Clinical Utilization and Infrastructure of Radiation Therapy in Korea in 2020 and 2021

doi:10.21203/rs.3.rs-4884054/v1

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Clinical Utilization and Infrastructure of Radiation Therapy in Korea in 2020 and 2021

https://doi.org/10.21203/rs.3.rs-4884054/v1

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Background

Radiation therapy (RT) is a critical component in the treatment of cancer, alongside surgery and chemotherapy. Monitoring RT utilization (RTU) rates and infrastructure of RT trends provides valuable information on cancer care. This study aimed to evaluate the clinical status of RT, including the RTU rate and infrastructure of RT in Korea in 2020 and 2021.

Methods

Patient data for individuals undergoing RT in 2020 and 2021 were sourced from the Health Insurance Review and Assessment Service (HIRA). Through the data from the HIRA, we assessed the following aspects: the total number of patients who received RT in 2020 and 2021, the RTU rate for patients with cancer, the RTU rate by cancer diagnosis, the number of RT patients by age, the RT rate by region, the rate of hypofractionated RT for breast cancer, and RT ratio by specific RT modality. The RT infrastructure and human resources were analyzed using data from the Korea Institute of Radiological and Medical Sciences Dosimetry Lab and a nationwide survey.

Results

In 2020 and 2021, 90,351 and 97,840 patients, respectively, underwent RT in Korea, indicating an annual increase in treatment frequency. The RTU rates for patients with cancer were 32.8% in 2020 and 31.7% in 2021. Breast, lung, prostate, colorectal, and liver cancers were the most commonly treated types, with prostate cancer showing the most rapid growth in RTU rate among cancer types. The adoption of intensity-modulated RT is swiftly replacing conventional RT, and there continues to be a concentration of RT services in Seoul. Hypofractionated RT for breast cancer saw a steady increase, with rates rising from 23.5% in 2017 to 38.6% in 2020. As the total number of patients receiving RT increased, the number of RT centers, RT machines, and human resources in radiation oncology departments nationwide also steadily increased.

Conclusion

The study’s data present the clinical status of RT in Korea during 2020 and 2021. The number of patients undergoing RT in Korea shows ongoing growth, accompanied by corresponding expansions in RT infrastructure.

Radiotherapy

utilization rate

infrastructure

statistics

Korea

Cancer continues to be a significant public health concern globally, with increasing incidence rates and mortality figures posing considerable challenges for healthcare systems worldwide [1]. In Korea, as in many other countries, cancer remains a leading cause of death, with its prevalence steadily rising over the years. In 2021, 277,523 patients were newly diagnosed with cancer, and 82,688 patients died of cancer in Korea. The probability of developing cancer over a lifetime is 38.1% (39.1% for men and 36.0% for women), and cancer accounts for 26.0% of all deaths in Korea [2]. Radiation therapy (RT) is a vital component of modern cancer treatment alongside surgery and chemotherapy. As the demand for cancer treatment increases, understanding the utilization and infrastructure of RT is crucial for assessing and addressing the evolving landscape of cancer treatment in Korea.

Historically, data on RT utilization (RTU) in Korea were collected through questionnaires and institutional reports from 1999 to 2006, providing valuable but potentially biased and time-consuming information [3–6]. In recent years, the availability of comprehensive national claims data, particularly from the Health Insurance Review and Assessment Service (HIRA), has advanced the ability to analyze clinical RTU more accurately [7–11]. In this study, following previous investigations, we analyzed the clinical status of RT in Korea in 2020 and 2021 using claims data from HIRA. Additionally, we analyzed the national RT infrastructure, including human resources, and the trend of hypofractionated RT in patients with breast cancer during the same period.

This study was performed after receiving an exemption from review by the Institutional Review Boards (No. KIRAMS 2021-09-006 and KIRAMS 2022-12-001). We obtained and analyzed the claims data from HIRA for 2020 and 2021 to identify the total number of patients who received RT each year. Additionally, we examined the number of patients who received RT according to diagnostic codes, sex, and age group. The customized source population criteria and the procedure codes related to implementing RT in this study are presented in Tables 1 and 2.

