Declining brachytherapy utilization for cervical cancer patients - Have we reversed the trend?

Abstract

Objective: Studies examining temporal trends in cervical brachytherapy use are conflicting and examined different health insurance populations. This study examined brachytherapy utilization over time by health insurance type and whether reported declines in brachytherapy have reversed. Methods: The National Cancer Database (NCDB) was queried for patients with FIGO IIB-IVA cervical cancer treated with definitive chemoradiotherapy between 2004 and 2014, identifying 17,442 patients. Brachytherapy utilization over time and by insurance type and other sociodemographic factors were compared using binary logistic regression. A sensitivity analysis was done in a sub-cohort of patients using the boost modality variable in the NCDB. Results: Brachytherapy utilization declined during 2008–10 (52.6%) compared to 2004–2007 (54.4%; odds ratio [OR] 0.93, 95% confidence interval [CI] 0.86–1.01) and declines were disproportionately larger for patients with government insurance (49.4% vs 52.3%, respectively) than privately-insured patients (57.6% vs 58.9%, respectively). However, rates of brachytherapy use subsequently recovered during 2011–14 in all insurance groups (58.0%, OR 1.24, 95% CI 1.16–1.34) and was especially improved for Medicaid (OR 1.44, 95% CI 1.26–1.65) and uninsured patients (OR 1.28, 95% CI 1.03–1.57). Sensitivity analysis using the boost modality variable confirmed these trends. Conclusions: In patients with FIGO IIB-IVA cervical cancer treated with definitive chemoradiotherapy from 2004 to 2014, brachytherapy utilization declined during the late 2000s and disproportionately affected patients with government insurance, but subsequently recovered in the early 2010s. Since government insurance covers vulnerable patient populations at-risk for future declines in brachytherapy use, proposed alternative payment models should incentivize cervical brachytherapy to solidify gains in brachytherapy utilization.