Changing practice patterns for breast cancer radiation therapy with clinical pathways: An analysis of hypofractionation in a large, integrated cancer center network.
OBJECTIVE
Hypofractionated whole breast irradiation (HF-WBI) following breast conserving surgery has produced excellent outcomes, but utilization remains limited. We evaluated the impact of a clinical pathway in the adoption of HF-WBI in a large, integrated radiation oncology network.


METHODS
We identified patients aged ≥70 years treated for breast cancer or ductal carcinoma in situ. Patients treated with palliative intent, accelerated partial breast radiation, following mastectomy, or with axillary nodal, supraclavicular, or internal mammary fields were excluded. HF-WBI was defined as ≤20 fractions with a dose/fraction ≥2.5 Gy. Multivariate analysis identified variables associated with increased HF-WBI utilization.


RESULTS
We identified 2426 patients meeting inclusion criteria. HF-WBI utilization increased significantly from 6.5% (22.0% academic, 2.0% community) before pathway modification to 33.8% afterwards (68.5% academic, 25.3% community, P<.001). For academic physicians, the relative risk of HF-WBI utilization was 3.8 following publication of the seminal HF-WBI trial and 10.6 following pathway modification (P < .001). For community physicians, the relative risk of HF-WBI utilization did not significantly change following publication but was 21.0 following pathway modification (P < .001). The increased adoption of HF-WBI saved an estimated $154,000 annually in our network.


CONCLUSIONS
We found that our implementation of clinical pathways substantially increased adoption of HF-WBI for breast cancer. We found no significant change in utilization of HF-WBI among community physicians following publication of a seminal trial for HF-WBI until after clinical pathway implementation, which increased the use of HF-WBI by 20-fold. Clinical pathways may be effective in changing practice patterns, disseminating evidence, and realizing health care savings.
Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
Malolan S
MS
Rajagopalan
Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
John C
JC
Flickinger
Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
Dwight E
DE
Heron
Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania. Electronic address: beriwals@upmc.edu.
Sushil
S
Beriwal
D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery; D005260:Female; D006801:Humans; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D000069473:Radiation Dose Hypofractionation; D018714:Radiotherapy, Adjuvant / Q000379:methods / Q000706:statistics & numerical data