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

Variation in Access to Palliative Radiotherapy in Prostate Cancer: A Population-Based Study in Canada

BACKGROUND

As a result of improvements in cancer therapies, patients with metastatic malignancies are living longer, and the role of palliative radiotherapy has become increasingly recognized. However, access to adequate palliative radiotherapy may continue to be a challenge, as is evident from the high proportion of patients dying of prostate cancer who never receive palliative radiotherapy. The main objective of this investigation is to identify and describe the factors associated with the receipt of palliative radiation treatment in a decedent cohort of prostate cancer patients in Ontario.

METHODOLOGY

 Population-based administrative databases from Ontario, Canada, were used to identify prostate cancer decedents, 65 years or older who received androgen deprivation therapy between January 1, 2013, and December 31, 2018. Baseline and treatment characteristics were analyzed using univariate and multivariate logistic regression models for association with receipt of radiotherapy in a two-year observation period before death.

RESULTS

We identified 3,788 prostate cancer decedents between 2013 and 2018; among these, 49.9% received radiotherapy in the two years preceding death. There were statistically significant positive associations between receipt of radiotherapy and younger age at diagnosis (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1-2.3); higher stage at diagnosis (OR 1.3, 95% CI 1.1-1.7); receipt of care at a regional cancer center (OR 1.8, 95% CI 1.3-2.4); and involvement of radiation oncologists (OR 155.1, 95% CI 83.3-288.7) or medical oncologists (OR 1.4, 95% CI 1.1-1.8). However, there were no associations between receipt of radiotherapy and income, distance to the nearest cancer center, involvement of urologists in cancer care, healthcare administrative region, home-care involvement, or number of hospitalizations in the observation period.

CONCLUSIONS

We found the utilization of palliative radiotherapy for prostate cancer patients in Ontario varies depending on age, stage at diagnosis, number of comorbidities, registration at regional cancer centers, and involvement of oncologists. There were no differences detected based on income or distance from a cancer center. The findings of this study represent an important opportunity to facilitate better access to palliative radiotherapy and referrals to multidisciplinary regional cancer centers, to improve the quality of life of this patient population.

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.

Message from the Guest Editor

Introduction

Anxiety in patients undergoing Magnetic resonance imaging (MRI) examinations has been well documented along with causes and strategies to support patent through this. During the Covid-19 pandemic, mask wearing in clinical settings became compulsory for both staff and patients. Whilst staff may be more familiar with wearing personal protective equipment it is unknown how this could affect patient experiences. We know that patients can get claustrophobic in MR scans which affects their wellbeing, scan attendance and even scan quality. This study aims to understand if wearing a mask had any effect of their willingness to comply with the scan, and if they were adequately prepared, and how it affects their feelings about attending for future scan appointments.

Methods

A purposive sampling technique was chosen with participants being invited nationally across the UK. Inclusion criteria required that participants be aged 18 years or older, their scan had taken place in a UK organisation either NHS or private between March 2020 and December 2021 and that they had worn a face mask during their scan. Ethical approval was gained from University of Derby Research and Ethics Committee. Informed consent and participation information sheets were completed. No identifying data was collected and therefore responses were anonymous. A mixed methods online survey design was utilised, and this was shared on social media using professional accounts and charities.

Results

Inductive thematic analysis was used with both researchers independently blind coded the qualitative data. The main themes emerged which were anxiety and discomfort, information and preparation and positivity around the experience. The quantitative data analysis in on-going and will be presented in the final presentation.

Conclusion

We should review patient experiences taking a holistic approach to the entire examination including preparatory material as well as activity in the waiting area and scan room. We need to consider the impact of mask wearing on anxiety and discomfort and revisit what patient preparation looks like to ensure patients have a better experience. This needs to take place in the education of student radiographers as well as qualified professionals in clinical departments. People want to feel prepared and be treated as individuals. We must embrace the principles of person-centred care at every level of what we do.

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.

Anti-tumor treatment and healthcare consumption near death in the era of novel treatment options for patients with melanoma brain metastases

Background

Effective systemic treatments have revolutionized the management of patients with metastatic melanoma, including those with brain metastases. The extent to which these treatments influence disease trajectories close to death is unknown. Therefore, this study aimed to gain insight into provided treatments and healthcare consumption during the last 3 months of life in patients with melanoma brain metastases.

Methods

Retrospective, single-center study, including consecutive patients with melanoma brain metastases diagnosed between June-2015 and June-2018, referred to the medical oncologist, and died before November-2019. Patient and tumor characteristics, anti-tumor treatments, healthcare consumption, presence of neurological symptoms, and do-not-resuscitate status were extracted from medical charts.

