Study finds one breast cancer radiation therapy leads others in cost-effectiveness, quality of life

In a study of three radiation therapies for early-stage breast cancer, one treatment option stands out as offering the most value based on factors including health outcomes, cost-effectiveness and quality of life.

The treatment, known as hypofractionated whole breast irradiation, or HF-WBI, also requires fewer patient visits. The study findings appear today in the Journal of the National Cancer Institute.

Patients are increasingly interested in high-quality care at a relatively low cost, especially with rising patient co-payments and a rise in high-deductible insurance plans, said lead author Ashish A. Deshmukh, Ph.D., M.P.H., an assistant professor in the department of health services research, management and policy in the UF College of Public Health and Health Professions, part of UF Health.

“We hope this study will provide important information both for patients and for providers who are making decisions about what is best for their patients,” he said. “Based on our findings, there is no reason at all to use conventional radiation therapy for early-stage breast cancer.”

After a lumpectomy is performed to remove the cancerous portion of the breast in patients with early-stage cancer, physicians typically prescribe radiation therapy to help prevent the cancer from coming back. In conventionally fractionated whole breast irradiation therapy, patients receive daily radiation treatments over a five- to six-week period. With HF-WBI, patients receive the same overall dose of radiation but in a condensed treatment period of three to four weeks. A third and relatively new treatment, intraoperative radiotherapy, is given as a single dose of radiation at the time of the lumpectomy surgery.

Previous clinical studies have found that HF-WBI is as effective as conventional radiation therapy in treating early-stage breast cancer, and organizations such as the National Comprehensive Cancer Network and the American Society for Radiation Oncology recommend HF-WBI over the conventional radiation treatment. Yet, health care providers have been slow to adopt HF-WBI, with only about a third of patients who are candidates for HF-WBI receiving the treatment.

There are likely a number of reasons for this, said the study’s senior author Anna Likhacheva, M.D., M.P.H., a staff radiation oncologist at Banner MD Anderson Cancer Center in Gilbert, Arizona, and an adjunct assistant professor at the University of Texas MD Anderson Cancer Center in Houston. These include the slow diffusion of new data and guidelines to individual practitioners outside of an academic setting, and financial incentives inherent in offering a longer course of treatment through conventional therapy.

“Our current fee-for-service reimbursement structure rewards the use of conventionally fractionated treatment over HF-WBI,” she said. “In general, patients prefer to have shorter treatment courses and would almost uniformly choose the hypofractionated approach if given the option.”

For the study, the researchers built a comprehensive mathematical model of early-stage breast cancer radiation therapy using health outcomes data, including cancer recurrence and mortality data from two large randomized controlled trials of HF-WBI, intraoperative radiotherapy and conventional radiation treatment that followed patients for five years. In addition, they calculated costs from the radiation treatment itself, any future treatment costs associated with recurrence, and patients’ travel costs and lost income from missing work. They also evaluated patients’ quality of life.

“Our objective was to simulate the outcomes that were closest to the real-world scenario,” Deshmukh said.

The researchers determined that of the three current treatment options, HF-WBI offered the highest cost savings, about $3,000 per patient, along with better health outcomes and quality of life.

The team found that the single-dose treatment, intraoperative radiotherapy, may provide cost savings and patient convenience for older patients and those with transportation issues, such as women in rural areas who may not be able to travel for daily radiation therapy visits over a period of weeks.

The study did not find any evidence to support continued use of the conventional radiation treatment for patients with early-stage breast cancer.

In addition to Deshmukh and Likhacheva, study researchers included Shervin M. Shirvani, M.D., M.P.H., of the Banner MD Anderson Cancer Center; Lincy Lal, Ph.D., of the University of Texas Health Science Center School of Public Health; J. Michael Swint, Ph.D., of the University of Texas Health Science Center School of Medicine; and Scott B. Cantor, Ph.D., and Benjamin Smith, M.D., of the University of Texas MD Anderson Cancer Center. The study was supported by a grant from the Janice Davis Gordon Memorial Postdoctoral Fellowship at The University of Texas MD Anderson Cancer Center and the National Institutes of Health.