Table 1

The customized source population
List	Criteria
Treatment period	1, January 2020 to 31, December 2021
Type of healthcare facility	Tertiary, secondary, primary, sanatorium
Diagnostic code	All codes
Type of insurance	Health insurance, medical aid, patriots and veterans affairs’ insurance
Sex	Male, female
Age	All ages

Table 2

Procedure codes related to implementing radiation therapy
Procedure code	Name of procedure code
HD051-HD056	Teletherapy-single or opposed ports
HD057-HD059	Rotational irradiation
HD061	3-Dimensional conformal therapy
HD080-HD089, HD150, HD160, HZ274	Brachytherapy
HD091- HD092	Total body or total lymph node irradiation
HD093	Total skin electron beam therapy
HD110-HD115, HD211-HD212	Stereotactic radiation therapy
HD121	Proton therapy
HD160	Intra-operative radiation therapy
HZ271	Intensity-modulated radiation therapy

Patients with diseases corresponding to diagnostic codes were classified based on the International Classification of Diseases, 10th edition. Based on these results, the overall RTU rate and the RTU rate for each cancer type were calculated using the cancer statistics in Korea for that year [2, 12]. The total RTU rate was defined as the cancer incidence and the proportion of patients with cancer who received RT in the corresponding year. The incidence of each cancer type and the proportion of patients who received RT for each cancer type in the corresponding year were also determined. In conjunction with the findings of this study, we referenced our previous research to confirm the trend changes over the past five years [11]. The analysis methods using claims data from the HIRA are described in detail in previous studies [7–11]. This study used HIRA research data (M20220121781 and M20221208001), and the views expressed are those of the authors and do not necessarily reflect those of HIRA or the Ministry of Health and Welfare.

The number of patients who received RT by region, based on the location of the hospital where RT was performed, and the regional disparities in RTU relative to the population size of each region were analyzed. The RT infrastructure was analyzed using data sources provided by the Korea Institute of Radiological & Medical Sciences (KIRAMS) Dosimetry Lab. The KIRAMS Dosimetry Lab, as a Secondary Standard Dosimetry Laboratory, performs calibration of ionization chambers for RT centers, supports dosimetry audits for RT machines, and RT-QA (Quality Assurance) for clinical trials in the Republic of Korea. In addition, a nationwide survey assessed RT infrastructure, including the number of RT centers, RT machines, and human resources in 2020 and 2021.

To analyze trends in the use of hypofractionated RT in breast cancer, we calculated the number of RT prescriptions for each patient with a diagnosis code of C50 who had one of the following procedure codes within 2 months after initial diagnosis: HD055-HD056, HD061, and HZ271 from January 1, 2017, to December 31, 2020. However, procedure codes HD051–HD053, which correspond to electron boost RT, were excluded from the total count of RT prescriptions. Patients who received 11–19 RT prescriptions were categorized as having received hypofractionated RT, while those who received 10 or fewer prescriptions, which are more indicative of palliative RT or RT discontinuation, were excluded.

The total number of patients who received RT in Korea in 2020 and 2021 was 90,351 and 97,840, respectively. These figures represent an increase of 3.5% (87,301 in 2019) and 8.3%, respectively, compared to the previous year. In 2020, the total numbers of male and female patients were 41,896 (46.4%) and 48,455 (53.6%), respectively. In 2021, these numbers were 44,993 (46.0%) and 52,847 (54.0%), respectively (Fig. 1).

Among patients who received RT in 2020, there were 81,374 with diagnostic codes C00–C97 and 7,754 with codes D00–D48. In 2021, these numbers increased to 87,912 and 8,572, respectively. According to cancer statistics in Korea, the RTU rate for patients with cancer was calculated to be 32.8% in 2020 and 31.7% in 2021 [2, 12]. The RTU rate has consistently remained above 30% since recording 30.4% in 2017 (Fig. 2).

