What Should Be Considered for Partial Breast Irradiation in Korea?

Yong Bae Kim, M.D.

Department of Radiation OncologyYonsei Cancer Center, Yonsei University College of Medicine

Current status of A-PBI

ASTRO consensusStatement (2009)

Balloon BT(FDA approved)

2002

ASTRO consensusAmendment (2017)

?

International Journal of Radiation Oncology, Biology, Physics 2013

Far from Widespread use in Korea

Patterns-of-care study (Survey, 2017)

• Only 3/64 hospital (4.7%)

CHONNAM NATIONAL UNIVERSITY HWASUN HOSPITAL

Park HJ, Park W et al. J Breast Cancer 2018

Why is Not so Popular in Korea ?01Patient

selection

02Small

breast volume

03Lack of

experience

04Reimbursement

1) Patient selection criteria

Age criteria in Early Consensus Statements of A-PBI

ABSASTRO

“Suitable”GEC-ESTRO “Low-risk”

ASBS

Published 2017 2018 2010 2011

Age ≥ 45 y ≥ 50 y > 50 y ≥ 45 y (Invasive ca)≥ 50 y (DCIS)

No data supporting exact cut-off age

1) Patient selection criteria

Younger age distribution of breast cancer in Korea

Health Insurance Review & Assessment Service (2011-2015)SEER 18 (2011-2015)

0%

10%

20%

30%

40%

50%

<20 20-34 35-44 45-54 55-64 65-74 75-84 >84

Korea

USA10-15 years younger

Much smaller population based on current guideline in Korean patients

NSABP B-39 / RTOG 0413

Actual patient accrual may affect inferior outcome of A-PBI

NSABP B39 from SABCS 2018

ASTRO consensus 1.0 (2009) → 2.0 (2017)

2) Small breast volume in Korea patients

Earlier reports for technical feasibility of A-PBI in Korean patients

Average cup size: A

KROG 0804 - Jeong et al., Cancer Res Treat, 2014

• Each dose limitation for normal tissues followed the criteria described in the RTOG 0319 protocol

• Poor dosimetricoutcomes in 3D CRT based A-PBI• Overall major variation

: 23.8%• PTV/IB is the most

important factor

3) Reluctance of RO doctors in adopting new technique

Radiologic background has been established

Qi et al. Radiother Oncol 2011

• Conclusions: The analysis of the available clinical data from multiple institutions support that breast cancer has a low ratio of α/β, encouraging shorter-scheduled radiotherapy regimens for breast cancer.

Many techniques can be adopted in A-PBI

3) Reluctance of RO doctors in adopting new technique

Applicator brachytherapy

Interstitial brachytherapy

APBIIntensity-modulated radiation therapy

Technique could affect different oncologic outcomes ? Tumor bed coverage..!

3) Reluctance of RO doctors in adopting new technique

Treatment group #of pts#of IBTR events

HR 95% CI

Whole breast irradiation ref

NSABP-B39 (Single-entry brachytherapy device) 358 24 2.15* 1.34-3.44

TARGIT (Intraoperative radiotherapy) 1,721 23 2.05 1.00-4.21

NSABP-B39 (Multi-catheter brachytherapy) 130 9 2.21* 1.10-4.46

GEC-ESTRO (Multi-catheter brachytherapy with QC) 633 9 0.69 0.20-2.39

NSABP-B39 (3D CRT) 1,535 55 1.04 0.73-1.49

RAPID (3D CRT) 1,070 37 1.27 0.84-1.91

Florence (IMRT) 260 3 1.16 0.23-5.75

RAPID, NSABP B39 from SABCS 2018Vratislav Strnad, Lancet Oncol 2016; Jayant S Vaidya, Lancet Oncol 2014

Livi, European J Cancer 2015

Heard in the halls over last decade …

3) Reluctance of RO doctors in adopting new technique

“It’s not how I was trained.”

“It’s just 1 week.”

“I have good outcomes with standard fractionation.”

