Impact of peer review on use of hypofractionated regimens for early-stage breast cancer for patients at a tertiary care academic medical center and its community-based affiliates

QUESTION ASKED: What is the impact of implementing a system-wide peer review process across a cancer care network on the use of hypofractionated treatment regimens in early-stage breast cancer? SUMMARY ANSWER: Rates of hypofractionation use increased from 66% in January 2016 to 81% in June 2017 across the entire cancer care network and from 51% to 69% at our community-based satellites alone; these rates continued to increase over time and approached 100% toward the end of the period studied. Treatment date after initiation of peer review was a significant predictor for use of hypofractionated radiation (HFRT) on multivariable analysis. WHAT WE DID: We recently implemented a system-wide peer review process in November 2016 in an effort to standardize care across our network. We evaluated patients treated with whole-breast radiation therapy from January 2016 to June 2017; various patient, tumor, and treatment characteristics, including treatment date after peer review, were analyzed for their effect on fractionation regimen. WHAT WE FOUND: HFRT regimens in early-stage breast cancer increased after implementation of peer review. This seemed to be driven by increases in hypofractionation in certain subgroups of patients, including patients younger than age 50 years, patients receiving chemotherapy, and patients with grade 3 tumors or T2 disease. Predictors of HFRT use across the cancer network included older age, tumor grade, initiation of treatment after peer review, and surgery performed by an academic-based surgeon. BIAS, CONFOUNDING FACTORS: Rates of hypofractionation use seemed to be increasing, albeit slowly, even before peer review. In addition, we did not collect detailed information about changes in radiation plans made after peer review; thus, the exact impact of implementation of this process cannot be determined for certain. REAL-LIFE IMPLICATIONS: Peer review seemed to have a positive impact on HFRT rates in early-stage breast cancer in our study, with our post–peer review rates approaching the highest in published literature. There have been multiple studies attempting to identify ways to promote adoption of HFRT regimens for early-stage breast cancer, but so far, nationwide success remains limited. Our study suggests that peer review may be one avenue to explore in improving these rates, perhaps by improving dissemination of relevant literature and encouraging discussion of appropriate uses for hypofractionation. Another potential avenue would be educating referring surgeons because they also seem to play a role in use of fractionation schemes in patient treatment.