Table 3 displays the distribution of patients who underwent RT categorized by diagnosis for the years 2020 and 2021. The predominant cancers treated with RT included breast, lung, prostate, colorectal, and liver cancer. Collectively, patients with breast, lung, and prostate cancers accounted for over half of all cancer cases receiving RT (Fig. 3). In 2021, patients with breast cancer and breast carcinoma in situ accounted for 30% of all patients who received RT. More than half of all female patients received RT for breast-related conditions (54.9% in 2020, 56.2% in 2021). Among major cancers, prostate cancer has exhibited the most notable increase in the number of patients receiving RT. Since 2019, prostate cancer has risen to third place and has continued to increase rapidly (Fig. 4).

Table 3

Distribution of patients who received radiotherapy according to diagnosis in 2020 and 2021 in Korea
Category	Primary diagnosis (diagnostic code)	Year ^a
Category	Primary diagnosis (diagnostic code)	2020	2021
Head and neck	Lip (C00)	17	24
	Base of tongue (C01)	151	159
	Tongue (C02)	365	423
	Gum (C03)	105	106
	Floor of mouth (C04)	61	76
	Palate (C05)	92	80
	Mouth (C06)	252	303
	Parotid gland (C07)	272	297
	Other salivary glands (C08)	192	210
	Tonsil (C09)	530	629
	Oropharynx (C10)	178	185
	Nasopharynx (C11)	561	578
	Piriform sinus (C12)	101	111
	Hypopharynx (C13)	423	429
	Nasal cavity and middle ear (C30)	195	216
	Accessory sinuses (C31)	197	187
	Larynx (C32)	1,016	1,119
	Eye and adnexa (C69)	82	95
	Thyroid (C73)	335	388
	Other (C14)	11	9
	Subtotal	5,136	5,624
Gastrointestinal	Esophagus (C15)	1,897	2,014
	Stomach (C16)	896	968
	Small bowel (C17)	70	62
	Colon (C18)	1,114	1,155
	Rectosigmoid junction (C19)	293	295
	Rectum (C20)	4,120	4,287
	Anus (C21)	272	314
	Liver (C22)	4,867	5,087
	Gallbladder (C23)	392	439
	Biliary tract (C24)	967	922
	Pancreas (C25)	1,426	1,433
	Other (C26)	2	2
	Subtotal	16,316	16,978
Thoracic	Trachea (C33)	31	36
	Bronchus and lung (C34)	14,132	14,919
	Thymus (C37)	516	547
	Mediastinum (C38)	62	65
	Other (C39)	0	0
	Subtotal	14,741	15,567
Breast	(C50)	23,034	25,520
Gynecologic	Vulva (C51)	93	109
	Vagina (C52)	73	74
	Uterine cervix (C53)	2,442	2,531
	Uterine corpus (C54-C55)	1,260	1,404
	Ovary and tube (C56)	437	462
	Other (C57-C58)	16	18
	Subtotal	4,321	4,598
Genitourinary	Penis (C60)	21	19
	Prostate (C61)	6,452	7,705
	Testis (C62-C63)	32	39
	Kidney (C64)	620	702
	Renal pelvis (C65)	100	144
	Ureter (C66)	198	213
	Bladder (C67)	793	881
	Other (C68)	33	21
	Subtotal	8,249	9,724
Central nervous system	Meninges (C70)	95	92
	Brain (C71)	1,820	1,939
	Spinal cord (C72)	48	48
	Other (C47)	49	45
	Subtotal	2,012	2,124
Lymphoma	Hodgkin's disease (C81)	118	116
	Non-Hodgkin's lymphoma (C82-C88)	2,079	2,227
	Others (C96)	17	16
	Subtotal	2,214	2,359
Primary bone and cartilage	(C40-C41)	247	260
Malignant melanoma	(C43)	354	391
Skin	(C44)	434	475
Mesothelioma	(C45)	43	43
Soft tissue	(C46, C49)	935	974
Endocrine	(C74-C75)	116	124
Myeloma and plasmacytoma	(C90)	526	555
Leukemia	(C91-C95)	421	445
Unknown primary	(C48, C76-C80, C97)	2,275	2,151
Total cancer patients		81,374	87,912
Carcinoma in situ	Carcinoma in situ of the breast (D05)	3,210	3,801
	Carcinoma in situ of the cervix (D06)	55	43
	Others (D00-D04, D07-09)	83	85
	Subtotal	3,348	3,929
Benign neoplasms	Benign neoplasm of meninges (D32)	1,777	2,093
	Benign neoplasm of central nervous system (D33)	995	934
	Benign neoplasm of endocrine (D34-D35)	459	432
	Others (D10-D31, D36)	147	156
	Subtotal	3,378	3,615
Neoplasms of uncertain or unknown behavior	Neoplasm of uncertain or unknown behavior of meninges (D42)	249	239
	Neoplasm of uncertain or unknown behavior of central nervous system (D43)	419	451
	Neoplasm of uncertain or unknown behavior of endocrine glands (D44)	97	82
	Others (D37-D41, D45-D48)	263	256
	Subtotal	1,028	1,028
Other D code diseases	(D*)	45	59
Total D code patients		7,799	8,631
Other than C or D code patients		1,178	1,297
Total		90,351	97,840
^a Values are presented as numbers.