Results

100 patients were included. A BRAF-mutation was present in 66 patients. Systemic anti-tumor therapy was given to 72% of patients during the last 3 months of life, 34% in the last month, and 6% in the last week. Patients with a BRAF-mutation more frequently received systemic treatment during the last 3 (85% vs. 47%) and last month (42% vs. 18%) of life than patients without a BRAF-mutation. Furthermore, patients receiving systemic treatment were more likely to visit the emergency room (ER, 75% vs. 36%) and be hospitalized (75% vs. 36%) than those who did not.

Conclusion

The majority of patients with melanoma brain metastases received anti-tumor treatment during the last 3 months of life. ER visits and hospitalizations occurred more often in patients on anti-tumor treatment. Further research is warranted to examine the impact of anti-tumor treatments close to death on symptom burden and care satisfaction.

Patterns of Palliative Radiotherapy Utilization for Patients With Metastatic Breast Cancer in Harare, Zimbabwe

PURPOSE

In sub-Saharan Africa, radiotherapy (RT) utilization and delivery patterns have not been extensively studied in patients with metastatic breast cancer.

METHODS

A retrospective cohort study of female patients with metastatic breast cancer seen at Parirenyatwa Radiotherapy Centre in Zimbabwe from 2014 to 2018 was conducted. Demographics, pathology, staging, and treatment data were abstracted through chart review. Fisher's exact test and chi-squared test of independence were used to compare proportions, and independent two-sample t-tests were used to compare means.

RESULTS

Of 351 patients with breast cancer, 152 (43%) had metastatic disease, median age 51 years (interquartile range: 43-61 years). Of those with metastatic disease, 30 patients (20%) received radiation to various metastatic sites: 16 spine; three nonspine bone metastases; six whole brain; and five chest wall or supraclavicular. Patients who received radiation were younger (46 v 52 years; P = .019), but did not differ significantly by performance status than those who did not. The most common dose prescription was 30 Gy in 10 fractions (33%). Five (17%) patients had treatment interruption and two (7%) had treatment noncompletion. Province of origin and clinical tumor stage were significant predictors of RT receipt (P = .002; and P = .018, respectively).

CONCLUSION

A minority of patients with metastatic breast cancer received RT (20%), and these were likely to be younger, with advanced tumor stage, and resided in provinces where RT is available. Conventional courses were generally prescribed. There is a need to strongly consider palliative RT as an option for patients with metastatic breast cancer and use of hypofractionated courses (e.g. 8 Gy in one fraction) may support this goal.

Palliative Radiotherapy Within the Veterans Health Administration: Barriers to Referral and Timeliness of Treatment

PURPOSE

Most Veterans Health Administration hospitals do not have radiation oncology (RO) departments on-site. The purpose of this study is to determine the impact of on-site RO on referral patterns and timeliness of palliative radiation therapy (PRT).

MATERIALS AND METHODS

A survey was sent to medical directors at 149 Veterans Health Administration centers. Questions evaluated frequency of referral for PRT, timeliness of RO consults and treatment, and barriers to referral for PRT. Chi-square analysis was used to evaluate differences between centers that have on-site RO and centers that refer to outside facilities.

RESULTS

Of 108 respondents, 33 (31%) have on-site RO. Chi-square analysis revealed that RO consult within 1 week is more likely at centers with on-site RO (68% v 31%; P = .01). Centers with on-site RO more frequently deliver PRT for spinal cord compression within 24 hours (94% v 70%; P = .01). Those without on-site RO were more likely to want increased radiation oncologist involvement (64% v 26%; P < .001). Barriers to referral for PRT included patient ability to travel (81%), patient noncompliance (31%), delays in consult and/or treatment (31%), difficulty contacting a radiation oncologist (14%), and concern regarding excessive number of treatments (13%). Respondents with on-site RO less frequently reported delays in consult and/or treatment (6% v 41%; P < .0001) and difficulty contacting a radiation oncologist (0% v 20%; P = .0056) as barriers.

CONCLUSION

Respondents with on-site RO reported improved communication with radiation oncologists and more timely consultation and treatment initiation. Methods to improve timeliness of PRT for veterans at centers without on-site RO should be considered.

