Variation in the use of palliative radiotherapy at end of life: examining demographic, clinical, health service, and geographic factors in a population-based study

Age- and gender-based social inequalities in palliative care for cancer patients: a systematic literature review

Objectives

Cancer is a major public health problem worldwide, given its magnitude and growing burden, in addition to the repercussions on health and quality of life. Palliative care can play an important role improving quality of life and it is cost-effective, but some population groups may not benefit from it or benefit less based on age and gender inequalities. The aim of this systematic review was to analyze the available evidence on age- and gender-based social inequalities in access to and use of palliative care in cancer patients.

Methods

A systematic review was conducted following the PRISMA guidelines. An exhaustive literature research was performed in Pubmed, CINHAL and Embase until November 2022 and were not restricted by language or date of publication. Eligible studies were observational studies analyzing the access and use of palliative care in cancer patients.

Results

Fifty-three studies were included in the review. Forty-five analyzed age and 44 analyzed gender inequalities in relation to use of and access to palliative care. Our results show that older people receive poorer quality of care, worst symptom control and less preferences for palliative care. In relation to gender, women have a greater preference for the use of palliative care and generally have more access to basic and specialized palliative care services and palliative care facilities.

Conclusion

This review reveals difficulties for older persons and men for access to key elements of palliative care and highlights the need to tackle access barriers for the most vulnerable population groups. Innovative collaborative services based around patient, family and wider community are needed to ensure optimal care.

Choreographed expansion of services results in decreased patient burden without compromise of outcomes: An assessment of the Ontario experience

Background

Neuro-oncology care in Ontario, Canada has been historically centralized, at times requiring significant travel on the part of patients. Toward observing the goal of patient-centered care and reducing patient burden, 2 additional regional cancer centres (RCC) capable of neuro-oncology care delivery were introduced in 2016. This study evaluates the impact of increased regionalization of neuro-oncology services, from 11 to 13 oncology centers, on healthcare utilization and travel burden for glioblastoma (GBM) patients in Ontario.

Methods

We present a cohort of GBM patients diagnosed between 2010 and 2019. Incidence of GBM and treatment modalities were identified using provincial health administrative databases. A geographic information system and spatial analysis were used to estimate travel time from patient residences to neuro-oncology RCCs.

Results

Among the 5242 GBM patients, 79% received radiation as part of treatment. Median travel time to the closest RCC was higher for patients who did not receive radiation as part of treatment than for patients who did (P = .03). After 2016, the volume of patients receiving radiation at their local RCC increased from 62% to 69% and the median travel time to treatment RCCs decreased (P = .0072). The 2 new RCCs treated 35% and 41% of patients within their respective catchment areas. Receipt of standard of care, surgery, and chemoradiation (CRT), increased by 11%.

Conclusions

Regionalization resulted in changes in the healthcare utilization patterns in Ontario consistent with decreased patient travel burden for patients with GBM. Focused regionalization did not come at the cost of decreased quality of care, as determined by the delivery of a standard of care.

Does Geography Play a Role in the Receipt of End-of-Life Care for Advanced Cancer Patients? Evidence from an Australian Local Health District Population-Based Study

Objectives: To assess the influence of geographic remoteness on health care utilization at end of life (EOL) by people with advanced cancer in a geographically diverse Australian local health district, using two objective measures of rurality and travel-time estimations to health care facilities. Methods: This retrospective cohort study examined the association between rurality (using the Modified Monash Model) and travel-time estimation, and demographic and clinical factors, with the receipt of >1 inpatient and outpatient health service in the last year of life in multivariate models. The study cohort comprised of 3546 patients with cancer, aged ≥18 years, who died in a public hospital between 2015 and 2019. Results: Compared with decedents from metropolitan areas, decedents from some rural areas had higher rates of emergency department visits (small rural towns: aRR 1.29, 95% CI: 1.07-1.57) and ICU admissions (large rural towns: aRR 1.32, 95% CI: 1.03-1.69), but lower rates of acute hospital admissions (large rural towns: aRR 0.83, 95% CI: 0.76-0.90), inpatient palliative care (PC) (regional centers: aRR 0.85, 95% CI: 0.75-0.97), and inpatient radiotherapy (lowest in small rural towns: aRR 0.07, 95% CI: 0.03-0.18). Decedents from rural and regional centers had lower rates of outpatient chemotherapy and radiotherapy use, yet higher rates of outpatient cancer service utilization (p < 0.05). Shorter travel times (10-<30 minutes) were associated with higher rates of inpatient specialist PC (aRR 1.48, 95% CI: 1.09-1.98). Conclusions: Reporting on a series of inpatient and outpatient services used in the last year of life, measures of rurality and travel-time estimates can be useful tools to estimate geographic variation in EOL cancer care provision, with significant gaps uncovered in inpatient PC and outpatient service utilization in rural areas. Policies aimed at redistributing EOL resources in rural and regional communities to reduce travel times to health care facilities could help to reduce regional disparities and ensure equitable access to EOL care services.

Guideline-discordant inhaler regimens after COPD hospitalization: associations with rurality, drive time to care, and fragmented care - a United States cohort study

Background

Many patients receive guideline-discordant inhaler regimens after chronic obstructive pulmonary disease (COPD) hospitalization. Geography and fragmented care across multiple providers likely influence prescription of guideline-discordant inhaler regimens, but these have not been comprehensively studied. We assessed patient-level differences in guideline-discordant inhaler regimens by rurality, drive time to pulmonary specialty care, and fragmented care.

Methods

Retrospective cohort analysis using national Veterans Health Administration (VA) data among patients who received primary care and prescriptions from the VA. Patients hospitalized for COPD exacerbation between 2017 and 2020 were assessed for guideline-discordant inhaler regimens in the subsequent 3 months. Guideline-discordant inhaler regimens were defined as short-acting inhaler/s only, inhaled corticosteroid (ICS) monotherapy, long-acting beta-agonist (LABA) monotherapy, ICS + LABA, long-acting muscarinic antagonist (LAMA) monotherapy, or LAMA + ICS. Rural residence and drive time to the closest pulmonary specialty care were obtained from geocoded addresses. Fragmented care was defined as hospitalization outside the VA. We used multivariable logistic regression models to assess associations between rurality, drive time, fragmentated care, and guideline-discordant inhaler regimens. Models were adjusted for age, sex, race/ethnicity, Charlson Comorbidity Index, Area Deprivation Index, and region.

Findings

Of 33,785 patients, 16,398 (48.6%) received guideline-discordant inhaler regimens 3 months after hospitalization. Rural residents had higher odds of guideline-discordant inhalers regimens compared to their urban counterparts (adjusted odds ratio [aOR] 1.18 [95% CI: 1.12-1.23]). The odds of receiving guideline-discordant inhaler regimens increased with longer drive time to pulmonary specialty care (aOR 1.38 [95% CI: 1.30-1.46] for drive time >90 min compared to <30 min). Fragmented care was also associated with higher odds of guideline-discordant inhaler regimens (aOR 1.56 [95% CI: 1.48-1.63]).

Interpretation

Rurality, long drive time to care, and fragmented care were associated with greater prescription of guideline-discordant inhaler regimens after COPD hospitalization. These findings highlight the need to understand challenges in delivering evidence-based care.

Funding

NIHNCATS grants KL2TR002492 and UL1TR002494.

Addressing Inequity in Spatial Access to Lung Cancer Screening

BACKGROUND

The successful implementation of an equitable lung cancer screening program requires consideration of factors that influence accessibility to screening services.

METHODS

Using lung cancer cases in British Columbia (BC), Canada, as a proxy for a screen-eligible population, spatial access to 36 screening sites was examined using geospatial mapping and vehicle travel time from residential postal code at diagnosis to the nearest site. The impact of urbanization and Statistics Canada's Canadian Index of Multiple Deprivation were examined.

RESULTS

Median travel time to the nearest screening site was 11.7 min (interquartile range 6.2-23.2 min). Urbanization was significantly associated with shorter drive time (p < 0.001). Ninety-nine percent of patients with ≥60 min drive times lived in rural areas. Drive times were associated with sex, ethnocultural composition, situational vulnerability, economic dependency, and residential instability. For example, the percentage of cases with drive times ≥60 min among the least deprived situational vulnerability group was 4.7% versus 44.4% in the most deprived group.

CONCLUSIONS

Populations at risk in rural and remote regions may face more challenges accessing screening services due to increased travel times. Drive times increased with increasing sociodemographic and economic deprivations highlighting groups that may require support to ensure equitable access to lung cancer screening.

Drive Time and Receipt of Guideline-Recommended Screening, Diagnosis, and Treatment

IMPORTANCE

Many patients do not receive recommended services. Drive time to health care services may affect receipt of guideline-recommended care, but this has not been comprehensively studied.

