Prior research has not shown extended courses of palliative radiation beyond the standard 10 treatments to improve rain relief or tumor control for patients with bone metastases, leading to multiple guidelines to discourage its use. “Since patient-centric treatment minimizes cost, maximizes convenience, and maximizes efficacy, we need to understand whether we are still treating patients inefficiently,” explains James B. Yu, MD, MHS.

For a study published in the American Journal of Clinical Oncology, Dr. Yu and colleagues assessed contemporary use and cost of prolonged palliative radiotherapy in fee-for-service Medicare beneficiaries with bone metastases from breast cancer who underwent palliative radiotherapy during 2011 to 2014. Patients were categorized according to the number of days (fractions) on which they received palliative radiotherapy: 1, 2 to 10, 11 to 19, or 20 to 30. Using logistic regression models, the study team examined the association of clinical, demographic, and provider characteristics with the use of extended (≥11 fractions) or very extended (≥20 fractions) fractionation. The cost of different fractionation schemes from the payer perspective were also compared.

“Inefficient practice still persists,” says Dr. Yu. Indeed, among the more than 7,500 patients, 40.8% received extended fractionation, with the proportion of those receiving 11 to 19 treatments (34.7% in 2011, 28.1% in 2014) and 20 to 30 treatments (10.3% in 2011, 9.0% in 2014) decreasing only modestly during the study period. Whereas patients with comorbidities were less likely to undergo extended fractionation (34.4% for ≥3 comorbidities vs. 44.9% for 0 comorbidities), those treated at free-standing practices were more likely to undergo extended fractionation (47.9%) compared with those treated at hospital-based practices (37.3%). Mean costs for treatment ranged from $633 for single-fraction treatment to $3,566 for 11 to 19 fractions and $6,597 for 20 to 30 fractions.

“Overly extended fractionation was greater than 10-fold more expensive than a single fraction treatment,” notes Dr. Yu. “Our patients bear the cost of our treatments. We need to understand the evidence and reasoning behind how we recommend radiation treatment schedules and keep in mind our responsibility to provide evidence-based care. We should redouble our efforts to practice according to the best available evidence.”