Current State of Geospatial Methodologic Approaches in Canadian Population Oncology Research

Geospatial analyses are increasingly used in population oncology. We provide a first review of geospatial analysis in Canadian population oncology research, compare to international peers, and identify future directions. Geospatial-focused peer-reviewed publications from 1992-2020 were compiled using PubMed, MEDLINE, Web of Science, and Google Scholar. Abstracts were screened for data derived from a Canadian cancer registry and use of geographic information systems. Studies were classified by geospatial methodology, geospatial unit, location, cancer site, and study year. Common limitations were documented from article discussion sections. Our search identified 71 publications using data from all provincial and national cancer registries. Thirty-nine percent (N = 28) were published in the most recent 5-year period (2016-2020). Geospatial methodologies included exposure assessment (32.4%), identifying spatial associations (21.1%), proximity analysis (16.9%), cluster detection (15.5%), and descriptive mapping (14.1%). Common limitations included confounding, ecologic fallacy, not accounting for residential mobility, and small case/population sizes. Geospatial analyses are increasingly used in Canadian population oncology; however, efforts are concentrated among a few provinces and common cancer sites, and data are over a decade old. Limitations were similar to those documented internationally, and more work is needed to address them. Organized efforts are needed to identify common challenges, develop leading practices, and identify shared priorities.

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.

What is the optimal radiotherapy utilization rate for lung cancer?-a systematic review

Lung cancer is a major cause of morbidity and mortality globally. Although radiotherapy (RT) may be beneficial in the radical and/or palliative management of many lung cancer patients, it is underutilized worldwide. Population-level development of RT resources requires estimates of optimal radiotherapy utilization rates (ORUR) and actual radiotherapy utilization rate (ARUR). A systematic review of PubMed database for English-language articles from January 2009 to January 2019 was performed. Keywords included utilization, underutilization, demand, epidemiologic, benchmark, RT and cancer. Data abstracted included: study population, diagnosis, stage, year of diagnosis, timing of RT, intent of RT, ARUR, and ORUR. Eligible studies provided ARUR or ORUR for lung cancer, small cell lung cancer (SCLC), or non-small cell lung cancer (NSCLC). Included ARUR were based on at least 1,000 patients who were diagnosed or treated in 2009 or later. Included ORUR were based on evidence review or ARUR in 2009 or later. The initial search strategy yielded 1,627 unique abstracts. After review, 105 articles were determined appropriate for full-text review. From these, a final set of 21 articles met all inclusion criteria. In eight papers, ORUR was estimated. Estimated lifetime ORUR ranged from 61% to 82%. Methods for estimation included the evidence-based guideline model, Malthus model, and criterion-based benchmarking (CBB) model. The majority of estimates (6/8) used the evidence-based guideline model. Fifteen papers provided ARUR on lung cancer, inclusive of SCLC and NSCLC. ARUR within 9 months to 1 year of diagnosis ranged from 39% to 46%. Lifetime ARUR was an estimated 52% in Ontario, Canada. Palliative intent ARUR ranged from 12% in Central Poland to 46% in Ontario, Canada. RT is underutilized for lung cancer globally, and there is wide geographical variation in the level of underutilization.

Access to radiotherapy and its association with cancer outcomes in a high-income country: Addressing the inequity in Canada

BACKGROUND AND PURPOSE

Canada is a high-income country with universal healthcare. In international comparisons, its overall level of access to radiotherapy appears sufficient. However, challenges exist due to Canada's large geographic area and small population density. The association between access and cancer outcomes nationally has not yet been described.

MATERIALS AND METHODS

We quantified geographic accessibility for 2012 using the linear distance from each Canadian health region centroid to the nearest radiotherapy center. We used geospatial analytic techniques to detect clusters of age-standardized all-cancer mortality-to-incidence ratios (MIRs) across health regions, from 2010-2012. Global ordinary least squares (OLS) and geographically-weighted regression (GWR) were conducted to examine relationships between distance and MIR, adjusting for sociodemographic factors.

RESULTS

Median distance from health region centroid to nearest radiotherapy center was 101.73 km (range 1.14-2095.12). One cluster of worse outcomes (MIR range 0.45-0.88) involved most of northern Canada, with a second cluster of better outcomes (MIR range 0.40-0.41) in southern British Columbia. In both regression models, regions with longer distance to radiotherapy center (ß = 0.0001), increased smoking (ß = 0.002), and poorer food security (ß = -0.003) were significantly associated with worse outcomes (OLS R² = 0.70, GWR R² = 0.74). Distance remained independently associated with MIR for lung and colorectal cancer subgroups, but not breast and prostate.

