Safe Way to Save $164 Million a Year in Breast Cancer

Nick Mulcahy

March 15, 2017

More than half of American women with early-stage breast cancer received more radiation therapy (RT) than evidence required. Scaling back treatments could provide $164 million in cost savings, according to new research using 2011 data.

Specifically, 57% of those patients were eligible for shorter courses of RT or omission of RT, depending on disease stage and patient age, but they were treated more extensively anyway, say the study authors, led by Rachel Greenup, MD, MPH, of the Duke Cancer Institute in Durham North Carolina.

The $164 million in savings was declared after the investigators found that estimated RT costs for this early-stage breast cancer population were $420.2 million during 2011, compared with $256.2 million had women been treated with the least expensive regimens for which they were safely eligible.

"Our study provides an example of a win-win situation, where patients can receive high-quality, evidence-based cancer care while also reducing the treatment burden for patients and the healthcare system," Dr Greenup said in a press statement.

She also said the savings are further relevant when seen as part of the overall US expenditure on breast cancer, which is projected by the National Cancer Institute to reach $20 billion in 2020.

The new study was published online March 14 in the Journal of Oncology Practice.

The Duke researchers looked at 43,247 cases of early-stage (T1-T2N0) breast cancer treated with lumpectomy in 2011 in the National Cancer Database. The women were considered candidates for three evidence-based adjuvant RT regimens: conventionally fractionated whole-breast irradiation (WBI) (64%), hypofractionated whole-breast irradiation (13.3%), and omission of RT (21.6%).

Notably, another RT regimen, accelerated partial breast radiation (1.1% of the total), was not included in the calculations because it currently awaits level one evidence.

Women aged 50 years or older with T1-T2N0 invasive breast cancers were deemed eligible for hypofractionated WBI; women aged 70 years and older with T1N0, ER-positive breast cancers were considered eligible for omission of RT; and all remaining women defaulted to conventionally fractionated WBI.

The authors point out that previous studies have shown that locoregional recurrence and overall survival rates are equivalent for these early-stage patients when treated with a 4-week course of hypofractionated WBI vs the conventional 6-week regimen (N Engl J Med. 2010;362:513-520; Lancet Oncol. 2013;14:1086-1094).

Another study demonstrated that for patients aged 70 years and older, there was no additional survival benefit when radiation therapy was added to treatment with tamoxifen after lumpectomy (J Clin Oncol. 2013;31:2382-2387).

The researchers used Medicare reimbursement data to estimate the costs of RT per patient: about $13,000 for the conventional, 6-week RT regimen; about $8,000 for the 4-week RT regimen; and zero when RT was omitted.

The authors say that the Medicare costs may underestimate the economic implications of additional treatment in light of charges and patient out-of-pocket costs.

But they also say that the National Cancer Database does not completely capture clinical details important to decision making. "As a result, our findings may not account for care that was appropriately delivered based on individual patient variables," they acknowledge.

At the same time, the authors highlight the fact that major organizations support use of less extensive radiation in this setting. For example, as part of the Choosing Wisely initiative, the American Society of Radiation Oncology has recommended that clinicians consider use of shorter treatment regimens for women aged 50 years and older with early-stage invasive cancer.

The study received funding support from the Building Interdisciplinary Research in Women's Health award from Duke. Dr Greenup has a financial relationship with Novartis. Mutliple coauthors also have relationships with industry.

J Oncol Pract. Published online March 14, 2017. Full text

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