More Complications with Brachytherapy vs Whole-Breast Irradiation
“Brachytherapy has disseminated into clinical practice as an alternative to whole-breast irradiation for early-stage breast cancer; however, current national treatment patterns and associated complications remain unknown,” noted Cary P. Gross, MD, of Yale University School of Medicine, New Haven, CT, and colleagues, in explaining the rationale for the study. “Currently, there are no large randomized controlled trials or population-based studies confirming brachytherapy as a safe and effective alternative to whole-breast irradiation.”
The investigators constructed a national sample of women aged 66 to 94 years—all Medicare beneficiaries—who underwent breast-conserving surgery from 2008 to 2009 and treated with brachytherapy or whole-breast irradiation. Hospital referral regions were used to assess national treatment variation. Overall, wound and skin, and deep-tissue and bone complications were compared at 1 year of follow-up between brachytherapy and whole-breast irradiation.
“Of 29,648 women in our sample, 4,671 (15.8%) received brachytherapy,” Dr. Gross reported. Percentages of patients receiving brachytherapy varied “substantially” across hospital referral regions, ranging from 0% to >70%. “There was a slightly higher rate of brachytherapy treatment among women treated at free-standing versus hospital-based radiation facilities, which may be in part because of potential financial incentives,” they found.
Use of brachytherapy was associated with several factors consistent with earlier-stage disease, such as not receiving chemotherapy, recent screening mammography, or seeing a primary care physician in the year before surgery for breast cancer.
“Of women treated with brachytherapy, 34.3% had a complication compared with 27.3% of women undergoing whole-breast irradiation (P<0.001).” After adjusting for patient and clinical characteristics, 35.2% of women treated with brachytherapy had a complication vs 18.4% treated with whole-breast irradiation (P<0.001).
Compared with whole-breast irradiation, brachytherapy was associated with a 16.9% higher rate of wound and skin complications (95% CI, 10.0–23.9; P<0.001); however, no difference in deep-tissue and bone complications were found.
“The marked regional variation in utilization suggests that nonclinical factors play an important role in its dissemination,” the authors reported. “Given the higher costs associated with brachytherapy, the higher risk of complications suggests that clinicians, patients, and policy makers should closely scrutinize the use of this treatment modality.”