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Why treating breast cancer with less may be more

Some therapies despite being convenient and less expensive, is associated with high cancer risks

Ashish A. Deshmukh | The Conversation 

National Comprehensive Cancer Network (NCCN) guidelines endorse the short hypofractionated course as the preferred approach
Women with breast cancer face many treatment decisions on the path to survivorship. One question has been: Can they have fewer doses of radiation and still keep their risks for recurrence low?


with breast have long faced complicated choices about the best course of treatment.


One particular concern has been the daily many with breast receive for six weeks after This form of therapy, also known as conventionally fractionated external beam radiation, has generally been recommended for most undergoing breast conservation The goal has been to rid the body of any remaining that the surgeon’s tools could not remove.

Radiation, however, can be time-consuming and expensive for the patient and society. It also carries a small risk for late complications, such as

New therapies have been tested that would shorten the length of from six weeks to three weeks, or deliver a single dose at the time of the lumpectomy procedure in the operating room.

A shorter course of means more convenience, perhaps, fewer side effects and fewer out-of-pocket expenses. And a single dose of is much cheaper than whole breast delivered over multiple weeks, but is associated with a slightly higher risk of local recurrence. So which option should patients and physicians choose?

In our recently published paper in the Journal of the National Cancer Institute, we came up with what we think is an answer. We showed through computer modeling that there is a better way for – and one that can save our care system nearly US$100 million every year.

Problem and possible solutions

For decades, breast was considered such a formidable foe that doctors who treated it and who had it wanted to use everything in their arsenal to fight it.

That included the radical Halsted mastectomy, which often took out chest muscles along with the breast and left disfigured.

It also included lengthy treatments, sometimes for as long as seven weeks (known as conventionally fractionated radiation), given every day Monday through Friday after This form of comes at great cost to and causes hardships for those who live far away from clinics.

In recent years, doctors studied new therapies for breast Halsted radical has been replaced with a lumpectomy procedure that is usually performed on an outpatient basis. The course has been shortened and is now delivered using sophisticated equipment, sparing unnecessary dose to the heart and lungs.

The better equipment also began to allow researchers to look at ways to shorten treatment. Hypofractionated radiation, in which a portion of the breast is treated for a shorter time, was one result.

Alternative therapies to conventional and hypofractionated have also been recently introduced to deliver a single dose of just to the tumor bed at the time of This is known is intraoperative radiotherapy, or IORT, meaning performed during the course of a surgical

Given the availability of choices with overlapping costs and outcomes, clinicians always face a dilemma: Which treatment is best for my patient? Likewise, patients can ask their clinicians, “What’s best for me?” And, if both treatments are equally effective, is there a difference in price that might guide decisions?

Multiple randomized trials have shown that a 3- to 4-week course of whole breast radiation therapy is equivalent to a 6- to 8-week course. In fact, the National Comprehensive Cancer Network (NCCN) guidelines endorse the short hypofractionated course as the preferred approach.

Despite all this, American doctors have not widely adopted the new strategy. The reasons for this are varied, including dissemination of new findings to private practitioners and financial incentives of treating with a longer course. Our current fee-for-service reimbursement structure pays more for the longer treatment, which may be a factor in the surprisingly slow adoption of the convenient hypofractionated whole breast approach.

What might be adding more to this dilemma?

Clinical trials have compared these treatment choices with one another. Several large randomized trials have compared a 6-week course to a 3- to 4-week course of whole breast treatment and found that the two treatment approaches are equivalent in terms of control. In fact, one trial found that the shorter course of treatment yielded lower rates of acute toxic effects compared to the longer course. Several randomized trials have compared conventionally fractionated radiation therapy to a single fraction intraoperative treatment just to the tumor bed at the time of Although extremely convenient, IORT was slightly worse at controlling recurrence.

Yet, no single clinical trial has compared all three available options head-to-head. Another dilemma is that clinical trials usually follow patients for a period of five to 10 years, not a lifetime. That left an important question unanswered: How do we know which treatment is most beneficial over patient lifetime, and at what cost?

Our study

To solve this conundrum, we used computer modeling along with a cost-effectiveness analysis.

In our study, our interdisciplinary team tried to identify the most optimal – that is, one that provides maximum value for money – for diagnosed with early stage breast

We simulated (created in computer) a hypothetical population of diagnosed with early stage breast As per standard of care guidelines, first get surgical treatment (lumpectomy).

Now comes the uncertainty! These hypothetical can get either conventional whole breast radiation, hypofractionated or one-time intraoperative

We obtained data from several clinical trials and databases to define treatment effectiveness and side effects, improvement or deterioration in quality of life, inconvenience (measures in term of travel time, lost wages, travel cost) and future consequences, including a possibility of coming back or spreading to other organs.

In our simulation, we then followed these hypothetical over their lifetime to identify which treatment strategy is most valuable, or cost-effective.

After extensive validation, we found that hypofractionated is the most valuable treatment almost under all scenarios. It not only improves quality of life without compromising survival (adds four additional months of life with improved quality of health) but it also saves nearly $3,500 per patient.

We also learned that IORT, or treatment at the time of operation, may be appropriate for older who live far from facilities and would have to endure hardship when traveling for daily whole breast for three to four weeks.

Win-win for all! Our society saves care dollars, and patients benefit most from treatment.

Key takeaways

Our analysis showed that conventionally fractionated radiation, in which receive the over six weeks, is not cost-effective under any scenario and should not be considered as a choice by physicians or patients. Our study is the first to evaluate this using the latest available data.

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A single dose of intraoperative therapy, despite being much more convenient and less expensive, is associated with higher recurrence rates. This difference in the risk of recurrence ends up costing the patient and society more than the hypofractionated treatment over a patient’s lifetime. Intraoperative might be an option for older who live in regions with poor access to services. The shorter hypofractionated course is less expensive and improves quality of life substantially!

With growing care costs and an aging population, we are starting to focus more and more on identifying treatments that are less expensive and equally effective. We found that the use of the optimal strategy in this situation has the potential to improve outcomes and save at least $100 million every year.

Ashish A. Deshmukh, Assistant Professor, University of Florida and Anna Likhacheva, Adjunct assistant professor, The University of Texas MD Anderson Cancer Center

This article was originally published on The Conversation. Read the original article.

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First Published: Fri, June 16 2017. 09:37 IST