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Whole-breast irradiation (WBI) has become the standard of care following breast-conserving surgery in patients with early-stage breast cancer. Patterns of failure in these patients suggest that limiting radiation therapy to the lumpectomy cavity via accelerated partial breast irradiation (APBI) may produce acceptable clinical outcomes in properly selected patients (1–4). APBI can be delivered via multiple techniques, including single catheter-based brachytherapy, interstitial brachytherapy, intraoperative radiation, and external beam irradiation (EBI). It has been widely acknowledged that APBI provides several potential advantages over WBI, including both decreased overall treatment times and reduced radiation dose delivery to normal breast tissue and adjacent organs. However, among several theoretical disadvantages to APBI, the most salient is the potential that occult foci of cancer elsewhere in the breast may remain untreated and result in subsequently higher rates of tumor recurrence. Several multicenter randomized clinical trials have been initiated or completed to compare the effectiveness and safety of APBI vs WBI (5–10). Most breast cancer experts agree that conservative patient selection criteria for APBI should be used until the results of phase III trials comparing APBI and WBI become available, particularly because of the growing body of evidence that WBI after lumpectomy provides a benefit in longterm survival (11). Historically, physicians have had to rely upon single-institution phase II trials to determine which patients could safely be treated with APBI off protocol. In response, the American Society of Radiation Oncology (ASTRO) Health Services Research Committee developed a consensus statement regarding patient selection criteria and best practices for the use of APBI outside the context of a clinical trial (12,13). The recommendations from this committee were based on the result of a systematic literature review supplemented by the expert opinions of the task force members. The consensus statement authors acknowledged that additional patients may actually be good candidates to receive APBI off protocol, but the authors were faced with insufficient long-term data with which to accurately classify patients. None of the categorizations of suitability for receipt of APBI by the ASTRO consensus statement were based on direct comparisons of rates of recurrence or other outcomes between these cohorts of patients. The article by Hattangadi et al. (14) in this issue of the Journal is the third one this year to document an increased utilization of APBI using brachytherapy (APBIb) nationally. Smith et al. (15) first examined a large national database of Medicare beneficiaries with private supplemental insurance. In their study of 6882 women with invasive breast cancer who were treated with breast-conserving surgery, they documented a rise in the usage of brachytherapy as an alternative to WBI over time, from less than 1% in 2001 up to 10% in 2006. The authors explained that this trend coincided with the approval by the United States Food and Drug Administration of the MammoSite device in 2002 and with Medicare reimbursement for APBIb in 2004. Abbott et al. (16) next published a retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER) database on the use of APBIb compared with WBI between 2000 and 2007 among 127 257 women with stage 0 to II breast cancer. During the time period examined, the proportion of women who received this treatment increased from 0.4% in 2000 to 6.8% in 2007, with the largest increase in use of this new technology among women who were aged 80 years or older. White race, lower-stage disease, and geographic location also predicted for greater utilization of APBIb. The study by Hattangadi et al. (14) examines the SEER data from the perspective of the ASTRO consensus statement, asking whether patients with stage 0 to III breast cancer who were treated with breast-conserving therapy and received treatment with APBIb (vs WBI) were “suitable” based on categorization by the ASTRO consensus statement. Overall, the use of APBIb has been higher among patients classified as suitable candidates Sounding A Warning Bell? Documentation of the Increased Utilization of Accelerated Partial Breast Irradiation