Behind Dr. Zimmerman’s JAMA Oncology study on hypofractionated radiation therapy

Robert Zimmerman, MD

Robert Zimmerman, MD 
Medical Director 
Radiation Oncology

Robert Zimmerman, MD, medical director of radiation oncology, expands on the recent JAMA Oncology study he contributed to, which shows how our Radiation Oncology Solution boosted adoption of hypofractionated radiation therapy.

In 2011, the American Society for Radiation Oncology (ASTRO) recommended hypofractionated radiotherapy for women older than 50 years with early-stage breast cancer. However, despite the recommendation, few providers were applying the guideline in their practice years later.

With co-authors from HealthCore, Perelman School of Medicine, Penn Center for Cancer Care Innovation, Corporal Michael J. Crescenz Veterans Affairs Medical Center, and the Wharton School, our medical director of radiation oncology, Robert Zimmerman, MD, decided to assess whether a large commercial payer’s utilization management program could increase the adoption of the guideline from ASTRO in clinical practice.

JAMA Oncology published their findings in an original investigation titled “Association of Utilization Management Policy with Uptake of Hypofractionated Radiotherapy among Patients With Early-Stage Breast Cancer.”

In our latest InterVū Q&A, Dr. Zimmerman goes behind the study and describes its importance, including its impact on the affordability of cancer care and members’ experience.

 

What is hypofractionated radiation therapy for breast cancer?

Like conventional radiation therapy, hypofractionation aims to eradicate cancer cells in the breast, but with larger radiation doses in fewer overall sessions.

Whereas conventional radiation typically requires 25 to 35 sessions, hypofractionation requires 15 to 20. In other words, the hypofractionated approach requires fewer visits to a treatment center, which is more convenient for patients.

In 2011, the American Society for Radiation Oncology (ASTRO) published a clinical guideline supporting use of hypofractionated radiotherapy for women older than 50 years with early-stage breast cancer. This guideline arose after clinical trials demonstrated that conventional radiotherapy does not provide incremental benefits – short-term or long-term – over hypofractionated radiation therapy.

In fact, the hypofractionated treatment generally has fewer side effects and improved quality of life compared to the prolonged regimen. Despite the ASTRO guideline, as of 2013, the conventional approach was still more common. Fewer than 40% of eligible patients were receiving hypofractionation.

This is why AIM Specialty Health developed a guideline that encouraged the use of hypofractionated radiotherapy for women older than 50 years with early-stage breast cancer.

Since then, ASTRO has updated their guideline, expanding the population of patients with breast cancer recommended to receive hypofractionated therapy. Our guideline has been updated to reflect the latest ASTRO recommendations.

Can you describe the design of the study and the findings?

We studied health care claims data from more than 10,000 women who met study criteria. This included roughly a third whose treatments underwent utilization management, or clinical appropriateness review.

We found that members whose care was subject to clinical appropriateness review were more likely to receive hypofractionated radiotherapy than those whose care was not subject to the review.

Additionally, our analysis showed that for physicians exposed to our clinical appropriateness review, they were more likely to utilize hypofractionated radiotherapy even in patients not subject to our review.

What is important about these findings?

To me, what’s significant is that last finding: that providers shifted to delivering evidence-based care more frequently when their care underwent our clinical appropriateness review.

As a result, the providers were optimizing the value-based health care equation: their patients were receiving high-quality care and health care dollars were being spent wisely.

Speaking of health care spending, what did the study show about how hypofractionation impacts treatment costs?

The study showed that management was associated with savings – approximately $2,200 per treated member (though this did not reach the level of statistical significance). More importantly, the purpose of our clinical review is to align care with established medical evidence.

Evidence-based care can be costly. But care that is not evidence-based or care that is evidence-based but more expensive than equally appropriate alternatives is wasteful.

This study looked at just one aspect of the AIM Radiation Oncology Solution, which consistently demonstrates significant savings for our clients. Beyond costs, there’s a more member-centric experience.

Hypofractionation reduces the number of radiation treatment sessions, meaning members are required to go to fewer appointments. And the shorter treatment produces fewer side effects, including pain and skin burning.

Is hypofractionated radiation therapy available for forms of cancer other than breast cancer?

Yes. Hypofractionated radiotherapy may be appropriate for some patients with lung cancer and for some patients with bone metastases (cancer that has spread to the bone).

The role of hypofractionation in treatment of prostate cancer is evolving and an area of research interest for my colleagues at HealthCore and me.

Study authors and affiliations

  • Ravi B. Parikh, MD, MPP – Perelman School of Medicine, University of Pennsylvania, Philadelphia; Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, Pennsylvania; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
  • Ezra Fishman, PhD – HealthCore Inc, Wilmington, Delaware
  • Winnie Chi, PhD – HealthCore Inc, Wilmington, Delaware
  • Robert P. Zimmerman, MD – AIM Specialty Health, Chicago, Illinois (Medical Director, AIM Radiation Oncology Solution)
  • Atul Gupta, PhD – Wharton School, University of Pennsylvania, Philadelphia
  • John J. Barron, PharmD – HealthCore Inc, Wilmington, Delaware
  • Gosia Sylwestrzak, MA – HealthCore Inc, Wilmington, Delaware
  • Justin E. Bekelman, MD – Perelman School of Medicine, University of Pennsylvania, Philadelphia; Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, Pennsylvania