“What’s the big deal, its not like we’re saving anyone’s life with A-PBI.”

The last, but The most concerned issue in National Insurance Health System..

4) Reimbursement

Conventional fractionation

Hypofractionation

A-PBI

Facing reduced income when adopting A-PBI in current system

4) Reimbursement

₩3,500,000

₩7,200,000

₩4,700,000

₩8,500,000

₩4,060,000

Conventional Fx(2D)

Conventional Fx(3D CRT)

Hypo Fx(3D CRT)

Hypo Fx(IMRT)

A-PBI

33 Fx 15 Fx 5 Fx

KSW (₩)USD ($)

33 Fx 20 Fx

$ 3,084

$ 6,344

$ 4,141

$ 7,489

$ 3,578

44%

14%

57%

Number of patients treated with RT in Korea

Health Insurance Review and Assessment Service 2011-2015Seo et al., Cancer Res Treat, 2017

4) Reimbursement

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

2011 2012 2013 2014 2015

Breast

Lung

Colorectal, Liver, Prostate, Uterine cervix

person

• Breast cancer is No.1 cancer that patients receive radiotherapy in Korea.

• Application of A-PBI may reduce the income of radiation oncology department

• Could have an impact on the maintenance of the facility.

• Current system only considers the fraction number and technique

→“Fraction size” as a new parameter for reimbursement

Need for Alternative Payment model for Radiation therapy

4) Reimbursement

₩107,744

₩172,285

₩76,667

₩0

₩2,000,000

₩4,000,000

₩6,000,000

₩8,000,000

₩10,000,000

₩0

₩50,000

₩100,000

₩150,000

₩200,000

Conventional Fx(3D CRT)

Hypo Fx(IMRT)

A-PBI

Current Cost per Gy & Total cost

per Gy Total cost

2 Gy 3 Gy 6 Gy 2 Gy 3 Gy 6 Gy

₩151,000

₩240,000

₩300,000

₩0

₩2,000,000

₩4,000,000

₩6,000,000

₩8,000,000

₩10,000,000

₩0

₩100,000

₩200,000

₩300,000

₩400,000

Conventional Fx(3D CRT)

Hypo Fx(IMRT)

A-PBI

Suggested Cost per Gy & Total cost

per Gy Total cost

Example

WS Yoon et al., J Korean Med Sci, 2019

Need for Alternative Payment model for Radiation therapy

4) Reimbursement

Plan to be implemented in the late summer of 2019 in USA.

• Under active reimbursement policy, radiation oncologists can search alternative methods to improve the cost-effectiveness of their practices.

• There has already been a move toward an episodic alternative payment model in USA.

Fiducial tracking with CyberKnife M6 Robotic SBRT system

Stereotactic-PBI Process in Yonsei Cancer Center

OPD Consult 3 fiducials insertionPost-Insertion

MMG

CT simulationTarget contour & planning & DQA

Fiducial testing Treatment start

D0 D0-1

D7 D5-7 D1

Initial report for selected early-stage breast cancer

Stereotactic-PBI Process in Yonsei Cancer Center

• 114 A-PBI with CyberKnife M6 between Nov. 2015 and Jun. 2018• Gold fiducials were used since Sep. 2017

• Dose regimen of 30 Gy in 5 fractions was used since Mar. 2017

• Categorized as “suitable” (71.1%) or “cautionary” (28.9%) • According to 2017 ASTRO guideline

• Median follow-up was 6 months

• No grade 2 or higher toxicity was report• 3 Breasts with grade 2 induration

• All patients remained disease free

Unpublished data. WH Lee, JS Chang, YB Kim et al.

Summary

• Currently, many things should be considered for A-PBI in Korea as mentioned. • Patient selection

• Breast volume

• Lack of experience

• Reimbursement

• However, the application of A-PBI will be gradually more expanded for early breast cancer in Korea.

With the Love of God, Free Humankind from Disease and Suffering