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Objective: Over the past 10 years APBI has been offered as an alternative to whole breast radiation for selected patients with early breast cancer who choose breast conservation. In 2009, the American Society for Radiation Oncology (ASTRO) held a consensus conference to establish practice guidelines. Patients were categorized into suitable, cautionary, and unsuitable groups based on clinical and pathologic data. This study evaluates the effect of these published guidelines on the clinical application of APBI.
Design: Before-after trial.
Setting: Community teaching hospital.
Patients: Patients with Stage 0-II breast cancer treated from 2004 to 2012.
Interventions: APBI.
Main Outcome Measures: Utilization of APBI before and after 2009.
Results: 259 patients received APBI, most having stage I (74%) or stage 0 (22%) breast cancer. Breakdown by ASTRO guidelines was: 40% suitable, 51% cautionary, 9% unsuitable. Since 2004 the number of APBI cases per year rose to a peak of 57 cases in 2009 (19% of stage I cancers that year), declining thereafter to a nadir of 22 cases in 2012 (6% of stage I cancers that year, P<0.001 compared to 2009). Less unsuitable cases received APBI after 2009 (12% vs. 4%, P<0.036). No difference in the proportion of suitable and cautionary cases was observed before and after 2009. The number of surgeons and breast cancer cases at our institution was stable during the study period.
Conclusions: We demonstrate decreased utilization of APBI following the publication of the ASTRO guidelines. A reduction in unsuitable cases treated does not explain the global loss of referrals. The reasons for a loss of enthusiasm in APBI after publication of the guidelines could not be identified and deserve further study.