ORIGINAL ARTICLE – BREAST ONCOLOGY Cost Comparison of Radiation Treatment Options After Lumpectomy for Breast Cancer Rachel A. Greenup, MD, MPH, Melissa S. Camp, MD, MPH, Alphonse G. Taghian, MD, PhD, Julliette Buckley, MD, Suzanne B. Coopey, MD, Michele Gadd, MD, Kevin Hughes, MD, Michelle Specht, MD, and Barbara L. Smith, MD, PhD Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA ABSTRACT Background. Radiation therapy (RT) after lumpectomy for breast cancer can be delivered with several different regimens. We evaluated a cost-minimization strategy to select among RT options. Methods. An institutional review board (IRB)-approved retrospective review identified a sample of 100 women who underwent lumpectomy for invasive or in situ breast cancer during 2009. Post lumpectomy RT options included: no radiation in women C70 years [T1N0, estrogen receptor (ER)?] per Cancer and Leukemia Group B (CALGB) 9343 (no-RT), accelerated external-beam partial-breast irradia- tion (APBI), and Canadian fractionation (C-RT), as alternatives to standard whole-breast radiation therapy (WBRT). Eligibility for RT regimens was based on pub- lished criteria. RT costs were estimated using the 2011 US Medicare Physician Fee Schedule and average Current Procedural Terminology (CPT) codes billed per regimen at our institution. Costs were modeled in a 1,000-patient the- oretical cohort. Results. Median patient age was 56.5 years (range 32–93 years). Tumor histology included invasive ductal cancer (78 %), ductal carcinoma in situ (DCIS) (15 %), invasive lobular cancer (6 %), and mixed histology (1 %). Median tumor size was 1 cm (range 0.2–5 cm). Estimated per-patient cost of radiation was US$5,341.81 for APBI, US$9,121.98 for C-RT, and US$13,358.37 for WBRT. When patients received the least expensive radiation regi- men for which they were eligible, 14 % received no-RT, 44 % received APBI, 7% received C-RT, and 35 % defaulted to WBRT. Using a cost-minimization strategy, estimated RT costs were US$7.67 million, versus US$13.36 million had all patients received WBRT, representing cost savings of US$5.69 million per 1,000 patients treated. Conclusions. A cost-minimization strategy results in a 43 % reduction in estimated radiation costs among women undergoing breast conservation. Lumpectomy followed by radiation therapy (RT) is a safe alternative to mastectomy in women with in situ or invasive breast cancer who desire breast conservation. 1,2 Historically, breast-conservation therapy (BCT) consisted of lumpectomy followed by 6–7 weeks of whole-breast radiation therapy (WBRT), which provided acceptable locoregional recurrence rates and survival equivalent to that seen with mastectomy. 3,4 More recently, alternatives to whole-breast radiation have been evaluated. These include hypofractionated whole-breast radiation therapy (‘‘Cana- dian fractionation’’) (C-RT), and accelerated partial-breast irradiation (APBI) through external-beam or catheter-based techniques. Five- and 10-year follow-up after Canadian fractionation demonstrate local recurrence, disease-free and overall survival rates that are equivalent to rates fol- lowing standard whole-breast radiation therapy. 5,6 Early results following APBI, regardless of delivery technique, have also demonstrated local recurrence rates comparable to those of whole-breast radiation. 7,8 The CALGB 9343 trial evaluated the possibility of omitting radiation alto- gether, and found no decrease in survival and acceptable local recurrence rates when lumpectomy without radiation was used in women C70 years old with hormone-receptor- positive cancers who received endocrine therapy. 9,10 These shorter, accelerated radiation treatment regimens have several potential benefits for patients, including increased convenience that may improve treatment com- pliance, and in the case of APBI, less radiation to cardiac Ó Society of Surgical Oncology 2012 First Received: 15 April 2012; Published Online: 1 August 2012 B. L. Smith, MD, PhD e-mail: Blsmith1@partners.org Ann Surg Oncol (2012) 19:3275–3281 DOI 10.1245/s10434-012-2546-5