Is Hypofractionation the Solution? The Financial Implications of Breast Cancer Treatments

Drs. Shaitelman and Kim have done an excellent job of describing the current practice of accelerated partial-breast irradiation (APBI) in this review. APBI is an example of how breast cancer treatments are constantly evolving as a result of advances in medicine and technology, and because of financial forces. While these advances have led to more treatment options for women with breast cancer, every change that occurs in treatment can potentially result in different side effect profiles, outcomes, and costs. If all outcomes are shown to be equal, yet the costs of the treatments differ, how will this affect the decision-making process and trends for treatments?

TABLE

Costs of Different Radiation Therapy Options for Breast Cancer in 2004 and 2012

Accountable care organizations (ACOs) are being organized across the country as a result of, and following, the guidelines set forth in the Patient Protection and Affordable Care Act (ACA). ACOs will be held responsible for quality, cost, and overall care of the Medicare beneficiaries enrolled in them. These ACOs are introducing a radical change in the reimbursement structure, from the current fee-for-service model to a “bundled payment for care improvement” (BPCI) model. Currently, reimbursements are given for individual services associated with treatment. For example, a breast cancer patient’s insurance company would pay separately for diagnostic tests, biopsy, surgery, chemotherapy, and all aspects of radiation therapy, with this last including the CT simulation for radiation planning, radiation treatments, and on-treatment visits. In an ACO, a single flat-rate payment bundle is delivered to an entire oncology team per disease diagnosis, regardless of the treatment or tests administered. A pilot program was begun on January 1, 2013 to promote coordination among oncology providers and improve quality. The various doctors and facilities involved in breast cancer detection and therapy, including radiologists, surgeons, medical oncologists, and radiation oncologists, would need to negotiate how the payment is divided. The ACA asks oncology providers to strike a balance between the wise and efficient use of resources and the patients’ preferences, and the changes flowing from the switch from the fee-for-service model to a BPCI model will likely influence treatment decisions.

The estimated costs of different breast cancer treatments in 2004 and 2012, according to the Center for Medicaid and Medicare Services (www.cms.gov), are displayed in the Table. These costs do not incorporate the transportation costs or opportunity costs incurred by patients as a result of missing time from work or other obligations. The treatment option with the lowest cost to the ACO for a patient who needs whole-breast irradiation (WBI) is a hypofractionated course of treatment, and for a patient who is suitable for APBI off-protocol, it is 3-dimensional conformal APBI.

The most obvious benefit of APBI is that it reduces overall time and offers an attractive option to people who live far from radiation centers or have busy work schedules. While local recurrence is low in published studies on APBI, we will not know the results of the randomized partial-breast irradiation trial (National Surgical Adjuvant Breast and Bowel Project [NSABP] 39/Radiation Therapy Oncology Group [RTOG] 0413) for several years. When the cost-effectiveness of different radiation therapy techniques was evaluated 15 years after radiotherapy in postmenopausal woman with early-stage breast cancer, using a decision analytic Markov model, external beam APBI was found to be more cost-effective than both external beam WBI and MammoSite-brachytherapy APBI. Brachytherapy has never been preferred due to the higher costs associated with this treatment.[1,2] It is also unlikely that brachytherapy would offer any significant differences in quality of life compared to external beam APBI; however, quality-of-life outcomes will be evaluated in the NSABP 39/RTOG 0413 study.

Hypofractionated WBI schedules offer an attractive alternative, since this treatment allows for treatment of the entire breast while still reducing the time and cost to complete a radiation treatment. Hypofractionated WBI followed by a sequential boost to the lumpectomy cavity can be completed in 20 treatments, instead of the standard 30 treatments. This effectively reduces a breast irradiation treatment course from the typical 6 weeks down to 4 weeks. The UK Standarisation of Breast Radiotherapy (START) A/B trials and the Ontario trial have established that hypofractionation is equivalent to standard treatments of 50 Gy in 25 fractions, in terms of local control, overall survival, and cosmesis.[3-5] In 2012, a hypofractionated course of radiation therapy would have cost about $8,567; this is a 20% reduction from conventional WBI, which would have cost about $10,815. An analysis of hypofractionation vs standard fractionation was performed in Australia; it found that if all eligible patients were treated with hypofractionation, then an additional 14 patients could be treated in the department and healthcare costs could be reduced by 24%.[6] This is especially important when radiation oncology resources are limited and patients are waiting for their radiation treatments.

Current hypofractionation trials aim to test whether the overall time and number of treatments for WBI can be even further reduced. The RTOG 1005 trial is currently accruing patients with ductal carcinoma in situ (DCIS) or early-stage breast cancer to compare accelerated hypofractionated WBI with a concurrent boost (3 weeks) vs standard WBI + a sequential boost (50 Gy in 25 fractions or 42.7 Gy in 16 fractions followed by a boost. The United Kingdom has taken a more aggressive approach to hypofractionation in the FAST and FAST-Forward trials. These trials are testing a 5-fraction (> 5 Gy per fraction) WBI schedule vs a standard arm (25 fractions at 2 Gy per fraction in FAST and 15 fractions of 2.67 Gy in FAST-Forward). As the number of treatments decreases, the costs will decrease accordingly, so that there may eventually not be a significant difference between external beam WBI and APBI.

The reduced cost to an ACO for external beam hypofractionation and APBI also means less income to the radiation facilities. However, if a fixed flat-rate bundled payment model is fully adopted, then it would be a more efficient use of resources in the radiation oncology department to use a hypofractionated or APBI schedule. Hypofractionated external beam WBI seems like a great option until the APBI data mature from NSABP 39/RTOG 0413. In the meantime, we will have to see whether the ACA’s mission to bend the cost curve in the face of added demand for cancer care will succeed and how our treatment decisions will be affected by this new healthcare model.

Financial Disclosure: The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

REFERENCES

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2. Gold HT, Hayes MK. Cost effectiveness of new breast cancer radiotherapy technologies in diverse populations. Breast Cancer Res Treat. 2012;136:221-9.

3. Group ST, Bentzen SM, Agrawal RK, et al. The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet. 2008;371:1098-107.

4. Group ST, Bentzen SM, Agrawal RK, et al. The UK Standardisation of Breast Radiotherapy (START) Trial A of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet Oncol. 2008;9:331-41.

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7. Konski A. Will partial breast irradiation be a cost-effective alternative to whole breast irradiation in the treatment of early-stage breast cancer? Community Oncology. 2004;1:93-7.