Payment Rates May Affect Breast Cancer Treatment

Use of a costly breast cancer therapy called intensity-modulated radiation therapy is strongly influenced by what Medicare will pay for the treatment and where radiation oncologists practice, according to a new study. Researchers analyzed Medicare data for 26,163 women with localized breast cancer who had surgery and radiation therapy between 2001 and 2005. During that time, Medicare billing for the treatment, called IMRT, increased more than 10-fold (from 0.9 percent to 11.2 percent of patients).

The average cost for radiation treatment within the first year after breast cancer diagnosis was $7,179 without IMRT and $15,230 with it. Billing for IMRT was five times higher in regions of the country where the treatment was covered by local Medicare carriers than it was in areas where it was not covered, the researchers said. They also found that billing for IMRT was more common among patients treated in freestanding radiation treatment centers (7.6 percent) than among those treated in hospital-based outpatient clinics (5.4 percent).

The findings "suggest that with respect to breast radiation therapy, much of the variation in cost can be directly attributed to inconsistent treatment definitions and reimbursement rates authorized by Medicare and its intermediaries," concluded Dr. Benjamin D. Smith, of the M.D. Anderson Cancer Center in Houston, and his colleagues. The study is published in the April 29 online edition of in the Journal of the National Cancer Institute.

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Breast Reconstruction After Mastectomy: Now or Later?

Two new studies may help breast cancer patients and their doctors make treatment decisions involving immediate breast reconstruction after mastectomy. One study finds that about half of women who need radiation therapy after having had a mastectomy with immediate reconstruction develop complications that require additional surgery. Another study finds that chemotherapy does not affect complication rates after mastectomy and immediate reconstruction. Both reports are published in the September issue of the Archives of Surgery. The growing trend toward immediate reconstruction "has turned into a runaway train," said researcher Dr. Rodney Pommier, professor of surgery at Knight Cancer Institute, Oregon Health & Science University in Portland. Some women, he said, would be better off delaying it.

Pommier and his colleagues evaluated 302 women who had mastectomies; of these, 152 had reconstruction, including 131 immediately, and 100 had radiation after the mastectomy. Among those 100 who needed radiation, complications occurred in 44 percent of those who had immediate reconstruction, but only in 7 percent of those who did not have immediate reconstruction. Both scenarios having radiation after mastectomy and having reconstruction done immediately strongly predicted the risk of complications, Pommier's team found. Radiation tripled the risk, and immediate reconstruction increased the risk eightfold.

Implants had to be removed in 31 percent of patients who had radiation after mastectomy, compared to just 6 percent of those who did not have to have radiation, the researchers reported. "We were surprised that one in three lost implants," he said. His team was also surprised at the complication rates overall. "I think it was known that complication rates are fairly high, but I don't think they have been quantified," he noted. The results, Pommier said, have changed his thinking. He now suggests that having a biopsy of the sentinel lymph node before deciding whether to have immediate reconstruction would be wise. "If the sentinel node is negative, there is a low probability they would get radiation," he explained.

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