Accelerating Adoption of Hypofractionation in Patients with Early-Stage Breast Cancer

Andrew Hertler, MD, Chief Medical Officer, New Century Health, discusses his study on the use of hypofractionation in patients with early-stage breast cancer.

Transcript: 

Andrew Hertler, MD: I am Andrew Hertler, and I am the Chief Medical Officer at New Century Health.

Can you give some background about your study and what prompted you to undertake it?

Dr Hertler: Despite there being multiple randomized controlled trials, which were quite large in size, and guidelines from experts that have recommended the use of hypofractionated radiation therapy for select patients with early stage breast cancer, the uptake of this approach has lagged, and this is despite the fact that compared to the more conventional fractionation regimens, hypofractionation has been found to be equivalent in terms of local control and overall survival, superior in toxicity and patient adherence, and it significantly decreases the number of trips that a patient has to make back and forth for radiation therapy. And so in an attempt to close this gap for patients covered in a large regional Medicaid plan, we implemented the use of clinical pathways, which we’re attempting through the prior authorization process to steer providers through selecting the hypofractionated regimen.

Can you briefly describe how the study was conducted?

Dr Hertler: We conducted the study through the use of prior authorization. Our prior authorization utilizes clinical pathways, and we can designate any particular treatment plan as the preferred plan, and we can offer instantaneous authorization when that pathway is selected.

So, in this study, within our prior authorization portal, we offered both conventional fractionation and hypofractionation for early stage breast cancer, but we offered instantaneous prior authorization through that electronic portal for the hypofractionated regimen. Whereas if the conventional fractionation was selected, we did not instantaneously authorize it, but instead had one of our radiation oncologists reach out to the requesting provider and review the evidence regarding hypofractionation with them and see if they could convince them to make a voluntary change to the hypofractionation. And if they did, the request was modified and approved, and if they did not, we approved the conventional fractionation.

What were the main findings of your study?

Dr Hertler: When we first started the study, and it ran from September of 2020 to July of 2022, but in the initial few weeks, which we used as a baseline period, the selection of hypofractionation and use of hypofractionation was 40%. And that was, as I said, in September of 2020. By the end of 2021, selection of hypofractionation increased to 54%, and during the last period, which completed in July of 2022, we were up to 61%. So, through the course of the study in these three time periods, we saw an increase in the use of hypofractionation adoption from 40% to 61%.

What factors do you think have caused the delay in widespread adoption of hypofractionated whole breast irradiation in the United States?

Dr Hertler: It's a really good question as to why hypofractionated radiation therapy has not been adopted more universally in the United States. The answer to this question that is often given is that it's our fee-for-service payment system where when you decrease the fractions, given that payment is per fraction, there's less reimbursement to the treating physician. I think this is a bit too simplistic.

I think that there are other reasons behind it, and one of the strongest reasons is likely quite simple. It's habit and what you've been trained to do. If a physician was trained, as many were, to use conventional fractionation, it's much simpler to simply continue to use the same protocol of conventional fractionation that you've always utilized. There's innate resistance to change, and this is a change, and I believe this is a greater factor than simply saying it's a matter of payment.

Looking ahead, what potential impact do you hope your findings will have on the implementation of hypofractionated whole breast irradiation among oncology providers?

Dr Hertler: It is our hope that when radiation oncologists look at this data and see the increasing adoption of hypofractionation by their peers, that this will disseminate the message more widely, as well as bring to light a phenomenon which I've seen before, which is physicians are innately competitive and they want to deliver the best care for their patients, and they never want to see be seen as out of step with their colleagues or with potentially not measuring up to their colleagues. As we increase the percentage of radiation oncologists who are adopting hypofractionation, and as this is publicized and as radiation oncologists who have not adopted it see this information, they will be driven to also adopt hypofractionation.

Is there anything else you would like to add?

Dr Hertler: One final thought that has occurred to me is that as we continue to look at alternative payment plans for radiation oncologists, bundling payments where there was a set fee for the entire treatment plan, that hypofractionation not only will be advantageous to the patient, who has less toxicity and makes less trips back and forth to the radiation oncologist, and to the payer who is going to have a lower cost treatment plan, but also to the treating oncologists. If they are bundling and receiving a set payment proceeding with hypofractionation will result in the decreased use of resources, and it now has become a win all around for all three of the major shareholders involved in these decisions.