CONCLUSIONS

A clear north-south discordance in cancer outcomes exists in Canada, with poorer outcomes in the north, while radiotherapy centers are concentrated along the south. Increased distance to radiotherapy, along with other sociodemographic and health-system factors, are associated with poorer cancer outcomes. Our study could be replicated, particularly in other high-income countries, to help identify national patterns and regional disparities in access and outcomes.

Characterizing Palliative Radiotherapy Education in Hospice and Palliative Medicine Fellowship: A Survey of Fellowship Program Directors

Background: Educational deficiencies among hospice and palliative medicine (HPM) physicians contribute to suboptimal utilization of palliative radiotherapy (PRT) for patients with advanced cancer. Objective: To survey HPM fellowship program directors regarding the need for PRT education in HPM fellowship. Design: We conducted a cross-sectional survey of HPM fellowship program directors in June 2018. We used a 5-point Likert-type scale to assess agreement with statements related to PRT education. Setting/Subjects: Program directors for all United States Accreditation Council for Graduate Medical Education-accredited HPM fellowship programs with at least one enrolled fellow at the time of survey distribution were included. Results: Eighty-one of 120 eligible program directors completed the survey (68% response rate). Nearly all of the respondents agreed that HPM physicians should possess a working knowledge of PRT and that the principles of PRT should be formally taught in HPM fellowship. Thirty percent of HPM fellowship programs, however, lacked a PRT curriculum and only 14% of programs provided more than two hours of PRT education. Limited didactic time, lack of interest among fellows, and lack of collaboration with radiation oncologists were not perceived to be significant barriers to incorporating PRT education into HPM fellowship. More than 75% of program directors indicated that they would consider implementing a PRT curriculum designed specifically for HPM physicians if one were available. Conclusion: There is a need for PRT education in HPM fellowship. This need may be best addressed by developing a widely accessible PRT curriculum designed to meet the needs of HPM physicians.

Palliative thoracic radiotherapy near the end of life in lung cancer: A population-based analysis

OBJECTIVES

Palliative thoracic radiotherapy (RT) can improve quality of life for patients with advanced lung cancer, but treatment can be associated with acute toxicity and symptomatic relief may take several weeks. The optimal fractionation schedule is not known. Delivery of RT near the end of life (EOL) is an emerging indicator of poor quality care. The aim of this study was to determine utilization of palliative thoracic RT in the last 4 weeks of life, and factors associated with its use, in patients with incurable lung cancer in a population-based healthcare system.

MATERIALS AND METHODS

All patients with lung cancer in British Columbia treated with palliative thoracic RT in 2014 and 2015 were identified. Associations between starting a course of palliative thoracic RT within 4 weeks of death and patient/treatment characteristics were assessed using univariate and multivariate logistic regression analysis.

RESULTS

1676 courses of palliative thoracic RT were delivered to 1584 lung cancer patients. Median survival was 20 weeks. 12% of palliative thoracic RT courses were delivered in the last 4 weeks of life, with short fractionation schedules and simple RT planning techniques used more frequently near EOL. Of RT courses delivered in the last 4 weeks of life 89% were courses of 1 - 5 fractions, 75% were completed as prescribed and 94% involved simple 1-2 field RT techniques. Receipt of RT in the last 4 weeks of life was associated with male gender, younger age, poor performance status, metastatic disease, small cell carcinoma histology and no prior chemotherapy.

CONCLUSION

Further study and standardization of quality indicators for palliative RT utilization near EOL is required. Whilst clarification occurs, physicians should consider the prognosis of patients with incurable lung cancer and the realistic expectation of benefit from palliative thoracic RT when considering treatment indications and fractionation schedules.

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.

Use of Radiation Therapy Within the Last Year of Life Among Cancer Patients

PURPOSE

We examined radiation therapy (RT) use within the last year of life (LYOL). As palliative RT (PRT) has been well studied in patients with ≥6-week life expectancies, we hypothesized that PRT use would be constant over the LYOL, except for the last 30 days, when use would decline given lack of prospective data supporting it.

MATERIALS AND METHODS

At a single institution, 870 cancer patients died between October 2, 2014, and September 30, 2015, and had ≥3 evaluation and management visits within the LYOL. Claims and RT data were extracted and linked. Over the LYOL, we evaluated RT use by intent (curative vs palliative) and indications.

RESULTS

Within the LYOL, one-third of patients underwent RT in the last 365 days of life to 444 sites, which decreased to 24.3% and 8.5% in the last 180 and 30 days of life, respectively. Patients who received any RT in the last 365 days of life were younger at death and had a higher proportion of lung, sarcoma, and transplant disease groups. One-quarter of sites were irradiated with curative intent, which remained constant over the LYOL. In contrast, PRT was used at a supralinear rate, in which treatment of bone metastases and use of single-fraction PRT increased closer to death.

