Despite Strong Data, Hypofractionated Radiation Underused

In recent years, hypofractionated radiation has eclipsed conventionally fractionated radiation as the preferred treatment option for a range of cancer types, including early breast, prostate, lung, and rectal cancers. 

A growing body of evidence has demonstrated that hypofractionated regimens, which provide higher doses of radiation in fewer sessions, are at least as effective and safe as conventional fractionation. Studies have also found that hypofractionated radiotherapy may be cost effective.

Another major benefit of the abridged approach is convenience for patients and physicians, with hypofractionated regimens shaving weeks off treatment schedules.

Patients often appreciate the hypofractionated approach. Rachel Jiminez, MD, a breast radiation oncologist at Massachusetts General Hospital, Boston, noted that patients are often prepared for at least 6 weeks of radiation and are then very happy to hear they might only need it for half that time. 

While the field is embracing hypofractionation, the move has hardly been complete. Many patients who would benefit from hypofractionation are still not receiving it, Jiminez said. 

A 2021 survey of 203 US radiation oncologists found that only about half offered hypofractionated approaches for early prostate cancer and about 40% did so for rectal cancer, indicating that hypofractionated radiation remains underused.

A 2024 review of over a million patients who received whole breast irradiation after lumpectomy for either early invasive breast cancer or ductal carcinoma in situ (DCIS) found that about 64% of those with invasive breast cancer and about 57% of those with DCIS received hypofractionated radiation in 2020. These findings came 2 years after the American Society for Radiation Oncology (ASTRO) recommended hypofractionation for this patient population. 

What can explain the disconnect between the evidence and clinical practice in the US?

It’s possible that some radiation oncologists are not familiar with the latest data on hypofractionated radiation or want more evidence in patients who are not well-represented in trials, Jiminez said.

It might also be a challenge for older physicians to change the way they’ve been doing things for years, noted Albert Koong, MD, PhD, chair of the radiation oncology department at MD Anderson Cancer Center, Houston. 

But the greatest obstacle to wider adoption may come down to reimbursement challenges. 

Reimbursement for radiation therapy is typically calculated per fraction. That means providing fewer fractions at higher doses with hypofractionation will lead to lower reimbursement payments from Medicare or private insurers. For instance, while Medicare hospital reimbursements could be about $23,000 for a 33-fraction course of intensity-modulated radiation therapy, payments could drop to just over $12,000 for 15 fractions. 

Whereas large academic institutions might be able to absorb the revenue loss, smaller community practices and rural hospitals may not. This reimbursement model may also explain why studies have found that hypofractionation is less likely to be offered in private community practices than in larger academic institutions.

“There are a lot of financial implications of hypofractionation, and that’s one of the reasons why there has been slower adoption” in lower volume settings, said radiation oncologist Arpit Chhabra, MD, co-founder of Bridge Oncology, a Mississippi-based company that helps community and rural radiation practices overcome barriers to care.

In smaller, private practices in particular, “you’re asking physicians to take on more overhead with lower reimbursement,” Casey Chollet-Lipscomb, MD, a breast and gynecologic radiation oncologist at Tennessee Oncology, Nashville, told Medscape Medical News. “The fear is that there’s only so much hypofractionation that can be adopted and still keep clinics viable, unless we change our reimbursement models.”

A new bill, backed by ASTRO lobbying efforts and currently before Congress, aims to stabilize Medicare payments for radiation oncology and shift reimbursements to a per-patient, per-disease model instead of a per-fraction scheme. The Radiation Oncology Case Rate Value Based Program Act of 2024 (S.4330/H.R.8404) has bipartisan support in both the Senate and House of Representatives, but it could be several years before a decision is made.

Chollet-Lipscomb is involved with ASTRO’s efforts to get the bill over the hump. Overall, “the field is trying to embrace hypofractionation, but the doctors who are doing that and providing top level care are facing a financial penalty for it, and that’s not a tenable position long-term,” she said.

M. Alexander Otto is a physician assistant with a master’s degree in medical science and a journalism degree from Newhouse. He is an award-winning medical journalist who worked for several major news outlets before joining Medscape. Email: aotto@mdedge.com