Old habits die hard, and in this regard the medical profession is no different from any other. Researchers at the Yale School of Medicine were surprised, though, at the results of their study showing that despite the fact that radiation has limited benefit for some older women with breast cancer, the treatment is still being prescribed.
A large clinical trial conducted by the National Cancer Institute (NCI) concluded that radiation for some women older than 70 with early stage, low-risk breast cancer offered limited benefit. So significant was the 2004 NCI trial that breast cancer treatment guidelines were changed to place radiation therapy in the “optional” category for these patients.
But the Yale researchers found that in the years following implementation of the new guidelines, there has been minimal change in the clinical care of older women with breast cancer. Their report was published in the March Journal of Clinical Oncology along with an editorial echoing our feeling that the perpetual motion treatment machine needs to be overhauled.
"[T]he medical community may react differently to withholding a treatment than to adding a new treatment,” it read. “Adding a new treatment with the possibility of improving patient outcomes is likely more motivating than the ability to omit a treatment without harm."
“… Some older women with breast cancer are clearly being overtreated. Offering radiation therapy to a woman with a good-prognosis tumor and a life expectancy of less than five years does not seem indicated, yet more than 40 percent of such women were treated with radiation. These women were at risk for unnecessary adverse effects, inconvenience of treatment and possibly increased personal costs for a treatment that was unlikely to offer them any benefit.”
The complication, as the editorial points out, is that identifying patients unlikely to survive five years is tricky. Still, there must be a greater acceptance that “The cost of whole-breast irradiation is more than $7,000 per patient, and the benefit in this group of patients is small. In our current health-care system, physicians are incentivized to favor treatment over no treatment, particularly when either option is considered appropriate."
Medicare beneficiaries diagnosed with early stage breast cancer were studied before and after the large NCI clinical trial was published. Nearly 8 in 10 patients received radiation before the study, and 3 in 4 received it after.
Even among the oldest women (85-94 years), the use of radiation decreased only four percentage points, from 37 percent before the study to 33 percent after.
Typically, older women with early stage breast cancer receive breast-conserving surgery followed by radiation therapy. The latter is designed to reduce recurrence of the disease. But many older women have less aggressive tumors; they are at lower risk for tumor recurrence.
“Clinical trials are considered the gold standard of medical research and in this case the trial was influential enough to lead to a change in treatment guidelines,” said Yale’s lead author. “We expected it to have more of an impact on clinical care at the bedside.”
It’s time to for this proven theory to be put into practice. As the researchers noted, the U.S. government invested more than $1 billion in comparative effectiveness research as part of the American Recovery and Reinvestment Act of 2009. The point of such efforts, which we’ve discussed before, is to choose the most effective, cost-efficient treatments for a given disorder; they’re meant to overrule the default of “just in case” treatments.
“Our societal interest in funding this type of research is appropriate,” Yale’s researchers concluded, “and the need is great, but we must ensure that the results of such research extend beyond the journal page and are actually incorporated into clinical decision-making.”
To learn more about breast cancer treatment, see our guide.