Retirement of Quality Measures

BCSRT

“For patients undergoing breast-conserving surgery without adjuvant chemo or immunotherapy for stage I-III breast cancer, radiation therapy, when administered, is initiated <= 60 days of definitive surgery” (BCSRT). 

The time to radiation therapy measure (BCSRT) will be retired. This decision was based on review of the literature and multiple conversations with key stakeholders, including practicing radiation oncologists, about the feasibility and relevance of the measure. There are no prospective or randomized studies examining the impact of the time interval from surgery to radiation therapy on cancer outcomes. There have been several single and multi-institution studies examining how the time interval from surgery to radiation impacts disease-specific survival, recurrence, and distant metastasis-free survival. However, none of these studies agree on a specific time interval associated with worse cancer outcomes. Most studies compared a longer time interval compared to a shorter time interval and examined the association with recurrence, except for one study that examined overall survival alone. The most recent study to examine this time interval utilized the National Cancer Database and showed that each month out from surgery to radiation therapy was associated with worse overall survival. A time interval >60 days was significantly associated with an approximately 20% worse overall survival¹. Another study from 2017 showed no association between a time interval >55 days compared to shorter time intervals for disease-free survival or locoregional recurrence-free survival². Two other studies showed that a delay of radiation therapy for up to 16 weeks was not associated with an increased risk of recurrence^3,4, and a third study showed delays up to 20 weeks showed no difference in breast cancer-specific survival or locoregional free survival⁵. 

In addition, the Breast Disease Site Group examined estimated performance rates (EPR) at different time intervals from surgery to radiation therapy to determine how lengthening the time interval on the quality measure would impact EPRs. Estimated performance rates at a time interval of 90 days were over 92%, indicating little room for improvement if a 90-day time interval was adopted for the measure. Lastly, several radiation oncologists commented that time intervals of greater than 90 days were acceptable in many radiation trials of breast cancer. These aforementioned factors and the insufficient data to support the 60-day time interval prompted the CoC to retire the BCSRT measure. 

References 

1. Bleicher RJ, Moran MS, Ruth K, Edge SB, Dietz JM, Wilke LG, Stearns V, Kurtzman SH, Klein J, Yao KA. The Impact of Radiotherapy Delay in Breast Conservation Patients Not Receiving Chemotherapy and the Rationale for Dichotomizing the Radiation Oncology Time-Dependent Standard into Two Quality Measures. Ann Surg Oncol. 2022 Jan;29(1):469-481. 
2. van Maaren MC, Bretveld RW, Jobsen JJ, Veenstra RK, Groothuis-Oudshoorn CG, Struikmans H, Maduro JH, Strobbe LJ, Poortmans PM, Siesling S. The influence of timing of radiation therapy following breast-conserving surgery on 10-year disease-free survival. Br J Cancer. 2017 Jul 11;117(2):179-188. 
3. Nixon AJ, Recht A, Neuberg D, Connolly JL, Schnitt S, Abner A, Harris JR. The relation between the surgery-radiotherapy interval and treatment outcome in patients treated with breast-conserving surgery and radiation therapy without systemic therapy. Int J Radiat Oncol Biol Phys. 1994 Aug 30;30(1):17-21. 
4. Hershman DL, Wang X, McBride R, Jacobson JS, Grann VR, Neugut AI. Delay in initiating adjuvant radiotherapy following breast conservation surgery and its impact on survival. Int J Radiat Oncol Biol Phys. 2006 Aug 1;65(5):1353-60. 
5. Olivotto IA, Lesperance ML, Truong PT, Nichol A, Berrang T, Tyldesley S, Germain F, Speers C, Wai E, Holloway C, Kwan W, Kennecke H. Intervals longer than 20 weeks from breast-conserving surgery to radiation therapy are associated with inferior outcome for women with early-stage breast cancer who are not receiving chemotherapy. J Clin Oncol. 2009 Jan 1;27(1):16-23.