Chapman Bhavana V, Rajagopalan Malolan S, Heron Dwight E, Flickinger John C, Beriwal Sushil
Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
Int J Radiat Oncol Biol Phys. 2015 Nov 15;93(4):854-61. doi: 10.1016/j.ijrobp.2015.08.013. Epub 2015 Aug 7.
Hypofractionated whole-breast irradiation (HF-WBI) remains underutilized in the United States despite support by multiple clinical trials. We evaluated the success of iterative modifications of our breast cancer clinical pathway on the adoption of HF-WBI in a large, integrated radiation oncology network.
The breast clinical pathway was modified in January 2011 (Amendment 1) to recommend HF-WBI as the first option for women ≥70 of age with stages 0 to IIA, while maintaining conventional fractionation (CF) as a pathway-concordant secondary option. In January 2013 (Amendment 2), the pathway's HF-WBI recommendation was extended to women ≥50 years of age. In January 2014 (Amendment 3), the pathway mandated HF-WBI as the only pathway-concordant option in women ≥50 years of age, and all pathway-discordant plans were subject to peer review and justification. Women ≥50 years of age with ductal carcinoma in situ or invasive breast cancer who underwent breast conserving surgery and adjuvant WBI were included in this analysis.
We identified 5112 patients from 2009 to 2014 who met inclusion criteria. From 2009 to 2012, the overall HF-WBI use rate was 8.3%. Following Amendments 2 and 3 (2013 and 2014, respectively), HF-WBI use significantly increased to 21.8% (17.3% in the community, 39.7% at academic sites) and 76.7% (75.5% in the community, 81.4% at academic sites), respectively (P<.001). Compared to 2009 to 2012, the relative risk of using HF-WBI was 7.9 (95% confidence interval: 7.1-8.6, P<.001) and 10.7 (95% CI: 10.3-11.0, P<.001), respectively, after Amendments 2 and 3, respectively. Age ≥70 and treatment at an academic site increased the likelihood of receiving HF-WBI in 2009 to 2012 and following Amendment 2 (P<.001).
This study demonstrates the transformative effect of a clinical pathway on patterns of care for breast radiation therapy. Although our initial HF-WBI use rate was low (8%-22%) and consistent with national rates, the clinical pathway approach dramatically increased adoption rate to >75%. In contrast to passive guidelines, clinical pathways serve as active tools to promote current best practices.
尽管多项临床试验提供了支持，但美国大分割全乳放疗（HF-WBI）的应用仍未得到充分利用。我们评估了在一个大型综合放射肿瘤学网络中，对乳腺癌临床路径进行迭代修改以采用HF-WBI的成效。
2011年1月（修订版1）对乳腺临床路径进行了修改，推荐HF-WBI作为年龄≥70岁、0至IIA期女性的首选方案，同时将传统分割放疗（CF）作为路径一致的次选方案。2013年1月（修订版2），该路径对HF-WBI的推荐扩展至年龄≥50岁的女性。2014年1月（修订版3），该路径规定HF-WBI为年龄≥50岁女性唯一的路径一致方案，所有不符合路径的计划都需经过同行评审并说明理由。纳入分析的是年龄≥50岁、接受保乳手术及辅助性全乳放疗的导管原位癌或浸润性乳腺癌女性患者。
我们确定了2009年至2014年期间符合纳入标准的5112例患者。2009年至2012年，HF-WBI的总体使用率为8.3%。在修订版2和3（分别为2013年和2014年）之后，HF-WBI的使用率显著提高，分别达到21.8%（社区为17.3%，学术机构为39.7%）和76.7%（社区为75.5%，学术机构为81.4%）（P<0.001）。与2009年至2012年相比，修订版2和3之后使用HF-WBI的相对风险分别为7.9（95%置信区间：7.1-8.6，P<0.001）和10.7（95%置信区间：10.3-11.0，P<0.001）。在2009年至2012年以及修订版2之后，年龄≥70岁和在学术机构接受治疗增加了接受HF-WBI的可能性（P<0.001）。
本研究证明了临床路径对乳腺癌放疗护理模式的变革性影响。尽管我们最初的HF-WBI使用率较低（8%-22%）且与全国水平一致，但临床路径方法显著提高了采用率，使其超过75%。与被动指南不同，临床路径是促进当前最佳实践的积极工具。