OBJECTIVE

To assess associations between drive time to care and receipt of guideline-recommended screening, diagnosis, and treatment interventions.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used administrative data from the National Veterans Health Administration (VA) data merged with Medicare data. Eligible participants were patients using VA services between January 2016 and December 2019. Women ages 65 years or older without underlying bone disease were assessed for osteoporosis screening. Patients with new diagnosis of chronic obstructive pulmonary disease (COPD) indicated by at least 2 encounter codes for COPD or at least 1 COPD-related hospitalization were assessed for receipt of diagnostic spirometry. Patients hospitalized for ischemic heart disease were assessed for cardiac rehabilitation treatment.

EXPOSURES

Drive time from each patient's residential address to the closest VA facility where the service was available, measured using geocoded addresses.

MAIN OUTCOMES AND MEASURES

Binary outcome at the patient level for receipt of osteoporosis screening, spirometry, and cardiac rehabilitation. Multivariable logistic regression models were used to assess associations between drive time and receipt of services.

RESULTS

Of 110 780 eligible women analyzed, 36 431 (32.9%) had osteoporosis screening (mean [SD] age, 66.7 [5.4] years; 19 422 [17.5%] Black, 63 403 [57.2%] White). Of 281 130 patients with new COPD diagnosis, 145 249 (51.7%) had spirometry (mean [SD] age, 68.2 [11.5] years; 268 999 [95.7%] men; 37 834 [13.5%] Black, 217 608 [77.4%] White). Of 73 146 patients hospitalized for ischemic heart disease, 11 171 (15.3%) had cardiac rehabilitation (mean [SD] age, 70.0 [10.8] years; 71 217 [97.4%] men; 15 213 [20.8%] Black, 52 144 [71.3%] White). The odds of receiving recommended services declined as drive times increased. Compared with patients with a drive time of 30 minutes or less, patients with a drive time of 61 to 90 minutes had lower odds of receiving osteoporosis screening (adjusted odds ratio [aOR], 0.90; 95% CI, 0.86-0.95) and spirometry (aOR, 0.90; 95% CI, 0.88-0.92) while patients with a drive time of 91 to 120 minutes had lower odds of receiving cardiac rehabilitation (aOR, 0.80; 95% CI, 0.74-0.87). Results were similar in analyses restricted to urban patients or patients whose primary care clinic was in a tertiary care center.

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study, longer drive time was associated with less frequent receipt of guideline-recommended services across multiple components of care. To improve quality of care and health outcomes, health systems and clinicians should adopt strategies to mitigate travel burden, even for urban patients.

Pursuing Connectivity in Cardio-Oncology Care-The Future of Telemedicine and Artificial Intelligence in Providing Equity and Access to Rural Communities

The aim of this review is to discuss the current health disparities in rural communities and to explore the potential role of telehealth and artificial intelligence in providing cardio-oncology care to underserviced communities. With advancements in early detection and cancer treatment, survivorship has increased. The interplay between cancer and cardiovascular disease, which are the leading causes of morbidity and mortality in this population, has been increasingly recognized. Worldwide, cardio-oncology clinics (COCs) have emerged to deliver a multidisciplinary approach to the care of patients with cancer to mitigate cardiovascular risks while minimizing interruptions in cancer treatment. Despite the value of COCs, the accessibility gap between urban and rural communities in both oncology and cardio-oncology contributes to health care disparities and may be an underrecognized determinant of health globally. Telehealth and artificial intelligence offer opportunities to provide timely care irrespective of rurality. We therefore explore current developments within this sphere and propose a novel model of care to address the disparity in urban vs. rural cardio-oncology using the experience in Canada, a geographically large country with many rural communities.

Opioid use and associated factors among pancreatic cancer patients diagnosed between 2007 and 2015

BACKGROUND

Opioid therapy provides essential pain relief for cancer patients. We used the population-based Surveillance Epidemiology and End Results (SEER) linked with Medicare database to identify the patterns of opioid use and associated factors in pancreatic adenocarcinoma cancer patients 66 years or older.

PATIENTS AND METHODS

We assessed opioid types, dispensed days, opioid uptake rates, and factors associated with opioid use after pancreatic adenocarcinoma cancer diagnosis in Medicare beneficiaries between 2007 and 2015 from the SEER-Medicare data. Multivariable regression analysis was used to adjust for a variety of patient-related factors.

RESULTS

We identified a cohort of 10,745 pancreatic cancer patients with a median age of 76 years old and median survival of 7 months; 75% of patients-initiated opioids after cancer diagnosis. African Americans had the lowest rate of opioid use of 69.1% compared with all other race/ethnicity groups at around 75%. No significant yearly trend of prescribing opioids was detected. Hydrocodone was the most frequently prescribed opioid type. Regression analysis revealed that age ≤80 years, residing in Southern or Western SEER registries, residing in urban/less urban versus big metro areas, having stage IV cancer at diagnosis, longer survival time, and undertaking cancer-directed treatment or using palliative care were positively associated with opioid initiation, more prescribed opioid types, and higher opioid doses.

DISCUSSION

While a range of sociodemographic variables were associated with opioid use in unadjusted analysis, the associations between race/ethnicity, gender, and socioeconomic status with opioid initiation disappeared when sociodemographic factors, tumor characteristics, and cancer treatment were adjusted.

CONCLUSION

Health care professionals' opioid prescription pattern for pancreatic cancer patients does not parallel the U.S. opioid epidemic. Racial/ethnic disparities in opioid treatment were not identified.

Geographical distance and reduced access to palliative radiotherapy: systematic review and meta-analysis

BACKGROUND

Palliative radiotherapy (PRT) is an effective way of reducing symptoms caused by advanced incurable cancer. Several studies have investigated factors that contribute to inequalities in access to PRT; distance to a radiotherapy centre has been identified as one potential barrier.

AIM

To assess whether there is an association between distance to a radiotherapy centre and utilisation rates of PRT in adults with cancer.

METHODS

A systematic review and meta-analysis protocol was registered in the PROSPERO database (CRD42020190772). MEDLINE, EMBASE, CINAHL and APA-PsycINFO were searched for relevant papers up to 28 February 2021.

RESULTS

Twenty-one studies were included. Twelve studies focused on whether patients with incurable cancer received PRT, as part of their treatment package. Pooled results reported that living ≥50 km vs <50 km from the radiotherapy centre was associated with a reduced likelihood of receiving PRT (OR 0.84 (95%CI 0.80, 0.88)). Nine focused on distance from the radiotherapy centre and compared single-fraction (SF) versus multiple-fraction PRT, indicating that patients living further away were more likely to receive SF. Pooled results comparing ≥50 km versus <50 km showed increased odds of receiving SF for those living ≥50 km (OR 1.48 (95%CI 1.26,1.75)).

CONCLUSION

Patients living further away from radiotherapy centres were less likely to receive PRT and those who received PRT were more likely to receive SF PRT, providing some evidence of inequalities in access to PRT treatment based on proximity to centres providing radiotherapy. Further research is needed to understand whether these inequalities are influenced by clinical referral patterns or by patients unwilling or unable to travel longer distances.

PROSPERO REGISTRATION NUMBER

CRD42020190772.

Geographic accessibility to cancer treatment in Brazil: A network analysis

Background

Geographic accessibility to healthcare services is a fundamental component in achieving universal health coverage, the central commitment of the Brazilian Unified Health System (SUS). For cancer patients, poor accessibility has been associated with inadequate treatment, worse prognosis, and poorer quality of life.

Methods

We explored nationwide healthcare data from the SUS health information systems, and mapped the geographic accessibility to cancer treatment in two time-frames: 2009-2010 and 2017-2018. We applied social network analysis (SNA) to estimate the commuting route, flow, and distances travelled by cancer patients to undergo surgical, radiotherapy, and chemotherapy treatment.

Findings

A total of 12,751,728 treatment procedures were analyzed. Overall, more than half of the patients (49·2 to 60·7%) needed to travel beyond their municipality of residence for treatment, a fact that did not change over time. Marked regional differences were observed, as patients living in the northern and midwestern regions of the country had to travel longer distances (weighted average of 296 to 870 km). Cancer care hubs and attraction poles were mostly identified in the southeast and northeast regions, with Barretos being the main hub for all types of treatment throughout time.

Interpretation

Important regional disparities in the accessibility to cancer treatment in Brazil were revealed, suggesting the need to review the distribution of specialized care in the country. The data presented here contribute to ongoing research on improving access to cancer care and can provide reference to other countries, offering relevant data for oncological and healthcare service evaluation, monitoring, and strategic planning.

Funding

This work was funded by the Oswaldo Cruz Foundation - Fiocruz (Inova - no. 8451635123 to BPF) and the National Council for Scientific and Technological Development - CNPq (no. 407060/2018-9 to BPF); Coordination for the Improvement of Higher Education Personnel - CAPES (scholarship to PCA, Finance Code 001); and Instituto Nacional de Ciência e Tecnologia de Inovação em Doenças de Populações Negligenciadas (INCT-IDPN).