Figure 5 shows the RTU rates for specific cancer types compared to the incidence of each cancer between 2017 and 2021. While the absolute number of patients receiving RT for each cancer type has generally increased, certain cancers—such as breast, lung, colon, rectum, uterine, and cervical— have seen a decrease in RTU rate due to a sharper rise in cancer incidences. In contrast, prostate cancer has seen an increase in both new cases and patients receiving RT, resulting in a higher utilization rate. For colorectal cancer, the RTU rate was 19.8% in 2020 and decreased to 17.5% in 2021. When specifically examining rectosigmoid cancer, the RTU rate was notably higher at 37.6% in 2020 and decreased to 30.4% in 2021.

Table 4 presents the number and proportion of patients who received RT over the past five years, categorized by age group. While the total number of patients receiving RT each year has increased, resulting in no significant decrease in the absolute number of patients under 50 receiving RT, the proportion of these patients has generally decreased. Conversely, the proportion of patients aged 60 and above receiving RT has steadily increased. Table 5 shows the 5 most common cancers treated with RT by age group in 2021. Compared to 2019, the rankings remained unchanged in the group aged 15 years or older. However, in the group younger than 15 years, the total number of patients receiving RT for each disease was less than 50, except for the first and second places, indicating a slight deviation in ranking from the 2019 data [11].

Table 4

Total number and proportion of patients who received radiation therapy by age group
Age group/year	2017^a	2018	2019	2020	2021
19 or younger	653 (0.84%)	625 (0.76%)	545 (0.62%)	616 (0.68%)	662 (0.68%)
20–29	930 (1.19%)	975 (1.19%)	1,035 (1.19%)	1,034 (1.14%)	1,074 (1.10%)
30–39	3,822 (4.91%)	3,846 (4.70%)	3,899 (4.47%)	3,912 (4.33%)	3,933 (4.02%)
40–49	12,835 (16.49%)	13,001 (15.90%)	13,107 (15.01%)	12,971 (14.36%)	13,758 (14.06%)
50–59	19,902 (25.57%)	20,318 (24.84%)	20,838 (23.87%)	20,811 (23.03%)	21,854 (22.34%)
60–69	20,281 (26.05%)	21,550 (26.35%)	23,704 (27.15%)	25,278 (27.98%)	28,232 (28.86%)
70–79	15,049 (19.33%)	16,492 (20.16%)	18,279 (20.94%)	19,009 (21.04%)	20,798 (21.26%)
80 or older	4,376 (5.62%)	4,986 (6.10%)	5,897 (6.75%)	6,720 (7.44%)	7,529 (7.70%)
Total	77,848 (100%)	81,793 (100%)	87,304 (100%)	90,351 (100%)	97,840 (100%)
^a Values are presented as numbers (%).

Table 5

The five most common cancers treated with radiation therapy by age group in 2021
Rank	Age group
Rank	0–14	15–34	35–64	≥ 65
1	Brain	Breast	Breast	Lung
2	Leukemia	Brain	Lung	Prostate
3	Endocrine^a, Soft tissue^a	Head and neck	Colorectum	Breast
4	-	Non-Hodgkin's lymphoma^a, Uterine cervix^a	Head and neck	Colorectum
5	Non-Hodgkin's lymphoma^a, Primary bone and cartilage^a, Head and neck^a	-	Liver	Liver
^a The number of radiation therapy patients for each cancer type within the relevant age group is the same.

