SAN ANTONIO – Hefty reductions in annual health care spending for breast cancer therapy would be achieved if physicians increased their use of evidence-based adjuvant radiation therapy following lumpectomy for early-stage breast cancer, according to Dr. Rachel A. Greenup.
The potential savings would amount to $164 million annually, based on the American College of Surgeons National Cancer Data Base for the year 2011. And since that database captures only about 70% of all newly diagnosed cancers in the United States, that savings figure is likely an underestimate, according to Dr. Greenup, a surgical oncologist at Duke University, Durham, N.C.
She and her coinvestigators identified 43,247 women in the national database with clinically node-negative, T1-T2 invasive breast cancer treated by lumpectomy during 2011. Their median age was 63 years, with a median tumor size of 1.2 cm. Only 26% of women received the least expensive adjuvant radiation therapy for which they were potentially eligible based upon current guidelines and best practices. Sixty-seven percent of patients received more costly regimens.
Overall, 22% of the women were deemed by investigators to be eligible for no radiotherapy because they fit the criteria laid out in the CALGB (Cancer and Leukemia Group B) 9493 study: age 70 years or older, with T1N0, estrogen receptor–positive disease. CALGB 9493 demonstrated at median follow-ups of 5 years (N. Engl. J. Med. 2004;351:971-7) and 12.6 years (J. Clin. Oncol. 2013;31:2382-7) that women who fit that profile could safely forego radiotherapy.
The investigators considered another 62% of patients to be eligible for hypofractionated whole breast irradiation (HF-WBI), defined as 15-24 fractions at 40-58 Gy, as their least costly appropriate radiotherapy option because they were at least 50 years old with T1-T2 NO invasive breast cancer. Sixteen percent of patients were deemed eligible for conventional fractionated whole breast irradiation (CF-WBI) as their least expensive option.
Treatment costs were determined using the Medicare Physician Fee Schedule payment data for 2011 and the average procedural codes billed per regimen. The cost per patient was $13,358.37 for CF-WBI and $8,327.98 for HF-WBI.
Of the 9,651 women considered eligible for no radiation therapy, only 36% actually did not undergo irradiation. Forty-four percent had CF-WBI, 18% had HF-WBI, and the rest had accelerated partial breast irradiation. The total cost of radiation therapy in this subgroup was $72.2 million.
Among the considerably larger group for whom HF-WBI was deemed the least costly radiation therapy option for which they were eligible, 68% had CF-WBI, 17% had no radiotherapy, and only 6.5% received HF-WBI. The total cost of radiation therapy in this group was $276.8 million in 2011. Had they undergone evidence-based therapy, the cost would have dropped to $185 million, Dr. Greenup said at the San Antonio Breast Cancer Symposium.
For the 6,685 women who were considered candidates for CF-WBI, 75% received that form of radiation therapy, 7% got HF-WBI, and 18% received no radiotherapy. Their total radiation therapy costs amounted to $71.2 million.
The total estimated cost of actual radiation treatment in the study population was $420.2 million, compared with $256.2 million, or 39% less, had the women received the least expensive regimen for which they were eligible.
An estimated $125 billion is spent annually on cancer treatment in the United States, with breast cancer therapy accounting for the largest proportion of that, Dr. Greenup noted.
She reported having no relevant financial conflicts.