Doctors have been slow to adopt a recommended short form of radiation therapy for early breast cancer. Data shows it has the potential to save millions of dollars.
Clinicians and patients can be slow to adopt evidence-based approaches to care, despite widespread agreement that unnecessary care can contribute to high healthcare costs.
But cheaper care can be adequate care both in a clinical sense and a financial sense. The slow uptake of evidence-based clinical guidelines and recommendations comes with a price.
Researchers from Duke University Medical Center found huge savings when doctors used a recommended short course of radiation therapy for women with early stage breast cancer.
Still, fewer than half of those eligible for the preferred approach to radiation therapy got it. The researchers estimated that one year of extra care cost $164 million.
The researchers looked at data from the American College of Surgeons cancer database for more than 43,247 breast cancer patients treated in 2011.
Of the patients who were eligible for the shorter course of radiation therapy or no therapy at all, 57% were treated with the longer, costlier regimens. The four-week course of radiation therapy was estimated to cost $8,000, as opposed to the $13,000 traditional six-week regimen.
Numerous studies have shown both treatment approaches to be equally effective.
The costs of treating the national cohort was about $420 million during 2011. Had these patients been treated with the preferred regimen, the bill would have been $256 million. The 39% difference translates to $164 million in savings.
Numerous, large clinical trials have shown that the short course works as well as the long course. That’s how it ended up in the guidelines of both Choosing Wisely (contributed by the American Society for Radiation Oncology).
And it is recommended in evidence-based guidelines from the National Comprehensive Cancer Network.
The Duke study’s lead author, Rachel Greenup, says the findings reveal that, in this case, quality doesn’t have to be sacrificed to reduce costs. “All the stars sort of align in this example,” she says. “Women get high quality care at a lower cost and it decreases their treatment burden.”
“Culturally… many people have a sense that backing off of healthcare, especially in cancer, is going to harm them or compromise the care they get,” she said. Many women who qualify for lumpectomies, for example, continue to opt for mastectomies, despite similar outcomes.
Medical Maximizers vs. Medical Minimizers
While the Duke results don’t explain why some breast cancer patients get more care, Brian Zikmund-Fisher said patient choice is a possible factor.
Zikmund-Fisher is a researcher who studies health behavior at the University of Michigan in Ann Arbor. He is one of the authors of a study that proposes a scale to measure of whether patients are medical maximizers “who are predisposed to seek healthcare even for minor problems,” versus medical minimizers “who prefer to avoid medical intervention unless it is necessary.”
“It is entirely plausible that part of what is going on here in the context of these radiation decisions is that the patients who are minimizers are agreeing and saying ‘Oh good. I don’t have to do more,’ but the patients who are maximizers are asking physicians to do everything possible,” said Zikmund-Fisher.
Then it’s up to the physicians to push back. But for many reasons, some are not comfortable doing that. Their reluctance stems in part from physicians’ perceptions that patients would find it difficult to accept less treatment.
Sometimes physician reluctance is driven by the ambiguity of guidelines, but that’s not the case with hypofractionation treatment for early stage breast cancer.
Kilian Salerno, MD, director of breast radiation at Roswell Park Cancer Institute in Buffalo, New York, will be speaking on the topic at this week’s NCCN annual conference in Orlando.
She notes that there has been a slow, but steady increase in the use of hypofractionation. The hope is that guidelines like those from NCCN and Choosing Wisely will inform physicians about the strong evidence supporting the approach.
Hospitals can also use the guidelines to do a self-assessment to determine whether their practices are consistent with the recommendations calling for the shorter course of radiation.
“If a practice were not ever utilizing this [treatment], and has large number of early-stage patients, it would be time for education,” Salerno said.