Table 6 presents the number of RT cases and their respective modalities over the past 5 years. During this period, the number of intensity-modulated radiation therapy (IMRT) cases nearly doubled, rising from 27,565 to 59,839. Concurrently, the proportions of stereotactic radiation therapy (SRT), brachytherapy (BT), and proton therapy (PT) relative to total RT cases remained consistent. In contrast, the utilization of other conventional methods, such as 2-dimensional (2D) or 3-dimensional conformal RT (3DCRT), decreased by approximately half.

Table 6

The number of patients according to specific radiotherapy modalities between 2017 and 2021
Radiation therapy modality	Year^a
Radiation therapy modality	2017	2018	2019	2020	2021
Intensity-modulated radiation therapy	27,565 (35.4%)	37,099 (45.4%)	45,882 (52.6%)	52,084 (57.7%)	59,839 (61.2%)
Stereotactic radiotherapy	10,335 (13.3%)	11,100 (13.6%)	12,598 (14.4%)	13,246 (14.7%)	14,200 (14.5%)
Brachytherapy	1,387 (1.8%)	1,345 (1.6%)	1,482 (1.7%)	1,436 (1.6%)	1,517 (1.6%)
Proton therapy	958 (1.2%)	1,154 (1.4%)	1,274 (1.5%)	1,378 (1.5%)	1,410 (1.4%)
Others	37,603 (48.3%)	31,095 (38.0%)	26,068 (29.9%)	22,207 (24.6%)	20,874 (21.3%)
Total radiation therapy case	77,848 (100%)	81,793 (100%)	87,304 (100%)	90,351 (100%)	97,840 (100%)
^aValues are presented as numbers (%).

Figure 6 illustrates the ratio of RTU compared to the population ratio by region in 2021, which was generally consistent with the 2019 survey results. The RTU-to-population ratio was observed to be low in all prefectures except Seoul. In Seoul, despite a population ratio of 18.4%, accounted for 44.3% of total RT conducted. In the metropolitan area comprising Seoul, Incheon, and Gyeonggi-do, where the total population ratio is 50.4%, approximately two-thirds (65.6%) of individuals received RT. The concentration of BT in Seoul is notably high, accounting for 51.3% of all BT procedures. Additionally, regions, such as Jeju and Chungcheongbuk-do were found to have no BT performed.

The RT infrastructure and human resources of radiation oncology departments in Korea are detailed in Table 7. The number of RT machines and human resources in radiation oncology departments in Korea has steadily increased over the past 5 years. From 2017 to 2021, the number of RT centers increased from 90 to 100, and the number of linear accelerators increased from 196 to 242. The total number of RT machines increased from 254 to 299, primarily due to the increase in linear accelerators, while the number of other machines showed minimal changes. The number of radiation oncologists increased from 250 to 300, whereas the number of residents in radiation oncology departments decreased from 53 to 24 during the same period.

Table 8 displays the ratio of RT implementation prescriptions for patients with breast cancer within 2 months of their initial diagnosis. Among patients who underwent RT within this timeframe, the proportion receiving 11 to 19 RT sessions increased from 23.5% in 2017 to 38.6% in 2020.

