New research reveals nearly half of women with advanced breast cancer did not receive post-mastectomy radiation therapy, despite evidence-based guidelines that show its benefits,

June 27, 2011

Forty-five percent of women with advanced breast cancer in the U.S. did not receive post-mastectomy radiation therapy (PMRT) despite the publication of evidence-based guidelines outlining PMRT as a potentially lifesaving treatment, according to new research from The University of Texas MD Anderson Cancer Center. The study, published in the July issue of Cancer, found that PMRT use rates for women with advanced breast cancer have remained static since 1999. According to the research, of the nearly 5,000 women diagnosed with high-risk breast cancer between 1999 through 2005, only 55 percent received PRMT. Paradoxically, PMRT use increased among intermediate-risk patients, even though the established guidelines do not strongly recommend the therapy for such patients.

"The findings add to the debate on the effectiveness of standardized treatment guidelines," says Benjamin Smith, M.D., assistant professor in the Department of Radiation Oncology at MD Anderson and lead author of the study. "There’s a clear gap between the scientific evidence demonstrating PMRT’s benefits and the proper use of the therapy in everyday clinical practice."

From 1999 to 2002, organizations including the National Cancer Institute, the American Society for Clinical Oncology and the National Comprehensive Cancer Network, published a series of evidence-based guidelines regarding the use of PMRT in response to three landmark randomized, controlled trials that proved PMRT decreased locoregional recurrence and improved survival rates among high-risk breast cancer patients.

According to Smith, better strategies are needed to bring clinical evidence into practice. The researchers offer several tactics to increase the use of PMRT among high-risk patients, which requires adopting an active dissemination model of materials and physician accountability. For example:

• Require compliance for accreditation. Organizations like the American College of Surgeons Commission on Cancer and the National Quality Forum track compliance with evidence-based guidelines as part of their accreditation process. Adding the PRMT guidelines to the already established list of quality measures would likely increase the use of PMRT among high-risk patients.
• Create financial incentives. Payers with widespread networks have an opportunity to influence evidence-based practice with financial incentives.
• Use electronic medical records (EMRs). EMRs can be used by government organizations, like the Centers for Medicare and Medicaid Services, to measure quality and compliance.
• Push for cancer societies to promote accountability. Encourage societies like the American Society for Therapeutic Radiology and Oncology (ASTRO) and the American Society for Clinical Oncology (ASCO) to promote the use of PMRT guidelines among its members.

"Women with advanced breast cancer benefit the most from PMRT, but for some reason they’re simply not getting it," says Smith. "While we need to identify and correct the treatment barriers, physician accountability is necessary to ensure women receive optimal care. For some patients, it can be the difference between life and death."

Smith and his colleagues used the Surveillance, Epidemiology and End Results (SEER)-Medicare database to identify women age 66 and older who underwent mastectomy for invasive breast cancer between 1992 and 2005. Patient characteristics included year of and age at diagnosis; race; marital status; SEER registry; urban/rural residence; median income; education; and co-morbid conditions spanning an interval from 12 months to one month before diagnosis. Patients were then stratified into low-risk, intermediate-risk and high-risk groups based on tumor-related variables to be consistent with current guidelines.

Further research is needed to determine why PMRT has been excluded as a treatment option in almost half of older patients with advanced breast cancer. Care barriers to consider include access to care, transportation limitations and access to radiation oncologists.