Mounting evidence finds that delivering higher doses of radiation per treatment is as effective in some breast cancer patients as a traditional course where smaller doses are given over a longer time period. The new method, called hypofractionation, involves about 3-4 weeks of daily radiation treatments, instead of the usual 5-week or longer course.
But several newly published studies have found that hypofractionated radiation is not widely used.
Reshma Jagsi, M.D., D.Phil., associate professor of radiation oncology at the University of Michigan, led two of these studies. Looking at a national database of patients, she and her colleagues found that hypofractionation was used in only 13.6% of Medicare patients with breast cancer. In Michigan, Jagsi’s other study found, fewer than one-third of patients who fit the criteria for offering this approach got the shorter course of treatment.
What is exactly is hypofractionated radiation and why is it recommended?
Dr. Jagsi: Radiation is usually given in multiple, small doses. We do this to allow normal tissues in the path of the radiation to repair themselves in between treatments (in a way that tumor cells cannot do). This helps make the radiation treatment safe. Multiple, high-quality randomized clinical trials have shown that for certain patients with breast cancer, it is safe to give slightly bigger doses per day than we have usually given, so that the whole treatment can be completed in about 3-4 weeks of daily treatments, rather than the 5-6 weeks that have traditionally been given.
Fewer treatments is far more convenient and cost-effective for patients. Because radiation is recommended following breast-conserving surgery, the longer treatment time may discourage some patients from having a lumpectomy instead of mastectomy.
Who is it recommended for?
Dr. Jagsi: Based on the clinical trials, the American Society for Radiation Oncology issued guidelines supporting this shorter radiation course for patients 50 and older with early stage breast cancer that has not spread to the lymph nodes, who did not receive chemotherapy and whose breasts are not too large to allow an even distribution of radiation dose. Other patients may also be candidates.
When we studied how often it’s being used, we looked specifically at older adults by using data from the National Cancer Institute’s Surveillance, Epidemiology and End Results Medicare-linked database. Patients were 65 and older. We know that in many of our oldest patients, radiation may not offer much benefit at all. So it was particularly distressing that this more-convenient approach was not being offered even in this group.
Why isn’t it being more widely used? Are there certain patients who should not have this approach?
Dr. Jagsi: Hypofractionation may not be right for all breast cancer patients. It’s based on the size of the tumor and whether it’s spread to the lymph nodes. There’s also some question about its use in heavier patients and younger patients, in particular.
In our study of patients in Michigan, our analyses showed that hospitals and physicians played a big part in the variation of use. Individual patient factors such as weight and age played a much smaller role.
In part, the issue may be that our health care system gives doctors and hospitals a disincentive to deliver fewer courses of radiation – they won’t get paid as much. In countries with different financial models, we do see greater use of hypofractionation.
But that’s likely not the only issue, though. Within the field of radiation oncology, we have long-held beliefs that these higher daily doses will cause more long-term side effects. Many doctors were likely waiting on the long-term follow-up to ensure this wasn’t the case. We now have this data, though, so we have reason as a specialty to start embracing hypofractionation.
They key is to make sure we as a profession are taking important scientific findings like this and reflecting them in everyday practice to deliver better care to our patients.
What do you suggest to patients who are considering radiation as part of their breast cancer treatment?
Dr. Jagsi: Radiation treatment substantially reduces the risk of breast cancer returning after breast-conserving surgery, so it is an important part of care for many patients. Ask your doctor how many radiation treatments are recommended and why, and ask them what they think about the approach of hypofractionation in your particular case. Not every patient is a good candidate for this approach, but we want to make sure it is being offered to those who are.
Take the next steps:
- Learn about radiation oncology at the University of Michigan
- Read Dr. Jagsi’s paper about hypofractionation use nationally and in Michigan
- Get tips on Managing the Side Effects of Radiation
- Read how Radiation Oncology at the U-M is taking a patient and family centered approach to care: email.
Reshma Jagsi, M.D., D.Phil., is an associate professor of radiation oncology at the University of Michigan Medical School. Dr. Jagsi’s research focuses on improving the quality of care received by breast cancer patients, both by advancing the ways in which breast cancer is treated with radiation and by advancing our understanding of patient decision-making, cost and access to appropriate care.
The University of Michigan Comprehensive Cancer Center’s 1,000 doctors, nurses, care givers and researchers are united by one thought: to deliver the highest quality, compassionate care while working to conquer cancer through innovation and collaboration. The center is among the top-ranked national cancer programs, and #1 in Michigan according to U.S. News & World Report. Our multidisciplinary clinics offer one-stop access to teams of specialists for personalized treatment plans, part of the ideal patient care experience. Patients also benefit through access to promising new cancer therapies.