CONCLUSIONS

PRT appears to be disproportionately used closer to death, with an increasing proportion of irradiated sites being bone metastases. This may be secondary to increased symptoms from advanced cancer toward the end of life. As patients with very poor prognoses (eg, within 30 days of death) are generally not included in RT clinical trials, further studies are warranted to assess whether PRT for bone metastases at the end of life is efficacious.

Metastatic Osseous Pain Control: Radiation Therapy

Metastatic disease to the bone is a common manifestation of advanced cancer, and can result in pain, pathologic fractures, hypercalcemia, and overall functional compromise. External beam radiation is a proven, highly efficacious, and noninvasive therapy that can provide symptomatic relief from painful osseous lesions. When deciding upon the best treatment regimen, it is important to consider patient factors such as overall life expectancy, performance status, disease burden, and site of osseous metastatic pain. Determination of best treatment ideally requires multidisciplinary input from radiologists, medical oncologists, surgeons, pain management, and palliative care specialists together with radiation oncologists.

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.

Impact of Radiation Therapy on Aggressive Care and Quality of Life Near Death

CONTEXT

Radiation therapy (RT) is used with palliative intent in patients with advanced stage cancer. Prior studies, primarily in patients with poor performance status (PS), suggest that RT is associated with aggressive medical care, which may impact patients' quality of life near death (QoD) adversely.

OBJECTIVE

This study examines associations between RT use and patients' receipt of aggressive care and QoD based on patients' PS.

METHODS

This is a multi-institutional, prospective cohort study of patients with end-stage cancers (N = 312) who were identified as terminally ill at study enrollment. RT use (n = 24; 7.7%) and Eastern Cooperative Oncology Group (ECOG) PS were assessed at study entry (median = 3.8 months before death). Aggressive care near death was operationalized as use of mechanical ventilation and/or resuscitation in the last week of life. QoD was determined using validated caregiver ratings of patients' physical and mental distress in their final week.

RESULTS

RT use was associated with higher QoD (8/8, 100.0%, vs. 58/114, 50.9%; P = 0.006) among patients with good PS (ECOG = 1), more aggressive care near death (3/9, 33.3%, vs. 6/107, 5.6%; P = 0.020) among patients with moderate PS (ECOG = 2), and lower QoD (1/7, 14.3%, vs. 28/51, 54.9%; P = 0.046) among patients with poor PS (ECOG = 3).

CONCLUSIONS

Targeted use of RT in end-of-life cancer care may benefit patients with good PS, but its use may adversely affect patients with poorer PS. Decisions about RT use in this setting should consider likely end-of-life outcomes based on patients' current PS.

Radioprotection of 1,2-dimethylhydrazine-initiated colon cancer in rats using low-dose γ rays by modulating multidrug resistance-1, cytokeratin 20, and β-catenin expression

Ionizing radiation is a widely used therapy for solid tumors. However, high-dose ionizing radiation causes apoptosis, transforms normal cells into tumor cells, and impairs immune functions, leading to the defects in the removal of damaged or tumor cells. In contrast, low-dose radiation has been reported to exert various beneficial effects in cells. This experimental study investigated the effect of γ rays at low dose on the development of colorectal tumor in a 1,2-dimethylhydrazine (DMH)-induced colon cancer. Colorectal tumor model was induced in Wistar rats by subcutaneous injection of DMH (20 mg/kg) once a week for 15 weeks. Starting from zero day of DMH injection, a single low dose of whole-body γ irradiation of 0.5 Gy/week was applied to the rats. A significant reduction in lipid peroxidation, nitric oxide, and elevation in the glutathione content and antioxidant enzyme activity (superoxide dismutase and catalase) were observed after γ irradiation comparing with DMH group. Moreover, γ ray reduced the expressions of multidrug resistance 1 (MDR1), β-catenin, and cytokeratin 20 (CK20) those increased in DMH-treated rats. However, survivin did not change with γ ray treatment. A histopathological examination of the DMH-injected rats revealed ulcerative colitis, dysplasia, anaplasia, and hyperchromasia. An improvement in the histopathological picture was seen in the colon of rats exposed to γ rays. In conclusion, the present results showed that low-dose γ ray significantly inhibited DMH-induced colon carcinogenesis in rats by modulating CK20, MDR1, and β-catenin expression but not survivin expression.