When Patricia Thomas received radiation therapy for her breast cancer last fall, the daily drive to and from the hospital took longer than the 15-minute treatments did.
“I thought, ‘This is kind of silly,’” she said.
But when Thomas, whose treatments ended in November, chatted with fellow patients in the waiting room, she learned others had to travel much farther. There was the couple from Powell Butte who drove to and from Bend each day. Another from John Day parked their RV on the hospital grounds.
Daily radiation therapy can be a hassle for cancer patients, especially for Oregonians who live far from the hospital. For those too far away to drive each day, it’s a long stretch of time to be away from home.
“If you’re stuck here for the full course, that cannot be very fun,” said Dr. Linyee Chang, medical director of the St. Charles Cancer Center.
That’s why St. Charles is adamant about promoting an accelerated radiation regimen that can cut treatment time in half, from the usual five to seven weeks to three to four weeks. Today, St. Charles oncologists offer the regimen to 100 percent of eligible breast cancer patients, up from 78 percent in 2013. Only about two-thirds of patients are eligible under the hospital’s guidelines.
Thomas, 68, received the accelerated regimen after learning about it from Chang. After the roughly three weeks of radiation she received, she said her fatigue was so severe she couldn’t imagine doing it any longer.
“By the end of the week, you’re ready to make a beeline for your bed when you get home,” she said. “It’s just nicer to have a shorter time frame to not have that additional stress.”
St. Charles appears to be well ahead of the curve when it comes to promoting the accelerated regimen, which does not provide an additional medical benefit, only convenience and slightly smaller medical bills. It delivers more intense bouts of radiation for a shorter length of time.
“The best way of looking at it is compressing what’s biologically about the same amount of radiation into a slightly shorter time,” said Dr. Bruce Haffty, a radiation oncology professor at the Rutgers Cancer Institute of New Jersey and the Robert Wood Johnson Medical School.
Use low, but gaining steam
Two widely publicized studies released in December highlighted the fact that relatively few breast cancer patients who fit widely used guidelines set by a national radiology association receive the accelerated regimen, although the proportion has increased in recent years. Most still receive the conventional regimen that’s been used for decades.
In 2011, 22.8 percent of patients studied received the accelerated regimen, also called hypofractionated whole-breast irradiation, compared with 5.4 percent in 2004, according to a December article in the International Journal of Radiation Oncology. The study also found patients who lived more than 50 miles away from the hospital tended to receive the accelerated regimen more than those who lived closer.
Another study published about two weeks later found 34.5 percent of women studied who met the guidelines received the accelerated regimen in 2013, an increase from 10.6 percent in 2008.
The accelerated regimen is already used widely in other countries, especially in Canada and the U.K., where the original studies came out showing medical outcomes did not change between the two regimens in the mid- and late-2000s.
There are different perspectives on why the U.S. usage rates are so low. Some, like Haffty of Rutgers, say it’s normal to take years for things to catch on, especially when much of the research occurred in a different country and the conventional regimen has been used for decades.
“We’ve really been doing it since the 1970s and ’80s, and so people are very comfortable with it,” he said. “They know it works, it’s been done in randomized trials and people have become very, very comfortable with that.”
Chang, of St. Charles, said many oncologists didn’t adopt the accelerated regimen earlier out of residual apprehension from years ago that more intense radiation treatments were thought to cause burning and scarring of the breasts. The guidelines for the regimen restrict it to women who’ve had surgery to remove breast tumors, not entire breasts.
“We didn’t have long-term data on that and it was not how many of us were trained,” she said. “So there was that hesitancy. It’s like, ‘Gosh, one of the benefits of doing breast conservation is to keep your breast, and you don’t want that breast to then be all scarred up and to have problems from that.’”
When given the option, not all patients choose the accelerated regimen, either. Currently, although all eligible St. Charles patients are offered the regimen, only 70 percent agree to it, Chang said. That’s simply because there is more data that proves it works just as well as the conventional regimen, she said.
That wasn’t the case with Thomas, who said she had faith in her doctors at St. Charles, and in the research that’s been done so far on the accelerated regimen.
“It kind of seemed to be like it might be the wave of the future instead of holding onto the past,” she said. “Medicine is so slow to change.”
Evolving over time
The American Society for Radiation Oncology has created a list of criteria it recommends patients meet in order to receive the accelerated regimen. Patients should be over 50 years of age, they should have had their tumor surgically removed as opposed to total breast removal, their cancer can’t have spread to the lymph nodes, they cannot have received chemotherapy and their cancer has to have been diagnosed at an early stage, among others.
Haffty, a member of ASTRO’s board of directors, said those guidelines were written conservatively, and they represent the population of patients that the accelerated regimen has been studied on.
“That doesn’t mean that patients who fall outside of those guidelines, so to speak, or outside of that spectrum, are not suitable candidates,” he said.
In fact, in the U.K. and Canada, the vast majority of patients receive the accelerated regimen regardless of whether they meet the guidelines, Haffty said.
Chang estimates only 25 percent of St. Charles’ breast cancer patients meet all of those guidelines. Some radiologists — especially those practicing at academic medical centers where research is happening — feel comfortable treating patients who don’t meet all of the guidelines, but she does not.
“I’m not in academic practice to where I would feel comfortable saying, ‘OK, I’m going to deviate from that,’” Chang said.
Dr. Carol Marquez, an associate professor of radiation oncology at Oregon Health & Science University, said she has already used the accelerated regimen on patients who don’t fit those guidelines — on patients who have had chemotherapy, for example.
As radiologists gain familiarity with the accelerated regimen, they’ll feel more comfortable using it on more patients, she said. As that happens, the guidelines will expand, she said.
“It’s going to kind of evolve over time,” Marquez said.
And that’s especially important in Oregon, where hospitals that offer radiation oncology are clustered along the Interstate 5 corridor, she said.
But while the accelerated regimen speeds up treatment time, it’s important to know it doesn’t decrease radiation exposure, nor the unavoidable side effects of radiation therapy, such as persistent fatigue, dry skin and soreness. Many breast cancer patients hear “accelerated” or “shorter” regimen and are under the misconception that they’re being overtreated with the conventional regimen, Chang said.
“They think they’re getting more treatment than they need because they’re getting treated longer, that’s just linked,” she said.
Marquez said the side effects of radiation are the same among her breast cancer patients regardless of which regimen they received.
“They always think their fatigue is going to be better,” she said. “I don’t think that that’s the case.”
— Reporter: 541-383-0304,