Resumo

A acessibilidade geográfica aos serviços de saúde é um componente fundamental para o alcance da cobertura universal de saúde, compromisso central do Sistema Único de Saúde (SUS). Para pacientes com câncer, a baixa acessibilidade aos serviços especializados tem sido associada ao tratamento inadequado, piora no prognóstico e na qualidade de vida.Neste estudo, dados de saúde dos sistemas de informação em saúde do SUS foram utilizados para mapear a acessibilidade geográfica ao tratamento do câncer em dois períodos: 2009-2010 e 2017-2018. Aplicamos a análise de redes sociais (ARS) para estimar os fluxos de deslocamento e as distâncias percorridas por pacientes com câncer para receberem tratamento cirúrgico, radioterápico e quimioterápico.Um total de 12.751.728 procedimentos de tratamento foram analisados. Em geral, mais da metade dos pacientes (49,2 a 60,7%) precisaram se deslocar de seus municípios de residência para receber tratamento, fato que não mudou comparando os dois períodos de tempo analisados. Foram observadas importantes diferenças regionais no acesso. Pacientes residentes das regiões norte e centro-oeste do país tiveram que percorrer maiores distâncias para alcançar os serviços (média ponderada = 296 a 870 km). A maioria dos hubs e polos de atração para atendimento oncológico foram identificados nas regiões Sudeste e Nordeste, sendo o município de Barretos o principal hub para todos os tipos de tratamento ao longo do tempo.As disparidades de acessibilidade para o tratamento de câncer, alertam para a necessidade de revisar a distribuição dos serviços de atenção especializada no país. A metodologia e os resultados apresentados neste estudo contribuem para as pesquisas sobre a melhoria do acesso ao tratamento do câncer e podem servir como referência para outros países, oferecendo dados relevantes para avaliação, monitoramento e planejamento estratégico de serviços oncológicos e de saúde em geral.

Patient-Reported Outcomes Assessing the Impact of Palliative Radiotherapy on Quality of Life and Symptom Burden in Head and Neck Cancer Patients: A Systematic Review

Incurable head and neck cancer has a poor prognosis and impairs a patient's health-related quality of life. Palliative radiotherapy may improve or stabilize health-related quality of life and symptoms, best measured by patient-reported outcomes. There is no systematic analysis if palliative radiotherapy for head and neck cancer improves or stabilizes health-related quality of life or symptoms as validly measured by patient-reported outcomes. Therefore, the primary objective of this systematic review (PROSPERO-ID: CRD42020166434) was to assess the effect of palliative radiotherapy for head and neck cancer on patient-reported outcomes. The secondary objective was to assess the rate and quality of use of patient-reported outcomes in relevant studies claiming a "palliative effect" of radiotherapy. The databases MEDLINE/PubMed, EMBASE, Cochrane CENTRAL, "ClinicalTrials.gov" were searched. Concerning the primary objective, four studies were eligible to assess the effectiveness of palliative radiotherapy as measured by patient-reported outcomes. A narrative synthesis suggests a favorable impact of palliative radiotherapy on health-related quality of life and symptom burden. The risk of bias, however, is considerable and the overall quality of evidence low. Concerning the secondary objective, over 90% of studies claiming a "palliative effect" of palliative radiotherapy did either not use patient-reported outcomes or did so by limited quality. In conclusion, implementation of patient-reported outcomes in studies assessing palliative radiotherapy for head and neck cancer should be fostered. Palliative radiotherapy remains an option for head and neck cancer patients, although more studies focusing on patient-reported outcomes are needed.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier CRD42020166434.

Examination of a distress screening intervention for rural cancer survivors reveals low uptake of psychosocial referrals

Purpose

To determine the impact of a telemedicine-delivered intervention aimed at identifying unmet needs and cancer-related distress (CRD) following the end of active treatment on supportive care referral patterns.

Methods

We used a quasi-experimental design to compare supportive care referral patterns between a group of rural cancer survivors receiving the intervention and a control group (N = 60). We evaluated the impact of the intervention on the number and type of referrals offered and whether or not the participant accepted the referral. CRD was measured using a modified version of the National Comprehensive Cancer Network Distress Thermometer and Problem List.

Results

Overall, 30% of participants received a referral for further post-treatment supportive care. Supporting the benefits of the intervention, the odds of being offered a referral were 13 times higher for those who received the intervention than those in the control group. However, even among the intervention group, only 28.6% of participants who were offered a referral for further psychosocial care accepted.

Conclusions

A nursing telemedicine visit was successful in identifying areas of high distress and increasing referrals. However, referral uptake was low, particularly for psychosocial support. Distance to care and stigma associated with seeking psychosocial care may be factors. Further study to improve referral uptake is warranted.

Implications for Cancer Survivors

Screening for CRD may be inadequate for cancer survivors unless patients can be successfully referred to further supportive care. Strategies to improve uptake of psychosocial referrals is of high importance for rural survivors, who are at higher risk of CRD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11764-021-01052-4.

Actual Versus Optimal Radiotherapy Utilisation for Metastatic Cancer Patients in the 45 and Up Study Cohort, New South Wales

AIMS

Radiotherapy can provide quality of life and/or survival benefits to patients with metastatic cancer on diagnosis (MCOD). However, little is known about radiotherapy utilisation in this population. We compared the optimal radiotherapy rates with actual uptake for people who present with MCOD in the 45 and Up Study cohort, and examined factors associated with utilisation.

MATERIALS AND METHODS

In total, 267 153 individuals aged ≥45 enrolled in the Sax Institute's 45 and Up Study completed a baseline questionnaire during 2006-2009, providing sociodemographic and health information and consent for linkage to administrative health databases. Participants diagnosed up to December 2013 with MCOD were identified in the New South Wales Cancer Registry. Radiotherapy receipt was determined from claims to the Medicare Benefits Schedule and/or records in the New South Wales Admitted Patient Data Collection (2006 to June 2016). The Collaboration for Cancer Outcomes, Research and Evaluation optimal utilisation model was adapted for patients with MCOD to provide a benchmark.

RESULTS

Of 17 687 participants diagnosed with cancer after completion of the baseline questionnaire, 2392 had MCOD. Of patients with MCOD, 25% had primary lung cancer, which was the most common site. The actual radiotherapy utilisation rate for all patients was 32.3%, lower than the optimal of 45.0%. From multivariable analysis, patients who were aged ≥80 years and/or needed help with daily tasks and/or had a Charlson Comorbidity Index ≥2 were less likely to receive radiotherapy.

CONCLUSIONS

Actual uptake of radiotherapy was below optimal. Elderly patients and/or those with more comorbidities were less likely to receive radiotherapy. These results suggest a potential role for advocacy and education around radiotherapy for these patient groups.

Palliative Care Physicians and Palliative Radiotherapy, Knowledge and Barriers for Referring: A Cross-sectional Study

CONTEXT

Palliative radiotherapy is effective in the management of symptoms resulting from advanced cancer. However, it remains underutilized. In developed countries, many factors have been linked to this phenomenon but data in developing and low-income countries, particularly in Latin America, are lacking.

OBJECTIVES

To conduct a cross-sectional survey to explore palliative care physicians' knowledge of palliative radiotherapy and to investigate possible factors that limit patient referral.

METHODS

This is a cross-sectional survey. An online questionnaire was sent to palliative care physicians (n = 170) registered in the Chilean Medical Society of Palliative Care directory.

RESULTS

The overall response rate was 58.8%. Nearly all respondents (98%) considered radiotherapy to be a useful treatment. Less than half the respondents (43%) had good knowledge of palliative radiotherapy. Knowledge was correlated with self-reported knowledge (P = 0.015), discussing cases with radiation oncologist (P = 0.001), and having attended educational events on palliative radiotherapy (P = 0.001). Patient reluctance, poor performance status, and family reluctance were identified as major barriers to the use of palliative radiotherapy. Physicians from cities other than the capital were more likely to be concerned about barriers such as distance to radiotherapy facilities (P = 0.01), the duration of the referral process (P = 0.01), and the lack of a radiation oncologist available for discussing cases (P = 0.01).

CONCLUSIONS

Several barriers affect referral to palliative radiotherapy. Some barriers seem to be more significant for physicians practicing in cities far from cancer centers. Physicians' knowledge is less than optimal and has been identified as a barrier to referral. Educational interventions and broadening the availability of cancer treatment resources are needed to improve the referral process.

Physician-Predicted Prognosis and Palliative Radiotherapy Treatment Utilization at the End of Life: An Audit of a Large Cancer Center Network

CONTEXT

At our institution, clinical pathways capture physicians' prognostication of patients being evaluated for palliative radiotherapy. We hypothesize a low utilization rate of long-course radiotherapy (LCRT) and stereotactic ablative radiotherapy (SAbR) among patients seen at the end of life, especially those with physician-predicted poor prognosis.

