Does persistent use of radiation in women > 70 years of age with early-stage breast cancer reflect tailored patient-centered care?

Purpose

: Randomized controlled trials demonstrate that omission of radiation therapy (RT) in older women with early-stage cancer undergoing breast conserving surgery (BCS) is an "acceptable choice." Despite this, high RT rates have been reported. The objective was to evaluate the impact of patient- and system-level factors on RT rates in a contemporary cohort.

Methods

: Through the National Cancer Data Base, we identified women with clinical stage I estrogen receptor-positive breast cancer who underwent BCS (n = 84,214). Multivariable logistic regression identified patient, tumor, and system-level factors associated with RT. Joinpoint regression analysis calculated trends in RT use over time stratified by age and facility-type, reporting annual percent change (APC).

Results

: RT rates decreased from 2004 (77.2%) to 2015 (64.3%). The decline occurred earliest and was most pronounced in older women treated at academic facilities. At academic facilities, the APC was − 5.6 (95% CI − 8.6, − 2.4) after 2009 for women aged > 85 years, − 6.4 (95% CI − 9.0, − 3.8) after 2010 for women aged 80 − < 85 years, − 3.7 (95% CI − 5.6, − 1.9) after 2009 for women aged 75 − < 80, and − 2.4 (95% CI, − 3.1, − 1.6) after 2009 for women aged 70 − < 75. In contrast, at community facilities rates of RT declined later (2011, 2012, and 2013 for age groups 70–74, 75–79, and 80–84 years).

Conclusions

: RT rates for older women with early-stage breast cancer are declining with patient-level variation based on factors related to life expectancy and locoregional recurrence. Facility-level variation suggests opportunities to improve care delivery by focusing on barriers to de-implementation of routine use of RT.