IMRT for Breast Cancer Fell After 2013 Statement Against Routine Use

By Anne Harding

November 09, 2019

NEW YORK (Reuters Health) - Breast-cancer patients were less likely to receive intensity-modulated radiation therapy (IMRT) as part of breast-conserving treatment after a 2013 Choosing Wisely recommendation against it, new research shows.

"It looks like the recommendation made a difference," Dr. David H. Howard of Emory University in Atlanta, one of the study's authors, told Reuters Health by phone.

IMRT quickly became a popular alternative to three-dimensional (3D) conformal RT in the early 2000s, Dr. Howard and his team note in the Journal of the National Cancer Institute, online October 24. However, they add, there was no evidence that IMRT was more efficacious or less toxic than the standard approach for most patients.

In 2013, the American Society for Radiation Oncology stated that IMRT should not be routinely used instead of 3D conformal RT for whole-breast radiotherapy in breast-cancer patients receiving breast-conserving therapy.

To investigate the impact of the recommendation, the authors looked at SEER-Medicare data on more than 13,000 breast-cancer patients diagnosed in 2012-2015 and treated with RT after breast-conserving surgery; 43.1% received treatment before the Choosing Wisely recommendation was issued, and 56.9% were treated afterwards. Just under one-third were treated at freestanding clinics and the rest received care at hospital-based clinics.

The percentage of patients receiving IMRT declined from 17.6% in 2012 to 10.3% in 2015.

Overall, the likelihood that a patient would receive IMRT in the post-recommendation period was 4.9 percentage points lower than before the recommendation was issued (P<0.001).

The drop in IMRT use was 6.1 percentage points for patients treated at freestanding clinics and 4.6 points at hospital-based clinics, both significant decreases.

"The recommendation doesn't say to never use it, but it should probably be used fairly rarely," Dr. Howard said. "There's still a lot of breast-cancer patients who receive IMRT."

Reimbursement rates for IMRT used to be much higher than for standard RT, he added, but Medicare has since cut reimbursement.

In 2020, Dr. Howard noted, 40% of all U.S. radiotherapy clinics will be randomly assigned to a new payment model in which Medicare pays the same amount for radiation treatment, regardless of the type of treatment received. "That has the potential to really upend radiation oncology practice and change physician incentives," he said.

"The pendulum is swinging toward successful implementation of high-value care for breast-cancer patients in the United States," Dr. Grace Li Smith of The University of Texas M.D. Anderson Cancer Center in Houston, who co-authored an editorial accompanying the study, told Reuters Health by email. "In addition, within the context of the rising priority of promoting value in oncology care, the field of radiation oncology needs to prepare for and embrace upcoming alternative payment models."

The National Cancer Institute funded the study.


J Natl Cancer Inst 2019.