OBJECTIVE

To analyze utilization rates and predictors of LCRT and SAbR at the end of life.

METHODS

A retrospective review was conducted on patients who were evaluated for palliative radiotherapy between January 2017 and August 2019 and died within 90 days of consultation. Binary logistic regression was used to identify predictors for utilization of LCRT (≥10 fractions) and SAbR.

RESULTS

A total of 1608 patients were identified, of which 1038 patients (64.6%) were predicted to die within a year. Six hundred ninety-three patients (66.8%) out of 1038 were prescribed LCRT or SAbR. On a multivariate analysis, patients were less likely to be prescribed LCRT if treated at an academic site (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.23-0.39; P < 0.01) and treated for bone metastases (OR, 0.08; 95% CI, 0.05-0.11; P < 0.01) or other nonbrain/nonbone metastases (OR, 0.19; 95% CI, 0.13-0.30; P < 0.01). SAbR was less likely to be prescribed among patients predicted to die within a year (OR, 0.09; 95% CI, 0.06-0.16; P < 0.01), treated for bone metastases (OR, 0.13; 95% CI, 0.07-0.22; P < 0.01), with poor performance status (OR, 0.51; 95% CI, 0.31-0.85; P = 0.01), and with a breast primary (OR, 0.35; 95% CI, 0.15-0.82; P = 0.02).

CONCLUSION

Although most patients were predicted to have a limited prognosis, LCRT and SAbR were commonly prescribed at the end of life.

External validation of life expectancy prognostic models in patients evaluated for palliative radiotherapy at the end-of-life

BACKGROUND

The TEACHH and Chow models were developed to predict life expectancy (LE) in patients evaluated for palliative radiotherapy (PRT). We sought to validate the TEACHH and Chow models in patients who died within 90 days of PRT consultation.

METHODS

A retrospective review was conducted on patients evaluated for PRT from 2017 to 2019 who died within 90 days of consultation. Data were collected for the TEACHH and Chow models; one point was assigned for each adverse factor. TEACHH model included: primary site of disease, ECOG performance status, age, prior palliative chemotherapy courses, hospitalization within the last 3 months, and presence of hepatic metastases; patients with 0-1, 2-4, and 5-6 adverse factors were categorized into groups (A, B, and C). The Chow model included non-breast primary, site of metastases other than bone only, and KPS; patients with 0-1, 2, or 3 adverse factors were categorized into groups (I, II, and III).

RESULTS

A total of 505 patients with a median overall survival of 2.1 months (IQR: 0.7-2.6) were identified. Based on the TEACHH model, 10 (2.0%), 387 (76.6%), and 108 (21.4%) patients were predicted to live >1 year, >3 months to ≤1 year, and ≤3 months, respectively. Utilizing the Chow model, 108 (21.4%), 250 (49.5%), and 147 (29.1%) patients were expected to live 15.0, 6.5, and 2.3 months, respectively.

CONCLUSION

Neither the TEACHH nor Chow model correctly predict prognosis in a patient population with a survival <3 months. A better predictive tool is required to identify patients with short LE.

Access to cancer care in northwestern Ontario-a population-based study using administrative data

Background

Despite universal access to health care in Canada, there are disparities relating to social determinants of health that contribute to discrepancies between rural and urban areas in cancer incidence and outcomes. Given that Canada has one of the highest-quality national population-based cancer registry systems in the world and that little information is available about cancer statistics specific to northwestern Ontario, the purpose of the present study was to estimate the percentage of cancer patients without documentation of a specialist consultation (medical or radiation oncology consultation) and to determine factors that affect access to specialist consultation in northwestern Ontario.

Methods

This population-based retrospective study used administrative data obtained through the Ontario Cancer Data Linkage Project. For each index case, a timeline was constructed of all Ontario Health Insurance Plan billing codes and associated service dates, starting with the primary cancer diagnosis and ending with death. Specific factors affecting access to specialist consultation were assessed.

Results

Within the 6-year study period (2010-2016), 2583 index cases were identified. Most (n = 2007, 78%) received a specialist consultation. Factors associated with not receiving a specialist consultation included older age [p < 0.0001; odds ratio (or): 0.29; 95% confidence interval (ci): 0.19 to 0.44] and rural residence (p < 0.0001; or: 0.48; 95% ci: 0.48 to 0.72). Factors associated with receiving a specialist consultation included a longer timeline (p < 0.0001; or: 1.32; 95% ci: 1.19 to 1.46), a diagnosis of breast cancer (p < 0.0001; or: 2.51; 95% ci: 1.43 to 4.42), and a diagnosis of lung cancer (p < 0.0001; or: 1.77; 95% ci: 1.38 to 2.26).

Conclusions

This study is the first to look at care access in northwestern Ontario. The complexity and multidisciplinary nature of cancer care makes the provision of appropriate care a challenge; a one-size-fits-all disease prevention and treatment strategy might not be appropriate.

End-of-Life Cancer Care Resource Utilisation in Rural Versus Urban Settings: A Systematic Review

BACKGROUND

Despite the advances in End-of-life (EOL) cancer care, disparities remain in the accessibility and utilisation of EOL cancer care resources. Often explained by socio-demographic factors, geographic variation exists in the availability and provision of EOL cancer care services among EOL cancer decedents across urban versus rural settings. This systematic review aims to synthesise mortality follow-back studies on the patterns of EOL cancer care resource use for adults (>18 years) during end-of-life cancer care.

METHODS

Five databases were searched and data analysed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria involved; a) original research; b) quantitative studies; c) English language; d) palliative care related service use in adults (>18 years) with any malignancy excluding non-melanoma skin cancers; e) exclusive end of life focus; f) urban-rural focus. Narrative reviews and discussions were excluded.

RESULTS

24 studies met the inclusion criteria. End-of-life cancer care service utilisation patterns varied by rurality and treatment intent. Rurality was strongly associated with higher rates of Emergency Department (ED) visits and hospitalisations and lower rates of hospice care. The largest inequities between urban and rural health service utilisation patterns were explained by individual level factors including age, gender, proximity to service and survival time from cancer diagnosis.

CONCLUSIONS

Rurality is an important predictor for poorer outcomes in end-of-life cancer care. Findings suggest that addressing the disparities in the urban-rural continuum is critical for efficient and equitable palliative cancer care. Further research is needed to understand barriers to service access and usage to achieve optimal EOL care for all cancer patient populations.

Assessing the utilization of the decision to implement a palliative goal for the treatment of cancer patients during the last year of life at Helsinki University Hospital: a historic cohort study

Background: To avoid aggressive treatments at the end-of-life and to provide palliative care (PC), physicians need to terminate futile anti-cancer treatments and define the palliative goal of the treatment in time. This single center study assesses the practices used to make the decision that leads to treatment with a palliative goal, i.e., the PC decision and its effect on anti-cancer treatments at the end of life.Material and methods: Patients with a cancer diagnosis treated in tertiary hospital during 1st January 2013 - 31st December 2014 and deceased by the end of 2014 were identified in the hospital database (N = 2737). Of these patients, 992 were randomly selected for this study. The PC decision was screened from patient records, i.e., termination of cancer-specific treatments and a focus on symptom-centered PC.Results: The PC decision was defined in 82% of the patients during the last year of life (49% >30 days and 33% ≤30 days before death, 18% with no decision). The median time from the decision to death was 46 days. Systemic cancer therapy was given during the last month of life in 1%, 36% and 38% (p < .001) and radiotherapy 22%, 40% and 31% (p = .03) cases, respectively; referral to a PC unit was made in 62%, 22% and 11%, respectively (p < .001). In logistic regression analyses younger age, shorter duration of the disease trajectory and type of cancer (e.g., breast cancer) were associated with a lack or late timing of the PC decision.Conclusion: The decision to initiate a palliative goal for the treatment was frequently made for cancer patients but occurred late for every third patient. Younger age and certain cancer types were associated with late PC decisions, thus leading to anti-cancer treatments continuing until close to the death with low access to a PC unit.

Physician And Patient Barriers To Radiotherapy Service Access: Treatment Referral Implications

Radiotherapy is one of the mainstays of cancer treatment, and about 60% of cancer patients receive this type of treatment during their course of treatment. An evident gap between optimal and actual radiotherapy utilization proportions has recently been reported, which has been ascribed to lack of referral to radiation oncology. There are many factors influencing the radiotherapy referral, including patient anxiety about toxicity, wrong perception of efficacy and side effects by physicians and patients, insufficient knowledge of referral process. These factors, defined as barriers can be categorized in health system barriers, physician and patient barriers. In the present brief narrative review, we discussed barriers to radiotherapy referral focusing on physician and patient barriers.

