Doctors may be over-treating many lower-risk breast cancer patients despite major research that should have persuaded them to consider using less or no radiation after surgery, according to a trio of new Duke University-led studies.
Less aggressive treatments could help patients avoid or reduce harsh side effects and slash tens of millions of dollars a year nationally from treatment costs, the researchers found.
One of the studies appeared Monday in the journal Cancer. It found that two-thirds of women age 70 and older with low-risk breast cancer were still treated with radiation after surgery despite a major trial in 2004 that found little benefit from the radiation in such cases.
The researchers presented two other studies Tuesday at the biggest annual international meeting on breast cancer, the San Antonio Breast Cancer Symposium. One examined nearly 218,000 pertinent cases and found that most were treated with a lengthier course of radiation, even though earlier trials had found a shorter course worked about as well.
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The other study examined more than 43,000 cases of relatively low-risk breast cancer treated in 2011 and found that using less or no radiation after surgery could have saved $164 million. The potential savings were actually higher because the data came from about 70 percent of the newly diagnosed cases in the United States.
The milder treatment options are gaining acceptance, but only slowly, the researchers found.
The study raises questions about how medicine is practiced in the U.S., said Dr. Rachel Blitzblau, a radiation oncologist at Duke Medicine who was senior author of two of the studies and was involved in the third. “I think it highlights the need for us to really look at how we disseminate information, how do practitioners incorporate care, and whether (medical) specialty societies (should) be more involved in setting consensus guidelines.”
The studies tracked the effect on clinical treatment methods of earlier research. Those earlier studies were considered unusually reliable because of the methods used and the large number of cases examined, and were themselves expensive and time-consuming.
The reasons that doctors didn’t quickly begin using those results aren’t clear. The new study involving treatment of older patients says that one cause may be a bias by physicians against adopting approaches that involve withholding a treatment. Evidence suggests they are more willing to change approaches when the new methods involve adding a procedure rather than subtracting one.
Also, money may play a role. “In our current health care system, physicians are incentivized to favor treatment over no treatment, particularly when either option is considered appropriate,” the study says.
When the statistics on older patients were initially released, back in 2004, they didn’t yet include patient outcomes more than five years after treatment, Blitzblau said, so it’s possible that some doctors were simply being careful.
“They may be thinking that since we know breast cancer can recur really late, maybe we shouldn’t be so quick to stop giving radiation until we see how those women did over 10 or 15 years, and be really sure that we’re not going to stop giving radiation to a bunch of people now and find out 10 years from now that was a mistake,” she said.
In the United Kingdom, the national health system sets guidelines for its doctors. In fact, in Great Britain and Canada, where many of the studies took place that supported the shorter course of radiation, shorter courses have become the standard method of treatment in pertinent cases, Blitzblau said. But here there is no direct, formal structure to ensure such research is put into common use.
Although professional groups such as the American Society for Radiation Oncology issue guidelines to their members, doctors make their own interpretation of the data, and along with patients, make decisions on treatment.
That’s not necessarily bad, because each case is different, and doctors need to be able to personalize treatment, Blitzblau said.
One thing that could help push research results into clinical use, she said, is outreach efforts such as the American Board of Internal Medicine Foundation’s Choosing Wisely Initiative, which is aimed at getting information to patients and doctors across a range of medical disciplines to help reduce excessive tests and procedures.
It features recommendations from the radiation oncology society that include considering the shorter course of treatment.
Also, she said, the increasing emphasis on reducing health care costs will likely help drive change.