Niska Joshua R, Keole Sameer R, Pockaj Barbara A, Halyard Michele Y, Patel Samir H, Northfelt Donald W, Gray Richard J, Wasif Nabil, Vargas Carlos E, Wong William W
Department of Radiation Oncology.
Division of General Surgery.
Breast Cancer (Dove Med Press). 2018 Feb 9;10:31-37. doi: 10.2147/BCTT.S153117. eCollection 2018.
Recent trials in early-stage breast cancer support hypofractionated whole-breast radiotherapy (WBRT) as part of breast-conserving therapy (BCT). Evidence also suggests that radiotherapy (RT) omission may be reasonable for some patients over 70 years. Among radiation-delivery techniques, intensity-modulated RT (IMRT) is more expensive than 3-dimensional conformal RT (3DCRT). Based on this evidence, in 2013, the American Society for Radiation Oncology (ASTRO) recommended hypofractionated schedules for women aged ≥50 years with early-stage breast cancer and avoiding routine use of IMRT for WBRT. To assess response to level I evidence and adherence to ASTRO recommendations, we evaluated the pattern of RT use for early-stage breast cancer at our National Comprehensive Cancer Network institution from 2006 to 2008 and 2011 to 2013 and compared the results with national trends.
Data from a prospective database were extracted to include patients treated with BCT, aged ≥50 years, with histologic findings of invasive ductal carcinoma, stage T1-T2N0M0, estrogen receptor-positive, and HER2 normal. We retrospectively reviewed the medical records and estimated costs based on 2016 Hospital Outpatient Prospective Payment System (technical fees) and Medicare Physician Fee Schedule (professional fees).
Among 55 cases from 2006 to 2008, treatment regimens were 11% hypofractionated, 69% traditional schedule, and 20% RT omission (29% of patients were aged >70 years). Among 83 cases from 2011 to 2013, treatment regimens were 54% hypofractionated, 19% traditional schedule, and 27% RT omission (48% of patients were aged >70 years). 3DCRT was used for all WBRT treatments. Direct medical cost estimates were as follows: 15 fractions 3DCRT, $7,197.87; 15 fractions IMRT, $11,232.33; 25 fractions 3DCRT, $9,731.39; and 25 fractions IMRT, $16,877.45.
Despite apparent resistance to shorter radiation schedules in the United States, we demonstrate that rapid practice change in response to level I evidence is feasible. Wider adoption of evidence-based guidelines in early-stage breast cancer may substantially lower health care costs and improve convenience for patients without sacrificing oncologic outcomes.
近期针对早期乳腺癌的试验支持将大分割全乳放疗（WBRT）作为保乳治疗（BCT）的一部分。证据还表明，对于一些70岁以上的患者，省略放疗（RT）可能是合理的。在放疗技术中，调强放疗（IMRT）比三维适形放疗（3DCRT）成本更高。基于此证据，2013年，美国放射肿瘤学会（ASTRO）建议对年龄≥50岁的早期乳腺癌女性采用大分割放疗方案，并避免在WBRT中常规使用IMRT。为了评估对一级证据的反应以及对ASTRO建议的遵循情况，我们评估了2006年至2008年以及2011年至2013年在我们国家综合癌症网络机构中早期乳腺癌的放疗使用模式，并将结果与全国趋势进行比较。
从前瞻性数据库中提取数据，纳入接受BCT治疗、年龄≥50岁、组织学检查为浸润性导管癌、T1 - T2N0M0期、雌激素受体阳性且HER2正常的患者。我们回顾性审查了病历，并根据2016年医院门诊前瞻性支付系统（技术费用）和医疗保险医师费用表（专业费用）估算成本。
在2006年至2008年的55例病例中，治疗方案为11%大分割、69%传统方案和20%省略放疗（29%的患者年龄>70岁）。在2011年至2013年的83例病例中，治疗方案为54%大分割、19%传统方案和27%省略放疗（48%的患者年龄>70岁）。所有WBRT治疗均使用3DCRT。直接医疗成本估算如下：15次分割的3DCRT为7197.87美元；15次分割的IMRT为11232.33美元；25次分割的3DCRT为9731.39美元；25次分割的IMRT为16877.45美元。
尽管在美国对较短放疗方案存在明显抵触，但我们证明了根据一级证据快速改变实践是可行的。在早期乳腺癌中更广泛地采用循证指南可能会大幅降低医疗成本，并在不牺牲肿瘤治疗效果的情况下提高患者的便利性。