Population surveillance of navigation frequency and palliative care contact before death among cancer patients

Cancer patient navigation in Canada began in 2002 in Nova Scotia with oncology nurses providing support to patients from diagnosis up to and including end of life. This novel study was carried out to determine navigation frequency and palliative care contact rates, and variations in these rates among adults who were diagnosed with cancer, navigated, and then died between 2011 and 2014. Among the 2,532 study subjects, 56.7% were navigated for more than one month and 30.6% had palliative care contact reported. Variations were observed by geographic area, cancer stage, time from diagnosis to death, and whether the person died of cancer. Further study of the role of navigation is advised for persons at end of life.

Étude en population de la fréquence de navigation et de contact pour soins palliatifs avant le décès de patients atteints de cancer

Au Canada, la navigation des patients atteints de cancer a vu le jour en Nouvelle-Écosse, en 2002, à l’instigation d’infirmières en oncologie ayant décidé de soutenir les patients du diagnostic au décès. La présente étude voulait déterminer la fréquence (et la variation de fréquence) des services de navigation et de contacts pour soins palliatifs chez les adultes décédés entre 2011 et 2014 après avoir reçu un diagnostic de cancer ainsi que des services de navigation. Parmi les 2 532 sujets de l’étude, 56,7 % ont bénéficié de services de navigation pendant plus d’un mois et 30,6 % ont eu un contact pour soins palliatifs. Certaines variations ont été observées entre les régions géographiques, les stades de cancer, le temps écoulé entre le diagnostic et le décès, et la cause du décès (attribuable ou non au cancer). Il serait bon d’étudier plus en détail le rôle de la navigation pour les personnes en fin de vie.

Factors influencing access to palliative radiotherapy: a Norwegian population-based study

BACKGROUND

Palliative radiotherapy (PRT) comprises half of all radiotherapy use and is an effective and important treatment modality for improving quality of life in incurable cancer patients. We have described the use of PRT in Norway and aimed to identify and quantify the impact of factors associated with PRT utilization.

MATERIAL AND METHODS

Population-based data from the Cancer Registry of Norway identified 25,281 patients who died of cancer, 1 July 2009-31 December 2011. Additionally, individual-level data on socioeconomic status and community-level data on travel distance were collected. The proportion of patients who received PRT in the last two years of life (PRT_2Y) was calculated, and multivariable logistic regression was used to determine factors that influenced the PRT_2Y. Analyses of geographic variation in PRT use were also performed for the time period 2012-2016.

RESULTS

PRT_2Y for all cancer sites combined was 29.6% with wide geographic variations (standardized inter-county range; 21.8-36.6%). Female gender, increasing age at death, certain cancer sites, short survival time, and previous receipt of curative radiotherapy were associated with decreased odds of receiving PRT. Patients with low education, those living in certain counties, or with travel distances 100-499 km, were also less likely to receive PRT. Patients with low household income (adjusted odds ratio (OR) = 0.63; 95% confidence interval (CI) = 0.56-0.72) and those diagnosed in hospitals without radiotherapy facility (OR = 0.70; 95% CI = 0.64-0.77) had especially low likelihood of receiving PRT. Significant inter-county variation in use of PRT remained during the time period 2012-2016.

CONCLUSIONS

Despite a publicly funded, universal healthcare system with equity as a stated health policy aim, utilization of PRT in Norway is significantly associated with factors such as household income and availability of radiotherapy facility at the diagnosing hospital. Even after adjustments for relevant factors, unexplained geographic variations in PRT utilization exist.

Analysis of predictors of pain response in patients with bone metastasis undergoing palliative radiotherapy: Does age matter?

INTRODUCTION

To evaluate whether age is a predictor of pain response after radiotherapy for painful bone metastasis (BM).

METHODS

Between June 2010 and June 2014, 204 patients with BM undergoing palliative radiotherapy participated in a multicentre prospective study. Patients completed the Brief Pain Inventory (BPI) to rate the intensity pain (from 0 to 10) at baseline and 4 weeks after radiotherapy. To determine which variables predicted pain response and particularly whether age is a predictor, logistic regression analysis was used. Baseline variables considered were: age (≤65/66-75/>75 years), sex, Eastern Cooperative Oncology Group performance status (0-1/≥2), pretreatment pain score (≤4/5-7/≥8), radiotherapy (single/multiple fraction), primary tumour location, visceral metastases (yes/no), concomitant systemic chemotherapy and bisphosphonate use (yes/no).

RESULTS

Pain response was assessed in the 128 patients who completed BPI pretreatment and at 4 weeks after radiotherapy. According to univariate analysis, pain response was better in over 75-year-olds than younger patients: (OR, 3.2; 95% CI, 1.1-9.1; P = 0.031). Response was better in patients receiving multiple fractions rather than a single fraction of 8 Gy (OR, 2.8; 95% CI, 1.2-6.1; P = 0.01), and in patients with a pretreatment pain score ≥8 vs ≤7 (OR, 2.4; 95% CI, 1.1-5.0; P = 0.017). No other variables were significant. Multivariate analysis showed that treatment schedule (OR, 3.4; 95% CI 1.4-7.9; P = 0.004) and pre-radiotherapy pain score (OR, 2.8; 95% CI 1.3-6.3; P = 0.009) were the only independent predictors of pain response.

CONCLUSION

All patients with painful bone metastasis should be referred for palliative radiotherapy to relieve the pain regardless of age. Therefore, an older age should not be a reason to withhold palliative radiation treatment.

Development of health-related quality of life and symptoms in patients with advanced cancer in Greenland

A prospective national cohort study assessed the development of health-related quality of life (HRQoL) and symptoms in adult patients undergoing treatment and care for advanced cancer in Greenland. HRQol was examined by EORTC QLQ-C30 version 3.0 questionnaire monthly for 4 months. Changes over time and between-group comparisons were examined. Of 58 patients included in the study, 47% completed the questionnaire four times. Functioning was generally high, and improved social functioning was observed after 1 and 2 months. The highest symptom score was for fatigue followed by pain and nausea/vomiting. A high score for financial problems remained unchanged during the entire period. Patients with higher income had reduced pain intensity (p = .03) and diarrhoea (p = .05) than patients with income below the poverty line. After 1 month, reduction in pain intensity was observed for Nuuk citizens compared with non-Nuuk citizens (p = .05). After 2 months, non-Nuuk citizens reported improved social functioning compared with Nuuk citizens (p = .05). After 3 months, Global Health in Nuuk citizens was improved compared with non-Nuuk citizens (p = .05). An important clinical finding was that patients' needs for support are related to social status, and geographical factors should be taken into account when planning palliative care.

Gender and age make no difference in the re-irradiation of painful bone metastases: A secondary analysis of the NCIC CTG SC.20 randomized trial

BACKGROUND AND PURPOSE

Patient's gender and age may influence physicians in prescribing palliative radiotherapy. The purpose of this secondary analysis of the National Cancer Institute of Canada Clinical Trials Group Symptom Control Trial SC.20 was to explore the gender and age differences in pain and patient reported outcomes in cancer patients with bone metastases undergoing re-irradiation.

MATERIALS AND METHODS

Response to radiation was evaluated using the International Bone Metastases Consensus Endpoint Definitions. Patients completed the Brief Pain Inventory (BPI) and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (C30) before and 2 months after re-irradiation.

RESULTS

A total of 847 patients were analyzed. At baseline, men had more dyspnea, and mild pain. Older patients consumed less analgesic. More women reported clinically significant improvement in mood and enjoyment of life in the BPI after radiation. Similarly, younger patients reported better improvement in enjoyment of life. There were no significant gender or age differences in overall survival, response to radiation, or in C30 scores at 2 months.

CONCLUSION

Similar benefit in terms of pain relief was observed across all patient groups. Cancer patients with bone metastases should be offered palliative re-irradiation irrespective of gender or age.

TRIAL REGISTRATION

NCT00080912; https://clinicaltrials.gov/ct2/show/NCT00080912.

Assessing the utilization of radiotherapy near end of life at a Finnish University Hospital: a retrospective cohort study

BACKGROUND

Palliative radiotherapy can improve quality of life for cancer patients during the last months of life. However, very short life expectancy may devastate the benefit of the treatment. This single center study assesses the utilization of radiotherapy during the last weeks of life.

MATERIAL AND METHODS

All cancer patients (N = 38,982) treated with radiotherapy (N = 11,395) in Turku University Central Hospital during 2005-2013 were identified in the database consisting of electronic patient records. One fourth (N = 2904, 25.5%) of the radiotherapy treatments were given during the last year of life. The last radiotherapy treatments and the time from the last radiotherapy treatment to death were assessed in regards to patients' age, cancer diagnosis, domicile, place of death and the treatment year. Treatments given during the last two weeks of life were also assessed regarding the goal of treatment and the reason for possible discontinuation.