In this study, we analyzed HIRA data to examine the current status of RT in Korea in 2020 and 2021. Analysis of RT trends using HIRA data, which began in 2009, reveals a steady annual increase in the total number of patients receiving RT [7–11]. The RTU rate has remained above 30% since reaching 30.4% in 2017. In 2021, the total number of patients receiving RT increased compared to the previous year. However, the RTU rate decreased by 1.1%, attributed to a significant rise in cancer incidence in Korea in 2021, with an approximate increase of 30,000 cases. According to Lee et al., the RTU rate in Korea from 2010 to 2019 was 0–5.2% higher than rates reported in our previous studies during the same period. This discrepancy arises because our study analyzed procedure codes regarding RT implementation, whereas they examined procedure codes regarding RT planning. Consequently, their RTU rate may include cases where RT was not actually administered and instances where boost planning was counted multiple times for each patient. Therefore, they commented that the RTU rate in their study might be 10–15% higher than the actual RTU rate [13]. Abu Awwad et al. reported an optimal RTU rate in the Asia-Pacific region of 49.1% in 2020, with variations depending on national income groups [14]. Their study presented South Korea's optimal RTU rate as 42.54%. Comparing this with the RTU rate in this study, it shows that South Korea's actual RTU rate is still approximately 10% lower than the optimal rate suggested in their analysis.

Over the past 5 years, the number of RT patients for the five major cancers has steadily increased, with prostate cancer exhibiting the most rapid growth. Prostate cancer, which was ranked fifth in 2017, rose to third place in 2019, with a consistent annual increase of over 10%. The RTU rate for prostate cancer exceeded 40% in 2021. According to a report by Abu Awwad et al., the optimal RTU rates by cancer type for high-income countries were presented as follows: 87% for breast, 77% for lung, 58% for prostate, 0% for liver, 71% for cervix, and 23% for colorectum [14]. Compared to the current study, the RTU rates for breast, colorectal, and cervical cancers were close to the optimal RTU rates, while the RTU rates for lung and prostate cancers were found to be lower than the optimal levels. Notably, the RTU for lung cancer was about 30% lower than the optimal RTU. Conversely, for liver cancer, the optimal RTU was reported as 0%, yet the RTU rate for patients with liver cancer in the current study was 33.6% in 2021. For hepatocellular carcinoma (HCC), the role of conventional RT has been limited due to technical difficulties in delivering high doses of radiation, and current HCC treatment guidelines do not clearly define the role of RT [15–17]. However, with the advent of SRT or PT, it has become possible to deliver tumoricidal doses, leading to an increase in RT with curative intent for relatively early-stage HCC. Nonetheless, since this study did not analyze the RT modality for each cancer type, whether the high RTU rate for liver cancer is attributable to the application of SBRT or PT remains unclear. Therefore, future research focusing on the RT modality for each disease is necessary.

Regarding RT modalities, there has been a notable shift in recent years. The proportions of SRT, BT, and PT have remained relatively stable. However, traditional RT methods, such as 2D and 3DCRT, have seen a significant decline, while the utilization of IMRT has correspondingly increased. This trend is attributed to the broader coverage of national health insurance and the widespread adoption of advanced RT equipment, a pattern expected to continue. As of 2021, only two institutions in the country were equipped to perform PT. The anticipated introduction of carbon therapy in 2023 is expected to gradually increase the adoption of charged-particle therapy in the RT landscape.

The focus of cancer treatment in Seoul, Korea, is well-documented. In 2009, medical institutions in Seoul provided 49% of the total medical care for patients with cancer, with 58% of the income from cancer management in these institutions originating from patients residing outside Seoul [18]. In our current study, an analysis of RT rates and population ratios by region reveals that, in all areas except Seoul, the RT rate is lower than the population ratio. However, Seoul, which comprises 18.4% of the national population, exhibits an RT rate of 44.3%, indicating a significant concentration. This concentration aligns with previous findings of a 43.9% RT rate in Seoul [10]. This trend is likely due to the clustering of advanced healthcare infrastructure, including radiation oncology expertise, and the improved regional accessibility provided by Seoul's comprehensive transportation network [19].

