The Lynx Group

Newer, More Costly Radiation Technologies Adopted in Elderly Patients with Breast Cancer

November 2012, Vol 3, No 8

Boston, MA—The patterns of use of radiotherapy have changed over time in elderly patients with stage I breast cancer, and these changes have financial implications for the healthcare system. In elderly patients with favorable-risk breast cancer, the use of intensity modulated radiation therapy (IMRT) and brachytherapy steadily increased from 2001 to 2007, while the use of standard external beam radiation therapy (EBRT) decreased. Data are lacking on whether the newer technologies improve outcomes in this patient population. In a study of patients who were enrolled in the Surveillance, Epidemiology and End Results–Medicare database, these utilization patterns led to a cost increase of 63% per patient. The study’s results were reported at the 2012 American Society for Radiation Oncology annual meeting.

In 2007, 52% of patients with favorable-risk breast cancer received EBRT, and 24% received a newer form of therapy. The median cost of EBRT was $6000 per patient compared with $12,469 for IMRT and $13,981 for brachytherapy, said Kenneth B. Roberts, MD, Associate Professor of Therapeutic Radiology and Medical Director, Yale-New Haven Shoreline Medical Center, CT.

“The incremental cost to our nation for new radiation therapy modalities in 2007 was $31 billion. We need to determine if the benefit is commensurate with the increased cost,” stated Dr Roberts. “Further study is needed to explore radiation modalities in this low-risk population.”

The CALGB C9343 trial, which was published in 2004, included women aged ≥70 years who had clinical stage T1 cancer and negative nodes treated with lumpectomy with negative margins. The 10-year follow-up showed that the local recurrence rate was 2% for those treated with radiation versus 9% for those who did not receive radiation.

Dr Roberts coauthored a study showing that this trial had no effect on the use of radiation in favorable-risk patients. “Radiation use remained stable even in patients with low life expectancy,” he said.

Over the past decade, new treatments have been adopted—including accelerated partial-breast irradiation and brachytherapy—without much evidence to support their use, Dr Roberts noted. The present study was conducted to determine temporal trends in the use of technology and the associated costs in elderly patients with favorable-risk breast cancer.

This new study included 12,925 women (mean age, 77.7 years; range, 70-94 years) with stage I breast cancer who were undergoing lumpectomy. Their tumor size was <2 cm, and all cancers were estrogen receptor positive. Of the total patients, 67% received some form of radiation therapy.

The utilization patterns changed over time. In 2007, 24% of the patients received no radiotherapy, and progressive increases in brachytherapy (11.2%) and IMRT (12.4%) were seen. The use of standard EBRT decreased from 76% in 2001 to 52% in 2007.

Fewer women aged ≥85 years received radiation therapy, but even in this group there were temporal changes; in 2008, 8.8% were treated with brachytherapy, 5.3% with IMRT, and 21.2% received standard EBRT. The study did not include data on quality of life and toxicity.

Meena S. Moran, MD, Associate Professor of Therapeutic Radiology and Assistant Clinical Professor of Nursing, Yale School of Medicine, and Medical Director, Radiation Oncology at William W. Backus Hospital, CT, commented that this study showed that the utilization of EBRT has decreased in older women, yet these patients are opting for costly newer technologies, with no data to show improved outcomes.

Dr Moran indicated that the real question is how to define “elderly.” Also, it is not clear whether radiation should be omitted in elderly patients with favorable-risk breast cancer. “The decision should encompass tumor characteristics, patient anxiety, and patient goals,” she stated.

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