RESULTS

The median time from the last fraction of radiotherapy to death was 84 d. During the last two weeks before death (N = 340), pain (29.4%) was the most common indication for radiotherapy. Treatment was discontinued in 40.6% of the patients during the last two weeks of life, and worsening of general condition was the most common reason for discontinuity (70.3%). The patients receiving radiotherapy during the last weeks of life were more likely to die in tertiary care unit. During the last year of life single-fraction treatment was used only in 7% of all therapy courses. There was a statistically significant (p < .05) decrease in the median number of fractions in the last radiotherapy treatment between 2005-2007 (8 fractions) and 2011-2013 (6 fractions).

CONCLUSIONS

Up to 70% of the treatments during the last two weeks of life were not delivered to alleviate pain and utilization of single fraction radiotherapy during the last year of life was infrequent. These observations suggest that practice of radiotherapy during the last weeks of life should be revisited.

Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review

OBJECTIVES

To investigate whether there is an association between differences in travel time/travel distance to healthcare services and patients' health outcomes and assimilate the methodologies used to measure this.

DESIGN

Systematic Review. We searched MEDLINE, Embase, Web of Science, Transport database, HMIC and EBM Reviews for studies up to 7 September 2016. Studies were excluded that included children (including maternity), emergency medical travel or countries classed as being in the global south.

SETTINGS

A wide range of settings within primary and secondary care (these were not restricted in the search).

RESULTS

108 studies met the inclusion criteria. The results were mixed. 77% of the included studies identified evidence of a distance decay association, whereby patients living further away from healthcare facilities they needed to attend had worse health outcomes (eg, survival rates, length of stay in hospital and non-attendance at follow-up) than those who lived closer. 6 of the studies identified the reverse (a distance bias effect) whereby patients living at a greater distance had better health outcomes. The remaining 19 studies found no relationship. There was a large variation in the data available to the studies on the patients' geographical locations and the healthcare facilities attended, and the methods used to calculate travel times and distances were not consistent across studies.

CONCLUSIONS

The review observed that a relationship between travelling further and having worse health outcomes cannot be ruled out and should be considered within the healthcare services location debate.

What is access to radiation therapy? A conceptual framework and review of influencing factors

OBJECTIVES

Optimal radiation therapy (RT) utilisation rates (RURs) have been defined for various cancer indications through extensive work in Australia and overseas. These benchmarks remain unrealised. The gap between optimal RUR and actual RUR has been attributed to inadequacies in 'RT access'. We aimed to develop a conceptual framework for the consideration of 'RT access' by examining the literature for existing constructs and translating it to the context of RT services. We further aimed to use this framework to identify and examine factors influencing 'RT access'.

METHODS

Existing models of health care access were reviewed and used to develop a multi-dimensional conceptual framework for 'RT access'. A review of the literature was then conducted to identify factors reported to affect RT access and utilisation. The electronic databases searched, the host platform and date range of the databases searched were Ovid MEDLINE, 1946 to October 2014 and PsycINFO via OvidSP,1806 to October 2014.

RESULTS

The framework developed demonstrates that 'RT access' encompasses opportunity for RT as well as the translation of this opportunity to RT utilisation. Opportunity for RT includes availability, affordability, adequacy (quality) and acceptability of RT services. Several factors at the consumer, referrer and RT service levels affect the translation of this opportunity for RT to actual RT utilisation.

CONCLUSION

'Access' is a term that is widely used in the context of health service related research, planning and political discussions. It is a multi-faceted concept with many descriptions. We propose a conceptual framework for the consideration of 'RT access' so that factors affecting RT access and utilisation may be identified and examined. Understanding these factors, and quantifying them where possible, will allow objective evaluation of their impact on RT utilisation and guide implementation of strategies to modify their effects.

Trend in and Correlates of Undergoing Radiotherapy in Taiwanese Cancer Patients' Last Month of Life

CONTEXT

A significant proportion of cancer patients at end of life (EOL) undergo radiotherapy, but this evidence is not from nationwide population-based studies.

OBJECTIVES

The aims of this population-based study were to investigate the trend in undergoing radiotherapy among Taiwanese cancer patients' last month of life (EOL radiotherapy) in 2001-2010 and to identify factors associated with EOL radiotherapy.

METHODS

This was a population-based retrospective cohort study analyzing data from Taiwan's national death registry, cancer registry, and National Health Insurance claims for EOL radiotherapy using multilevel generalized linear mixed modeling. Participants were Taiwanese cancer patients (N = 339,546) who died in 2001-2010.

RESULTS

Overall, 8.59% (7.97%-9.85%) of patients underwent EOL radiotherapy with a decreasing trend over time. Correlates of EOL radiotherapy included male gender, younger age, residing in less urbanized areas, diagnosis of lung cancer, metastatic disease, death within two years of diagnosis, and without comorbidities. Cancer patients were more likely to undergo EOL radiotherapy if they received primary care from medical oncologists and pediatricians, in a nonprofit, teaching hospital with a larger case volume of terminally ill cancer patients, and greater EOL care intensity.

CONCLUSION

Approximately one-tenth of Taiwanese cancer patients underwent EOL radiotherapy with a decreasing trend over time. Undergoing EOL radiotherapy was associated with demographics, disease characteristics, physician specialty, and primary hospital's characteristics and EOL care practice patterns. Clinical and financial interventions should target hospitals/physicians that tend to aggressively treat at-risk cancer patients at EOL to carefully evaluate the appropriateness and effectiveness of using EOL radiotherapy.

Barriers to radiotherapy utilization: Consumer perceptions of issues influencing radiotherapy-related decisions

AIMS

Radiation therapy (RT) is an essential and cost-effective cancer treatment, but it is underutilized in Australia. We aimed to quantify consumers' perceptions of factors that influence RT decisions.

METHODS

A cross-sectional, survey-based study was conducted in March-August 2012. Potential participants were invited to complete an electronic survey disseminated through multiple patient support and advocacy groups throughout New South Wales (NSW), Australia. Study invitations were also placed in local newspapers across NSW with hard copy surveys mailed to respondents. Current or past cancer patients (and carers) who had been offered RT were eligible to participate regardless of their RT decision.

RESULTS

Of the 1191 participants (electronic, n = 1153; hard copy, n = 38), 91% were female, most (88%) were current or past patients, and 78% had accepted RT. Issues commonly perceived to be moderate to strong influencers of RT decisions were: concern about acute and long-term side effects; management of side effects; fear and anxiety regarding RT; lack of awareness of RT; lack of local availability of RT; and lack of RT information resources. Those who declined RT were significantly more likely to highlight practical difficulties with receiving RT.

CONCLUSIONS

Although availability of RT is well recognized, other issues such as fear and anxiety about RT and perceived side effects appear to feature prominently in consumers' decisions. Perceived practical difficulties with receiving RT may have influenced those who declined RT. There may be a need for information resources, support services and interventions to increase awareness of RT.

Use of Palliative Chemo- and Radiotherapy at the End of Life in Patients With Cancer: A Retrospective Cohort Study

BACKGROUND

Administration of chemotherapy and radiotherapy near the end of life is a frequently discussed issue nowadays. We have evaluated the factors associated with the use of chemotherapy and radiotherapy at the end of life among terminally ill patients in China.

METHODS

This study included the data from patients who had died from advanced cancer who underwent palliative chemotherapy and radiotherapy between January 2007 and December 2013 at the Department of Palliative Care of Fudan University, Shanghai Cancer Center. Data were collected from hospital medical records. Univariate and multivariate analyses were conducted to identify the factors independently associated with the use of chemo- and radiotherapy.

RESULTS

Among the 410 patients included (median age, 68 years; range, 18-93; 53% males), 47 (11.5%) underwent palliative chemotherapy and 28 (6.8%) underwent radiotherapy in the last 30 days. Age <65 years (odds ratio [OR]: 1.33, 95% confidence interval [CI]: 1.06-2.88), performance status <3 (OR: 3.95; 95% CI: 1.56-5.07), and cardiopulmonary resuscitation (OR: 4.09, 95% CI: 2.66-5.34) were independently associated with the use of chemotherapy. Performance status <3 (OR: 4.06, 95% CI: 2.17-5.83) and cardiopulmonary resuscitation (OR: 5.28, 95% CI: 3.77-7.21) were independently associated with the use of radiotherapy.

CONCLUSION

The findings indicate that younger patients with a lower performance status who do not have complications are more likely to opt for chemo- or radiotherapy. Further, the use of palliative chemo- and radiotherapy should be considered carefully in terminally ill patients with cancer, as they seem to indicate a higher risk of cardiovascular complications requiring resuscitation.

Palliative care costs in Canada: A descriptive comparison of studies of urban and rural patients near end of life

BACKGROUND

Significant gaps in the evidence base on costs in rural communities in Canada and elsewhere are reported in the literature, particularly regarding costs to families. However, it remains unclear whether the costs related to all resources used by palliative care patients in rural areas differ to those resources used in urban areas.

