Hypofractionated radiation therapy for early stage breast cancer: outcomes, toxicities, and cost analysis

A French prospective randomized trial comparing whole breast radiotherapy with 45 Gy in 25 fractions versus 23 Gy in four fractions demonstrated equivalent 5-year local control and survival. On the basis of this data, we offer the hypofractionated regimen to women who refuse to undergo standard radiotherapy. We report our outcomes and a cost analysis. Between 2000 and 2012, 84 patients participated in this IRB-approved study and underwent whole breast radiation to 23 Gy in four fractions. Local control and survival were analyzed using the Kaplan-Meier method. Acute toxicities and overall long-term cosmetic results were assessed. Costs were estimated from 2012 Medicare reimbursement data and compared to costs from standard courses of 25 and 16 fractions. All 84 patients are included in this report. Median age was 83 (range 42-98). Most patients had stage I (80%), hormone receptor positive (90%) breast cancer. Fifty-eight patients (69%) were treated prone and 26 (31%) supine. At a median follow-up of 3 years, one local recurrence has occurred, of ductal carcinoma in situ histology. Among the 13 patients deceased, two died of metastatic breast cancer. Five-year actuarial local control is 99%, breast cancer-specific survival is 98%, and overall survival is 79%. Toxicities were limited to grade 1 dermatitis in 32 patients (38%) and grade 2 fatigue in three (4%). Sixty-three patients (75%) reported good or excellent cosmetic outcome at their last follow-up. Collected Medicare reimbursement was $4,798 for the hypofractionated course. Compared to the projected reimbursement of standard regimens, $10,372 for 25 fractions and $8,382 for 16 fractions, it resulted in a difference of $5,574 and $3,584, respectively. At a follow-up of 3 years, this hypofractionated regimen appears to be a promising approach, primarily for elderly women who are unable to undergo longer treatment courses but have indications for whole breast radiotherapy.