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
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