Has Choosing Wisely Altered American Breast Cancer Practice?

Nick Mulcahy

September 24, 2014

SAN FRANCISCO — The Choosing Wisely campaign to reduce wasteful and non-evidence-based medical treatment in the United States has received a great deal of media coverage since it began 4 years ago.

But has the campaign actually affected clinical practice?

Possibly, according to research presented here at the American Society for Radiation Oncology (ASTRO) 56th Annual Meeting.

A shorter, less costly, and more convenient schedule of radiation therapy for early-stage breast cancer, known as hypofractionation, was prescribed by clinicians significantly more often after being championed by the campaign in 2013.

Specifically, the rate of hypofractionation prescription increased from 9.67% of eligible patients before Choosing Wisely started in radiation oncology to 21.30% after the campaign (P = .0084).

The study only involved 322 eligible patients from a private insurance database, which limits its authority, acknowledged lead author Heather Curry, MD, director of radiation oncology at eviti, Inc., an oncology decision-support company in Philadelphia.

"Although our study had a small sample size, I think it gives some 'real-time' insight into how current practice patterns have evolved since last year's Choosing Wisely. It will be several years before larger databases, like SEER–Medicare, will be available for analysis," Dr. Curry told Medscape Medical News.

In addition, she said, the study cannot prove a cause-and-effect relation.

But the review of the data, which involved medical insurance authorizations from 9 payers that collectively cover 50 states, "does show a general population" in the United States, Dr. Curry pointed out.

ASTRO's Role

At its 2013 annual meeting, ASTRO recommended that oncologists not initiate whole-breast radiotherapy as part of breast-conservation therapy in women 50 years or older with early-stage invasive breast cancer without considering shorter treatment schedules.

In short, they recommended that hypofractionated radiotherapy (3 to 4 weeks) be considered for these patients before any use of a conventionally fractionated schedule (6 to 8 weeks).

The advice was part of ASTRO's initial participation in the Choosing Wisely campaign, an initiative of the American Board of Internal Medicine Foundation to reduce waste and unnecessary cost in medical practice.

This year, Dr. Curry and 2 colleagues from the Department of Radiation Oncology at the University of Michigan in Ann Arbor decided to see whether Choosing Wisely was influencing breast cancer care.

Clinical trials have established the efficacy of hypofractionated regimens as part of breast-conserving therapy, Dr. Curry told the ASTRO audience. But "use of hypofractionated regimens in the United States remains low," she reported.

In their study, the team reviewed and assessed treatment requests submitted for preauthorization through a nationally used Web-based application developed by eviti, Inc.

During the study period (June 2011 to June 2014), there were 1636 radiation treatment requests for the management of breast cancer. Of those, 869 were for breast-conserving therapy, and 322 (37%) of those patients were considered eligible for hypofractionation.

To be eligible for hypofractionation (defined as a daily fraction size of at least 2.5 Gy), patients had to be receiving adjuvant breast radiation for breast-conserving therapy for stage I to IIA breast cancer and be 50 years or older.

Overall, 16.7% of all patients undergoing breast-conserving therapy (including those younger than 50 years or with tumors that were stage IIA or higher) and 11.3% of eligible patients were prescribed hypofractionation.

Notably, the rate of hypofractionation prescribing before and after Choosing Wisely did not differ significantly for the cohort of patients undergoing breast-conserving therapy (15.6% vs 18.9%; P = .93).

As noted above, the rate only differed significantly for the patients actually eligible for hypofractionated radiotherapy.

A potential confounder in this study is the fact that positive results from a major clinical trial of hypofractionated radiotherapy in this setting were published at the same time as ASTRO made its first Choosing Wisely recommendations, Dr. Curry said.

These were 10-year results, from the British START (Standardization of Breast Radiotherapy) trials, which showed that 3 weeks of adjuvant radiotherapy for early-stage breast cancer is as effective and safe as 5 weeks.

However, although the START results were published in September 2013, they were first presented in December 2012 at the San Antonio Breast Cancer Symposium. Thus, the dissemination of the START results predates, by nearly a year, the Choosing Wisely recommendations issued by ASTRO, suggesting a lesser influence of the study results.

Dr. Curry is an employee of eviti, Inc.

American Society for Radiation Oncology (ASTRO) 56th Annual Meeting: Abstract 130. Presented September 16, 2014.


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