Newer More Costly Radiation Technologies Adopted in the Elderly

Phoebe Starr

Uncategorized

Patterns of use of radiotherapy have changed over time in elderly patients with stage I breast cancer, and these changes have financial implications for the healthcare system. In elderly patients with favorable-risk breast cancer, use of intensity-modulated radiation therapy (IMRT) and brachytherapy steadily increased from 2001 to 2007, while use of standard external beam radiation therapy (EBRT) decreased. Data are lacking on whether the newer technologies improve outcomes in this group of patients. These patterns of utilization led to an increase of 63% per treated patient, according to a study of Medicare patients enrolled in the SEER Medicare database reported at the 54th Annual Meeting of ASTRO.

In 2007, 52% of favorable-risk breast cancer patients received EBRT, and 24% received a newer form of therapy. The median cost of EBRT was $6000 per patient, while the costs of IMRT and brachytherapy were twice as high: $12,469 and $13,981, respectively.

“The incremental cost to our nation for new radiation therapy modalities in 2007 was $31 billion. We need to determine if the benefit is commensurate with the increased cost,� stated Kenneth Roberts, MD, Yale University School of Medicine in New Haven, CT. “Further study is needed to explore radiation modalities in this low-risk population.�

The CALGB C9343 trial, published in 2004, included women aged 70 and older with clinical stage T1 N0 treated with lumpectomy with negative margins. Ten-year follow-up showed that the local recurrence rate was 2% for those treated with radiation versus 9% for those who did not receive radiation.

Roberts coauthored a study showing that this trial had no effect on the usage of radiation in favorable-
risk patients. “Radiation use remained stable even in patients with low life expectancy,� he said.

Over the past decade new treatments have been adopted, including accelerated partial breast irradiation and brachytherapy, without much evidence to support their use, he said. The present study was conducted to determine temporal trends in usage of technology and the associated cost in elderly, favorable-risk breast cancer patients.
The study included 12,925 women with a mean age of 77.7 years (range, 70-94 years) with stage I breast cancer undergoing lumpectomy. Tumor size was <2 cm, and all cancers were estrogen receptor positive. Seventy-
six percent were treated with some form of radiation therapy.

Patterns of usage changed over time. In 2007, 24% did not receive radiotherapy, and a progressive increase in brachytherapy (11.2%) and IMRT (12.4%) was seen. Use of standard EBRT decreased from 76% in 2001 to 52% in 2007.

Fewer women aged 85 and older received radiation therapy, but even in this group there were temporal changes as follows: in 2008, 8.8% were treated with brachytherapy, 5.3% with IMRT, and 21.2% with standard EBRT.
The study did not include data on quality of life and toxicity.

Discussant of this abstract, Meena Moran, MD, Yale University School of Medicine, said that this study showed the utilization of EBRT has decreased in older women, yet they are opting for costly newer technologies with no data to show improved outcomes.

The real question, she indicated, is how to define el­derly. Also, it is not clear that radiation should be omitted in elderly patients with favorable-risk breast cancer. “The decision should encompass tumor characteristics, patient anxiety, and patient goals,� she stated.

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