AIM

The study aimed to compare both the costs that occurred over 6 months of participation in a palliative care program and the sharing of these costs in rural areas compared with those in urban areas.

DESIGN

Data were drawn from two prior studies performed in Canada, employing a longitudinal, prospective design with repeated measures.

SETTING/PARTICIPANTS

The urban sample consisted of 125 patients and 127 informal caregivers. The rural sample consisted of 80 patients and 84 informal caregivers. Most patients in both samples had advanced cancer.

RESULTS

The mean total cost per patient was CAD 26,652 in urban areas, while it was CAD 31,018 in rural areas. The family assumed 20.8% and 21.9% of costs in the rural and urban areas, respectively. The rural families faced more costs related to prescription medication, out-of-pocket costs, and transportation while the urban families faced more costs related to formal home care.

CONCLUSION

Despite the fact that rural and urban families assumed a similar portion of costs, the distribution of these costs was somewhat different. Future studies would be needed to gain a better understanding of the dynamics of costs incurred by families taking care of a loved one at the end of life and the determinants of these costs in urban versus rural areas.

Examining Determinants of Radiotherapy Access: Do Cost and Radiotherapy Inconvenience Affect Uptake of Breast-conserving Treatment for Early Breast Cancer?

AIMS

Radiotherapy utilisation is likely affected by multiple factors pertaining to radiotherapy access. Radiotherapy is an integral component of breast-conserving treatment (BCT) for early breast cancer. We aimed to determine if stepwise improvements in radiotherapy access in regional Australia affected the uptake of BCT and thus radiotherapy.

MATERIALS AND METHODS

Breast cancer operations in the Central Coast of New South Wales between January 2010 and March 2014 for T1-2N0-1M0 invasive or in situ (≤5 cm) disease in female patients eligible for BCT were examined. BCT uptake was calculated for three 1 year periods: period 1 (local radiotherapy available at cost to user or out of area radiotherapy with travel cost and inconvenience); period 2 (as per period 1 + publicly funded transport and radiotherapy at out of area facilities at no cost to user); period 3 (as per period 1 + publicly funded local radiotherapy at no cost to user).

RESULTS

In total, 574 cases met eligibility criteria. BCT declined with increasing distance to publicly funded radiotherapy (P = 0.035). BCT rates for periods 1, 2 and 3 were 63% (113/180), 61% (105/173) and 71% (156/221). There were no statistically significant differences in BCT between periods 1 and 2 in the whole cohort or within age, histology or tumour size subgroups. Overall, there was a 9% increase in BCT in the whole cohort in period 3 compared with periods 1 and 2 (P = 0.031). This increase was statistically significant for women over 70 years (19% increase, P = 0.034), for women with ductal carcinoma in situ (25% increase, P = 0.013) and for women with primary tumours that were ≤10 mm (21% increase, P = 0.016).

CONCLUSIONS

Improving the affordability of radiotherapy through publicly funded transport and radiotherapy at out of area facilities did not improve BCT uptake in a region where radiotherapy was locally available, albeit at cost to the user. Improving both affordability and convenience through the provision of local publicly funded radiotherapy increased BCT uptake. Service availability and affordability have long been recognised as important determinants of radiotherapy access. Our findings suggest that inconvenience may also influence radiotherapy utilisation.

Access to oncology consultation in a cancer cohort in northeastern Ontario

BACKGROUND

To enhance cancer symptom management for residents of Sudbury-Manitoulin District, an ambulatory palliative clinic (pac) was established at the Northeast Cancer Centre of Health Sciences North. The pac is accessed from a medical or radiation oncology consultation. The primary purpose of the present population-based retrospective study was to estimate the percentage of cancer patients who died without ever having a medical or radiation oncology consultation. A secondary purpose was to determine factors associated with never having received one of those specialized consultations.

METHODS

Administrative data was obtained through the Ontario Cancer Data Linkage Project. For each index case, we constructed a timeline, in days, of all Ontario Health Insurance Plan billing codes and associated service dates starting with the primary cancer diagnosis and ending with death.

RESULTS

Within the 5-year study period (2004-2008), 6683 people in the area of interest with a valid record of primary cancer diagnosis died from any cause. Most (n = 5988, 89.6%) had 1 primary cancer diagnosis. For that subgroup, excluding those with a disease duration of 0 days (n = 67), about 18.4% (n = 1088) never had a consultation with a medical or radiation oncologist throughout their disease trajectory. Patients who were older or who resided in a rural area were significantly less likely to have had a consultation.

CONCLUSIONS

Specific strategies directed toward older and rural patients might help to address this important access-to-care issue.

Resource use, costs and quality of end-of-life care: observations in a cohort of elderly Australian cancer decedents

Background

The last year of life is one of the most resource-intensive periods for people with cancer. Very little population-based research has been conducted on end-of-life cancer care in the Australian health care setting. The objective of this program is to undertake a series of observational studies examining resource use, costs and quality of end-of-life care in a cohort of elderly cancer decedents using linked, routinely collected data.

Methods/Design

This study forms part of an ongoing cancer health services research program. The cohorts for the end-of-life research program comprise Australian Government Department of Veterans’ Affairs decedents with full health care entitlements, residing in NSW for the last 18 months of life and dying between 2005 and 2009. We used cancer and death registry data to identify our decedent cohorts and their causes of death. The study population includes 9,862 decedents with a cancer history and 15,483 decedents without a cancer history. The median age at death is 86 and 87 years in the cancer and non-cancer cohorts, respectively. We will examine resource use and associated costs in the last 6 months of life using linked claims data to report on health service use, hospitalizations, emergency department visits and medicines use. We will use best practice methods to examine the nature and extent of resource use, costs and quality of care based on previously published indicators. We will also examine factors associated with these outcomes.

Discussion

This will be the first Australian research program and among the first internationally to combine routinely collected data from primary care and hospital-based care to examine comprehensively end-of-life care in the elderly. The research program has high translational value, as there is limited evidence about the nature and quality of care in the Australian end-of-life setting.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0148-2) contains supplementary material, which is available to authorized users.

Retrospective studies of end-of-life resource utilization and costs in cancer care using health administrative data: a systematic review

BACKGROUND

There has been an increase in observational studies using health administrative data to examine the nature, quality, and costs of care at life's end, particularly in cancer care.

AIM

To synthesize retrospective observational studies on resource utilization and/or costs at the end of life in cancer patients. We also examine the methods and outcomes of studies assessing the quality of end-of-life care.

DESIGN

A systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) methodology.

DATA SOURCES

We searched MEDLINE, Embase, CINAHL, and York Centre for Research and Dissemination (1990-2011). Independent reviewers screened abstracts of 14,424 articles, and 835 full-text manuscripts were further reviewed. Inclusion criteria were English-language; at least one resource utilization or cost outcome in adult cancer decedents with solid tumors; outcomes derived from health administrative data; and an exclusive end-of-life focus.

RESULTS

We reviewed 78 studies examining end-of-life care in over 3.7 million cancer decedents; 33 were published since 2008. We observed exponential increases in service use and costs as death approached; hospital services being the main cost driver. Palliative services were relatively underutilized and associated with lower expenditures than hospital-based care. The 15 studies using quality indicators demonstrated that up to 38% of patients receive chemotherapy or life-sustaining treatments in the last month of life and up to 66% do not receive hospice/palliative services.

CONCLUSION

Observational studies using health administrative data have the potential to drive evidence-based palliative care practice and policy. Further development of quality care markers will enhance benchmarking activities across health care jurisdictions, providers, and patient populations.

Palliative radiotherapy utilization for cancer patients at end of life in British Columbia: retrospective cohort study

BACKGROUND

The use of palliative radiotherapy (PRT) is variable in advanced cancer. Little is known about PRT utilization by end-of-life (EOL) cancer patients in Canada. This study examined the PRT utilization rates and factors associated with its use in a cohort of cancer patients who died in British Columbia (BC).

METHODS

BC residents with invasive cancer who died between April 1, 2010 and March 31, 2011 were included in the study. Their cancer registry and radiotherapy treatment records were extracted from the BC Cancer Agency information systems and linked for the analysis. The PRT utilization rates by age, sex, primary cancer diagnosis, geographic region, survival time and travel time to the cancer centre were examined. Multivariable logistic regression was used to determine the factors that influenced the PRT utilization rates.

RESULTS

Of the 12,300 decedents in the study 2,669 (21.7%) had received at least one course of PRT in their last year of life. The utilization rates dropped to 5.0% and 2.2% in the last 30 and 14 days of life, respectively. PRT utilization varied across diagnosis and was highest for lung cancer (45.7%) and lowest for colorectal cancer (8.9%). The rates also varied by age, survival time and travel time to the nearest radiotherapy centre. There was a greater odds of receiving PRT for those with primary lung cancer, survival time between 1.5-26 months from diagnosis or living within 2 hours from a cancer centre. The 85+ age group was least likely to receive PRT in their last year of life.