Our results indicate a growing preference for hypofractionated RT among patients with breast cancer in Korea, with rates increasing from 23.5% in 2017 to 38.6% in 2020. Generally, it is known that patients with breast cancer are more commonly administered hypofractionated RT following breast-conserving surgery (BCS) compared to those who have undergone mastectomy. Data from the National Cancer Database in the United States, covering patients diagnosed with breast cancer from 2012 to 2016, reported an increase in the proportion of patients receiving hypofractionated RT after BCS for stage 0–I breast cancer, rising from 20.93% in 2012 to 59.02% in 2016 [20]. In contrast, a study focusing on patients undergoing post-mastectomy radiation therapy (PMRT) from 2004 to 2014 reported a much lower rate of 1.1% receiving hypofractionated RT [21]. In Korea, breast cancer statistics from 2019 indicate that 68.6% of patients underwent BCS, while 30.4% underwent mastectomy. The proportion of BCS has been increasing gradually, whereas the proportion of mastectomy has been decreasing, continuing a trend observed since 2002 [22]. According to a nationwide survey by Park et al., 88.6% of Korean radiation oncologists reported using hypofractionated RT of 2.5 Gy or more in 2022, a substantial increase from 35.9% in 2017. For PMRT, the use of hypofractionated RT increased from 7.8% in 2017 to 35.7% in 2022 [23]. These findings suggest that the utilization of hypofractionated RT for breast cancer is likely to continue increasing in the future. Additionally, the Korean health service's reimbursement policy, which sets a higher reimbursement rate for IMRT with a fraction size of 2.5 Gy or higher from 2024, is expected to further promote the adoption of hypofractionated RT.

A limitation of this study is that the number of patients receiving RT was derived from HIRA data, which encompasses new patients diagnosed within the respective year and those who underwent overlapping RT sessions. This approach may lead to inaccuracies when calculating the RTU rate compared to newly diagnosed patients with cancer in the same year. There is a possibility of overestimation if the same patient receives multiple RT sessions, thereby affecting the accuracy of our findings. Another limitation is that uninsured patients and foreign patients, who are not represented in the HIRA data, were excluded from our analysis. The methodology employed in this study for evaluating hypofractionated RT among patients with breast cancer has limitations that may impact the accuracy of our findings. Using claims data to categorize hypofractionated RT based on prescription counts involves several assumptions, which could introduce inaccuracies. Additionally, the current procedure codes do not differentiate fraction sizes above and below 2.5 Gy, which is crucial for accurately classifying hypofractionated treatments. However, starting in 2024, different RT procedure codes will be applied for fraction sizes of 2.5 Gy or more and those less than 2.5 Gy, allowing for more accurate analysis of the trends in hypofractionated RT for breast cancer in the future.

In conclusion, the RTU rate in Korea has steadily increased, according to HIRA data. Particularly noteworthy is the sharp rise in the RTU rate, which correlates with the increasing number of patients with prostate cancer in an aging society. The trend of hypofractionated RT in patients with breast cancer is increasing, with expectations for more precise analysis starting in 2024. Additionally, traditional RT methods are rapidly being replaced by IMRT. We plan to continue our research to determine whether these trends continue.

RT: Radiation therapy

RTU: Radiation therapy utilization

HIRA: Health Insurance Review and Assessment Service

RT-QA: Radiation therapy-quality assurance

IMRT: Intensity-modulated radiation therapy

SRT: Stereotactic radiation therapy

BT: Brachytherapy

PT: Proton therapy

2D: 2-dimensional

3DCRT: 3-dimensional conformal radiation therapy

HCC: Hepatocellular carcinoma

BCS: Breast-conserving surgery

PMRT: Post-mastectomy radiation therapy

Ethics approval and consent to participate

This study was performed after receiving an exemption from review by the Institutional Review Boards (No. KIRAMS 2021-09-006 and KIRAMS 2022-12-001).

Consent for publication

Not applicable

Data availability statement

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

All authors have no potential conflicts of interest.

Funding

This work was supported by a grant from the Korean Institute of Radiological and Medical Sciences (KIRAMS), funded by Ministry of Science and ICT (MSIT), Republic of Korea (No.50572-2024 and No.50432-2024).

Authors’ contributions

All authors contributed to the review and editing of the manuscript. WJ and MK conceptualized, oversaw its progress, and secured funding of the study. JK, EK, JY, HK YS, JWK, and KK were responsible for data collection, analysis, and validation. JK wrote the draft of the manuscript. WJ, MK, EK, YS, and JWK made substantial contributions to drafting and revising of the manuscript.

Acknowledgments

Not applicable

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Clinical Utilization and Infrastructure of Radiation Therapy in Korea in 2020 and 2021

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