ratio, 1.31; P < .001) or mastectomy with radiation (hazard ratio, 1.47; P < .001). 

The authors conclude that patients who underwent BCT versus mastectomy alone or mastectomy and radiation therapy for early stage invasive ductal cancer- defined as having a tumor size of 4 cm or smaller and 3 or less positive lymph nodes- have higher breast cancer specific survival.

Agarwal S, Pappas L, Neumayer M et al; Effect of Breast Conservation Therapy vs Mastectomy on Disease-Specific Survival for Early-Stage Breast Cancer.  JAMA Surg. Published online January 15, 2014

doi:10.1001/jamasurg.2013.3049