Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California.
Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California.
Int J Radiat Oncol Biol Phys. 2017 Mar 1;97(3):571-580. doi: 10.1016/j.ijrobp.2016.11.009. Epub 2016 Nov 15.
Despite multiple randomized trials showing the efficacy of hypofractionated radiation therapy in early-stage breast cancer, the United States has been slow to adopt this treatment. The goal of this study was to evaluate the impact of individual radiation oncologists on the early adoption of hypofractionated radiation therapy for early-stage breast cancer.
We identified 22,233 Medicare beneficiaries with localized breast cancer that was diagnosed from 2004 to 2011 who underwent breast-conserving surgery with adjuvant radiation. Multilevel, multivariable logistic models clustered by radiation oncologist and geographic practice area were used to determine the impact of the provider and geographic region on the likelihood of receiving hypofractionated compared with standard fractionated radiation therapy while controlling for a patient's clinical and demographic covariates. Odds ratios (OR) describe the impact of demographic or clinical covariates, and the median OR (MOR) describes the relative impact of the individual radiation oncologist and geographic region on the likelihood of undergoing hypofractionated radiation therapy.
Among the entire cohort, 2333 women (10.4%) were treated with hypofractionated radiation therapy, with unadjusted rates ranging from 0.0% in the bottom quintile of radiation oncologists to 30.4% in the top quintile. Multivariable analysis found that the individual radiation oncologist (MOR 3.08) had a greater impact on the use of hypofractionation than did geographic region (MOR 2.10) or clinical and demographic variables. The impact of the provider increased from the year 2004 to 2005 (MOR 2.82) to the year 2010 to 2011 (MOR 3.16) despite the publication of long-term randomized trial results in early 2010. Male physician and radiation oncologists treating the highest volume of breast cancer patients were less likely to perform hypofractionation (P<.05).
The individual radiation oncologist strongly influenced the likelihood of a patient's receiving hypofractionated radiation therapy, and this trend increased despite the publication of long-term data showing equivalence to standard fractionation. Future research should focus on physician-related factors that influence this decision.
尽管多项随机试验表明，在早期乳腺癌中采用低分割放射治疗具有疗效，但美国采用这种治疗方法的速度却较为缓慢。本研究旨在评估个体放射肿瘤学家对早期采用低分割放射治疗早期乳腺癌的影响。
我们从 2004 年至 2011 年期间接受保乳手术联合辅助放射治疗的 22233 名局部乳腺癌的 Medicare 受益人群中识别出 22233 名患者。使用按放射肿瘤学家和地理实践区域聚类的多层次、多变量逻辑模型，控制患者的临床和人口统计学协变量，确定提供者和地理区域对接受低分割与标准分割放射治疗的可能性的影响。比值比（OR）描述了人口统计学或临床协变量的影响，中位数 OR（MOR）描述了个体放射肿瘤学家和地理区域对接受低分割放射治疗可能性的相对影响。
在整个队列中，有 2333 名女性（10.4%）接受了低分割放射治疗，未经调整的比例从放射肿瘤学家排名最低的五分位数的 0.0%到排名最高的五分位数的 30.4%不等。多变量分析发现，个体放射肿瘤学家（MOR 3.08）对低分割的应用影响大于地理区域（MOR 2.10）或临床和人口统计学变量。尽管在 2010 年初公布了长期随机试验结果，但从 2004 年至 2005 年（MOR 2.82）到 2010 年至 2011 年（MOR 3.16），提供者的影响逐渐增加。男性医生和治疗乳腺癌患者数量最多的放射肿瘤学家更不可能进行低分割治疗（P<.05）。
个体放射肿瘤学家强烈影响患者接受低分割放射治疗的可能性，尽管公布了长期数据表明与标准分割等效，但这一趋势仍在增加。未来的研究应集中于影响这一决策的与医生相关的因素。
