The case for shorter radiation therapy courses

The evidence supports hypofractionation in many cancer treatment scenarios, but there are still many missed opportunities.

Shortened courses of radiation therapy offer potential advantages for both patients and payers. Prominent medical societies have endorsed the approach, called hypofractionation, which is typically used for localized cancers of the breast, prostate, lung, brain and skin. Yet, while hypofractionation has long been the standard of care in Europe and Canada, adoption has lagged in the United States.

Hypofractionation offers several benefits.

Shorter courses of radiotherapy offer equivalent overall survival and non-inferior toxicity, as well as:

Decreased costs

Out-of-pocket costs were $500 less, in inflation adjusted dollars, for Medicare Advantage members who received hypofractionated whole breast irradiation. Insurers paid $5,200 less.

Lower time toxicity

Shortened courses can avoid weeks of treatments. Among patients who missed work due to treatment, those undergoing short-course radiotherapy took off 41% fewer unpaid hours.

Better experience

By reducing the total time spent at a cancer treatment center, hypofractionation improves the quality of life for patients who are in pain, are fragile, lack transportation, or lack caregiver support.

Yet it remains underutilized and highly variable.

Despite progress, the U.S. health care system has room to improve.

• Adoption has increased steadily. For example, in invasive breast cancer, use of hypofractionation increased from less than 1% in 2000 to 64% in 2020.
• Provider patterns vary widely. While some U.S. oncology practices use hypofractionation in 100% of all appropriate cases, others use it much less than 50% of the time, according to Evolent internal data.
• Certain populations are less likely to receive it. Black men undergoing treatment for prostate cancer were about 10% less likely than White patients to receive moderately hypofractionated regimens and 22% less likely to receive ultra-hypofractionated regimens.

Across-the-board improvement requires a systemic approach.

Our program aims to increase hypofractionation across populations and providers via:

• Policies and high-value pathways that give preference to hypofractionation in appropriate cases.
• Clinical decision support making hypofractionation the default selection when indicated.
• Targeted outreach and education to individual providers and practices with lower adherence.
• Specialty-matched peer-to-peer reviews that provide the evidence while inquiring about any unique patient factors that may favor the longer conventional regimens.

Adoption rates

Between January and March 2024, we worked with our health plan partners and providers to achieve the following adoption rates:

92% Breast cancer

87% Skin cancer

86% Lung cancer

61% Prostate cancer