CONCLUSIONS

This study found PRT utilization rates of EOL cancer decedents to be variable across the province of BC. Age, diagnosis, survival time and travel time to the nearest radiotherapy centre were found to influence the odds of PRT treatment. Further work is still needed to establish the appropriate PRT utilization rates for the EOL cancer population.

Palliative radiotherapy at the end of life: a critical review

When delivered with palliative intent, radiotherapy can help to alleviate a multitude of symptoms related to advanced cancer. In general, time to symptom relief is measured in weeks to months after the completion of radiotherapy. Over the past several years, an increasing number of studies have explored rates of radiotherapy use in the final months of life and have found variable rates of radiotherapy use. The optimal rate is unclear, but would incorporate anticipated efficacy in patients whose survival allows it and minimize overuse among patients with expected short survival. Clinician prediction has been shown to overestimate the length of survival in repeated studies. Prognostic indices can provide assistance with estimations of survival length and may help to guide treatment decisions regarding palliative radiotherapy in patients with potentially short survival times. This review explores the recent studies of radiotherapy near the end of life, examines general prognostic models for patients with advanced cancer, describes specific clinical circumstances when radiotherapy may and may not be beneficial, and addresses open questions for future research to help clarify when palliative radiotherapy may be effective near the end of life.

Use of opioid analgesics among older persons with colorectal cancer in two health districts with palliative care programs

CONTEXT

Prescription of opioid analgesics is a key component of pain management among persons with cancer at the end of life.

OBJECTIVES

To use a population-based method to assess the use of opioid analgesics within the community among older persons with colorectal cancer (CRC) before death and determine factors associated with the use of opioid analgesics.

METHODS

Data were derived from a retrospective, linked administrative database study of all persons who were diagnosed with CRC between January 1, 2001 and December 31, 2005 in Nova Scotia, Canada. This study included all persons who 1) were 66 years or older at the date of diagnosis; 2) died between January 1, 2001 and April 1, 2008; and 3) resided in health districts with formal palliative care programs (PCPs) (n=657). Factors associated with having filled at least one prescription for a so-called "strong" opioid analgesic in the six months before death were examined using multivariate logistic regression.

RESULTS

In all, 36.7% filled at least one prescription for any opioid in the six months before death. Adjusting for all covariates, filling a prescription for a strong opioid was associated with enrollment in a PCP (odds ratio [OR]=3.18, 95% CI=2.05-4.94), residence in a long-term care facility (OR=2.19, 95% CI=1.23-3.89), and a CRC cause of death (OR=1.75, 95% CI=1.14-2.68). Persons were less likely to fill a prescription for a strong opioid if they were older (OR=0.97, 95% CI=0.95-0.99), male (OR=0.59, 95% 0.40-0.86), and diagnosed less than six months before death (OR=0.62, 95% CI=0.41-0.93).

CONCLUSION

PCPs may play an important role in enabling access to end-of-life care within the community.

Does Time between Imaging Diagnosis and Initiation of Radiotherapy Impact Survival after Whole-Brain Radiotherapy for Brain Metastases?

Aims. To evaluate whether reduced waiting time influences survival of patients treated with whole-brain radiotherapy (WBRT) for brain metastases. Materials and Methods. Retrospective intention-to-treat study including 110 patients treated with primary WBRT (typically 10 fractions of 3 Gy; no other treatment between diagnosis and WBRT). Uni- and multivariate tests were performed. Results. Median delay between imaging diagnosis and WBRT was 12 days (range 0–66 days). WBRT started within 1 week in 36%, during the second week in 28%, and during the third week in 18% of patients. No significant correlation between waiting time and survival was evident, except for one subgroup of patients. Those without extracranial metastases (potentially more threatened by worse intracranial disease control) survived for a median of 2.5 months from WBRT if waiting time was 2 weeks or longer as compared to 5.6 months if waiting time was shorter than 2 weeks (P = 0.03). The same correlation was seen if survival was computed from imaging diagnosis. Conclusion. If departmental resources are not sufficient to provide immediate WBRT within 2 weeks to all patients, those without extracranial metastases should be prioritised. This study did not address the impact of waiting time on quality of life or symptom palliation.

Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the United States

PURPOSE

Our goal was to evaluate use and associated costs of radiation therapy (RT) in the last month of life among those dying of cancer.

METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) -Medicare linked databases to analyze claims data for 202,299 patients dying as a result of lung, breast, prostate, colorectal, and pancreas cancers from 2000 to 2007. Logistic regression modeling was used to conduct adjusted analyses of potential impacts of demographic, health services, and treatment-related variables on receipt of RT and treatment with greater than 10 days of RT. Costs were calculated in 2009 dollars.

RESULTS

Among the 15,287 patients (7.6%) who received RT in the last month of life, its use was associated with nonclinical factors such as race, gender, income, and hospice care. Of these patients, 2,721 (17.8%) received more than 10 days of treatment. Nonclinical factors that were associated with greater likelihood of receiving more than 10 days of RT in the last 30 days of life included: non-Hispanic white race, no receipt of hospice care, and treatment in a freestanding, versus a hospital-associated facility. Hospice care was associated with 32% decrease in total costs of care in the last month of life among those receiving RT.

CONCLUSION

Although utilization of RT overall was low, almost one in five of patients who received RT in their final 30 days of life spent more than 10 of those days receiving treatment. More research is needed into physician decision making regarding use of RT for patients with end-stage cancer.

Improving access to specialist multidisciplinary palliative care consultation for rural cancer patients by videoconferencing: report of a pilot project

PURPOSE

Palliative care (PC) and palliative radiotherapy (RT) consultation are integral to the care of patients with advanced cancer. These services are not universally available in rural areas, and travel to urban centers to access them can be burdensome for patients and families. The objectives of our study were to assess the feasibility of using videoconferencing to provide specialist multidisciplinary PC and palliative RT consultation to cancer patients in rural areas and to explore symptom, cost, and satisfaction outcomes.

METHODS

The Virtual Pain and Symptom Control and Palliative Radiotherapy Clinic was piloted from January 2008 to March 2011. Cancer patients in rural northern Alberta attended local telehealth facilities, accompanied by nurses trained in symptom assessment. The multidisciplinary team at the Cross Cancer Institute in Edmonton was linked by videoconference. Team recommendations were sent to the patients' family physicians. Data were collected on referral, clinical, and consultation characteristics and symptom, cost, and satisfaction outcomes.

RESULTS

Forty-four initial consultation and 28 follow-up visits took place. Mean Edmonton Symptom Assessment Scale scores for anxiety and appetite were statistically significantly improved at the first follow-up visit (p < 0.01 and p = 0.03, respectively). Average per visit savings for patients seen by telehealth versus attending the CCI were 471.13 km, 7.96 hours, and Cdn $192.71, respectively. Patients and referring physicians indicated a high degree of satisfaction with the clinic.

CONCLUSION

Delivery of specialist multidisciplinary PC consultation by videoconferencing is feasible, may improve symptoms, results in cost savings to patients and families, and is satisfactory to users.

Epidemiologic study of radiotherapy use in China in patients with breast cancer between 1999 and 2008

BACKGROUND

To investigate the use of radiotherapy (RT) in China in patients with breast cancer over a 10-year period. A hospital-based, nationwide, multicenter, retrospective epidemiologic study of women with primary breast cancer was conducted.

PATIENTS AND METHODS

Patients were selected randomly in 7 hospitals from 1999 to 2008. Data on overall RT, postmastectomy RT (PMRT), RT after conservative breast surgery (PBRT) and palliative RT (PRT) were recorded. RT use was analyzed, and differences were compared by using the Cochran-Armitage trend test and the χ(2) test. A total of 3732 patients were included: 1009 (27%) received RT, including 688 (18.4%) PMRT, 170 (4.6%) PBRT, 86 (2.3%) PRT, 47 (1.3%) both PMRT and PRT, and 18 (0.5%) other RT.

RESULTS

Overall use of RT increased significantly from 1999 to 2008 (2P < .001). There was a slight but significant increase in PMRT (2P = .012) and a 10-fold increase in PBRT (2P < .001); use of PRT was relatively constant (2P = .777). There was a significant difference among regions in the use of RT, PMRT, PBRT, and PRT (2P < .01). Of patients with stage III disease, 51.6% and of those with node-positive stage II disease treated by radical mastectomy, 21% had received PMRT. In patients treated by using breast conservative surgery, 83.7% received PBRT, which was not affected by stage.

CONCLUSION

In summary, in China, the overall use of RT in patients with breast cancer was quite low, but there was an increasing trend in those treated between 1999 and 2008.